Publications by authors named "Matthew J Kraeutler"

138 Publications

An Applicant's Review of Virtual Fellowship Interviews: The New Norm?

Arthroscopy 2021 Jun;37(6):1704-1705

Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey.

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http://dx.doi.org/10.1016/j.arthro.2021.04.020DOI Listing
June 2021

The Everted Acetabular Labrum: Patho-anatomy, Magnetic Resonance Imaging and Arthroscopic Findings of a Native Variant.

Arthroscopy 2021 May 4. Epub 2021 May 4.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: The purpose of this study was to introduce a native labral variant, the everted acetabular labrum, and to describe the patho-anatomy, magnetic resonance imaging and magnetic resonance arthrogram (MRI/MRA) characteristics and the arthroscopic findings in this condition.

Methods: All primary hip arthroscopy procedures performed by the senior author between June 2013 and January 2020 were reviewed retrospectively. An everted acetabular labrum was identified as a segment of labrum that lacked apposition to the femoral head with the hip off traction. All everted labra were treated with labral advancement and repair with or without augmentation or reconstruction. The labrum-to-femoral head distance was measured in 3T MRI/MRA at the 1-2 o'clock position. A random selection of 38 hips without an everted labrum served as controls to compare radiographic parameters.

Results: A total of 68 hips were identified as having an everted labrum during the study period (mean age, 29.1 years), and 55 hips had advanced imaging available for review. MRI/MRA scans revealed the everted labrum to have a triangular shape in 17 hips (31%) and a blunted/round shape in 38 hips (69%), which differed significantly from controls (triangular 25/38 [66%], blunted 13/38 [34%], P < 0.001). The average labrum-to-femoral head distance was 1.4 mm for everted labra versus 0.0 mm for controls (P < 0.0001) and the mean labral lengths and widths were significantly shorter than those of controls (both P < 0.01). Of the hips, 8 underwent labral reconstruction or augmentation, and 61 underwent labral advancement/repair.

Conclusion: The everted acetabular labrum is a native variant that is identifiable during hip arthroscopy by assessing the labral seal off traction. Preoperative MRI/MRA findings can be highly predictive of an everted labrum. Surgical treatment includes labral advancement and repair or reconstruction to restore contact between the labrum and the femoral head.

Level Of Evidence: III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2021.04.038DOI Listing
May 2021

Use of Preoperative Magnetic Resonance Imaging to Predict Clinical Outcomes After Core Muscle Injury Repair.

Orthop J Sports Med 2021 Apr 7;9(4):2325967121995806. Epub 2021 Apr 7.

Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey, USA.

Background: Core muscle injury (CMI), often referred to as a sports hernia or athletic pubalgia, is a common cause of groin pain in athletes. Imaging modalities used to assist in the diagnosis of CMI include ultrasound (US) and magnetic resonance imaging (MRI).

Purpose: To determine if preoperative MRI findings predict clinical outcomes after surgery for CMI.

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

Methods: A retrospective cohort study was performed on a consecutive series of patients who were operatively treated for CMI by a single surgeon. CMI was diagnosed based on history, physical examination, and a positive US. In addition, all patients underwent a preoperative MRI. Patients were divided into 2 groups based on whether the MRI was interpreted as positive or negative for CMI. All patients underwent mini-open CMI repair. Patient-reported outcomes (PROs) were collected both pre- and postoperatively and included a visual analog scale (VAS) for pain, the University of California, Los Angeles (UCLA) activity score, and the modified Harris Hip Score.

Results: A total of 39 hips were included in this study, of which 17 had a positive MRI interpretation for CMI (44%) and 22 had a negative MRI interpretation (56%). Mean age at the time of surgery was 35 years (range, 17-56 years), and mean follow-up was 21 months (range, 12-35 months). No significant difference was found between groups in mean age or time to follow-up. Patients in both groups demonstrated significant improvement from preoperative to most recent follow-up in terms of the UCLA activity score ( < .05). VAS scores significantly improved for patients with a positive MRI interpretation ( = .001) but not for those with a negative MRI interpretation ( = .094). No significant difference on any PROs was found between groups at the most recent follow-up.

Conclusion: Successful clinical outcomes can be expected in patients undergoing surgery for CMI diagnosed based on history, physical examination, and US. Patients with a preoperative MRI consistent with CMI may experience greater improvement in pain postoperatively, although MRI does not predict postoperative activity level in these patients.
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http://dx.doi.org/10.1177/2325967121995806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033399PMC
April 2021

A Systematic Review Shows High Variation in Terminology, Surgical Techniques, Preoperative Diagnostic Measures, and Geographic Differences in the Treatment of Athletic Pubalgia/Sports Hernia/Core Muscle Injury/Inguinal Disruption.

Arthroscopy 2021 Apr 9. Epub 2021 Apr 9.

Department of Orthopaedic Surgery, St Joseph's University Medical Center, Paterson, New Jersey, U.S.A.; New Jersey Orthopaedic Institute, Wayne, New Jersey, U.S.A.

Purpose: To perform a systematic review of reported terminologies, surgical techniques, preoperative diagnostic measures, and geographic differences in the treatment of core muscle injury (CMI)/athletic pubalgia/inguinal disruption.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify clinical studies or articles that described a surgical technique to treat CMI refractory to nonoperative treatment. The search phrase used was "core muscle injury" OR "sports hernia" OR "athletic pubalgia" OR "inguinal disruption." The diagnostic terminology, country of publication, preoperative diagnostic measures, surgical technique, and subspecialty of the operating surgeons described in each article were extracted and reported.

Results: Thirty-one studies met the inclusion and exclusion criteria, including 3 surgical technique articles and 28 clinical articles (2 Level I evidence, 1 Level II, 4 Level III, and 21 Level IV). A total of 1,571 patients were included. The most common terminology used to describe the diagnosis was "athletic pubalgia," followed by "sports hernia." Plain radiographs and magnetic resonance imaging of the pelvis were the most common imaging modalities used in the preoperative evaluation of CMI/athletic pubalgia/inguinal disruption. Tenderness-to-palpation testing was the most common technique performed during physical examination, although the specific locations assessed with this technique varied substantially. The operating surgeons were general surgeons (16 articles), a combination of orthopaedic and general surgeons (7 articles), or orthopaedic surgeons (5 articles). The most common procedures performed were open or laparoscopic mesh repair, adductor tenotomy, primary tissue (hernia) repair, and rectus abdominis repair. The procedures performed differed on the basis of surgeon subspecialty, geographic location, and year of publication.

Conclusions: A variety of diagnostic methods and surgical procedures have been used in the treatment of a CMI/athletic pubalgia/sports hernia/inguinal disruption. These procedures are performed by orthopaedic and/or general surgeons, with the procedures performed differing on the basis of surgeon subspecialty and geographic location.

Level Of Evidence: Level V, systematic review of Level I to V studies.
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http://dx.doi.org/10.1016/j.arthro.2021.03.049DOI Listing
April 2021

Comparing Intra-articular Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Low-Molecular Weight Hyaluronic Acid for the Treatment of Symptomatic Osteoarthritis of the Hip: A Double-Blind, Randomized Pilot Study.

Orthop J Sports Med 2021 Jan 20;9(1):2325967120969210. Epub 2021 Jan 20.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Hyaluronic acid (HA) and leukocyte-poor platelet-rich plasma (LP-PRP) are 2 nonoperative treatment options that have been studied in patients with hip osteoarthritis (OA).

Purpose: To compare the efficacy of intra-articular injections of low-molecular weight (LMW) HA and LP-PRP in patients with hip OA.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A total of 34 patients (36 hips) presenting with signs of hip OA were randomized to receive 3 blinded, weekly intra-articular injections of either LP-PRP or LMW-HA. Patients were prospectively evaluated before injections and at 6 weeks and then at 3, 6, 12, and 24 months. The primary outcome, conversion to total hip arthroplasty (THA) or a hip resurfacing procedure, was analyzed along with secondary outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and hip range of motion.

Results: The final analysis included 33 hips (mean Kellgren-Lawrence grade, 2.73) (LMW-HA: n = 14; LP-PRP: n = 19) in 31 patients (18 male; mean age, 53.8 years). Significantly more patients converted to THA or a hip resurfacing procedure in the LMW-HA group (7/14; 50.0%) (mean, 1.3 years after first injection) than the LP-PRP group (3/19; 15.8%) (mean, 0.73 years after first injection) ( = .035). There was no significant improvement or decline in any outcome scores within the LMW-HA group from before injections to 6 weeks or 3, 6, and 12 months. For the LP-PRP group, WOMAC overall ( = .032), joint ( = .030), and function scores ( = .025) significantly improved from before injections to 6 weeks, and WOMAC joint scores significantly improved from before injections to 6 months ( = .036). When comparing the difference between groups in internal rotation at 90° of hip flexion from before injections to 6 months, the LP-PRP group demonstrated a mean 5.0° improvement, while the LMW-HA group showed a mean 1.5° decrease ( = .028).

Conclusion: Intra-articular hip injections of LP-PRP in patients with hip OA resulted in an improvement in WOMAC scores and hip internal rotation at 6 months and delayed the need for THA or a hip resurfacing procedure compared with treatment with LMW-HA. A longer follow-up is necessary to further compare the effects of LP-PRP and LMW-HA injections in patients with hip OA.

Registration: NCT01920152 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967120969210DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934058PMC
January 2021

Fascia Iliaca Block for Postoperative Pain Control After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials.

Am J Sports Med 2021 Mar 12:363546521996713. Epub 2021 Mar 12.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Various analgesic modalities have been used to improve postoperative pain in patients undergoing hip arthroscopy.

Purpose: To systematically review the literature to compare the efficacy of the fascia iliaca block (FIB) with that of other analgesic modalities after hip arthroscopy in terms of postoperative pain scores and analgesic consumption.

Study Design: Systematic review.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to April 2020 to identify randomized controlled trials that compared postoperative pain and analgesic consumption in patients after hip arthroscopy with FIB versus other pain control modalities. The search phrase used was "hip arthroscopy fascia iliaca randomized." Patients were evaluated based on postoperative pain scores and total postoperative analgesic consumption.

Results: Five studies (3 level 1, 2 level 2) were identified that met inclusion criteria, including 157 patients undergoing hip arthroscopy with FIB (mean age, 38.3 years; 44.6% men) and 159 patients among the following comparison groups: lumbar plexus block (LPB), intra-articular ropivacaine (IAR), local anesthetic infiltration (LAI), saline placebo, and a no-block control group (overall mean age, 36.2 years; 36.5% men). No significant differences in pain scores were reported in the postanesthesia care unit (PACU) between the FIB and LPB (3.4 vs 2.9; = .054), IAR (7.7 vs 7.9; = .72), control group (no FIB: 4.1 vs 3.8; = .76); or saline placebo (difference, -0.2 [95% CI, -1.1 to 0.7]). One study reported significantly higher pain scores at 1 hour postoperation in the FIB group compared with the LAI group (5.5 vs 3.4; = .02). Another study reported significantly greater total analgesic consumption (in morphine equivalent dosing) in the PACU among the FIB group compared with the LPB group (20.8 vs 17.0; = .02). No significant differences were observed in total PACU analgesic consumption between FIB and other analgesic modalities.

Conclusion: In patients undergoing hip arthroscopy, the FIB does not appear to demonstrate superiority to other forms of analgesics in the immediate postoperative period. Therefore, it is not recommended as a routine form of pain control for these procedures.
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http://dx.doi.org/10.1177/0363546521996713DOI Listing
March 2021

Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures.

J Bone Joint Surg Am 2021 05;103(9):829-836

Department of Orthopaedic Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.

: Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation.

: In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF).

: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty.

: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.
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http://dx.doi.org/10.2106/JBJS.20.00665DOI Listing
May 2021

Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials.

J Shoulder Elbow Surg 2021 May 26;30(5):951-960. Epub 2020 Dec 26.

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy.

Methods: We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity.

Results: Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study.

Conclusion: Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.
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http://dx.doi.org/10.1016/j.jse.2020.11.012DOI Listing
May 2021

The Anterolateral Ligament of the Knee: An Updated Systematic Review of Anatomy, Biomechanics, and Clinical Outcomes.

Arthroscopy 2021 05 17;37(5):1654-1666. Epub 2020 Dec 17.

University of Colorado School of Medicine, Department of Orthopaedics, University of Colorado, Aurora, Colorado, U.S.A.

Purpose: To perform an updated systematic review of the anatomy, biomechanics, function of the anterolateral ligament (ALL), and the clinical outcomes of anterolateral ligament reconstruction (ALLR) when performed in conjunction with anterior cruciate ligament reconstruction (ACLR).

Methods: A systematic search of the literature was performed by searching PubMed, the Cochrane Library, and Embase with the search phrase anterolateral ligament for articles published from February 2017 to May 2020. Inclusion criteria included studies that evaluated the anatomy, function, or biomechanics of the ALL; surgical technique articles on ALLR; clinical articles reporting outcomes of ALLR; studies published in English; and full-text articles. Exclusion criteria included studies published before February 2017. A subjective synthesis was performed, in which ranges were reported, and individual study data were presented in forest plots.

Results: Overall, 40 articles were included in this systematic review, with 11 articles describing ALL anatomy, 14 articles analyzing ALL function and biomechanics, 7 articles discussing the surgical technique of combined ACLR and ALLR (ACLR/ALLR), and 8 articles describing the clinical outcomes of ACLR/ALLR. The addition of ALLR in combination with ACLR (ACLR+) results in lower graft failure rates for ACLR/ALLR (0.0%-15.7%) when compared with isolated ACLR (I-ACLR) patients (7.4%-21.7%). Three of 5 studies using the Subjective International Knee Documentation Committee score, 2 of 5 studies using the Lysholm score, and 1 of 2 studies using the Tegner score reported significantly better scores at latest follow-up among ACLR+ patients compared with I-ACLR (P < .05).

Conclusions: The ALL acts as a secondary stabilizer to the anterior cruciate ligament and helps resist internal knee rotation and anterior tibial translation. Based on the current literature, combined ACLR with ALLR may result in lower graft failure rates and improved patient-reported outcomes when compared with I-ACLR in patients with specific indications, although several studies have shown equivalent outcomes between these 2 cohorts.

Clinical Relevance: The contents of this review provide great insight for orthopaedic surgeons who are performing ACLR and considering additional procedures to increase overall knee stability and decrease likeliness for re-rupture. The postoperative functional and clinical outcomes shown in patients undergoing ACLR+ compared with I-ACLR should be given proper consideration when evaluating available treatment courses.
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http://dx.doi.org/10.1016/j.arthro.2020.12.190DOI Listing
May 2021

A Systematic Review of Basic Science and Animal Studies on the Use of Doxycycline to Reduce the Risk of Posttraumatic Osteoarthritis After Anterior Cruciate Ligament Rupture/Transection.

Am J Sports Med 2020 Nov 20:363546520965971. Epub 2020 Nov 20.

Tulane University School of Medicine, Department of Orthopaedic Surgery, New Orleans, Louisiana, USA.

Background: Posttraumatic osteoarthritis (PTOA) after injury to the anterior cruciate ligament (ACL) is common.

Purpose: To perform a systematic review of basic science and animal studies to determine the effect of doxycycline treatment on the prevention of PTOA after ACL rupture/transection.

Study Design: Systematic review.

Methods: A systematic review was performed by searching the PubMed, Cochrane Library, and Embase databases to identify basic science and animal studies evaluating the effect of doxycycline treatment on the prevention of PTOA of the knee joint after ACL/cranial cruciate ligament (CCL) injury. The search phrase used was "doxycycline cruciate ligament." Inclusion criteria were basic science and animal studies evaluating the effect of oral administration of doxycycline in ACL/CCL-deficient animals with or without a control group.

Results: Seven studies met inclusion criteria and were included in this systematic review. Five studies were performed in dogs, 1 in rabbits, and 1 in mice. Overall, the effects of doxycycline treatment on the prevention of PTOA after ACL/CCL rupture/transection were mixed. In dogs, no significant effects of doxycycline treatment were found in terms of matrix metalloproteinase (MMP) activity, while a mouse study found significantly lower MMP-13 expression on the tibia in doxycycline-treated animals, suggesting that doxycycline may protect against proteoglycan loss and decrease osteoarthritis progression. Cartilage nitric oxide concentrations were lower in doxycycline-treated dogs compared with untreated dogs, suggesting decreased cartilage degradation among doxycycline-treated dogs, although there were no significant effects on cartilage stromelysin levels with no significant effects in terms of physiological remodeling or catabolism of cartilage. Bone formation or resorption was not found to be affected by doxycycline treatment. One study demonstrated a substantial beneficial effect of doxycycline on gross morphology of the medial femoral condyle. Doxycycline was found to conserve bone strain energy density and appeared to limit subchondral bone loss in 1 study.

Conclusion: Based on the limited available animal studies, doxycycline appears to demonstrate some benefits in the prevention of PTOA after ACL/CCL rupture/transection. Additional studies are needed to further characterize the potential benefits, side effects, dosage, and duration of this treatment after ACL injury in human patients.
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http://dx.doi.org/10.1177/0363546520965971DOI Listing
November 2020

Pain Scores and Activity Tolerance in the Early Postoperative Period After Hip Arthroscopy.

Orthop J Sports Med 2020 Oct 28;8(10):2325967120960689. Epub 2020 Oct 28.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Despite the rapid growth in the use of hip arthroscopy, standardized data on postoperative pain scores and activity level are lacking.

Purpose: To quantify narcotic consumption and use of the stationary bicycle in the early postoperative period after hip arthroscopy.

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

Methods: In this prospective case series, patients undergoing a primary hip arthroscopy procedure by a single surgeon were asked to fill out a daily survey for 9 days postoperatively. Patients were asked to report their pain level each day on a visual analog scale from 1 to 10, along with the amount of narcotic pain pills they used during those postoperative days (PODs). Narcotic usage was converted to a morphine-equivalent dosage (MED) for each patient. Patients were also instructed to cycle daily starting on the night of surgery for a minimum of 3 minutes twice per day and were asked to rate their pain as a percentage of their preoperative pain level and the number of minutes spent cycling on a stationary bicycle per day.

Results: A total of 212 patients were enrolled in this study. Pain levels (POD1, 5.5; POD4, 3.8; POD9, 2.9; < .0001) and the percentage of preoperative pain (POD1, 51.6%; POD4, 31.8%; POD9, 29.5%; < .01) significantly decreased over the study period. The amount of narcotics used per day (reported in MED) also significantly decreased (POD1, 27.3; POD4, 22.3; POD9, 8.5; < .0001). By POD4, 41% of patients had discontinued all narcotics, and by POD9, 65% of patients were completely off narcotic medication. Patients were able to significantly increase the number of minutes spent cycling each day (POD1, 7.6 minutes; POD4, 13.8 minutes; POD9, 19.0 minutes; < .0001). Patients who received a preoperative narcotic prescription for the affected hip were significantly more likely to require an additional postoperative narcotic prescription ( < .001).

Conclusion: Patients can expect a rapid decrease in narcotic consumption along with a high degree of activity tolerance in the early postoperative period after hip arthroscopy.
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http://dx.doi.org/10.1177/2325967120960689DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604997PMC
October 2020

Primary Autologous Chondrocyte Implantation of the Knee Versus Autologous Chondrocyte Implantation After Failed Marrow Stimulation: A Systematic Review.

Am J Sports Med 2020 Nov 6:363546520968284. Epub 2020 Nov 6.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Marrow stimulation (MST) surgery, which includes microfracture, subchondral drilling, and abrasion arthroplasty, and autologous chondrocyte implantation (ACI) are 2 surgical options to treat articular cartilage lesions in the knee joint. Recent studies have suggested worse outcomes when ACI is used after failed MST.

Purpose: To investigate the failure rates and clinical outcomes of primary knee ACI versus ACI after failed MST surgery (secondary ACI).

Study Design: Systematic review.

Methods: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases to identify studies evaluating clinical outcomes of patients undergoing primary versus secondary ACI of the knee joint. The search terms used were as follows: "knee" AND ("autologous chondrocyte implantation" OR "osteochondral allograft") AND (microfracture OR "marrow stimulation"). Patients undergoing primary ACI (group A) were compared with those undergoing secondary ACI (group B) based on treatment failure rates and patient-reported outcomes (PROs).

Results: Seven studies (2 level 2 studies, 5 level 3 studies) were identified and met inclusion criteria, including a total of 1335 patients (group A: n = 838; group B: n = 497). The average patient age in all studies was 34.2 years, and the average lesion size was 5.43 cm. Treatment failure occurred in 14.0% of patients in group A and 27.6% of patients in group B ( < .00001). Four studies reported PROs. One study found significantly better Subjective International Knee Documentation Committee scores ( = .011), visual analog scale (VAS) pain scores ( = .028), and VAS function scores ( = .005) in group A. Another study found significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) Pain scores ( = .034), KOOS Activities of Daily Living scores ( .024), VAS pain scores ( = .014), and VAS function scores ( = .032) in group A. Two studies found no significant difference in PROs between groups A and B ( < .05).

Conclusion: Patient-reported improvement can be expected in patients undergoing primary or secondary ACI of the knee joint. Patients undergoing secondary ACI have a significantly higher risk of treatment failure and may have worse subjective outcomes compared with patients undergoing primary ACI.
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http://dx.doi.org/10.1177/0363546520968284DOI Listing
November 2020

Traumatic Primary Anterior Glenohumeral Joint Dislocation in Sports: A Systematic Review of Operative versus Nonoperative Management.

Curr Sports Med Rep 2020 Nov;19(11):468-478

Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, CO.

Anterior shoulder (glenohumeral joint [GHJ]) dislocations are relatively common injuries in sports. Previous studies have evaluated clinical outcomes of operative and nonoperative management for primary traumatic anterior GHJ dislocations. The purpose of this study was to systematically review the literature in an effort to provide a thorough analysis of patients after undergoing closed reduction of a traumatic anterior GHJ dislocation, particularly among the athletic population. Two independent reviewers performed a comprehensive search of PubMed and the Cochrane Library through February 23, 2020. Unfortunately, the quantity and quality of published articles on this subject is very limited. In many studies, younger age (between 21 and 30 years) was associated with greater risk for recurrence of GHJ dislocations. Twelve studies (total N = 753) directly compared outcomes of operative versus nonoperative management. It seems that operative management significantly reduces recurrence rates with patients treated operatively among the young and active population. Operative management should be considered as a treatment option for young and athletic patients presenting with a first-time anterior GHJ dislocation.
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http://dx.doi.org/10.1249/JSR.0000000000000772DOI Listing
November 2020

Microfracture Versus Drilling of Articular Cartilage Defects: A Systematic Review of the Basic Science Evidence.

Orthop J Sports Med 2020 Aug 21;8(8):2325967120945313. Epub 2020 Aug 21.

Tulane University School of Medicine, Department of Orthopaedic Surgery, New Orleans, Louisiana, USA.

Background: Microfracture (MFx) is one of the most common techniques used for the treatment of articular cartilage defects, although recently there has been a trend toward the use of drilling rather than MFx for the treatment of these defects.

Purpose: To perform a systematic review of basic science studies to determine the effect of microfracture versus drilling for articular cartilage repair.

Study Design: Systematic review.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and EMBASE to identify basic science studies comparing outcomes of MFx versus drilling. The search phrase used was . Inclusion criteria were basic science studies that directly compared the effect of MFx versus drilling on subchondral bone, bone marrow stimulation, and cartilage regeneration.

Results: A total of 7 studies met the inclusion criteria and were included in this systematic review. Of these, 4 studies were performed in rabbits, 1 study in sheep, and 2 studies in humans. All of the included studies investigated cartilage repair in the knee. In the animal studies, microfracture produced fractured and compacted bone and led to increased osteocyte necrosis compared with drilling. Deep drilling (6 mm) was superior to both shallow drilling (2 mm) and MFx in terms of increased subchondral hematoma with greater access to marrow stroma, improved cartilage repair, and increased mineralized bone. However, the overall quality of cartilage repair tissue was poor regardless of marrow stimulation technique. In 2 studies that investigated repair tissue after MFx and/or drilling in human patients with osteoarthritis and cartilage defects, the investigators found that cartilage repair tissue did not achieve the quality of normal hyaline articular cartilage.

Conclusion: In the limited basic science studies that are available, deep drilling of cartilage defects in the knee resulted in improved biological features compared with MFx, including less damage to the subchondral bone and greater access to marrow stroma. Regardless of marrow stimulation technique, the overall quality of cartilage regeneration was poor and did not achieve the characteristics of native hyaline cartilage. Overall, there is a general lack of basic science literature comparing microfracture versus drilling for focal chondral defects.
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http://dx.doi.org/10.1177/2325967120945313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443991PMC
August 2020

Augmentation of Meniscal Repair With Platelet-Rich Plasma: A Systematic Review of Comparative Studies.

Orthop J Sports Med 2020 Jun 17;8(6):2325967120926145. Epub 2020 Jun 17.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA.

Background: The effect of platelet-rich plasma (PRP) augmentation for meniscal repair (MR) is unclear, as current evidence is limited to small, mostly nonrandomized studies.

Purpose: To systematically review the literature to evaluate the efficacy and safety of MR with PRP augmentation.

Study Design: Systematic review; Level of evidence, 3.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies (level of evidence 1-3) that compared the clinical efficacy of MR performed with versus without PRP. The search phrase used was Patients were assessed based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analog scale (VAS) for pain, the Lysholm score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the subjective International Knee Documentation Committee (IKDC) score, and treatment failure.

Results: We identified 6 studies (2 studies with level 1 evidence; 4 studies with level 3 evidence) that met inclusion criteria, for a total of 309 patients undergoing MR with PRP (mean age, 31.9 years) and 445 patients without PRP augmentation (mean age, 29.6 years). The mean follow-up was 32.8 months (range, 12-72 months). Overall, 17.0% of PRP patients experienced MR failure compared with 22.1% of non-PRP patients. No differences in VAS, Lysholm, or subjective IKDC scores were found between groups except in 1 study, in which postoperative subjective IKDC scores were significantly better in the PRP group ( < .01). Another study found significantly better postoperative WOMAC scores among PRP patients, and 2 studies found significantly better KOOS subscores among PRP patients.

Conclusion: There are a limited number of high-quality studies comparing outcomes and healing rates between patients undergoing MR with versus without PRP augmentation. Based on the available evidence, patients undergoing MR with PRP augmentation experience similar clinical outcomes at midterm follow-up when compared with conventional MR, and additional studies are needed to determine the efficacy of MR augmented with PRP.
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http://dx.doi.org/10.1177/2325967120926145DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301666PMC
June 2020

Diagnostic Accuracy of Physical Examination Tests in Core Muscle Injury.

Am J Sports Med 2020 07 8;48(8):1983-1988. Epub 2020 Jun 8.

St Joseph's University Medical Center, Paterson, New Jersey, USA.

Background: Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury.

Purpose: To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI.

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

Methods: A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient's chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard.

Results: A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%).

Conclusion: Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.
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http://dx.doi.org/10.1177/0363546520926029DOI Listing
July 2020

Adductor Canal Versus Femoral Nerve Block after Anterior Cruciate Ligament Reconstruction: A Systematic Review of Level I Randomized Controlled Trials Comparing Early Postoperative Pain, Opioid Requirements, and Quadriceps Strength.

Arthroscopy 2020 07 18;36(7):1973-1980. Epub 2020 Apr 18.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To systematically review the literature to compare the adductor canal block (ACB) with the femoral nerve block (FNB) following primary anterior cruciate ligament reconstruction (ACLR) in terms of early postoperative analgesic requirements and postoperative quadriceps strength.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase up to August 2019 to identify randomized controlled trials that compared postoperative pain and functional outcomes in patients following primary ACLR with ACB versus FNB. The search phrase used was: adductor canal femoral nerve anterior cruciate ligament. Patients were evaluated based on analgesic consumption and quadriceps muscle strength. Study quality and risk of bias were evaluated with the Modified Coleman Methodology Score and Cochrane risk-of-bias tool respectively.

Results: Five studies (all Level I evidence) were identified that met inclusion criteria, including 221 patients undergoing primary ACLR with ACB (mean age 26.8 years, 68.3% male) and 221 with FNB (mean age 28.2 years, 67.0% male). Statistical assessment for heterogeneity found for opioid consumption of ACB versus FNB groups was I = 97% (P < .0001). There were no significant differences in analgesic consumption within the first 24 hours following surgery between groups except in 1 study, in which patients receiving ACB required significantly greater analgesics (P < .001). Three studies using 3 different techniques to measure strength found patients receiving ACB to have significantly greater quadriceps muscle function within 24 hours of surgery when compared with patients receiving FNB (P < .05).

Conclusions: In patients undergoing ACLR, the ACB may provide similar analgesic requirements, and the included studies suggest a potential advantage in preserving muscle strength at short-term (24-48 hours) follow-up when compared with FNB. However, the differences in muscle strength assessments between studies do not allow for strong conclusions.

Level Of Evidence: I, systematic review and meta-analysis of Level I studies.
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http://dx.doi.org/10.1016/j.arthro.2020.03.040DOI Listing
July 2020

Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review.

J Shoulder Elbow Surg 2020 May;29(5):867-873

Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, USA.

Background: Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection.

Results: A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001).

Conclusions: C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients.
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http://dx.doi.org/10.1016/j.jse.2019.12.032DOI Listing
May 2020

Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Am J Sports Med 2021 01 17;49(1):249-260. Epub 2020 Apr 17.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA.

Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention.

Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA.

Study Design: Meta-analysis of level 1 studies.

Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was . Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP.

Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores ( < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients ( < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients ( < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP ( < .05).

Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.
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http://dx.doi.org/10.1177/0363546520909397DOI Listing
January 2021

Psychological Readiness to Return to Sport Following Anterior Cruciate Ligament Reconstruction.

JBJS Rev 2020 03;8(3):e0110

Department of Orthopaedic Surgery (S.M.B. and M.K.M.), Tulane University School of Medicine (M.L.A.), New Orleans, Louisiana.

Anterior cruciate ligament (ACL) tears are among the most common athletic injuries in the United States, and reconstruction is often necessary for athletes to be able to return to their pre-injury level of sport. Following ACL reconstruction, many athletes are not able to return to sport. A number of factors have been identified that could account for the return-to-sport discrepancy; however, psychological readiness can have an important influence on an athlete's ability to return to sport. Various interventions aimed at improving psychological factors have shown mixed results, although overall they seem promising. Sociodemographic factors (e.g., age, sex, and race) appear to have an influence on psychological readiness to return to sport; however, little research has been conducted on this topic.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00110DOI Listing
March 2020

Comparing Hamstring Autograft With Hybrid Graft for Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Arthroscopy 2020 04 7;36(4):1189-1201. Epub 2020 Jan 7.

University of Colorado School of Medicine, Department of Orthopaedics, Aurora, Colorado.

Purpose: To systematically review the literature in an effort to compare the demographics and clinical outcomes of patients undergoing anterior cruciate ligament reconstruction (ACLR) with a hamstring tendon autograft (HT) versus an irradiated or nonirradiated hybrid autograft-allograft.

Methods: A systematic review of the PubMed, Cochrane Library, and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All English-language literature that reported general demographics and compared the clinical outcomes of patients undergoing primary ACLR with autograft versus hybrid graft (HG) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Search terms used were "anterior cruciate ligament" and "hybrid graft." Patients were assessed based on graft failure, anteroposterior laxity, and patient-reported outcomes (Knee Injury and Osteoarthritis Outcome Score, visual analog scale, Subjective International Knee Documentation Committee score, Lysholm, and Tegner scores). Study quality was evaluated with the Modified Coleman Methodology Score and ROBINS-I risk of bias tool.

Results: Twelve studies (1 level II, 11 level III) met inclusion criteria (follow-up, 2.0-8.9 years), including 471 patients undergoing ACLR with an irradiated hybrid graft (IH), 89 patients with a nonirradiated hybrid graft, and 829 patients with HT. Graft diameter ranged from 7.5 to 10.0 mm and from 6.5 to 10.0 mm in HG and HT patients, respectively. Overall, graft failure ranged from 0% to 30.0% and from 0% to 28.3% in HG and HT patients, respectively (I = 35.9%; 95% confidence interval 0%-74.8%). Among HG patients, graft failure ranged from 0%-30.0% and from 2.4%-4.2% in IH and nonirradiated hybrid graft groups, respectively (I = 33.6%; 95% confidence interval, 0%-71.8%). Results for postoperative anteroposterior laxity and patient-reported outcomes were also inconsistent.

Conclusions: Patients undergoing ACLR with HT demonstrate inconsistent differences in clinical outcomes at midterm follow-up compared with IH patients.

Level Of Evidence: III, systematic review of level II and III studies.
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http://dx.doi.org/10.1016/j.arthro.2019.10.010DOI Listing
April 2020

Longitudinal versus transverse hip arthroscopy portal cosmesis: a case-control trial of simultaneous bilateral cases.

J Hip Preserv Surg 2019 Aug 9;6(3):265-270. Epub 2019 Sep 9.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

The direction and nature of incisions can impact the healing and appearance of a surgical scar. This can be attributed mainly due to skin tension and direction of force. The aim of this study was to identify differences in healing rates and scar esthetics between transverse and longitudinal portals used for hip arthroscopy. A total of 75 patients underwent bilateral hip arthroscopy for femoroacetabular impingement. All patients received a portal perpendicular to the long axis of the body on the left side (transverse portal) and parallel with the long axis of the body on the right side (longitudinal portal) for the standard anterolateral viewing portal. Postoperatively, patients were reviewed at 2 weeks, 6 weeks, 3 months and 6 months and the portal scars were assessed, photographed and measured. No patients were lost to follow-up. The transverse scars, although slightly longer, were found to be narrower at 6 weeks (3.8 mm versus 2.7 mm,  < 0.01), 3 months (4.3 mm versus 3.4 mm,  = 0.01) and 6 months postoperatively (6.1 mm versus 4.5 mm,  < 0.01). At 3 months (43 mm versus 35 mm,  = 0.029) and 6 months (49 mm versus 43 mm,  = 0.024), transverse incisions were noted to have significantly reduced total area compared with longitudinal incisions. There were no wound complications in either group. This study demonstrates that transverse portal positions for hip arthroscopy have an advantage over longitudinal portal positions in terms of total scar area and thickness up to 6 months postoperatively.
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http://dx.doi.org/10.1093/jhps/hnz036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874773PMC
August 2019

Primary Arthroscopic Repair of the Anterior Cruciate Ligament: A Systematic Review of Clinical Outcomes.

Arthroscopy 2019 12;35(12):3318-3327

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.

Purpose: To describe the clinical outcomes after primary arthroscopic anterior cruciate ligament (ACL) repair.

Methods: A systematic review of the PubMed, Embase, and Cochrane Library databases was performed according to the PRISMA guidelines. All English-language literature published from 2000 to 2018 that reported the clinical outcomes after primary arthroscopic repair (AR) of complete tear of the ACL (without augmentation) with a minimum 2-year follow-up was reviewed by 2 independent reviewers. Outcomes included repair failure, reoperation, postoperative knee stability, and patient-reported outcomes. Descriptive statistics are presented. Study quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Nonrandomized Studies (MINORS) score.

Results: Six studies (2 level III, 4 level IV) were included. The mean MCMS was 62.2. The mean MINORS score for noncomparative studies was 11.8, and for comparative studies, 18. Six studies reported outcomes of 89 patients who underwent AR of the ACL from 2007 to 2016 (age, 8 to 67 years; follow-up, 24 to 110 months). All 6 studies included exclusively proximal avulsion tears. Overall, 0% to 25.0% of patients experienced repair failure (I = 23.7%; 95% confidence interval, 0% to 67.6%), and 0% to 20.0% of patients had a subsequent reoperation (I = 12.1%; 95% confidence interval, 0% to 77.7%). Similar inconsistent results were shown for postoperative knee stability measures and patient-reported outcomes.

Conclusions: The literature on clinical outcomes of primary arthroscopic ACL repair is limited. The reported rates of repair failure and reoperation are highly inconsistent. Most studies report relatively high failure rates.

Level Of Evidence: IV, systematic review of level III and IV studies.
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http://dx.doi.org/10.1016/j.arthro.2019.06.034DOI Listing
December 2019

A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia.

Am J Sports Med 2020 07 14;48(9):2314-2323. Epub 2019 Nov 14.

Department of Orthopedics, School of Medicine, University of Colorado, Aurora, Colorado, USA.

Background: Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO.

Purpose: To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD.

Study Design: Narrative review.

Methods: A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase .

Results: The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented.

Conclusion: Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.
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http://dx.doi.org/10.1177/0363546519881411DOI Listing
July 2020

Use of the United States Medical Licensing Examination Step-1 Score as a Screening Tool for Orthopaedic Surgery Away Rotations.

J Bone Joint Surg Am 2019 Oct;101(20):e106

Department of Orthopaedic Surgery (M.A., S.B., and M.K.M.), Tulane University School of Medicine (C.H.), New Orleans, Louisiana.

Background: Orthopaedic surgery has become an increasingly competitive specialty for medical students applying to residency. Aside from residency interviews, away rotations are one of the only opportunities for residency programs to qualitatively evaluate an applicant. The purpose of this study was to determine if residency program directors (PDs) use a minimum United States Medical Licensing Examination (USMLE) Step-1 score as a screening tool for students applying for away rotations at their institution.

Methods: An anonymous 12-question survey about residency selection criteria and which criteria are used to select applicants for away rotations was distributed to PDs at U.S. allopathic orthopaedic surgery residency programs who are members of the Council of Orthopaedic Residency Directors (CORD). Questions included information on minimum USMLE Step-1 scores, the number of students who complete away rotations at the program each year, and how applicants are selected for rotations.

Results: Survey responses were received from 87 (58%) of 149 PDs. Seventy-one (82%) of these PDs reported that their program uses a minimum Step-1 score for residency applications, with the most common cutoff score being between 231 and 240 (as answered by 33 [46%] of 72 PDs). Twenty-seven (31%) of 87 PDs reported that if a student does not meet their residency minimum Step-1 score, he or she is not offered the opportunity to rotate at the program. Eleven (25%) of 44 PDs reported that they do not inform students when their score is below the program's minimum.

Conclusions: A substantial proportion of orthopaedic surgery residency PDs use the USMLE Step-1 score as a screening tool for students interested in doing away rotations at their programs. If a student's Step-1 score does not meet the program's minimum, the majority of programs still will allow the student to rotate at their institution. Students should take this information into account when selecting away rotations in order to maximize their chances of matching into an orthopaedic surgery program.
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http://dx.doi.org/10.2106/JBJS.19.00265DOI Listing
October 2019

"Doctor, What Happens After My Meniscectomy?"

J Bone Joint Surg Am 2019 Nov;101(21):1965-1973

The Steadman Clinic, Vail, Colorado.

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http://dx.doi.org/10.2106/JBJS.19.00082DOI Listing
November 2019

The "Outside-In" Lesion of Hip Impingement and the "Inside-Out" Lesion of Hip Dysplasia: Two Distinct Patterns of Acetabular Chondral Injury.

Am J Sports Med 2019 10 6;47(12):2978-2984. Epub 2019 Sep 6.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, Colorado, USA.

Background: Femoroacetabular impingement (FAI) and acetabular dysplasia lead to acetabular cartilage damage that commonly results in the chondral flaps seen during hip arthroscopy.

Purpose: To compare the acetabular chondral flap morphology seen during hip arthroscopy ("outside-in" vs "inside-out") with clinical and radiographic parameters underlying FAI and hip dysplasia.

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

Methods: Patients who underwent hip arthroscopy by the senior author between 2013 and 2017 with a finding of Outerbridge grade IV acetabular chondral flap were included. Each procedure was retrospectively reviewed on video and chondral flaps were categorized as inside-out or outside-in. An inside-out designation was made for flaps exhibiting an intact chondrolabral junction with a detached sleeve of chondrolabral tissue from the central acetabulum, and an outside-in designation was made for centrally anchored flaps exhibiting a break in the chondrolabral junction. Radiographic markers of hip impingement/dysplasia were noted for each patient during assignment into 1 of 2 radiographic groups: group 1, lateral center edge angle (LCEA) >20 with FAI, and group 2, LCEA ≤20 with or without cam FAI. Associations between chondral flap morphology and clinical diagnosis were tested using a chi-square test.

Results: Overall, 95 patients (103 hips) were included (group 1, 78 hips; group 2, 25 hips). Among hips in group 2, 24 had concurrent cam FAI. There was a significant relationship between chondral flap type and radiographic diagnosis ( < .001). Among group 1 hips, 78% exhibited outside-in type chondral flaps, 12% exhibited combined outside-in and inside-out flaps, and 10% exhibited inside-out flaps. Group 2 hips showed 72% inside-out type chondral flaps, 16% combined, and 12% outside-in. Hips exhibiting outside-in type flaps were significantly more likely to be in group 1 (positive predictive value [PPV], 91%; negative predictive value [NPV], 69%). Similarly, hips exhibiting inside-out type flaps were significantly more likely to be in group 2 (PPV, 56%; NPV, 95%). Altogether, 90% of group 1 hips exhibited an outside-in lesion and 88% of group 2 hips exhibited an inside-out lesion.

Conclusion: Acetabular chondral flap type visualized during hip arthroscopy correlates with radiographic markers of hip impingement and hip instability. Outside-in flaps are highly predictive of FAI, whereas inside-out flaps are highly predictive of acetabular dysplasia.
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http://dx.doi.org/10.1177/0363546519871065DOI Listing
October 2019

Evaluation of information available on the internet regarding reverse total shoulder arthroplasty.

Shoulder Elbow 2019 Jul 13;11(2 Suppl):29-34. Epub 2017 Jun 13.

University of Colorado School of Medicine, Department of Orthopedics, Aurora, CO, USA.

Background: Prior studies have analyzed the quality of information available on the Internet regarding common orthopaedic surgical procedures. The purpose of the present study was to evaluate the quality of information available for reverse total shoulder arthroplasty (rTSA).

Methods: Websites were identified using the search term 'reverse total shoulder arthroplasty' and the first 50 websites from three separate search engines (Google, Yahoo, and Bing) were selected for evaluation of authorship and quality of information using the DISCERN instrument (www.discern.org.uk). After disregarding duplicated or overlapping websites within and among search engines, 90 of the total 150 websites were evaluated. A one-way analysis of variance test was used to compare differences in DISCERN scores between three categories of authorship (academic, private, other).

Results: The majority of the websites evaluated were authored by academic (43%) and private institutions (36%). These were the most credible sources, providing overall better quality and reliability than other sources. DISCERN reliable ( = 0.017) and overall scores ( = 0.020) were significantly higher for academic institutions compared to other websites.

Conclusions: The information available on the Internet pertaining to reverse total shoulder arthroplasty is highly variable and provides moderate quality information about treatment choices with some limitations based on the DISCERN instrument.
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http://dx.doi.org/10.1177/1758573217713720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688157PMC
July 2019

The CU PAO: A Minimally Invasive, 2-Incision, Interlocking Periacetabular Osteotomy: Technique and Early Results.

J Bone Joint Surg Am 2019 Aug;101(16):1495-1504

Southern California Hip Institute, North Hollywood, California.

Background: The aims of this study were to describe a novel minimally invasive, interlocking periacetabular osteotomy (PAO) for the treatment of hip dysplasia that was developed at our institution and to report on its safety, complications, and early clinical outcomes.

Methods: This was a prospective longitudinal study of the first 200 consecutive hips that underwent the CU (University of Colorado) PAO, an interlocking osteotomy combining the benefits of the Birmingham interlocking pelvic osteotomy (BIPO) and the Ganz PAO. The technique provides direct visualization of the sciatic nerve during the ischial osteotomy and allows for immediate weight-bearing postoperatively. Demographic characteristics, intraoperative and perioperative parameters, and functional outcomes were documented. All patients underwent hip arthroscopy 3 to 10 days prior to the PAO to address concomitant intra-articular pathology. Mechanical deep venous thrombosis (DVT) prophylaxis was used for 2 weeks postoperatively. Results were stratified to compare the first 100 and the second 100 cases.

Results: A total of 161 patients (200 hips) underwent primary PAO; mean follow-up was 20 months (range, 3 to 33 months). The mean patient age at the time of surgery was 29.4 years (range, 13 to 55 years). Females accounted for 89% of the patients included in this study. The average length of stay was 4 days. A concomitant proximal femoral derotational osteotomy was performed in 19 hips. The lateral center-edge angle (LCEA) improved from a mean of 18.8° preoperatively to 31.5° postoperatively (p < 0.001). The mean Non-Arthritic Hip Score (NAHS) improved from 56.0 preoperatively to 89.4 at the 24-month follow-up (p < 0.0001). Paresthesias in the distribution of the lateral femoral cutaneous nerve were common (65% at 2 weeks postoperatively) but resolved in 85% of the patients within the first 6 months. There were no sciatic nerve-related complications, deep infections, or DVTs.

Conclusions: The CU PAO enables corrective realignment of symptomatic acetabular dysplasia with direct visualization of the sciatic nerve, early weight-bearing, cosmetic incisions, and good short-term outcomes.

Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.19.00005DOI Listing
August 2019