Publications by authors named "Jorge Chahla"

388 Publications

Bone Marrow Aspirate Concentrate Augmentation may Accelerate Allograft Ligamentization in Anterior Cruciate Ligament Reconstruction: A Double Blinded Randomized Controlled Trial.

Arthroscopy 2022 Jan 15. Epub 2022 Jan 15.

Department of Sports Medicine, Midwest Orthopaedics at Rush, Chicago, IL.

Purpose: To assess the effect of bone marrow aspiration concentrate (BMAC) augmentation on clinical outcomes and MRI findings in anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BTB) allografts.

Methods: A double-blinded, randomized controlled trial was conducted on 80 patients undergoing ACLR using BTB allografts. Patients were randomized to two groups: 1) bone marrow aspirate (BMA) was collected from the iliac crest, concentrated, and approximately 2.5 ml was injected into the BTB allograft, or 2) a small sham incision was made at the iliac crest (control). Magnetic resonance imaging (MRI) was performed at 3 months and 9 months post-operatively to determine the signal intensity ratio (SIR) of the anterior cruciate ligament (ACL) graft.

Results: Seventy-three patients were available for follow-up at 1 year post-operatively (36 BMAC, 37 control). IKDC scores were significantly higher in the BMAC group versus the control at the nine-month post-operative period (81.6±10.5 vs 74.6±14.2, p=0.048). There was no significant difference in the proportion of patients who met the minimal clinically important difference (MCID) for IKDC between the BMAC and control groups at 9 months (89% vs. 85%; p=0.7). Three months post-operatively, SIR of the inferior third of the ACL graft was significantly higher in the BMAC group versus the control group (3.2±2.2 vs 2.1±1.5; p=0.02).

Conclusion: Patients who received BMAC augmentation of the BTB allograft during ALCR demonstrated higher signal intensity scores on MRI at 3 months, suggesting increased metabolic activity and remodeling, and potentially accelerated ligamentization. Additionally, patients in the BMAC group had higher patient-reported outcomes (IKDC) at 9 months post-operatively when compared to those who underwent standard surgical procedure. There was no significant difference in the proportion of patients who met MCID for IKDC between the BMAC and control groups at 9 months suggesting limited clinical significance at this time point. .
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http://dx.doi.org/10.1016/j.arthro.2022.01.010DOI Listing
January 2022

Transtibial Anterior Cruciate Ligament Reconstruction: Tips for a Successful Anatomic Reconstruction.

Arthrosc Tech 2021 Dec 29;10(12):e2783-e2788. Epub 2021 Nov 29.

Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A.

Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed orthopaedic sports procedures. Two main techniques are used for accomplishing an ACL reconstruction: transtibial and anteromedial portal techniques. The transtibial technique has been criticized for its inability to create an anatomic femoral tunnel given the intrinsic constraint of the tibial tunnel during drilling. However, technical modifications of the transtibial technique can result in anatomic tunnel entrance positioning and a properly oriented graft. This Technical Note presents our technique for anatomic transtibial ACL reconstruction.
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http://dx.doi.org/10.1016/j.eats.2021.08.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8719302PMC
December 2021

Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate.

Arthrosc Tech 2021 Dec 16;10(12):e2699-e2708. Epub 2021 Nov 16.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures performed each year. The majority of patients undergoing these reconstructions will experience long-term stability and symptomatic relief; however, some will require a revision ACLR procedure. In general, revision ACLRs are more challenging than primary ACLRs due to several diagnostic and technical considerations. A revision ACLR can be performed with either a one-stage or two-stage procedure, which is based on the presence or absence of malpositioned tunnels, bone loss, and tunnel expansion. Recently, the introduction of preshaped allograft bone dowels as a bone grafting option has gained popularity. They provide immediate structural stability and avoid donor site morbidity associated with autografts. The purpose of this article is to outline a bone-grafting tunnel technique with cannulated allograft bone dowels soaked in bone marrow aspirate concentrate (BMAC) used in the first stage of a staged revision ACLR procedure.
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http://dx.doi.org/10.1016/j.eats.2021.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8719137PMC
December 2021

Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery.

Arthrosc Sports Med Rehabil 2021 Dec 1;3(6):e1905-e1912. Epub 2021 Dec 1.

Department of Orthopedic Surgery, Rush University Medical Center, Chicago Illinois, U.S.A.

Purpose: To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair.

Methods: A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported.

Results: Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, "always" counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills.

Conclusions: While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal.

Clinical Relevance: ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.
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http://dx.doi.org/10.1016/j.asmr.2021.09.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689250PMC
December 2021

Three-Dimensional Measures of Bony Resection During Femoral Osteochondroplasty Are Related to Alpha Angle Measures: A Cadaveric Study.

Arthrosc Sports Med Rehabil 2021 Dec 27;3(6):e1857-e1863. Epub 2021 Sep 27.

Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Hip Preservation Center, Rush University, Chicago, Illinois.

Purpose: To determine whether 3-dimensional (3D)-reconstructed proximal femoral bone models can be used to quantify femoral osteochondroplasty and to determine whether the 3D-based metrics are related to clinical alpha angle measures.

Methods: Six cadaveric specimens with cam-type morphology underwent open femoral osteochondroplasty. Alpha angles were measured on the oblique axial computed tomography slice before and after femoral osteochondroplasty. Preoperative and postoperative computed tomography-based 3D reconstructed femur models were generated for each cadaveric specimen. A 3D-3D registration technique was used to merge the preoperative and postoperative models to measure the surface-to-surface distance between the model surfaces. Bivariate correlation analyses were used to determine the correlations between the preoperative, and the difference between the preoperative and postoperative alpha angle (Δ alpha angle) measures and each of the femoral osteochondroplasty variables of surface area (mm), volume (mm), maximum height (mm), and mean height (mm). The strength of the bivariate correlations was defined as follows: weak 0.1 to 0.3, moderate 0.3 to 0.5, and strong as 0.5 to 1.00.

Results: Bivariate correlations revealed a strong positive correlation between preoperative alpha angle with femoral osteochondroplasty volume (r = 0.899,  = .007) and surface area (r = 0.899,  = .007). No significant correlations were found between the change in alpha angle and the osteochondroplasty variables.

Conclusions: In this study, pre- and postoperative 3D bone models could be used to quantify femoral osteochondroplasty and to determine if the 3D-based metrics are related to clinical alpha angle measures.

Clinical Relevance: 3D-reconstructed image bone models may be helpful to ensure that adequate femoroplasty is performed intraoperatively, in particular with arthroscopic approach in which visualization may be challenging due to capsular management issues and surgeon experience.
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http://dx.doi.org/10.1016/j.asmr.2021.08.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8689252PMC
December 2021

Machine Learning Algorithms Predict Achievement of Clinically Significant Outcomes After Orthopaedic Surgery: A Systematic Review.

Arthroscopy 2021 Dec 27. Epub 2021 Dec 27.

Department of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To determine what subspecialties have applied machine learning (ML) to predict clinically significant outcomes (CSOs) within orthopaedic surgery and to determine whether the performance of these models was acceptable through assessing discrimination and other ML metrics where reported.

Methods: The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were queried for articles that used ML to predict achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) after orthopaedic surgical procedures. Data pertaining to demographic characteristics, subspecialty, specific ML algorithms, and algorithm performance were analyzed.

Results: Eighteen articles met the inclusion criteria. Seventeen studies developed novel algorithms, whereas one study externally validated an established algorithm. All studies used ML to predict MCID achievement, whereas 3 (16.7%) predicted SCB achievement and none predicted PASS achievement. Of the studies, 7 (38.9%) concerned outcomes after spine surgery; 6 (33.3%), after sports medicine surgery; 3 (16.7%), after total joint arthroplasty (TJA); and 2 (11.1%), after shoulder arthroplasty. No studies were found regarding trauma, hand, elbow, pediatric, or foot and ankle surgery. In spine surgery, concordance statistics (C-statistics) ranged from 0.65 to 0.92; in hip arthroscopy, 0.51 to 0.94; in TJA, 0.63 to 0.89; and in shoulder arthroplasty, 0.70 to 0.95. Most studies reported C-statistics at the upper end of these ranges, although populations were heterogeneous.

Conclusions: Currently available ML algorithms can discriminate the propensity to achieve CSOs using the MCID after spine, TJA, sports medicine, and shoulder surgery with a fair to good performance as evidenced by C-statistics ranging from 0.6 to 0.95 in most analyses. Less evidence is available on the ability of ML to predict achievement of SCB, and no evidence is available for achievement of the PASS. Such algorithms may augment shared decision-making practices and allow clinicians to provide more appropriate patient expectations using individualized risk assessments. However, these studies remain limited by variable reporting of performance metrics, CSO quantification methods, and adherence to predictive modeling guidelines, as well as limited external validation.

Level Of Evidence: Level III, systematic review of Level III studies.
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http://dx.doi.org/10.1016/j.arthro.2021.12.030DOI Listing
December 2021

Current Concepts in Anterior Tibial Closing Wedge Osteotomies for Anterior Cruciate Ligament Deficient Knees.

Curr Rev Musculoskelet Med 2021 Dec 15;14(6):485-492. Epub 2021 Dec 15.

Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison Street, Suite 300, Chicago, IL, 60612, USA.

Purpose Of Review: Anterior closing wedge osteotomies (ACWO) are utilized to better restore knee stability and in situ forces on anterior cruciate ligament (ACL) grafts during ACL revision reconstruction while reducing the risk of retearing and subsequent revision procedures. However, clinical outcomes following ACWO for patients undergoing ACL reconstruction remains largely limited. The purpose of this review was to provide a concise overview of the current literature on indication, techniques, and outcomes following ACWO in ACL-deficient patients undergoing primary or revision ACL reconstruction while discussing the authors' preferred technique to ACWO during a staged ACL revision reconstruction.

Recent Findings: Currently available clinical studies and case reports have demonstrated ACWO to improve knee stability and outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction with low complication rates. The ACWO provides an adjunct surgical option to decrease graft failure while improving knee stability and post-surgical outcomes for patients with an increased posterior tibial slope undergoing primary or revision ACL reconstruction. Further investigations are warranted to validate currently reported outcomes following ACWO in higher-level clinical studies with longer-term follow-up.
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http://dx.doi.org/10.1007/s12178-021-09729-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8733136PMC
December 2021

Improved Outcomes for Proximal Humerus Fracture Open Reduction Internal Fixation Augmented with a Fibular Allograft in Elderly Patients: A Systematic Review and Meta-Analysis.

J Shoulder Elbow Surg 2021 Dec 11. Epub 2021 Dec 11.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.

Background: To date, no meta-analysis has been performed on the efficacy of fibular allograft augmentation for the management of proximal humerus fractures. The purpose of this study was to evaluate the radiographic and clinical outcomes of proximal humerus fractures treated with a locking compression plate (LCP) with or without fibular allograft augmentation.

Methods: The Cochrane Database of Systematic Reviews, the Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, and SCOPUS were queried in June of 2021 for literature comparing the radiographic and clinical outcomes for patients with proximal humerus fractures that were treated with a LCP only or a LCP augmented with a fibular allograft. Data describing study design, level of evidence, demographic information, final follow-up, radiographic changes in humeral head height (HHH), radiographic changes in neck shaft angle (NSA), final American Shoulder and Elbow Surgeons (ASES) scores, final Constant-Murley scores, and major complications were collected. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed using pooled weighted mean differences (WMD) to compare changes in HHH, NSA, final ASES and final Constant-Murley scores between the two groups; a pooled odds ratio was used to compare complications between the groups.

Results: Ten studies with a total of 802 patients were identified. There was a significant difference that favored patients augmented with a fibular allograft for change in HHH (WMD = -2.40; 95% CI, -2.49 to -2.31; p < 0.00001), change in NSA (WMD = -5.71; 95% CI, -6.69 to -4.72; p < 0.00001), final ASES scores (WMD = 5.08; 95% CI, 3.69 to 6.48; p < 0.00001), and odds ratio for developing a major complication (OR = 0.37; 95% CI, 0.23 to 0.59; p < 0.0001). There was no significant difference in final Constant-Murley scores (WMD = 3.36; 95% CI, -0.21 to 6.93; p = 0.06) or revision surgery rate (p = 0.182) between the two groups.

Conclusion: The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with a LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared to patients treated with a LCP alone. Limitations of this study include a relatively short average final follow-up time (< 2 years) and a potential lack of standardization for radiographic outcomes among included studies.
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http://dx.doi.org/10.1016/j.jse.2021.11.004DOI Listing
December 2021

Recurrence of Hamstring Injuries and Risk Factors for Partial and Complete Tears in the National Football League: An Analysis From 2009-2020.

Phys Sportsmed 2021 Dec 20:1-5. Epub 2021 Dec 20.

Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Hip Preservation Center, Chicago, IL, USA.

Purpose: To (1) characterize hamstring injury (HSI) recurrence rates across the 2009-2010 to 2019-2020 NFL seasons and (2) to identify HSI recurrence risk factors among positions and determine the weekly return to play (RTP) recurrence risk. We hypothesized that older players, skill position players, and players returning to play faster were most at risk.

Methods: Public data from the 2009-2010 to 2019-2020 seasons were reviewed to identify HSIs. Player characteristics were collected before and two seasons following injury. A week-by-week analysis of recurrence risk was evaluated with linear and logarithmic trendlines of the best fit.

Results: A total of 2075 HSI were identified with a mean age of 26.2 years (20.0-43.0), BMI of 29.6 (22.7-43.5), and 3.4 seasons of experience (0-17), with 1826 strains (88.0%), 236 partial tears (11.3%), and 13 complete tears (0.63%). Of the 2075 injuries, 796 (38.4%) were recurrent, with 247 (11.9%) being a same-season reinjury. Logistic regression found that fewer weeks before RTP, in-game injury, and lower BMI were risk factors for same-season recurrence. For any recurrence, logistic regression identified more recent year of injury, lower BMI, and longer playing experience as significant risk factors. Wide receivers were found to be at risk for same-season recurrence. For any-season recurrence, defensive backs, linebackers, running backs, tight ends, and wide receivers were at risk. Week-by-week recurrence analysis determined the greatest risk to be when players returned within 2 weeks (13.4%).

Conclusions: There is a high rate of HSI recurrence in the NFL. Risk factors for same-season injury include shorter time to RTP, in-game injury, lower BMI, and playing wide receiver. Risk factors for any-season recurrence were more recent year of injury, lower BMI, longer playing experience, and playing defensive back, linebacker, running back, tight end, or wide receiver. The greatest risk factor for HSI recurrence was RTP within 2 weeks.
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http://dx.doi.org/10.1080/00913847.2021.2013106DOI Listing
December 2021

Anterior cruciate ligament (ACL) repair using cortical or anchor fixation with suture tape augmentation vs ACL reconstruction: A comparative biomechanical analysis.

Knee 2021 Dec 4;34:76-88. Epub 2021 Dec 4.

Department of Orthopedic Surgery, UConn Health Center, Farmington, CT 06030, United States; Elite Sports Medicine @ Connecticut Children's Medical Center, Farmington, CT 06032, United States. Electronic address:

Background: The purpose was to compare knee kinematics in a cadaveric model of anterior cruciate ligament (ACL) repair using an adjustable-loop femoral cortical suspensory (AL-CSF) or independent bundle suture anchor fixation (IB-SAF) with suture tape augmentation to a bone-patellar tendon-bone (BPTB) ACL reconstruction.

Methods: Twenty-seven cadaveric knees were randomly assigned to one of three surgical techniques: (1) ACL repair using the AL-CSF technique with suture tape augmentation, (2) ACL repair using the IB-SAF technique with suture tape augmentation, (3) ACL reconstruction using a BPTB autograft. Each specimen underwent three conditions according to the state of the ACL (native, proximal transection, repair/reconstruction) with each condition tested at four different angles of knee flexion (0°, 30°, 60°, 90°). Anterior tibial translation (ATT) and internal tibial rotation (ITR) were evaluated using 3-dimensional motion tracking software.

Results: ACL transection resulted in a significant increase in ATT and ITR when compared to the native state (P < 0.001, respectively). ACL repair with the AL-CSF or IB-SAF technique as well as BPTB reconstruction restored native ATT and ITR at all tested angles of knee flexion, while showing significantly less ATT at 0°, 30°, 60°, and 90° as well as significantly less ITR at 30°, 60°, and 90° of knee flexion when compared to the ACL-deficient state. There were no significant differences in ATT and ITR between the three techniques utilized.

Conclusion: ACL repair using the AL-CSF or IB-SAF technique with suture tape augmentation as well as BPTB ACL reconstruction each restored native anteroposterior and rotational laxity, without significant differences in knee kinematics between the three techniques utilized.

Level Of Evidence: Controlled Laboratory Study.
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http://dx.doi.org/10.1016/j.knee.2021.09.003DOI Listing
December 2021

Return to Sport in Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Am J Sports Med 2022 Jan 26;50(1):30-39. Epub 2021 Nov 26.

Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA.

Background: Data on outcomes in patients with borderline hip dysplasia (BHD) who undergo hip arthroscopy remain limited, particularly in regard to return to sport (RTS).

Purpose: To evaluate outcomes in patients with BHD and their ability to RTS after hip arthroscopy for treatment of femoroacetabular impingement syndrome (FAIS).

Study Design: Case series; Level of evidence, 4.

Methods: Consecutive patients with self-reported athletic activity and radiographic evidence of BHD, characterized by a lateral femoral center-edge angle (LCEA) between 18° and 25° and a Tönnis angle >10°, who underwent hip arthroscopy for FAIS between November 2014 and March 2017 were identified. Patient characteristics and clinical outcomes including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction were analyzed at minimum 2-year follow-up. In addition, all patients completed an RTS survey.

Results: A total of 41 patients with a mean age and body mass index (BMI) of 29.6 ± 13.4 years and 25.3 ± 5.6, respectively, were included. Mean LCEA and Tönnis angle for the study population were 22.7°± 1.8° and 13.3°± 2.9°, respectively. A total of 31 (75.6%) patients were able to RTS after hip arthroscopy at a mean of 8.3 ± 3.2 months. A total of 14 patients (45.2%) were able to RTS at the same level of activity, 16 patients (51.6%) returned to a lower level of activity, and only 1 (3.2%) patient returned to a higher level of activity. Of the 11 high school and collegiate athletes, 10 (90.9%) were able to RTS. All patients demonstrated significant improvements in all patient-reported outcome measures (PROMs) as well as in pain scores at a mean of 26.1 ± 5.4 months after surgery. Patients who were able to RTS had a lower preoperative BMI than patients who did not RTS. Analysis of minimum 2-year PROMs demonstrated better HOS-ADL, HOS-SS, mHHS, iHOT-12, and VAS outcomes for pain in patients able to RTS versus those who did not RTS ( < .05).

Conclusion: Of the patients with BHD studied here, 75.6% of patients successfully returned to sport at a mean of 8.3 ± 3.2 months after hip arthroscopy for FAIS. Of the patients who successfully returned to sport, 45.2% returned at the same level, and 3.2% returned at a higher activity level.
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http://dx.doi.org/10.1177/03635465211056082DOI Listing
January 2022

Quantification of Acetabular Coverage on 3-Dimensional Reconstructed Computed Tomography Scan Bone Models in Patients With Femoroacetabular Impingement Syndrome: A Descriptive Study.

Orthop J Sports Med 2021 Nov 19;9(11):23259671211049457. Epub 2021 Nov 19.

Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA.

Background: Accurate assessment of osseous morphology is imperative in the evaluation of patients with femoroacetabular impingement syndrome (FAIS) and hip dysplasia. Through use of computed tomography (CT), 3-dimensional (3D) reconstructed hip models may provide a more precise measurement for overcoverage and undercoverage and aid in the interpretation of 2-dimensional radiographs obtained in the clinical setting.

Purpose: To describe new measures of acetabular coverage based on 3D-reconstructed CT scan bone models.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Preoperative CT scans were acquired on the bilateral hips and pelvises of 30 patients before arthroscopic surgical intervention for FAIS. Custom software was used for semiautomated segmentation to generate 3D osseous models of the femur and acetabulum that were aligned to a standard coordinate system. This software calculated percentage of total acetabular coverage, which was defined as the surface area projected onto the superior aspect of the femoral head. The percentage of coverage was also quantified regionally in the anteromedial, anterolateral, posteromedial, and posterolateral quadrants of the femoral head. The acetabular clockface was established by defining 6 o'clock as the inferior aspect of the acetabular notch. Radial coverage was then calculated along the clockface from the 9-o'clock to 5-o'clock positions.

Results: The study included 20 female and 10 male patients with a mean age of 33.6 ± 11.7 years and mean body mass index of 27.8 ± 6.3. The average percentage of total acetabular coverage for the sample was 57% ± 6%. Acetabular coverages by region were as follows: anteromedial, 78% ± 7%; anterolateral, 18% ± 7%, posterolateral, 33% ± 13%, and posteromedial, 99% ± 1%. The acetabular coverage ranged from 23% to 69% along the radial clockface from 9 to 5 o'clock.

Conclusion: This study demonstrated new 3D measurements to characterize acetabular coverage in patients with FAIS and elucidated the distribution of acetabular coverage according to these measurements.
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http://dx.doi.org/10.1177/23259671211049457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8607491PMC
November 2021

Cement augmentation of suture anchors in the proximal humerus during rotator cuff repair improves pullout strength: a systematic review.

J ISAKOS 2021 11 21;6(6):349-355. Epub 2021 Jun 21.

Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA.

Importance: Rotator cuff pathology is a growing concern in the ageing population. If cement augmentation of suture anchors improves pullout strength, its application can potentially be applied in cases of poor bone quality to prevent anchor failure.

Objective: To evaluate the biomechanical benefits and fixation strength of cement-augmented versus non-augmented suture anchors in the proximal humerus during rotator cuff repair (RCR).

Evidence Review: A systematic review of PubMed, Embase and Cochrane Library was performed to identify all published articles reporting on biomechanical analysis of suture anchors in the shoulder in a cadaveric model. Inclusion criteria required fresh-frozen specimens, placement in the footprint of the proximal humerus, and comparative assessment of fixation constructs with or without polymethylmethacrylate (PMMA) or bioabsorbable composite cement augmentation. Biomechanical testing procedure, cement augmentation method and pullout force were assessed.

Findings: After review of 105 abstracts, seven full manuscripts met inclusion criteria. Six of seven studies reported statistically significant differences in mean pullout force between augmented (three PMMAs, three composites, one PMMA vs composite) and non-augmented anchors. Of two studies evaluating cycles to failure, both found a significant increase in the augmented versus non-augmented anchors. Of two studies stratifying by anchor position, both investigations identified significant differences in mean pullout strength between augmented and non-augmented anchors at the posteromedial and anterolateral anchor positions.

Conclusions And Relevance: Cement augmentation of suture anchors in cadaveric humeri for RCR improves pullout strength regardless of cement type used or anchor position. Cement augmentation may provide a viable option for future clinical application.

Level Of Evidence: IV, systematic review.
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http://dx.doi.org/10.1136/jisakos-2020-000603DOI Listing
November 2021

Capsular Management with Traction-Assisted T-Capsulotomy Technique During Hip Arthroscopy.

Arthrosc Tech 2021 Oct 14;10(10):e2271-e2278. Epub 2021 Sep 14.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Capsular management, from the initial capsulotomy to capsule closure is essential to success in hip arthroscopy to achieve optimal outcomes. Although an interportal capsulotomy is typically sufficient for resection of proximal cam lesions and for performing central compartment procedures, T-capsulotomy is usually performed when large cam deformity needs to be addressed because it provides a broader field of view. The purpose of this Technical Note is to summarize each step of capsule management and to define a traction-assisted T-capsulotomy technique that allows for accurate placement of the T-capsulotomy while also avoiding damage to the articular cartilage.
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http://dx.doi.org/10.1016/j.eats.2021.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556758PMC
October 2021

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement.

Knee 2021 Dec 30;33:290-297. Epub 2021 Oct 30.

Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.

Background: The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery.

Methods: Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05.

Results: 379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID).

Conclusion: Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.
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http://dx.doi.org/10.1016/j.knee.2021.10.010DOI Listing
December 2021

Cemented vs. uncemented reverse shoulder arthroplasty for proximal humeral fractures: a systematic review and meta-analysis.

J Shoulder Elbow Surg 2021 Nov 2. Epub 2021 Nov 2.

Rush University Medical Center, Chicago, IL, USA.

Background: The purpose of this systematic review was to compare functional outcomes, complications, and revision rates between cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs).

Methods: A systematic search was performed in April 2021 within PubMed, Scopus Web of Science, and Cochrane Library databases for clinical studies reporting outcomes of RSA performed for PHF. Included studies were published in English, had a minimum 1-year follow-up, specified whether the humeral stem was cemented (cRSA) or uncemented (ucRSA), and were evidence level I-IV. Data including range of motion (ROM), functional status, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant-Murley score, visual analog scale (VAS) score, tuberosity healing, complications, and reoperations were extracted. DerSimonian-Laird random effects models with subgroup stratification analyses were applied to investigate differences in outcomes between patients with cRSA and ucRSA.

Results: A total of 45 studies comprising 1623 patients were included. The overall pooled age was 75.9 ± 3.4 years. At a mean follow-up of 34.6 (range, 12-108) months, there were no significant differences in ROM, VAS score, Constant-Murley score, rate of tuberosity healing, or reoperation rates between the cRSA and ucRSA cohorts. The mean postoperative ASES score in the cRSA cohort (73.9, 95% CI 71.4-76.5) was significantly lower than the ucRSA cohort (82.9, 95% CI 75.9-90.0, P = .013). The incidence of postoperative all-cause complications was significantly lower in the cRSA cohort (5.5%, 95% CI 4.0%-6.9%) compared with the ucRSA cohort (9.7%, 95% CI 4.5%-14.9%, P = .044).

Conclusion: The use of uncemented humeral stems in RSA for PHF confers similar functional results to the use of cemented stems in terms of pain, range of motion, functional scores, and tuberosity healing. Although the rate of complications was significantly higher in the uncemented cohort compared with the cemented cohort (9.7% vs. 5.5%, respectively), the rate of reoperations was similar between the groups (1.6% vs. 1.9%, respectively). The uncemented reverse prosthesis seems to be a valid alternative for the management of patients with complex proximal humerus fractures.
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http://dx.doi.org/10.1016/j.jse.2021.10.011DOI Listing
November 2021

Acromioclavicular Joint Separation in UEFA Soccer Players: A Matched-Cohort Analysis of Return to Play and Player Performance From 1999 to 2018.

Orthop J Sports Med 2021 Oct 21;9(10):23259671211026262. Epub 2021 Oct 21.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Background: Acromioclavicular joint (ACJ) separation injuries are uncommon in professional soccer players, threatening future performance and team contributions. Data regarding return to play (RTP) in professional soccer players after ACJ separation are limited.

Purpose: To determine the rate, time to RTP, and player performance after ACJ separation in soccer players from the top 5 professional European leagues when compared with a retrospective, matched cohort of uninjured players.

Study Design: Cohort study; Level of evidence, 3.

Methods: Professional soccer players suffering ACJ separation injuries between 1999 and 2018 were identified and were matched to uninjured players (2 controls to 1 injured player) by position, height, age, season year, and length of time played. Information on date of injury, timing to RTP, and player performance metrics (minutes played, games played, goals scored, assists made, and points per game) were collected from transfermarkt.co.uk, uefa.com, fifa.com, official team websites, public injury reports, and press releases. Change in performance metrics for the 4 seasons after the season of injury were based on metrics 1 season before injury. Univariate comparisons were performed using independent 2-group tests and Wilcoxon rank-sum tests when normality of distributions was violated.

Results: A total 59 soccer players with ACJ separation injuries were identified. Mean age at injury was 24.6 ± 5.3 years. Of these, 81% of the players returned to play, with 69% returning within postinjury season 1. Mean time to RTP was 49.8 ± 24.3 days (5.9 ± 4.1 games). Two players suffered recurrent ACJ separation injuries in their professional soccer careers. There were no significant differences between athletes who sustained ACJ injuries versus control athletes in the number of games played, minutes per game per season, goals scored, assists, or points in the 4 seasons after injury. Defenders played fewer minutes and recorded fewer assists during postinjury season 1 when compared with control athletes.

Conclusion: Of the 59 elite soccer players who sustained ACJ separation injuries during the study period, 81% returned to elite competition. Performance metrics were similar to preinjury levels and matched, uninjured control players.
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http://dx.doi.org/10.1177/23259671211026262DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543588PMC
October 2021

The Effect of a Single Freeze-Thaw Cycle on Matrix Metalloproteinases in Different Human Platelet-Rich Plasma Formulations.

Biomedicines 2021 Oct 6;9(10). Epub 2021 Oct 6.

Steadman Philippon Research Institute, Vail, CO 81657, USA.

Storing platelet-rich plasma (PRP) for future use is a compelling approach, presuming the retention of biological properties is maintained. However, certain factors in PRP preparations have deleterious effects for the treatment of certain musculoskeletal conditions. The purpose of this study was to measure and compare matrix metalloproteinase protein (MMP) concentrations between fresh and freeze-thawed leukocyte-rich PRP (LR-PRP) inactivated (LR-I) and activated (LR-A) preparations, and leukocyte-poor PRP (LP-PRP) inactivated (LP-I) and activated (LP-A) preparations. A volume of 60 mL of whole blood was drawn from 19 healthy donors. LP-I and LR-I samples were processed using a manual extraction and centrifugation methodology. LP-A and LR-A products were activated with 10% CaCl and recombinant thrombin. Blood fractions were either immediately assayed and analyzed or stored at -80 °C for 24, 72 and 160 h. Multiplex immunoassay was used to measure MMP-1, MMP-2, MMP-3, MMP-9, MMP-10, and MMP-12. MMP-1 concentrations increased in LR-A ( < 0.05) and MMP-9 significantly increased in LR-I ( < 0.05), while MMP-2 significantly decreased in LR-I ( < 0.05) and MMP-3 concentrations significantly decreased in LR-A ( < 0.05). MMP-12 concentrations also significantly decreased in LR-I ( < 0.05) from baseline concentrations. There were no significant differences between LP-A and LP-I preparations and MMP concentrations. MMP-10 concentrations in all PRP samples compared to each freezing time point were also not significantly different. MMPs regulate components of the extracellular matrix (ECM) in the remodeling phase of musculoskeletal injury. In this study, we observed a significant increase and decrease in MMP concentrations in response to a single freeze-thaw cycle in inactivated PRP and activated PRP preparations. This evidence contributes to the growing body of literature on the optimization of PRP preparation and storage strategies prior to delivery. Our findings suggest that specific PRP preparations after a single freeze-thaw may be more advantageous for certain musculoskeletal applications based on the presence of MMP concentrations.
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http://dx.doi.org/10.3390/biomedicines9101403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8533272PMC
October 2021

Independent Suture Augmentation With All-Inside Anterior Cruciate Ligament Reconstruction Reduces Peak Loads on Soft-Tissue Graft. A Biomechanical Full-Construct Study.

Arthroscopy 2022 01 13;38(1):88-98. Epub 2021 Oct 13.

Department of Orthopedic Research, Arthrex Inc., Munich, Germany. Electronic address:

Purpose: To evaluate the effect of suture augmentation (SA) of 7-mm and 9-mm diameter graft on load sharing, elongation, stiffness, and load to failure for all-inside anterior cruciate ligament reconstruction (ACLR) in a biomechanical Study was funded by Arthrex ID: EMEA-16020. full-construct porcine model.

Methods: Bovine tendon grafts, 7-mm and 9-mm diameter, with and without SA were tested using suspensory fixation (n = 8). The independent SA was looped over a femoral button and knotted on a tibial button. Preconditioned constructs were incrementally increased loaded (100N/1,000 cycles) from 100N to 400N for 4,000 cycles (0.75 Hz) with final pull to failure (50 mm/min). Isolated mechanical and optical measurements during construct loading of the SA allowed to quantify the load and elongation range during load sharing. Construct elongation, stiffness and ultimate strength were further assessed.

Results: Load sharing in 7-mm grafts started earlier (200N) with a significant greater content than 9-mm grafts (300N) to transfer 31% (125N) and 20% (80N) of the final load (400N) over the SA. Peak load sharing with SA reduced total elongation for 7-mm (1.90 ± 0.27 mm vs 4.77 ± 1.08 mm, P < .001) and 9-mm grafts (1.50 ± 0.33 mm vs 3.57 ± 0.54 mm, P < .001) and adequately increased stiffness of 7-mm (113.4 ± 9.3 N/mm vs 195.9 ± 9.8 N/mm, P < .001) to the level of augmented 9-mm grafts (208.9 ± 13.7N/mm). Augmentation of 7-mm (835 ± 92N vs 1,435 ± 228N, P < .001) and 9-mm grafts (1,044 ± 49N vs 1,806 ± 157N, P < .001) significantly increased failure loads.

Conclusions: Load sharing with SA occurred earlier (200N vs 300N) in lower stiffness 7-mm grafts to carry 31% (7-mm) and 20% (9-mm) of the final load (400N). Loads until peak load sharing were transferred over the graft. Augmented constructs showed significantly lower construct elongation and increased stiffness without significance between variable grafts. Failure load of augmented grafts were significantly increased.

Clinical Relevance: Suture tape ligament augmentation may potentially protect biological grafts from excessive peak loading and elongation, thus reducing the risk of graft tears.
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http://dx.doi.org/10.1016/j.arthro.2021.09.032DOI Listing
January 2022

The Natural History of Medial Meniscal Root Tears: A Biomechanical and Clinical Case Perspective.

Front Bioeng Biotechnol 2021 23;9:744065. Epub 2021 Sep 23.

Twin Cities Orthopedics, Edina-Crosstown Surgery Center, Minneapolis, MN, United States.

Posterior medial meniscus root tears (PMMRTs) make up a relatively notable proportion of all meniscus pathology and have been definitively linked to the progression of osteoarthritis (OA). While known risk factors for development of OA in the knee include abnormal tibial coronal alignment, obesity and female gender, PMMRTs have emerged in recent years as another significant driver of degenerative disease. These injuries lead to an increase in average contact pressure in the medial compartment, along with increases in peak contact pressure and a decrease in contact area relative to the intact state. Loss of the root attachment impairs the function of the entire meniscus and leads to meniscal extrusion, thus impairing the force-dissipating role of the meniscus. Anatomic meniscus root repairs with a transtibial pullout technique have been shown biomechanically to restore mean and peak contact pressures in the medial compartment. However, nonanatomic root repairs have been reported to be ineffective at restoring joint pressures back to normal. Meniscal extrusion is often a consequence of nonanatomic repair and is correlated with progression of OA. In this study, the authors will describe the biomechanical basis of the natural history of medial meniscal root tears and will support the biomechanical studies with a case series including patients that either underwent non-operative treatment (5 patients) or non-anatomic repair of their medial meniscal root tears (6 patients). Using measurements derived from axial MRI, the authors will detail the distance from native root attachment center of the non-anatomic tunnels and discuss the ongoing symptoms of those patients. Imaging and OA progression among patients who were treated nonoperatively before presentation to the authors will be discussed as well. The case series thus presented will illustrate the natural history of meniscal root tears, the consequences of non-anatomic repair, and the findings of symptomatic meniscal extrusion associated with a non-anatomic repair position of the meniscus.
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http://dx.doi.org/10.3389/fbioe.2021.744065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8495066PMC
September 2021

The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis.

Orthopedics 2021 Sep-Oct;44(5):299-305. Epub 2021 Sep 1.

This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all <.001) and SCB achievement (chi-square=26.02-53.24, all <.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, <.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [. 2021;44(5):299-305.].
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http://dx.doi.org/10.3928/01477447-20210819-03DOI Listing
October 2021

Qualitative and Quantitative Anatomy of the Human Quadriceps Tendon in Young Cadaveric Specimens.

Orthop J Sports Med 2021 Sep 14;9(9):23259671211037305. Epub 2021 Sep 14.

Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Background: A detailed understanding of the anatomy of the quadriceps tendon (QT) is clinically relevant, owing to its increased use as a graft in anterior cruciate ligament reconstruction.

Purpose: To qualitatively and quantitatively describe the anatomy of the QT in younger adult specimens.

Study Design: Descriptive laboratory study.

Methods: A total of 18 nonpaired cadaveric knees with a mean age of 30.1 years (range, 18-38 years) were utilized for this study. A 3-dimensional coordinate measuring system was used to assess the structural relationships between the different layers of the QT and their attachments to the patella, and QT thickness was measured medially, centrally, and laterally at 2-cm intervals from the patellar eminence line (PEL; defined as a straight line between the medial and lateral patellar eminences) and proximally.

Results: In all specimens, 3 distinct layers formed the QT. The first (superficial) layer was formed by the rectus femoris, which was fused to the second layer with an unclearly defined direct attachment to the patella. The median length of the QT was 86.9 mm (range, 68.4-98.9 mm). The second (middle) layer consisted of the vastus medialis and vastus lateralis and was found to have fibers running in an oblique direction that attached on the patella. A "fuse point," where the proximal part of the rectus femoris started to merge to the second layer, was identified at a median of 48.7 mm (range, 27.9-62.6 mm) from the PEL. The third (deep) layer consisted of the vastus intermedius. The median thickness of the graft centrally at 20, 40, 60, 80, and 100 mm from the PEL was 8.5, 7.2, 7.5, 6.5, and 5.4 mm, respectively.

Conclusion: Overall, 3 different layers of the QT were consistently found in all specimens. The first layer was fused with the second layer, and the direction of the fibers of the second layer or the vastus medialis and vastus lateralis was oblique. The median length of the QT was 86.9 mm, and the thickness of the tendon diminished proximally.

Clinical Relevance: This study allows for a better understanding of QT anatomy when harvesting the tendon as a graft for ligamentous reconstruction.
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http://dx.doi.org/10.1177/23259671211037305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445542PMC
September 2021

Diagnostic Accuracy of Clinical Tests and Imaging Exams for Femoroacetabular Impingement: An Umbrella Review of Systematic Reviews.

Clin J Sport Med 2021 Sep 17. Epub 2021 Sep 17.

Department of Surgery, Federal University of Santa Catarina (UFSC), Postgraduate Program in Medical Sciences (PPGCM-UFSC), Florianópolis, Santa Catarina, Brazil; Postgraduate Program in Dentistry, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil; Department of Orthopedics and Traumatology, Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil; Department of Orthopaedics, Regional Hospital of São José Dr Homero de Miranda Gomes, Florianópolis, Santa Catarina, Brazil; Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, Illinois; and Internal Medicine Department, Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil.

Objective: To synthesize available evidence about diagnostic accuracy of clinical tests and imaging examinations for femoroacetabular impingement (FAI) syndrome.

Design: Umbrella review.

Setting: N/A.

Participants: N/A.

Interventions: N/A.

Main Outcome Measures: Systematic reviews (SR) indexed in Embase, LIVIVO, PubMed, SCOPUS, the Cochrane Library, and Web of Science were searched in a 2-phase process. SR assessing diagnostic accuracy were considered eligible.

Results: From 1520 studies, 6 SR were included, which evaluated 24 primary studies related to FAI syndrome. Of these, 5 SR assessed clinical tests, and a substantial heterogeneity was found concerning reference standards adopted across primary studies, which included arthroscopy, clinical examination (associated or not with imaging exams), intra-articular injections, and open surgery. Most clinical tests presented higher values of sensitivity compared with specificity, although evidence was considered limited because the same primary studies were often included across SR. Nonetheless, evidence around the flexion adduction internal rotation (FADIR) test was considered stronger and its use as a screening tool was consistently supported. Only one SR assessed the accuracy of imaging examinations, which adopted open surgery as the sole reference standard. Most imaging exams presented considerably high values of sensitivity, although specificity values were notably lower.

Conclusions: No robust recommendations can be provided for most clinical tests, although the FADIR test, in particular, was consistently supported as a screening tool. Moreover, although imaging examinations showed considerably high sensitivity values, evidence was considered sparse and further research is strongly recommended to validate its use as reference standards for diagnostic accuracy data.
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http://dx.doi.org/10.1097/JSM.0000000000000978DOI Listing
September 2021

The Large Focal Isolated Chondral Lesion.

J Knee Surg 2021 Sep 10. Epub 2021 Sep 10.

Knee Preservation and Cartilage Restoration Center, OrthoIndy, Indianapolis, Indiana.

Focal chondral defects (FCDs) of the knee can be a debilitating condition that can clinically translate into pain and dysfunction in young patients with high activity demands. Both the understanding of the etiology of FCDs and the surgical management of these chondral defects has exponentially grown in recent years. This is reflected by the number of surgical procedures performed for FCDs, which is now approximately 200,000 annually. This fact is also apparent in the wide variety of available surgical approaches to FCDs. Although simple arthroscopic debridement or microfracture are usually the first line of treatment for smaller lesions, chondral lesions that involve a larger area or depth require restorative procedures such as osteochondral allograft transplantation or other cell-based techniques. Given the prevalence of FCDs and the increased attention on treating these lesions, a comprehensive understanding of management from diagnosis to rehabilitation is imperative for the treating surgeon. This narrative review aims to describe current concepts in the treatment of large FCDs through providing an algorithmic approach to selecting interventions to address these lesions as well as the reported outcomes in the literature.
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http://dx.doi.org/10.1055/s-0041-1735278DOI Listing
September 2021

Influence of Fatty Infiltration on Hip Abductor Repair Outcomes: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 Sep 8:3635465211027911. Epub 2021 Sep 8.

Midwest Orthopaedics, Rush, Chicago, Illinois, USA.

Background: Increasing evidence supports surgical intervention for hip abductor tears; however, the influence of fatty infiltration (FI) on outcomes after repair remains uncertain and has been addressed only in small case series.

Purpose: To clarify the relationship between FI and surgical outcomes for hip abductor tears.

Study Design: Meta-analysis; Level of evidence, 4.

Methods: A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. FI severity was assessed by Goutallier-Fuchs (G-F) grade. The relationship between FI and improvement in Harris Hip Score (HHS)/modified Harris Hip Score (mHHS) and visual analog scale (VAS) score for pain was examined with mixed-effects metaregression. Outcomes with open and endoscopic techniques were also compared.

Results: A total of 4 studies (206 repairs in 201 patients) were eligible. High-grade FI was associated with significantly less improvement in HHS/mHHS than both no FI (6.761 less; 95% CI, 3.983-11.570; = .002) and low-grade FI (7.776 less; 95% CI, 2.460-11.062; < .001) but did not significantly influence VAS score ( > .05). Controlling for FI severity, we found no significant difference in HHS/mHHS improvement between open versus endoscopic repair ( > .05 at each level), but open repair resulted in significantly greater improvement in VAS score for every G-F grade (all < .005).

Conclusion: Surgical intervention for symptomatic hip abductor tendon tears improved outcomes as reflected by change in HHS/mHHS; however, the presence of high-grade FI resulted in less improvement. FI severity did not influence VAS scores for pain. Although no differences were found between open and endoscopic repairs in terms of FI-adjusted improvement in HHS/mHHS, open repairs resulted in significantly greater pain relief at each FI level.
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http://dx.doi.org/10.1177/03635465211027911DOI Listing
September 2021

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale.

Am J Sports Med 2021 10 8;49(12):3250-3260. Epub 2021 Sep 8.

Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA.

Background: A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

Purpose: To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.

Study Design: Case-control study; Level of evidence, 3.

Methods: A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.

Results: A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.

Conclusion: Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.
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http://dx.doi.org/10.1177/03635465211034511DOI Listing
October 2021

Lowering the Learning Curve: Intraoperative Automated Radiographic Visualization Tool Allows for Higher Accuracy of Cam Lesion Resection When Used By Novice Surgeon For Arthroscopic Femoroplasty.

Arthroscopy 2021 Aug 24. Epub 2021 Aug 24.

Division of Sports Medicine Surgery, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Purpose: To compare the accuracy of conventional fluoroscopy versus an intraoperative radiographic visualization tool in assisting a novice and experienced hip arthroscopist in comprehensive cam correction to a desired alpha angle (AA).

Methods: A cadaveric study was performed using 28 hemi-pelvises with cam-type deformity (AA > 55˚) measured on anteroposterior, lateral, and Dunn-view radiographs. Two fellowship-trained hip arthroscopists each performed 14 arthroscopic femoroplasties. The specimens were randomly assigned: 14 of the procedures were performed by the experienced surgeon, with 7 using the automated radiographic visualization tool (Guided Femoroplasty) and 7 using routine fluoroscopy (Control). The same number of hips was assigned to the novice surgeon, completing 7 femoroplasties with and without the visualization tool. Each hip was imaged before and after femoroplasty in 6 different positions using intraoperative fluoroscopy to evaluate head-neck offset. Femoroplasty AAs were compared between groups with and without visualization tool use, as well as between surgeons. One-way analysis of variance analysis was performed to evaluate the consistency of cam resection.

Results: For the experienced hip arthroscopist, comparison of Guide Femoroplasty and Control groups resulted in similar accuracy when compared to the controls, with post-femoroplasty AA averages ranging from 41.4° ± 3.8˚ to 44.8° ± 2.8˚ (P = .511) and 40.2° ± 5.3˚ to 45.6° ± 2.2˚ (P = .225), respectively. For the novice hip arthroscopist, the Guided Femoroplasty group had higher accuracy, with post-femoroplasty AA averages ranging from 42.8° ± 2.6˚ to 46.1° ± 7.2˚(P = .689) with and 39.8° ± 3.1˚ to 51.9° ± 8.1˚ (P = .001) without the visualization tool. Comparison of procedure time did not show any statistically significant difference between the use of the radiographic visualization tool and controls for either surgeon (P > .05 for all).

Conclusions: Femoroplasty with and without the use of automated radiographic visualization tool results in accurate cam resection when used by both the experienced and novice surgeon. However, higher accuracy was observed when resecting to a desired AA performed by a novice surgeon using the visualization tool. Additionally, use of the visualization tool did not result in longer procedure times for either surgeon.

Clinical Relevance: The impact of incomplete cam resections and over-resection on patient outcomes in the literature has led to the recent development of automated intraoperative radiographic visualization tools that allow for assistance of cam resection accuracy for the treatment of femoroacetabular impingement syndrome. This cadaveric study demonstrates that femoroplasty with the use of an intraoperative automated radiographic visualization tool may result in more accurate cam resections.
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http://dx.doi.org/10.1016/j.arthro.2021.08.020DOI Listing
August 2021

Are there different gait profiles in patients with advanced knee osteoarthritis? A machine learning approach.

Clin Biomech (Bristol, Avon) 2021 08 14;88:105447. Epub 2021 Aug 14.

Universidade Federal de São Paulo, Escola Paulista de Medicina, Programa de Pós Graduação em Radiologia Clínica, São Paulo, Brazil.

Background: Determine whether knee kinematics features analyzed using machine-learning algorithms can identify different gait profiles in knee OA patients.

Methods: 3D gait kinematic data were recorded from 42 patients (Kellgren-Lawrence stages III and IV) walking barefoot at individual maximal gait speed (0.98 ± 0.34 m/s). Principal component analysis, self-organizing maps, and k-means were applied to the data to identify the most relevant and discriminative knee kinematic features and to identify gait profiles.

Findings: Four different gait profiles were identified and clinically characterized as type 1: gait with the knee in excessive varus and flexion (n = 6, 14%, increased knee adduction and increased maximum and minimum knee flexion, p < 0.01); type 2: gait with knee external rotation, either in varus or valgus (n = 11, 26%, excessive maximum and minimum external rotation, p < 0.001); type 3: gait with a stiff knee (n = 17, 40%, decreased knee flexion range of motion, p < 0.001); and type 4: gait with knee varus 'thrust' and decreased rotation (n = 8, 19%, increased and reduced range of motion in the coronal and transverse plane, respectively, p < 0.05).

Interpretation: In a group of patients with homogeneous Kellgren-Lawrence classification of knee OA, gait kinematics data permitted to identify four different gait profiles. These gait profiles can be a valuable tool for helping surgical decisions and treatment. To allow generalization, further studies should be carried with a larger and heterogeneous population.
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http://dx.doi.org/10.1016/j.clinbiomech.2021.105447DOI Listing
August 2021

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

Am J Sports Med 2021 Aug 17:3635465211029659. Epub 2021 Aug 17.

Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Background: In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest.

Purpose: To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up.

Study Design: Meta-analysis of randomized controlled trials; Level of evidence, 1.

Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes.

Results: All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo.

Conclusion: PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.
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http://dx.doi.org/10.1177/03635465211029659DOI Listing
August 2021

Top Ten Pearls for Successful Hip Arthroscopy for Femoroacetabular Impingement.

Arthrosc Tech 2021 Aug 21;10(8):e2033-e2042. Epub 2021 Jul 21.

Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois.

Hip arthroscopy is an increasingly popular procedure used to treat femoroacetabular impingement. However, the procedure is technically challenging with a steep learning curve. To prevent complications and to optimize patient outcomes, proper patient positioning, correct portal placement, and adequate capsular closure are necessary. For central compartment procedures, creation of a minimal interportal capsulotomy, placement of traction stitches, adequate rim trimming, and balanced labral repair are recommended. For peripheral compartment procedures, adequate osteochondroplasty should be performed and assessed intraoperatively. The purpose of this technical note is to describe the senior author's top 10 pearls for a successful hip arthroscopy procedure to treat femoroacetabular impingement.
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http://dx.doi.org/10.1016/j.eats.2021.05.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8355535PMC
August 2021
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