Economopoulos, Kostas J.

ABSTRACT Snapping proximal hamstring is an uncommon phenomenon, with few case reports documenting surgical treatment. The purpose of this study is to report snapping resolution, minimum 2-year post-operative patient-reported outcome (PRO), satisfaction scores and complications from patients who underwent surgical release of the conjoint tendon from the sacrotuberous ligament with reattachment to the ischial tuberosity. Prospectively collected data from two institutional databases were retrospectively reviewed for patients who underwent hamstring repair for partial- or full-thickness tears. Patients were included if they demonstrated ‘snapping proximal hamstrings’ on preoperative physical examination, including ultrasound confirmation, and repair subsequently performed. Patients were excluded if they had reconstruction of the proximal hamstring tendon or claimed worker’s compensation. With a total of 20 patients (15 females and 5 males), successful resolution of snapping was reported in 100% of the cohort. For patients with pre- and post-surgical lower-extremity functional scores (LEFS), post-surgical LEFS were significantly higher than pre-surgical LEFS (pre-surgical: 17.0 ± 4.0, post-surgical: 73.6 ± 3.3, P < 0.001). Average post-operative PROs were as follows: International Hip Outcome Tool-12, 92.3 ± 8.3; modified Harris Hip Score, 93.2 ± 7.8; Non-arthritic Hip Score, 92.5 ± 6.8; Hip Outcome Score-Sports Specific Subscale, 94.4 ± 6.7; LEFS, 73.9 ± 3.4; and median visual analog scale of 0 with an interquartile range of 0-1. Patient satisfaction was ‘very satisfied’ in 19 (95%) patients and ‘satisfied’ in 1 (5%) patient. At a minimum 2-year follow-up, patients who underwent surgical treatment for chronic snapping of the proximal hamstrings demonstrated complete resolution of painful posterior snapping, reported high PROs and satisfaction, and had no reported post-operative complications.

Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow‐up (6 weeks) and 1‐year (or most recent) follow‐up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow‐up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow‐up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow‐up ( P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow‐up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow‐up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case–control study.

Purpose To compare the 5‐year clinical and functional outcomes of the soft‐tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. Methods A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft‐tissue QT or double‐tendon HT autograft with at least 5 years of follow‐up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. Results A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2‐years’ postoperatively. At 5 years’ postoperatively, the QT group demonstrated significantly greater IKDC ( P = .018) and Lysholm ( P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years’ postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. Conclusions Although the QT autograft demonstrated increased patient‐reported outcome scores when compared with the HT at 5 years’ postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years’ postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid‐term follow‐up. Level of Evidence III, retrospective comparison study.

Background: Revision anterior cruciate ligament (ACL) reconstruction is being performed at an increasing rate. Previous literature has suggested that autograft ACL reconstruction is a better option than allograft in revision surgery, although the optimal autograft choice remains unknown. The all–soft tissue quadriceps tendon (ASTQT) autograft has been found to be an effective option for primary ACL reconstruction. However, few studies have evaluated ASTQT autograft in revision ACL reconstruction. Purpose/Hypothesis: The purpose of this study was to evaluate the ASTQT autograft in revision ACL reconstruction in athletes compared with bone–patellar tendon–bone (BTB) autograft. We hypothesized that the ASTQT autograft would lead to similar return to play, time to return to play, retear rate, and patient-reported outcomes compared with BTB autograft. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was performed on all athletes undergoing revision ACL reconstruction between August 2013 and December 2019 at a single institution. Patients participating in high school or college athletics undergoing first-time revision with either ASTQT or BTB autograft with ≥2 years of follow-up were included. Demographic variables, complications, return to sports, and outcome scores including the International Knee Documentation Committee (IKDC) and Lysholm were collected and compared between the 2 cohorts. Results: A total of 58 revision ACL reconstructions were included, with 32 in the ASTQT cohort and 26 in the BTB cohort. Return to sports at the same level occurred in 62.5% of the ASTQT group and 53.8% of the BTB group. The ASTQT group returned to sports significantly faster than the BTB group (8.9 vs 10.3 months; P = .020). There was no difference in retear rates (3.1%, ASTQT; 7.7%, BTB) or other complications between the 2 groups. The IKDC scores were significantly higher at the 6- and 12-month follow-up for the ASTQT autograft group compared with the BTB group (6 months: ASTQT, 71.3; BTB, 61.7, P = .001; 12 months: ASTQT, 82.7; BTB, 78.6; P = .021). Lysholm scores were also greater in the ASTQT cohort at these time points (6 months: ASTQT, 75.1; BTB, 63.6; P < .001; 12 months: ASTQT, 82.0; BTB, 74.5; P < .001). However, IKDC and Lysholm scores were similar between both groups at final follow-up (IKDC: ASTQT, 82.9; BTB, 81.7; P = .344; Lysholm: ASTQT, 83.0; BTB, 81.0; P = .104) There was no significant clinical difference in the absolute difference in scores or rate of achieving clinical thresholds between the 2 cohorts. Conclusion: ASTQT autograft for revision ACL in athletes has similar outcomes compared with BTB autograft. However, the ASTQT may possibly afford quicker return to sports and better early improvements in patient-reported outcomes that normalize by 1 year. The soft tissue quadriceps autograft should be considered a viable graft option in revision ACL reconstruction in athletes.

Purpose To determine structural knee injury rates and to identify risk factors and the number of games missed associated with these injuries in National Basketball Association (NBA) players from the 2015 to 2020 seasons. Methods Publicly available player records of active NBA players between the 2015 and 2020 seasons (excluding the shortened 2019 season) were reviewed to identify players with a knee injury associated with missing one or more games. Player demographics, anthropometric measurements, statistics, injury characteristics, and history of other lower‐extremity injuries were recorded. We sought factors associated with having a structural knee injury in bivariate analysis and multivariable logistic regression. Negative binomial regression was conducted to evaluate factors associated with the total number of games missed. Results Two hundred twelve players (of 1,011, 21%) sustained a structural knee injury. Accounting for potential confounders, having a structural knee injury was associated with more minutes per game played (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0‐1.2; P = .002), a greater usage rate (OR 1.1; 95% CI 1.0‐1.2; P = .004), and a lower player efficiency rating (OR 0.94; 95% CI 0.89‐1.0; P = .041). A greater number of missed games was associated with more minutes per game (regression coefficient [RC] 0.065; 0.028‐0.10; P = .001), fewer points per game (RC –0.078; –0.14 to –0.017; P = .013), and greater usage rate (RC 0.032; 0.0040‐0.060; P = .025). Conclusions Structural knee injuries occurred in 21% of players in this study with an overall rate of 5.42 injuries per 1,000 game exposures. Significant risk factors associated with injury were minutes per game, usage rate, and true shooting percentage. Player efficiency was significantly associated with a decreased risk of injury. Increased minutes per game and usage rate were significantly associated with a longer duration of game loss. Level of Evidence Level IV, case series.

Objectives: ACL reconstruction is one of the most common knee procedures performed annually in the United States. Athletes participating in cutting and pivoting sports are at high risk for ACL injury. In the general population, most graft choices including allograft, bone-patellar tendon-bone (BTB) autograft, hamstring autograft and quadriceps autograft have all been shown to excellent results following reconstruction. However, in the high-level cutting and pivoting athlete, the optimal graft for reconstruction remains controversial. Most consider BTB autograft to be the gold standard for such athletes. However, BTB autografts have drawbacks including anterior knee pain, difficulty kneeling and possible patellar fracture and patellar tendon rupture. Quadriceps autograft has increased in popularity since it offers a thicker graft with more favorable tensile properties compared to BTB and hamstring autografts. The quadriceps autograft has nearly twice the cross sectional area, higher load to failure and greater stiffness than the BTB autograft. Studies have shown equivalent outcomes when directly comparing BTB autograft vs. soft tissue quadriceps autograft in the general population. No studies have directly compared these two grafts in athletes participating in cutting and pivoting sports. We hypothesized that the quadriceps autograft would lead to similar patient outcomes, re-tear rates, return to sport and complications as BTB autografts in the cutting and pivoting athlete. Methods: A retrospective review of cutting and pivoting athletes with ACL tears treated with BTB autograft or soft tissue quadriceps autograft with at least 2 years of follow up was performed. Only athletes participating in cutting and pivoting sports were included in the study. Four sports were considered to be cutting and pivoting including soccer, football, lacrosse and basketball. The decision on which graft to use was based on the athlete’s choice after discussing the pros and cons of each graft. Exclusion criteria included those athletes with recurrent ACL tears, multiligamentous injuries, previous meniscal surgery and those requiring osteotomies. International Knee Documentation Committee Subjective Knee Evaluation (IKDC) and Lysholm knee scoring scale were used to evaluate patient reported outcomes. Through chart review, ability to return to sport, time to return to sport and complications were identified. The postoperative rehabilitation protocol for both grafts was identical. Results: There were 32 athletes in the soft tissue quadriceps autograft group and 36 in the BTB autograft group. The average age was 18.6 years for the quad group and 19.7 years for the BTB autograft group (p=0.63). Females made up 62.5% of the quadriceps group and 44.4% of the BTB group (p=0.14). The quad group was made up of 56.3% high school and 43.7% college athletes compared to 61.1% high school and 38.9% college athletes in the BTB autograft group (p=0.53). Soccer was the most common sport with 16 in the quad group and 14 in the BTB group. The rest of the quad group included 8 football players, 4 lacrosse and 4 basketball players. The remaining BTB group consisted of 12 football players, 8 lacrosse and 2 basketball players. Meniscal surgery was performed in combination with the ACL reconstruction in 17 (53.1%) of the quad group and 22 (61.1%) of the BTB autograft group (p=0.37). Average graft size was 9.5mm for the quad autograft group and 10 for the BTB autograft group. The 2-year IKDC score was 93.6 for the quad group and 95.1 for the BTB group (p=0.45). The 2 year Lysholm scores were 95.7 and 96.1 for the quad and BTB groups respectively. Return to play at the same or higher level was 90.6% in the quad group and 86.1% in the BTB autograft group (p=0.82). Time to return was also similar between the groups with 7.1 months for the quad group and 7.6 months for the BTB autograft group. There was 1 re-tear which required revision in the BTB group and no re-tears in the quad group (p=0.34). Arthrofibrosis requiring MUA and lysis of adhesions occurred in 2 quad autografts and 4 BTB autografts (p=0.49). One contralateral ACL rupture occurred in the quad autograft group and 4 in the BTB autograft group (p=0.21). Conclusions: The optimal ACL graft in high level athletes participating in cutting and pivoting sports remains in question. In our comparison of quadriceps autograft compared to BTB autograft in this athletic population, no difference in patient reported outcomes, return to sport or re-tear rates was identified. Based on these findings, quadriceps autograft is as effective as BTB autografts in cutting and pivoting athletes and should be part of the graft choice discussion with the athlete.

Background: Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients. Purpose: To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic. Study Design: Descriptive epidemiology study. Level of evidence, 2. Methods: The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data. Results: Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantly more likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users ( P < .001) for management of their pain. Conclusion: In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment.

Background: In patients with femoroacetabular impingement, preoperative diagnostic injections are commonly used to establish a diagnosis of intra-articular pathology. In some cases, intra-articular steroid injections are also used for therapeutic purposes. Purpose/Hypothesis: The purpose of this study was to determine if a positive response to intra-articular steroid injection was predictive of superior outcomes after hip arthroscopy to determine if the response to intra-articular steroid injection was predictive of outcomes after hip arthroscopy. It was hypothesized that a positive response to a preoperative hip injection would be predictive of improved short- to midterm outcomes after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective study of 208 patients who elected to have ultrasound-guided intra-articular steroid injection before they underwent hip arthroscopy between January 2016 and December 2016. Patients were divided into 2 groups: those who showed improvement in pain after the injection (steroid responder group) and those who showed no response (nonresponder group). The authors compared the preoperative and 2-year postoperative patient-reported outcomes (modified Harris Hip Score [mHHS] and Hip Outcome Score–Activities of Daily Living [HOS-ADL]) and radiographic findings between groups. Clinical endpoints, including rates of revision and conversion to total hip arthroplasty, were also reviewed. Results: There were 88 patients in the nonresponder group and 120 patients in the responder group, with no significant between-group differences in preoperative descriptive variables. The responder group had significantly higher 2-year mHHS and HOS-ADL, pre- to postoperative change in mHHS and HOS-ADL, percentage of patients achieving the patient acceptable symptomatic state (PASS) on the mHHS, and percentage of patients reaching the minimum clinically important difference and the PASS on the HOS-ADL. There was no difference in Tönnis grade, acetabular labrum articular disruption grade, revision rate, or conversion to total hip arthroplasty between the 2 groups. Conclusion: The response to preoperative intra-articular injection did aid in predicting 2-year patient-reported outcomes of hip arthroscopy for femoroacetabular impingement. Overall, the result of a preoperative intra-articular injection can be a helpful clinical tool for surgical decision-making and counseling patients on expected outcomes after hip arthroscopy.

Background: Recent literature has suggested that capsular closure following hip arthroscopy restores native hip-joint kinematics and may lead to better patient-reported outcomes, especially in high-level athletes 1–4 . Description: Capsular closure of the hip occurs following standard hip arthroscopy, which typically includes labral repair and osteoplasty of the femoral neck and/or acetabulum accessed through an interportal capsulotomy. Viewing through an anterolateral portal with use of a 70° scope, a suture-passing device loaded with a #2 FiberWire (Arthrex) is passed down into the mid-anterior portal. The suture is then passed through the anterior aspect of the proximal leaflet of the capsulotomy. The suture-passing device is then passed through the distal leaflet, and the previously passed suture is grasped and brought out of the cannula. The capsular bites are typically made 1 cm from the edge of the capsule. This process is repeated 1.5 cm posteriorly to the initially placed suture. Typical capsular closure takes 2 to 3 sutures for complete closure. Once the sutures are passed, they are tied with use of half-hitches and excess suture is cut. Alternatives: Alternatives include capsular plication, which is more frequently performed in the setting of capsular laxity preoperatively or connective-tissue disorders 5,6 . Additionally, there is evidence suggesting that leaving the capsulotomy unrepaired may lead to similar results in select populations 7 . Rationale: This procedure is performed largely secondary to the restoration of native anatomy and kinematics of the hip joint 3,8 . Arthroscopy of the hip requires a capsulotomy in order to access the joint, unlike other, more superficial joints such as the shoulder. Capsular closure is often technically challenging and adds length to the procedure. However, recent literature has shown improved patient-reported outcomes with routine capsular closure specifically among high-level athletes 9,10 . Expected Outcomes: Routine capsular closure has been associated with good mid-term patient-reported outcomes 10 . Patients who undergo hip arthroscopy and routine capsular closure can expect to meet the minimal clinically important difference and the patient acceptable symptomatic state for the modified Harris hip score and the Hip Outcome Score Activities of Daily Living component. Patients who participate in high-level sports activities may experience a quicker return to play and more normal kinematics with routine capsular closure. Important Tips: Clear off the capsule immediately following the capsulotomy. Utilize an over-the-top view to better visualize the capsule. Place the sutures from anterior to posterior.