Okoroha, Kelechi R.

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain in female athletes. There are limited data on midterm outcomes for female athletes undergoing hip arthroscopic surgery. Purpose: To evaluate return-to-sport rates and clinical outcomes in female athletes with FAI after primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of a single institution’s database was performed to identify female athletes who underwent primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty from July 2011 to October 2019 with a minimum 5-year follow-up. Preoperative radiographs were evaluated for the lateral center-edge angle, Tonnis angle, Tonnis grade, and alpha angle. Patient-reported outcome measure (PROM) scores, including those for the modified Harris Hip Score, Hip Outcome Score, Tegner Activity Scale, and visual analog scale for pain, as well as patient satisfaction with surgery were analyzed postoperatively. Results: A total of 63 hips (27 left, 36 right) in 56 female patients (mean age, 21.6 ± 8.0 years; mean body mass index, 24.7 ± 4.8 kg/m 2 ) were included and followed for a mean of 8.4 ± 2.1 years (range, 5.0-13.2 years). Preoperatively, patients participated in basketball (n = 18), dance (n = 21), hockey (n = 8), and soccer (n = 12). Of the 56 patients, 41 attempted to return to sport. There were 28 (68%) female athletes who successfully returned to their preoperative sport. Of the total cohort, 21 (38%) patients cited non–hip-related factors for discontinuing their sport. All postoperative PROM scores improved significantly compared with preoperatively ( P ≤ .002) for patients with available preoperative data. Those who returned to sport had significantly improved Hip Outcome Score values compared with those who did not return to sport ( P ≤ .010). Conclusion: Female athletes who underwent primary hip arthroscopic surgery for FAI had significant improvements in PROM scores and moderate return-to-sport rates at a minimum 5-year follow-up. Most athletes discontinued sports because of non–hip-related factors, although hip-related issues were also cited. Our analysis highlights the need for thorough perioperative counseling and establishing appropriate patient expectations for female athletes before hip arthroscopic surgery.

Background: Patellofemoral instability (PFI) is a condition that leads to recurrent dislocation events and is typically secondary to extensor mechanism malalignment and rotational deformities. To correct malalignment, a tibial tubercle osteotomy (TTO) can be performed; however, an understanding of the associated complications, recurrence rates, and potential for reoperation is necessary. Purpose: To systematically review the literature to determine the incidence of postoperative complications, rate of recurrent instability, and all-cause reoperation rate after TTO for PFI. Study Design: Systematic review; Level of evidence 4. Methods: The Cochrane Database of Systematic Reviews, PubMed, Embase, MEDLINE, and CINAHL were queried for studies that reported complications after TTO. No date limits were applied. A total of 1050 studies were identified. Complications were categorized into “minor” and “major” groups using a modified Clavien-Dindo Classification. A meta-analysis was conducted to examine complication rates, recurrent instability, and all-cause reoperation, utilizing a DerSimonian and Laird random-effects model. A meta-analysis for recurrent instability was subgrouped according to follow-up periods of ≤2 years and >2 years. Results: A total of 38 studies were included, comprising 1546 patients, representing 1733 knees. The study dates ranged from 1989 to 2024, and the level of evidence ranged from 2 to 4. The weighted mean age at surgery was 24.1 years (range, 20-54 years), and 67% of patients were women. The weighted mean follow-up of all studies was 4.2 years. Overall, 197 minor complications, 39 major complications, 90 recurrent instability events, and 275 reoperations were identified. The minor complication rate was 9% (range, 0%-65% [95% CI, 6%-13%]). The major complication rate was 3% (range, 0%-10% [95% CI, 3%-4%]). Seven studies had a ≤2-year follow-up, and the remaining 31 studies had a >2-year follow-up. The recurrent instability rate was 3% in studies with ≤2 years of follow-ups (range, 0%-26% [95% CI, 1%-13%]). In studies with >2 years of follow-up, the recurrent instability rate was 8% (range, 0%-31% [95% CI, 6%-12%]). The all-cause reoperation rate was 16% (range, 0%-54% [95% CI, 11%-21%]). Conclusion: This systematic review and meta-analysis identified the incidence of complications (17%), the rate of recurrent instability (3%-8%), and the all-cause reoperation rate (16%) after TTO. TTO, performed alone or in combination with medial patellofemoral ligament reconstruction for the treatment of PFI, reliably improved clinical outcome scores in the setting of variable complication rates. Interestingly, rates of recurrent instability increased over time, and most reoperations were undertaken for hardware removal rather than revision patellar stabilization surgery.

Background: Treatment decisions in patients with anterior cruciate ligament (ACL) injuries are influenced by multiple factors, such as the desire to return to sports or symptomatic instability. Identifying the differential treatment effect of ACL reconstruction (ACLR) compared with nonoperative management on a patient-specific level can inform surgical decision-making. Hypothesis: Unsupervised machine learning can identify distinct patient subgroups based on outcome achievement after ACL injury, and ACLR will exert a protective effect on the development of posttraumatic osteoarthritis (PTOA) over nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: A longitudinal populational registry identified patients with ACL injuries from 1990 to 2016 with a minimum 7.5-year follow-up. An unsupervised random forest algorithm was utilized to develop and validate patient subgroups. Treatment effects of ACLR on outcomes were analyzed using a machine learning causal inference estimator. Patient subgroup membership was incorporated into a multivariable logistic regression to identify factors predictive of optimal outcomes. Results: A total of 923 patients (785 primary ACLR, 138 nonoperative) were included. The random forest algorithm arrived at an optimal partition of 2 subgroups, with 653 patients in the optimal outcome subgroup (368 male [56.4%]; mean age, 26.0 ± 10.2 years; mean body mass index [BMI], 26.5 ± 4.30) and 270 patients in the suboptimal outcome subgroup (152 male [56.3%]; mean age, 35.0 ± 10.1 years; mean BMI, 30.5 ± 5.54). The latter group demonstrated significantly increased rates of secondary meniscal injury, development of symptomatic PTOA, and progression to total knee arthroplasty (TKA) at the final follow-up (all P < .01). In the optimal outcome subgroup, ACLR had significantly protective treatment effects on the risk of secondary meniscal injury (average treatment effect [ATE], 61%), contralateral ACL injury (ATE, 8%), symptomatic PTOA (ATE, 16%), and progression to TKA (ATE, 6%) (all P < .01). Conversely, in the suboptimal outcome subgroup, ACLR only protected against symptomatic PTOA (ATE, 11%) and progression to TKA (ATE, 8%) (both P < .01). Conclusion: Two clinically meaningful subgroups were identified from retrospectively collected data and found to experience differential treatment responses after ACL injuries. ACLR decreased the rate of development of PTOA and TKA in both subgroups but was not as effective in preventing secondary meniscal injuries or contralateral ACL injuries in patients who were older, heavier, or had concomitant medial meniscus injuries.

Abstract Anterior cruciate ligament reconstruction (ACLR) using bone–patellar tendon–bone autograft remains one of the most common autografts used, and there is significant evidence to support its title as the “gold standard.” There are nuances and technical challenges associated with every step of an ACLR, which always leave room for improvement. The purpose of this Technical Note is to provide reproducible, technical pearls where errors are commonly encountered during ACLR. In this article, we detail 10 technical pearls that surgeons should consider to enhance operative workflow and optimize success during ACLR with a bone–patellar tendon–bone autograft. Technique Video video See video under supplementary data.

Abstract Arthrofibrosis of the knee is a difficult‐to‐manage complication after meniscoligamentous knee injuries, traumatic injuries with articular extension, and surgeries to treat these conditions. Treatment protocols for the management of postoperative arthrofibrosis exhaust nonoperative therapies before proceeding to the operating room for lysis of adhesions (LOA). Although LOA restores range of motion in most cases, a recurrence of arthrofibrosis is possible when postoperative therapy protocols are not strictly followed. Limited treatment options exist in the setting of recalcitrant arthrofibrosis. Revision arthroscopic LOA may be performed in this scenario. This revision procedure places neurovascular anatomy in the posterior compartment at risk. Performing a posterior capsule release in the arthroscopic management of recalcitrant arthrofibrosis is challenging but important to optimize recovery of range of motion. This Technical Note and accompanying video present a stepwise approach to LOA that demonstrates a safe method for performing an arthroscopic posterior capsule release in these challenging cases. Technique Video video See video under supplementary data.

» Femoroacetabular impingement (FAI) is the premature contact of the femoral head-neck junction with the superior acetabular rim during hip range of motion, which may further damage intra-articular soft tissue structures and lead to the accelerated development of osteoarthritis. » FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings, and is a common cause of hip pain in young patients that have a significant impact on patient hip-related function and quality of life. » The treatment of FAI syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy. For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term » In this article, we examine the available literature regarding the nonoperative treatment of FAI and provide insight into the effectiveness of current treatment modalities.

Background: While patients may report painful or prominent hardware after tibial tubercle osteotomy (TTO), little is known about the frequency, associated factors, and outcomes after removal of symptomatic hardware. Purpose/Hypothesis: The purpose was to investigate the incidence of hardware removal after TTO due to pain or complications, factors associated with hardware removal, and postoperative outcomes after removal. It was hypothesized that clinical outcomes would be similar between patients who underwent TTO without hardware removal and those who underwent TTOs and subsequently hardware removal. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective analysis was performed on patients who underwent TTO at a single institution from 2000 to 2023. Age at the time of the index surgery, sex, race, body mass index, number and size of screws, tibial tubercle–trochlear groove distance, and reason for hardware removal were collected retrospectively. Knee radiographs were reviewed for measurement of soft tissue–hardware distance. Patients were contacted via email to capture final patient-reported outcome measures (PROMs). A univariate logistic regression model was used to determine factors associated with hardware removal. Results: A total of 152 patients representing 171 knees were included. Of the overall cohort, 38 knees (22.2%) in 32 patients underwent TTO with subsequent hardware removal. The most common reason for hardware removal was anterior knee pain (79%). Compared with patients aged 11 to 20 years, patients aged 21 to 30 years demonstrated higher odds of undergoing hardware removal (OR, 3.67; 95% CI, 1.51-9.44; P = .009). Compared with a soft tissue–hardware distance of 0 to 4.9 mm, a distance of 10.0 to 14.9 mm demonstrated lower odds of hardware removal (OR, 0.24; 95% CI, 0.07-0.84; P = .027). Visual analog scale scores (0-10 scale) improved by a mean of 3.6 points after hardware removal ( P = .003). In patients undergoing hardware removal for pain, no difference in final PROMs was found compared with patients who underwent TTO without hardware removal. Conclusion: Hardware removal in patients undergoing TTO was mainly attributed to hardware-related pain/irritation. On average, pain scores improved after hardware removal. There was no difference in final PROMs between patients who had their hardware removed due to pain (eg, without any clinically relevant concomitant pathology) and patients who did not require hardware removal. Size and number of screws were not associated with a subsequent hardware removal procedure. The thickness of the soft tissue envelope overlying implanted hardware was inconsistently associated with lower odds of hardware removal.

Background: Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopaedic procedures and one of the most well studied. Despite extensive research dedicated to ACLR, there is limited understanding of how chronic inflammatory systemic diseases (CIDs) such as rheumatoid arthritis and systemic lupus erythematosus affect outcomes. Purpose: To compare the outcomes of ACLR in cohorts of patients with and without CID. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective query of a regional data set was conducted for all patients who underwent ACLR from 1990 to 2021 for traumatic ACL rupture. All patients with CID were identified and propensity matched to non-CID controls. Baseline characteristics and clinical outcomes were identified through retrospective chart review, and patients were contacted for subjective outcomes. Results: A total of 30 patients with ACLR and a diagnosis of CID were identified. These patients were propensity matched to 120 non-CID controls. Baseline demographic and surgical characteristics demonstrated no statistical differences. Follow-up duration was similar between the CID and non-CID groups (mean, 14.6 vs 14.2 years; P = .868). The CID cohort had a higher arthrofibrosis rate (16.7% vs 4.3%; P = .031), higher osteoarthritis rate (33.3% vs 16.7%; P = .041), higher total knee arthroplasty (TKA) rate (16.7% vs 3.3%; P = .016), and earlier time to TKA (14.7 vs 23.5 years; P = .032). Knee range of motion, infection rate, retear rate, time to retear, and time to osteoarthritis were not statistically different between the cohorts. The CID cohort had higher visual analog scale pain scores (mean, 2.00 vs 1.20; P = .043) but slightly higher satisfaction (mean, 3.92 vs 3.39; P = .043). There were no differences in preinjury Tegner, postoperative Tegner, change in Tegner, or IKDC score. In a univariate Cox regression model, the CID cohort had a retear hazard ratio of 1.43 (95% CI, 0.46-4.51; P = .537). Kaplan-Meier survival revealed no significant differences in retear-free survival between the CID and non-CID cohorts at 25 years (85.7% vs 87.3%; P = .53). The CID cohort had a TKA hazard ratio of 3.94 (95% CI, 1.05-14.8; P = .042). Kaplan-Meier survival demonstrated significantly decreased TKA-free survival at 25 years in the CID cohort (64.9% vs 91.2%; P = .029). Conclusion: CID increases the incidence of arthrofibrosis, osteoarthritis, and TKA in those undergoing ACLR. Patients with CID also undergo TKA significantly sooner than non-CID counterparts. Notably, the majority of patient-reported outcome measures are no worse in patients who have a CID diagnosis. Thus, ACLR constructs themselves may not necessarily fare worse in patients with CID. Nonetheless, these patients need to be cautiously counseled on the clinical outlook after their ACLR.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. Purpose: To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. Results: A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Conclusion: Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.

Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has experienced significant growth in the last 30 years; nevertheless, reduced utilization of orthopaedic procedures has been observed among the underrepresented population. Purpose/Hypothesis: The purpose of this study was to examine racial differences in case incidence rates, outcomes, and complications in patients undergoing hip arthroscopy. It was hypothesized that racial and ethnic minority patients would undergo hip arthroscopy at a decreased rate compared with their White counterparts but that there would be no differences in clinical outcomes. Study Design: Cross-sectional study. Methods: The State Ambulatory Surgery and Services Database and the State Emergency Department Database of New York were queried for patients undergoing hip arthroscopy between 2011 and 2017. Patients were stratified into White and racial and ethnic minority races, and intergroup comparisons were performed for utilization over time, total charges billed per encounter, 90-day emergency department (ED) visits, and revision hip arthroscopy. Temporal trends in the utilization of hip arthroscopy were identified, and racial differences in secondary outcomes were analyzed with a semiparametric method known as targeted maximum likelihood estimation (TMLE) backed by a library of machine learning algorithms. Results: A total of 9745 patients underwent hip arthroscopy during the study period, with 1081 patients of minority race (11.1%). White patients underwent hip arthroscopy at 5.68 (95% CI, 4.98-6.48) times the incidence rate of racial and ethnic minority patients; these incidence rates grew annually at a ratio of 1.11 in White patients compared with 1.03 in racial and ethnic minority patients ( P < .001). Based on the TMLE, racial and ethnic minority patients were significantly more likely to incur higher costs ( P < .001) and visit the ED within 90 days ( P = .049) but had negligible differences in reoperation rates at a 2-year follow-up ( P = .53). Subgroup analysis identified that higher likelihood for 90-day ED admissions among racial and ethnic minority patients compared with White patients was associated with Medicare insurance ( P = .002), median income in the lowest quartile ( P = .012), and residence in low-income neighborhoods ( P = .006). Conclusion: Irrespective of insurance status, racial and ethnic minority patients undergo hip arthroscopy at a lower incidence and incur higher costs per surgical encounter.