Hartigan, David E.

Background: Up to 50% of National Collegiate Athletic Association (NCAA) football players have a history of shoulder injuries. The quarterback position has been shown to have a high prevalence of these injuries because of its unique exposures. There is little information regarding the shoulder injury type and mechanism in NCAA quarterbacks. Purpose: To understand the 10-year epidemiology of specific shoulder injury rates in NCAA quarterbacks. Study Design: Descriptive epidemiology study. Methods: Shoulder injury data for collegiate football quarterbacks from the 2004 through 2014 academic years were analyzed using the NCAA Injury Surveillance Program (ISP) data set. Results: Over the 10-year study period, a total of 133 shoulder injuries to collegiate quarterbacks were reported, with 157,288 quarterback exposures. There was approximately 1 shoulder injury per 1221 exposures. The most common injuries noted were acromioclavicular sprains (45.1%, n = 60), followed by shoulder contusions (9.0%, n = 12), clavicular fractures (7.5%, n = 10), and anterior instability (5.3%, n = 7). The majority of injuries were caused by contact with a player (60.2%, n = 80) or contact with a playing surface (28.6%, n = 38), and 88% (n = 117) were deemed nonsurgical in nature. Conclusion: NCAA ISP data analysis suggests that collegiate quarterbacks sustain acute contact injuries 89% of the time and that they typically occur while being tackled, resulting in a time loss of less than 2 weeks. These injuries are commonly treated nonsurgically.

Abstract The medial patellofemoral ligament (MPFL), which is critical for both patellar stability and normal kinematics of the patellofemoral joint, is disrupted in most patellar dislocations. Consequently, MPFL reconstruction is advocated in recurrent dislocations to restore native patellar constraints. Fixation of the MPFL graft to the medial border of the patella can be achieved through various methods, each with its own benefits and drawbacks. We present a technique for MPFL fixation to the patella using all‐soft suture anchors, theoretically decreasing the risk of patellar fracture and articular surface violation. Technique Video video See video under supplementary data.

Purpose To evaluate clinical outcomes, demographics, and radiographic findings for patients whose hip arthroscopies involved amorphous calcification (AC) excision and to compare them with a control group with no AC and with the general population regarding diabetes mellitus and hypothyroidism. Methods Patients who underwent primary hip arthroscopy involving surgical excision of AC deposit in the anterosuperior labralcapsular recess between October 2008 and July 2014 were reviewed. Demographics, radiographic findings, intraoperative findings, and procedures were reviewed. Minimum follow‐up was 2 years and included visual analog scale for pain, patient satisfaction, and the following patient‐reported outcome scores: modified Harris hip score, hip outcomes score sport‐specific subscale, and nonarthritic hip score. These patients were matched (1:2 ratio) to patients who underwent hip arthroscopy with no AC using the following matching criteria: age at surgery ± 5 years, body mass index ± 5, gender, type of labral treatment, and type of capsular treatment. Results We reviewed 12 cases in 11 female patients. Mean latest follow‐up scores improved from 64.0 to 83.4 ( P = .003) for modified Harris hip score, from 57.6 to 80.6 ( P < .001) for nonarthritic hip score, from 35.4 to 62.7 ( P = .021) for hip outcomes score sport‐specific subscale, and from 6.4 to 2.8 ( P = .016) for visual analog scale. The survivorship rate was 91.7%, with one hip converting to total hip arthroplasty. Mean patient satisfaction was 8.4 ± 2.3. Six hips of the 12 (50%) had clock face localization of the AC. They were all between 11 and 12 with a mean of 12:30. Postoperative radiographic findings showed no subsequent AC in all 12 hips. No complications or revisions were reported. There were no significant differences between the AC group and the control group. Conclusions The treatment of AC as part of hip arthroscopy for labral tear and femoro‐acetabular impingement is safe and has favorable and similar outcomes compared with a control group at minimum 2‐year follow‐up. Female gender may be a risk factor for the development of AC. There is no strong evidence that AC should be debrided. Level of Evidence Level III, case control study.

Purpose To compare the minimum 2‐year outcomes and return to sports in competitive athletes after arthroscopic iliopsoas fractional lengthening (IFL) and treatment for femoroacetabular impingement (FAI) to competitive athletes treated for FAI who did not undergo IFL. Methods Data were prospectively collected and retrospectively reviewed between November 2009 and April 2014. Included patients were high school, collegiate, or professional athletes who underwent arthroscopic IFL, treatment for FAI, and preoperative modified Harris Hip Score, Non‐Arthritic Athletic Hip Score, Hip Outcome Score–Sports Specific Subscale, and visual analog scale. Exclusion criteria were patients younger than 16 years, Tönnis grade >1, microfracture, abductor pathology, and previous hip conditions. A subgroup of athletes were matched to athletes who did not undergo IFL by age ± 5 years, sex, and body mass index ± 5. Results There were 75 athletes eligible for inclusion, 60 (80.0%) of whom had minimum 2‐year follow‐up. All patient‐reported outcome (PRO) scores demonstrated significant improvements at latest follow‐up ( P < .001). Mean satisfaction was 7.9. No patients converted to arthroplasty. Painful snapping was resolved in 55 athletes (91.7%). Nine athletes (15.0%) had nonpainful snapping at follow‐up. Thirty‐nine (65%) returned to their sport. Forty (66.7%) maintained or improved their competitive abilities. There was one case (1.6%) of temporary postoperative numbness. There were no complaints of weakness in hip flexion. Forty‐one IFL athletes were matched to 41 controls. No differences were detected in demographics, follow‐up time, intraoperative findings, procedures, mean magnitudes of improvement, or return to sports. Conclusions In competitive athletes, IFL during hip arthroscopy is safe and demonstrates favorable improvements in PROs and VAS, high satisfaction, and high rate of symptom resolution at a minimum of 2 years postoperatively. Most patients were able to return to sports and maintain or improve their competitive levels. These results were similar to a control group of athletes not requiring IFL. Level of Evidence Level III, case‐control study.

Purpose To report the minimum 2‐year outcomes of transtendinous repair of partial‐thickness undersurface tears of the abductor tendon using patient‐reported outcomes (PROs), visual analog scale (VAS) scores, and patient satisfaction scores. Methods All patients who underwent endoscopic transtendinous gluteus medius repair between October 2009 and May 2013 at 1 institution were prospectively evaluated. The exclusion criteria consisted of less than 2 years' follow‐up, previous hip surgery, inflammatory arthritis, open surgery, full‐thickness abductor tear, and Workers' Compensation patients. All patients underwent a documented preoperative physical examination with strength testing (scale of 0‐5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively; at 3 months postoperatively; and at 1, 2, 5, and 10 years after surgery. The PRO scores collected were the modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living Subscale, Hip Outcome Score–Sports‐Specific Subscale, Non‐arthritis Hip Score, and VAS score. Preoperative strength and gait were compared with latest follow‐up. Results There were 25 patients who fit our criteria. Significant improvement in PRO scores were shown for the modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living Subscale, Hip Outcome Score–Sports‐Specific Subscale, Non‐arthritis Hip Score, and VAS score from 54.9 to 76.2, from 50.2 to 80.6, from 30.1 to 67.3, from 51.9 to 82.4, and from 7.1 to 2.7, respectively ( P < .001). Before surgery, 11 patients had objective weakness; 7 of these patients moved up at least 1 strength grade by final follow‐up. Preoperatively, 14 patients had a Trendelenburg gait; 12 of them had a normal gait at latest follow‐up ( P < .001). The average patient satisfaction rating was 7.5. There were no revision surgical procedures, and no complications were noted. Conclusions Partial‐thickness undersurface tears of the abductor can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of the superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to nonoperative treatment because patients showed clinical benefit at greater than 2 years' follow‐up that exceeded substantial clinical benefit and the minimal clinically important difference. Level of Evidence Level IV, case series.

Abstract Arthroscopy is currently the gold standard for diagnosing intra‐articular knee pathology. Magnetic resonance imaging (MRI) can be a clinical adjunct for diagnosis; however, it is not without its shortcomings. Although highly accurate, even advanced imaging misdiagnoses the condition in 1 in 14 patients with regard to anterior cruciate ligament pathology. Previous studies have indicated that MRI fails to identify meniscal pathology when one exists in 1 of every 10 cases, and diagnoses pathology when pathology truly does not exist in 1 of every 5 patients. In‐office arthroscopy offers an alternative to formal diagnostic arthroscopy, with reduced cost and risk of complications. This is a technique article that discusses the use of small‐bore needle arthroscopy in the office setting. Technique Video video See video under supplementary data.

Background: Femoral retroversion has been noted as a possible risk factor for poor clinical results after hip arthroscopic surgery. Purpose: To compare the outcomes of the arthroscopic treatment of hip abnormalities in patients with femoral retroversion to patients with femoral anteversion between 10° and 20°. Study Design: Cohort study; Level of evidence, 3. Methods: Between November 2011 and September 2013, 790 hip arthroscopic procedures were performed at a single institution. Of these, 59 hips (7.5%) were located in patients with femoral version ≤0°, calculated using preoperative magnetic resonance imaging. These patients were pair matched, based on body mass index ±5 kg/m 2 , age ±5 years, and Tönnis grade, with 59 patients with femoral anteversion between 10° and 20°. Exclusion criteria included Perthes disease, inflammatory arthritis, slipped capital femoral epiphysis, previous hip surgery, abductor repair, lateral center-edge angle <20°, Tönnis grade >1, and acetabular profunda or protrusio. Patient-reported outcomes (PROs) were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PROs utilized were the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS). The visual analog scale (VAS) was collected to assess the patients’ pain; patient satisfaction scores (0-10) were also collected. Radiographs were collected at the above time intervals as well. Results: Two patients from the control group and 1 patient from the retroverted group required total hip arthroplasty at a mean 19.5 and 26.3 months, respectively. Both groups demonstrated significant improvement from their preoperative state in all PRO and VAS scores ( P < .001). No differences in preoperative, postoperative, or change in PRO and VAS scores between the groups were noted. Conclusion: Patients with femoral retroversion reported similar outcomes compared to patients with normal femoral version when undergoing hip arthroscopic surgery. Both groups had similar improvements from the preoperative state.

Background: The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown. Purpose: To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), Tönnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery. Results: A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent periacetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI >30 kg/m 2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI ≤30 kg/m 2 ( P < .01). Patients aged >35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged ≤35 years ( P = .03). Patients with Tönnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score ( P = .02) and a 23.0-point worse HOS-SSS score ( P < .01) when compared with patients with Tönnis grade 0. Conclusion: Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with Tönnis grade 2 changes preoperatively, BMI >30 kg/m 2 , and age >35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.

Abstract This article presents the authors' technique for evaluation of possible abductor tears with magnetic resonance imaging (MRI). By using T2 fat‐saturated coronal and axial slices of the hip and T1 coronal images of the pelvis, the authors show how to visualize all tears of the abductor tendons and signs of chronic abductor deficiency. After diagnosis has been made, signs that may help the surgeon determine if open or arthroscopic surgery would be best used are reviewed. Finally, the author reviews indications for a gluteus medius repair with concomitant gluteus maximus reconstruction. Technique Video video See video under supplementary data.

Background: The lever sign test is a new physical examination tool to diagnose anterior cruciate ligament (ACL) tears. Preliminary results suggest almost 100% sensitivity and specificity to diagnose acute and chronic complete ACL tears and clinically significant partial tears as compared with magnetic resonance imaging (MRI). Purpose: To assess the sensitivity and specificity of the lever sign test for the diagnosis of acute ACL injuries, as compared to MRI. We also aimed to determine the accuracy of the lever sign test compared with 3 other tests (anterior drawer, Lachman, and pivot shift) when performed by providers of various training levels, and with the patient awake or under anesthesia. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: We evaluated patients with a chief concern of acute (≤4 weeks) knee pain seen between October 2014 and January 2015, with a thorough history, physical examination, and standard radiographs. MRI was the reference standard; patients without an MRI evaluation were excluded. The 4 physical examination maneuvers were performed on each symptomatic knee during the initial clinic visit (for nonsurgical patients) or under anesthesia in the operating room (for surgical patients) by a randomly assigned undergraduate student, medical student, orthopaedic resident, or orthopaedic fellow. The senior author trained all staff to perform the lever sign test. Statistical analyses were performed. Results: Of 102 patients, 54 were surgical (28 female, 26 male), and 48 were nonsurgical (16 female, 32 male); the mean patient age was 23 years (range, 15-66 years). The overall accuracy of the lever sign test was 77% (63% sensitivity, 90% specificity); the accuracy was similar between patients under anesthesia and awake (77% vs 76%, respectively). There were no significant differences when comparing the sensitivity and specificity of the lever sign test with patients under anesthesia and awake (sensitivity: under anesthesia, 86%, and awake, 68% [ P = .40]; specificity: under anesthesia, 85%, and awake, 96% [ P = .17]). Furthermore, the accuracy of the lever sign test was similar when performed on female versus male patients (75% vs 79%, respectively) or when performed by undergraduate students and medical students compared with orthopaedic residents and fellows (84% vs 88%, respectively). Conclusion: Our study results challenge the exceptional sensitivity and specificity values (both 100%) of the lever sign test, as reported by the original author of the test.