McQuivey, Kade S.

Background: Young female patients undergoing hip arthroscopy have an increased prevalence of baseline capsular laxity of the hip joint. This laxity, along with superimposed postoperative iatrogenic capsular deficiency secondary to an unrepaired capsule, could potentially lead to worse outcomes after arthroscopic treatment of femoroacetabular impingement (FAI) in this population. Purpose: To compare outcomes and revision rates for young female patients undergoing hip arthroscopy for FAI and labral tear with capsular closure (CC group) versus capsular nonclosure (CNC group). Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data of patients who underwent index hip arthroscopy using interportal capsulotomies by a single surgeon between January 2014 and February 2020 was performed. Female patients aged 12 to 21 years who underwent hip arthroscopy with cam or pincer osteoplasty and labral repair with a 2-year minimum follow-up were included. The Beighton score was assessed. The Hip Outcome Score–Activities of Daily Living (HOS-ADL) and Hip Outcome Score–Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at 3 months, 1 year, and 2 years postoperatively. Data were analyzed using the Mann-Whitney U test and Fisher exact test. Results: A total of 23 hips (20 patients) were included in the CC group and 17 hips (16 patients) were included in the CNC group. The groups were not different regarding characteristics and preoperative patient-reported outcome scores. At all follow-up intervals postoperatively, the CC group scored significantly higher HOS-ADL and HOS-SSS. Fifteen of 17 (88.2%) patients in the CC group returned to sports versus 8 of 14 (57.1%) in the CNC group ( P = .03). Four (17.4%) hips in the CC group had revision surgery compared with 9 (52.9%) hips in the CNC group (odds ratio, 5.1; 95% CI, 1.2-22.5; P = .02). Conclusion: Young female patients treated with CC while undergoing arthroscopic FAI had improved outcomes, fewer revisions, and a higher return-to-sports rate than those treated without CC.

Purpose To compare the surgical outcomes of anterior cruciate ligament (ACL) reconstruction using hamstring autograft (HA) plus lateral extra‐articular tenodesis (LET), isolated all‐soft tissue quadriceps autograft (QA), and isolated HA. Methods A retrospective review was performed comparing high‐risk patients undergoing ACL reconstruction with isolated HA, isolated QA, or HA + LET from August 2013 to January 2023. High‐risk patients, as determined by high‐grade pivot shift or generalized ligament laxity, with at least a 2‐year follow‐up, were included. Lysholm and International Knee Documentation Committee scores were compared at 3, 6, 12, and 24 months postoperatively. Retear rate, postoperative pivot‐shift grade, return to sport, and complications were recorded. Results In total, 159 patients (56 HA, 47 HA + LET, and 56 QA) were included. At 6 months postoperatively, the HA International Knee Documentation Committee score was significantly lower than that of the HA + LET and QA groups ( P < .0001). Similarly, the Lysholm score was significantly lower in the HA cohort at 6 months, 1 year, and 2 years postoperatively ( P < .0001‐.02). There was no difference in the rate of achieving the minimally important clinical difference between the cohorts for either of these outcome scores. The retear rate was significantly higher in the HA group (17.9%) compared to the HA + LET (4.3%) and QA (1.8%) cohorts ( P = .01). The rate of postoperative pivot shift of grade 2 or more was also higher in the isolated HA group ( P = .04). Conclusions The use of an all‐soft tissue QA or HA + LET for ACL reconstruction resulted in a lower retear rate and postoperative pivot‐shift grade compared to an isolated HA graft in high‐risk patients at 2 years postoperatively. There was no difference in the rate of achieving the minimal clinically important difference between the cohorts. The QA and HA + LET reconstruction options may improve stability and decrease the failure rate compared with HA reconstruction alone. Level of Evidence Level III, retrospective cohort study.

Purpose To assess surgeon reimbursement for common arthroscopic procedures, including arthroscopic meniscal debridement and arthroscopic rotator cuff repair, in patients with differing risk profiles within the Medicare population. Methods A publicly available Medicare database was used to identify all cases of arthroscopic meniscal debridement and arthroscopic rotator cuff repair procedures billed to Medicare from 2013 to 2020. The surgeon reimbursement from Medicare was collected and adjusted for inflation. All procedure episodes were split into 2 cohorts; those with a hierarchical condition category (HCC) risk score ≥1.5, and those with patient HCC risk scores <1.5. Reimbursement rates were compared between groups. Results From 2013 to 2020, a total of 624,077 meniscal debridement procedures and 567,794 arthroscopic rotator cuff repairs were billed to Medicare Part B. During this time, the mean adjusted surgeon reimbursement for arthroscopic rotator cuff repair decreased by 9.2% from 2013 to 2020. During the same time period, the adjusted mean surgeon reimbursement for arthroscopic both compartment meniscal debridement and single compartment meniscal debridement decreased by 7.9% and 9.9%, respectively. Throughout the study period, the mean HCC risk score increased from 1.19 in 2013 to 1.31 in 2020 ( P < .001). Across all years in the study, the sicker cohort had a significantly greater rate of all comorbidities and a greater mean body mass index ( P < .001 for all variables). The mean reimbursement across this cohort was lower for both rotator cuff repair ( P = .037) and meniscal debridement procedures ( P < .001) compared with the healthier cohort. Conclusions This study demonstrates that from 2013 to 2020, inflation‐adjusted surgeon reimbursement for arthroscopic rotator cuff repair and meniscal debridement decreased while patient complexity increased. Further, mean surgeon reimbursement was lower among patients with more complexity in comparison with their healthier counterparts for such procedures. Level of Evidence Level III, retrospective cohort study.

Purpose To use Google trends to explore differences in public interest among types of anterior cruciate ligament (ACL) autografts, specifically quadriceps tendon, patellar tendon, and hamstring tendon autografts, between 2008 and 2019. Methods Data were obtained by querying Google Trends for key terms and phrases for online search data ranging from January 2008 to December 2019. Relative search volumes were created based on searches related to ACL reconstruction with comparative analysis generated for search terms related to quadriceps ACL, patellar tendon ACL, and hamstring ACL autografts. Statistical analysis included linear regression analysis, comparison of quarterly search volume trends over time, and comparison of cumulative annual search volumes for 2008 versus 2019. Results Linear models for respective search terms were statistically significant for the quadriceps ( P < .001) and patellar ( P = .007) tendon autograft groups but not the hamstring group ( P = .129). The quadriceps autograft group demonstrated a 12‐year search volume trend change of 0.56, which was significantly greater than the hamstring (0.07; P < .001) and patellar tendon (0.168; P < .001) groups. There was no significant difference in the trend change between hamstring and patellar tendon groups ( P = .20). Percent change in cumulative relative annual search volumes between 2008 and 2019 was 112% for the quadriceps tendon group, 12.9% for the hamstring group, and 18.6% for the patellar tendon group. Conclusions This study indicates a consistently increasing public interest in quadriceps tendon autograft for ACL reconstruction. The quadriceps autograft group demonstrated a significantly greater 12‐year online search volume, greater linear correlation, and larger percent change between 2008 and 2019 compared with patellar tendon or hamstring autograft groups. Clinical Relevance Awareness of patient perceptions has value in informing shared decision‐making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

Purpose To characterize the prevalence and incidence of in‐game hand and wrist injuries in the National Basketball Association (NBA), to determine the factors associated with an equal or greater player efficiency rating (PER), and to determine the factors associated with an equal or greater true shooting percentage (TS%) 2 years after a hand and wrist injury using a large‐scale national database of NBA players. Methods Injury data from seasons 2015‐2016 to 2020‐2021, with exclusion of the 2019‐2020 because of abbreviated play due to the coronavirus disease 2019, were extracted from a public online database, Pro Sports Transactions. Injury characteristics and NBA player demographic information were assessed using descriptive statistics. Poisson logistic regression analyses were performed to identify risk factors associated with equal or increased PER and TS% 2years after injury. Results There were 214 reported hand and wrist injuries, and of these injuries, 173 (81%) were classified as structural. The most common injury types were a strain or sprain (0.63 per 1,000 game exposures), followed by fractures (0.37 per 1,000 game exposures). Older age (relative risk [RR] 0.89; 95% confidence interval [CI] 0.84‐0.95) and more years played in the NBA were modestly associated with relative risk of having a decreased PER at 2 years after injury. Increased weight (RR 1.02; 95% CI 1‐1.05) and increased body mass index (RR 1.14; 95% CI 1.01‐1.29) were also modestly associated with having a decreased PER and TS%, respectively at 2 years after injury. Conclusions Strains/sprains and fractures are the most common hand and wrist injuries sustained by NBA players. Regardless of dominant or nondominant hand and wrist injuries, NBA players are likely to return to baseline overall player efficiency based on PER and TS% within 2 years of injury. Clinical Relevance Our study characterizes hand and wrist injuries of NBA players and provides an understanding for these injuries on player performance at 2 years.

Objectives: Despite attaining satisfactory knee function following anterior cruciate ligament (ACL) reconstruction, many athletes are unable to return to their pre-injury level of play. ACL tears are known to take a significant psychological toll on the injured athlete and an athlete’s “psychological readiness” may play a large role in their ability to return to sport. The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale is the only questionnaire to specifically assess the psychological readiness to return to sport after ACL reconstruction. Several factors have been identified to affect an athlete’s psychological readiness to return to sport including age and sex. However, the effect of graft choice on psychological readiness to return to sport have not been studied. The purpose of this study was to evaluate the effect of graft choice on the athlete’s psychological readiness to return to sport. We hypothesized that patients undergoing ACL reconstruction with quadriceps autograft (QA) would reach higher ACL-RSI scores earlier than patients using hamstring autograft (HA) and bone-patellar tendon- bone (BTB) autografts. Methods: The study was a prospective, non-randomized study involving high-level athletes undergoing primary ACL reconstruction with or without meniscal surgery. The participants were involved in varsity high-school, college or professional sports. Each athlete was placed in a group depending on if an all- soft-tissue quadriceps autograft (QA Group), bone-patellar tendon-bone autograft (BTB Group) or hamstring autograft (HA Group) was used for their reconstruction. Graft choice was made by the athlete after the benefits and risks of each graft were discussed in detail. Over the study period, thirty consecutive athletes in each group undergoing primary ACL reconstruction with each specific graft were entered into the study. Athletes undergoing concomitant surgery other than meniscal surgery were excluded from the study. The athletes were asked to fill out the ACL-RSI scale 6-months following surgery, at the time of release to full sport and 2-years following surgery. Current literature shows an ACL-RSI score of 65 or higher as being the score that best predicts return to sport. In addition to comparing the ACL-RSI raw scores between groups, we also compared the percentage of patients reaching an ACL-RSI score of 65 (A-R 65) between the graft types. In addition, patient reported outcomes (PROs) including the International Knee Documentation Committee (IKDC) and Lysholm surveys were completed at the same time points as the ACL-RSI scores. Clinical outcomes included return to sport (RTS), RTS at the same or higher level, time to RTS and graft re-tear. All patients underwent the same rehabilitation protocol regardless of the graft used. RTS was allowed based on appropriate progression through the rehab program, quadriceps strength 90% that of the non-operated leg and triple-hop test 90% the non-operative leg. Return to sport was defined as participation in an official game within the chosen sport of the athlete. Results: The demographics between the three groups was homogenous with the overall average age of the group being 19.1 years. The study included 43.3% high school, 50% college and 6.7% professional athletes with no difference between the groups. The HA group had an ACL-RSI score of 49.2 at 6- months, 59.2 at RTP and 61.7 at the 2-year follow up. The BTB group had scores of 48.1, 64.7 and 63.1 at 6-month, RTP and 2-years postoperatively. The QA group had significantly higher scores than both the HA and BTB groups at the 6-month time period (65.3), and RTP time point (70.6) and similar scores compared to the other two groups at the 2-year follow up (72.7). The HA and BTB groups had similar ACL-RSI raw scores throughout the study. The QA group had a higher percentage of patients reaching the A-R 65 level (53.3%) compared to the HA group (23.3%) and the BTB group (13.3%) at the 6-month postoperative time point. At the RTS time point, the QA group again had a significantly higher rate of patients reaching the A-R 65 level (65.4%) than the other two groups (33.3% HA and 36% BTB group). At the 2-year time point, there was no difference between the three groups with regards to reaching the A- R 65 level. The percentage of athletes reaching the A-R 65 level was not different between the HA and BTB groups at any time point. The IKDC and Lysholm scores were similar between the three groups at all time points. The overall RTP for the study was 82.2% and RTP at the same or higher level was 62.2%. There was no significant difference in return to play between the three groups (HA group 77%, BTB group 83.3% and QA group 87%). Likewise, RTP at the same or higher level was similar between the groups at 57%, 63% and 67% for the HA, BTB and QA groups respectively. There was a significant difference between the QA group and the HA and BTB groups with respect to time to RTS. The average time to RTS for the QA group was 8.1 months compared to 10.5 months for the HA group and 9.6 months for the BTB group. All three groups showed a significant intragroup difference in the ACL-RSI score at all time points between the cohort of patients in each group who were able to return to sport at the same or higher level and those who could not. Clinically, graft re-tears occurred in 17% of the HA group, 10% of the BTB group and 0% of the QA group (p=.02). Conclusions: The QA lead to a higher ACL-RSI score and higher percentages of athletes reaching the A-R 65 level at the 6-month and RTS time points compared to both the hamstring and BTB groups. This fact may explain why the quad group was able to return to sport in significantly less time than the other two groups. The higher ACL-RSI score may be an indication of an athlete’s confidence in their reconstructed knee. This confidence after surgery may allow the athlete to break through the psychological barriers that can make return to sport difficult.

Objectives: To describe outcomes of posterior capsular release to treat knee extension deficits after anterior cruciate ligament (ACL) reconstruction in athletes. Methods: A retrospective review was performed between January 2014 and December 2019 for patients undergoing arthroscopic posterior capsular release for knee extension loss following ACL reconstruction. Patients were indicated for the procedure if they had greater than 10° of extension loss at least three months after ACL reconstruction that was refractory to physical therapy. Patients were included in the study if they were involved in either high school or college athletics, had complete outcomes of interest, and had at least two years of follow up. Collected outcomes included preoperative and postoperative measurement of knee extension, international knee documentation committee (IKDC) score, Lysholm score, return to sport data, and complications. Results: Over the study period a total of 38 arthroscopic posterior capsular releases were performed. Of these, 20 were high school or college athletes. Two of these patients did not have 2-year follow up, leaving a total of 18 patients included in the analysis. Patients underwent surgery at an average of 16 weeks after ACL reconstruction. Knee extension improved an average of 13.8° at 2-years follow up (pre- release extension deficit 15.1°, post-release extension deficit 1.3°, p < 0.005). Improvements in the IKDC score averaged 21.7 at 6 months and 35.0 at 24 months, both of which were statistically significant (p < 0.001). Similarly, differences in Lysholm included a significant improvement of 23.0 and 34.2 at 6 months and 2 years, respectively (p < 0.001). In total, 77.8% returned to sport at an average of 9.8 months from their primary surgery and 6.5 months following posterior capsular release surgery. Complications included one patient that required revision capsular release for persistent extension loss, one ACL tear of the ipsilateral knee, and two ACL tears of the contralateral knee. No infections or neurovascular injuries occurred. Conclusions: Knee extension loss after ligamentous repair surgery can have significant consequences including diminished patient satisfaction, reduced return to sport, and an increased risk of osteoarthritis development. Although arthroscopic posterior capsular release is a recognized treatment for knee extension loss, outcomes have not been reported in athletes. In our series, arthroscopic posterior capsular release resulted in significant improvement of knee extension and patient reported outcome scores at 6 month and 2 years postoperatively. Additionally, the procedure appears to be safe with few complications and only 5.6% of patients requiring repeat arthroscopy for knee extension loss. Posterior capsular release appears to be a reliable and safe treatment for athletes with persistent knee extension loss after ACL reconstruction.

Objectives: ACL reconstruction using hamstring autograft (HA) has been found to have a high re-tear rate in high risk patients including those with a Pivot shift of 2 or higher and those with generalized ligamentous laxity (GLL). Because of this, the use of lateral extra-articular tenodesis (LET) has gained traction in the sports community. Several studies have shown lower ACL graft re-tears with the addition of LET and is felt by many to be necessary when using a HA in high risk patients. However, no study has compared hamstring autograft + LET versus other graft types. The purpose of our study was to compare the surgical outcomes of HA+LET vs an all-soft-tissue quadriceps autograft (QA) without LET. We hypothesized that a QA would lead to similar graft re-tear and rotational instability rates as HA+LET. Methods: This retrospective study compared high risk patients including those with a Pivot shift of 2 or more and GLL undergoing ACL reconstruction with either a HA, HA+LET and QA. In this study, GLL was defined as patients with a Beighton score of 4 or more. Patients were included in the study if they were undergoing a primary ACL reconstruction with either hamstring autograft (HA group), hamstring autograft with extra-articular tenodesis (HA+LET group) or all-soft-tissue quadriceps autograft (QA group) and no other procedures other than meniscal work. All surgeries were performed by the senior surgeon and followed the same rehabilitation protocol after surgery regardless of what type of graft was used during the surgery. Graft choice was dependent on the when during the study the procedure was performed. Early in the study period, HA were used on most patients regardless of whether they were high risk or not. Later, HA+LET was performed due to emerging studies showing higher failure rates in high risk patients undergoing HA alone compared to those undergoing HA+LET. Finally, the senior author transitioned to using QA for most cases. Patient reported outcomes (PROs) were obtained on each patient preoperatively, 3,6,12 and 24-months after surgery. The PROs used in this study included the International Knee Documentation Committee (IKDC) and Lysholm scores. Clinical failure was defined by a patient who had a graft re-tear or those with a residual pivot shift of 2 or more after surgery. Pivot shift was tested for at the 6,12 and 24-month follow up. Other complications associated with the procedure were documented. Results: A total of 166 high risk patients underwent ACL reconstruction over the 7 year study period. There were 63 patients in the HA group, 47 in the HA+LET and 56 in the QA group. The demographics between the three groups was similar with an overall age of the patients in the study being 17.8 years. The mean Beighton score was 3.2 for the group with 24% of the population having GLL. The overall rate of Grade 2 or higher pivot was 82%. There was no difference between the groups with regards to percentage GLL or 2+pivot shift. All three groups had a higher percentage of women than men (HA group 66%; HA+LET group 62% and QA group 56%), but there was no significant difference between the groups. The QA group had a significantly larger graft diameter (9.6mm) compared to the HA group (7.9mm) and the HA+LET group (8.1mm) (p<.001). The number of meniscal repair and partial meniscectomy was similar between all three groups with 21.1% of the population undergoing meniscectomy and 48% of the entire population undergoing meniscal repair. The study was made up of 68.4% athletes for the HA group, 62.4% for the HA+LET and 72.6% for the QA group (p=.32). A significant increase in both IKDC and Lysholm scores were seen at every timepoint compared to preoperative levels. There was no difference between the three groups at any time point for either the IKDC and Lysholm scores. The preoperative IKDC score for the HA group increased from 51.7 to 90.3 at the 2-year follow-up. The HA+LET IKDC scores increased from 53.1 preoperatively to 88.4 at the 2-year follow-up. The QA group had IKDC scores of 49.8 pre op and 90.6 at 2 years. The Lysholm scores increased from 53 to 91.9, 54.8 to 89.4 and 51.9 to 92.6 preoperatively to the 2-year follow-up for the HA, HA+LET and QA groups respectively. The graft re-tear rate of the HA group was significantly higher than the HA+LET and QA groups (14.3%, 2.1% and 1.8% respectively). Residual pivot shift of 2 or more was found in 36.5% of the HA group, 14.9% in the HA+LET group and 19.6% in the QA group. The residual pivot shift in the HA group was significantly higher than the HA+LET and QA groups, but no difference was identified between the HA+LET and QA groups. Return to sport (RTS) was similar between the three groups with 80% of athletes returning to sport with HA grafts, 81% with HA+LET and 86% with QA grafts. The use of a QA in this high-risk population lead to a significantly faster RTS (8.6 months) compared to the HA and HA+LET groups; however, the addition of a LET did not lead to a shorter time to return to sport (10.7 months for the HA group and 11.7 months for the HA+LET group). There was no difference between the three groups for contralateral ACL tears, arthrofibrosis or infection. Conclusions: The use of an all-soft-tissue QA or the addition of an LET to a HA both lead to significant decreases in graft re-tear rate and residual pivot shifts of 2 or greater compared to a HA graft alone in high risk patients undergoing primary ACL reconstruction. However, the use of QA and LET do not improve the patient reported outcome scores at 2-year follow up compared to HA alone. RTS was significantly faster with QA compared to the HA and HA+LET; however, the addition of an LET to a HA did not increase the rate to which an athlete was able to return to play. In conclusion, high risk patients including those with GLL and pivot shifts greater than 2 should undergo ACL reconstruction with either a quadriceps autograft or have a LET added to a hamstring autograft.

Purpose To quantify and analyze public interest trends in platelet‐rich plasma (PRP) therapy for shoulder pathology between 2011 and 2020 using Google Trends data. Methods Google Trends data were queried for online search data ranging from January 2011 to December 2020. Various combinations of terms related to PRP and shoulder pathology were queried. Terms related to corticosteroid therapy in association with shoulder pathology were also generated for comparative analysis. Analyses were performed regarding trends in online search volumes. Results Linear models were generated to evaluated trends in the volume of online searches for PRP and corticosteroid therapy for shoulder pathology. For both the PRP and steroid groups, linear models showed a statistically significant increase in search volume for the period studied ( P < .001). The PRP group showed a significantly greater growth rate than the steroid group ( P < .001). There were no statistically significant differences in online search volume when compared between different geographic and socioeconomic locations. Conclusions This study indicates consistently increasing public interest in PRP injections in the shoulder. The rate of online search volume growth of PRP is significantly greater than that of corticosteroid injections for the period studied. Clinical Relevance Awareness of patient perceptions has value in informing shared decision making, aligning patient expectations, and guiding areas of future research. Each of these has an impact on patient care. Being aware of patient interest and expectations is particularly important in areas with controversial or emerging research.

In the setting of total hip arthroplasty (THA), pseudoaneurysms are extremely rare and can be difficult to diagnose, as clinical symptoms can mimic symptoms of other more common complications, such as periprosthetic joint infection, hematoma, and nerve damage. We present a case of a 69-year-old male with a history of slipped capital femoral epiphysis 56 years prior and subsequent right THA. The right hip primary arthroplasty was subsequently complicated by multiple dislocations and recurrent prosthetic joint infections. The most recent infection was treated with debridement, antibiotics, and implant retention (DAIR) in 2017. The patient later presented in 2019 with right thigh pain. Upon further analysis, he was diagnosed with Streptococcus bovis positive periprosthetic joint infection. The patient underwent a two-stage revision of the hip using an antibiotic spacer. Two weeks following the second stage, he presented with a sudden onset of uncontrolled atrial fibrillation with rapid ventricular response and a low hemoglobin. The computed tomography scan revealed a large hematoma involving both the anterior and posterior thigh compartments with lab markers that were questionable for infection. An operation to remove the hematoma revealed no purulence, and a large pulsatile pseudoaneurysm on the posterolateral aspect at the mid femur was found. A sharp bone fragment was noted next to the pseudoaneurysm. The pseudoaneurysm was repaired by a vascular surgeon, and the bone fragment was removed. Following this procedure, the patient developed a subsequent periprosthetic joint infection requiring a double DAIR procedure six weeks following the pseudoaneurysm repair and is now on chronic antibiotic suppression. Orthopedic surgeons should be aware of the potential for pseudoaneurysm in the setting of total joint arthroplasty when treating a postsurgical hematoma of sudden onset.