Clark, Sean C.

The total number of total hip arthroplasties performed each year is expected to increase significantly over the coming decades. As a result, an increasing number of young patients are undergoing total hip arthroplasty while similarly, a growing subset of active elderly patients desire to return to sports or high-impact activity after surgery. Patients are typically provided restrictions and activities to avoid following surgery. For these patients, there is no clear consensus or guidelines regarding whether they should limit their activity level postoperatively and in particular, if returning to high-impact exercise increases their risk of complications and subsequent revision surgery. This article will discuss the most common complications after total hip arthroplasty and whether patients who return to sports or a high-impact activity after surgery may be more predisposed to these complications in comparison to their more sedentary peers.

Background: Total knee arthroplasty (TKA) is the treatment of choice for end-stage knee osteoarthritis in many patients. In younger patients with predominantly medial compartment disease, high tibial osteotomy (HTO) is performed as a joint-preserving treatment. However, concerns remain regarding potentially compromised outcomes of TKA after previous HTO given the axial deviation, osteotomy site, secondary surgery, previous hardware, and instrumentation. Therefore, this study compared long-term implant survival, revision, and infection rates, and patient-reported outcomes between patients undergoing TKA after HTO and matched TKA-only controls. Methods: Postoperative complications and revision surgeries were prospectively recorded in patients who underwent TKA from 2000 to 2023 at a single academic center. Patients with previous ipsilateral HTO formed the study group and were propensity matched 1:2 to TKA-only patients without a previous osteotomy based on age, sex, and body mass index. Knee Society Scores (KSS) were collected prospectively. Implant survivorship was analyzed using Kaplan-Meier survival curves and Cox proportional hazards models. Results: The study included 134 HTO-TKA and 268 matched TKA-only patients, with a mean follow-up of 10.5 ± 6.4 years (range: 0-24 years) after TKA. Both groups showed significant postoperative improvements in KSS (p < 0.02) with comparable clinical outcomes (HTO-TKA: 79.0 (6.0), TKA-only: 79.0 (11.8)). Revision arthroplasty rates were 5.2% for HTO-TKA and 4.5% for TKA-only (p = 0.69); the mean time to revision was 8.1 ± 8.7 years vs. 4.4 ± 3.5 years, respectively (p = 0.30). Infection rates were 2.2% and 1.1%, respectively (p = 0.74). Conclusions: Revision and infection rates were comparable between HTO-TKA and matched TKA-only patients, with no statistically significant differences. Our findings demonstrate comparable patient-reported outcomes in both groups. These findings indicate that a previous HTO does not adversely affect TKA implant longevity or clinical outcomes when compared with matched primary TKA patients within the US population. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Chronic hip abductor insufficiency remains a challenging problem to treat and can result in significant disability in some patients. Tendon transfers involving the gluteus maximus (GM) or combined GM with tensor fascia latae (GM+TFL) are common options for surgical reconstruction. The purpose of this systematic review was to compare clinical outcomes, complications, and revisions rates of patients who underwent GM transfer or GM+TFL transfer for irreparable hip abductor tears. Methods: PubMed (MEDLINE), Scopus (EMBASE, MEDLINE, COMPENDEX), and Cochrane databases were used to conduct a systematic review of articles from inception to February 2025. A total of 18 studies were included (11 GM transfer, 7 GM+TFL transfer). Demographics, hip setting (native hip, primary total hip arthroplasty [THA], revision THA), patient-reported outcome measures, presence of Trendelenburg gait, abduction strength, complication rates, and revision rates were analysed. Results: A total of 207 patients (208 hips) underwent GM transfer, while 55 patients (55 hips) underwent GM+TFL transfer. Meta-analyses demonstrated that both techniques yielded significant preoperative to postoperative improvements in modified Harris Hip Scores/Harris Hip Scores and Visual Analogue Scale pain scores ( p < 0.001). In total, 33.9% of patients who underwent GM transfer had a persistent Trendelenburg gait postoperatively, compared to 48.1% of those who underwent GM+TFL transfer. The complication rate was 16.8% (23/137) for patients who underwent GM transfer and 2.7% (1/37) for those who underwent GM+TFL transfer; while revision rates were 5.9% (9/152) and 3.6% (2/55), respectively. Conclusions: Both GM and GM+TFL transfers yielded comparable outcomes in patients with chronic hip abductor insufficiency not amendable to primary repair. The complication rate was substantially higher in patients who underwent GM transfer, whereas revision rates were comparably low for both techniques. In particular, a sizeable proportion of patients continued to exhibit a persistent Trendelenburg gait postoperatively following both surgical techniques, highlighting the complexity of this pathology. PROSPERO registration number: CRD420251002466

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback for throwing athletes, often requiring reconstruction with 12 to 18 months of rehabilitation. The authors previously described a more anatomic technique with improved mechanical strength as compared with the docking technique, which may allow for an accelerated return to sport. Purpose: To evaluate return-to-sport rates, time to return to sport, and the effect on the functional performance of amateur and professional throwing athletes who underwent anatomic MUCL reconstruction with suture tape augmentation. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series was performed including baseball players who underwent anatomic MUCL reconstruction with suture tape augmentation by a single surgeon from 2018 to 2022. Inclusion criteria consisted of a minimum 2-year follow-up, participation in baseball, and utilization of autograft (palmaris longus or gracilis). Patients who underwent previous MUCL reconstruction were excluded from the study. All patients initially followed an accelerated rehabilitation protocol. Outcome measures were collected, including Kerlan-Jobe Orthopaedic Clinic (KJOC), Single Assessment Numeric Evaluation (SANE), and Conway-Jobe scores, as well as throwing metrics such as ball velocity and spin rate. Results: Thirty-four baseball players (mean ± SD age, 21 ± 3 years) underwent primary MUCL reconstruction. Time of final follow-up was 36.1 ± 10.3 months. Of these, 16 were professional athletes and 18 were amateur. All throwers returned to live gameplay at a mean 10.1 ± 2.0 months after reconstruction (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8). Furthermore, 97% (94% professional, 100% amateur) advanced through the accelerated postoperative protocol without issues, and 91% (88% professional, 94% amateur) returned to the same role and 85% (75% professional, 94% amateur) to the same level of play. Professional postinjury KJOC scores improved from 42.6 ± 16 to 87.5 ± 8.3 and SANE scores from 25.0 ± 11.2 to 95.6 ± 4.2. Amateur postinjury KJOC scores improved from 35.6 ± 10.7 to 90.9 ± 8.6 and SANE scores from 57.5 ± 16.9 to 95.2 ± 7.2. No significant difference was identified in preinjury versus postreconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. The overall failure rate was 2.9%, with 1 professional pitcher requiring revision for graft rupture at 3 years postoperatively. Conclusion: Anatomic reconstruction of the MUCL with suture tape is a viable option for MUCL injuries, allowing an expedited return to sport at 10.1 ± 2.0 months (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8) in baseball players, with a low failure rate.

Background: Chronic hamstring tears can result in challenging surgical repairs. Allografts may be used to augment the repair; however, there is limited clinical evidence supporting their use. Purposes: To (1) evaluate clinical outcomes of patients who underwent proximal hamstring repair with allograft augmentation or interposition and (2) compare them to matched controls who underwent primary hamstring repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 117 patients who underwent proximal hamstring repair were included, consisting of 19 allograft augmentations, 20 allograft interpositions, and 78 primary repairs. Allograft cohorts were propensity-matched with those who underwent primary repair in a 1 to 2 ratio. Clinical outcomes were obtained at the final follow-up. Data were extracted using continuous variables, with normality reported as mean values ± standard deviation, and non-normality reported as median values with interquartile ranges (IQR). Results: The median follow-up of the augmentation cohort was 1.9 [IQR, 0.8-3.9] years, while it was 3.2 [IQR, 1.6-5.1] years ( P = .182) for the primary repair cohort. The mean follow-up for the interposition cohort was 3.5 ± 2.4 years, while it was 4.2 ± 2.5 years for the primary repair cohort ( P = .227). Forty-two percent of the augmentation cohort had undergone previous surgery, compared with 5% of the interposition cohort. The time from injury to surgery for the augmentation and primary repair cohorts was 6.4 and 1.3 months, respectively ( P < .001). For the interposition and primary repair cohorts, the durations were 17.8 and 1 months, respectively ( P < .001). Clinical outcomes, including the Tegner Activity Scale (3 vs 3), pain with activity (47.4% vs 23.7%), and muscle spasms (36.8% vs 26.3%), did not show significant differences between the augmentation and primary repair cohorts. The augmentation cohort had a significantly worse Lower Extremity Functional Scale (LEFS) score (64 vs 75; P < .001) and were more likely to experience pain with sitting (52.6% vs 21.1%; P = .034) than the primary repair cohort. There was no significant difference in clinical outcomes between the interposition and primary repair cohorts (LEFS: 69 vs 75.5, Tegner Activity Scale: 4 vs 4; pain with sitting: 26.3% vs 27.5%; pain with activity: 42.1% vs 30%; muscle spasms: 26.3% vs 30%). Revision rates were similar between cohorts ( P ≥ .255). Conclusion: Proximal hamstring repair for chronic tears with allograft augmentation or interposition is a reproducible procedure that results in satisfactory, yet poorer clinical outcomes compared with patients who underwent primary hamstring repair. These procedures should be considered in symptomatic patients with chronic tears that are not amenable to primary repair.

Objectives: The medial ulnar collateral ligament (MUCL) is the primary stabilizer of valgus forces across the elbow. Injury to the MUCL has a large impact on the throwing athlete, particularly in baseball. The incidence of MUCL injury in baseball pitchers is on the rise. Surgical treatment and rehabilitation is evolving to improve outcomes and improve return to sport time frames. The purpose of this study was to highlight the trends in MUCL repair and reconstruction in professional baseball pitchers, describe relevant outcomes such as return to any level of play (RTP) for surgical repair and reconstruction, and distinguish what factors might impact these outcomes. The authors hypothesize that primary and revision MUCL surgery is increasing with revision surgery requiring the greatest time to RTP. Methods: The Major League Baseball (MLB) Health and Injury Tracking System (MLB HITS) database was used to procure data during the targeted study period (2010 – 2023). All professional pitchers who underwent MUCL surgery within the study period were included. Variables analyzed included age, career length, and level of play. Surgical variables included date and type of procedure, RTP status, time required to RTP, return to same level of play (RTSL), career length before and after surgery, number of revision surgeries, and time between surgeries. Successful RTP was designated if a pitcher had returned in at least one professional game after index surgery. Analyses of trends over time were performed. The year 2020 was considered an outlier and omitted from the analysis of trends due to the coronavirus pandemic which limited games played. Results: A total of 2,287 pitchers underwent MUCL surgery during the study period (Table 1). The annual number of MUCL surgeries on all pitchers increased year over year (R 2 = 0.821, p < 0.001), as did the annual number of reconstructions with internal brace (IB) augmentation (R 2 = 0.896, p < 0.001) (Figure 1). The RTP rate (93%) for MLB pitchers was significantly higher compared to the RTSL rate (71%, P < 0.001). This difference was not observed in Minor League Baseball (MiLB) (RTP 76% vs. RTSL 74%, P = 0.142) (Figure 2). The percentage of players who RTP after revision surgery was significantly lower compared to primary surgery (71%vs. 80% respectively, P = 0.020). Mean time to RTP is significantly shorter (470 ± 135 days) compared to the mean time to RTSL (499 ± 153 days, P < 0.001) (Figure 3). The annual number of revision MUCL surgeries on all pitchers increased year over year as well (R 2 = 0.322, p = 0.043). Conclusions: MUCL surgery continues to increase, also leading to increasing numbers of revisions in professional pitchers. Overall, 80% of pitchers were able to RTP at a mean of 470 days (15.5 months), while only 71% were able to RTSL at a mean of 499 days (16.5 months), but this varied based on level of play. Surgical techniques continue to evolve as MUCL repairs and reconstructions with IB augmentation have increased significantly in recent years. This study will help guide athlete expectations and surgeon decision-making.

Background: Injuries of the medial ulnar collateral ligament (MUCL) among baseball pitchers are increasing. Surgical treatment is evolving to optimize outcomes. Purpose/Hypothesis: This study’s purpose was to highlight trends in MUCL repair and reconstruction in professional pitchers, describe outcomes such as return to any level of play (RTP), and identify factors impacting these outcomes. It was hypothesized that primary and revision MUCL surgery is increasing, with revision surgery requiring greater RTP time. Study Design: Case series; Level of evidence, 4. Methods: The Major League Baseball (MLB) Health and Injury Tracking System database was used to procure data during the study period (2010-2023). All professional pitchers who underwent MUCL surgery during this period were included. RTP was defined as a pitcher returning to at least 1 professional game after index surgery. Return to the same level of play (RTSL) was defined as return to at least 1 game in the same league of play as before surgery. Because of the coronavirus pandemic, the year 2020 was considered an outlier and omitted from time-trend analysis. Results: A total of 2281 pitchers who underwent MUCL surgery during the study period were included for analysis. The number of MUCL surgeries for pitchers increased yearly ( R 2 = 0.821; P < .001), as did the number of reconstructions with internal brace augmentation ( R 2 = 0.896; P < .001). The RTP rate for MLB pitchers was significantly higher than the RTSL rate (93% vs 71%; P < .001). This difference was not observed in Minor League Baseball (MiLB) pitchers (RTP 76% vs RTSL 74%; P = .142). RTP rates after revision surgery were lower than those after primary surgery (71% vs 80%; P = .020). The mean time to RTP was shorter (470 ± 135 days) than the mean time to RTSL (499 ± 153 days; P < .001). Conclusion: The incidence of MUCL surgery and revision surgery is increasing among professional pitchers. Overall, 79% of pitchers returned to any level of play at a mean of 470 days, while 74% returned to the same level of play at a mean of 499 days, but this varied based on level of play. This study will guide athlete expectations and surgeon decision-making.

Background: Periacetabular osteotomy (PAO) is a complex procedure historically requiring inpatient stay. However, there is increased emphasis for other complex orthopaedic procedures (eg, arthroplasty) to be performed on an outpatient basis by insurance companies. Increasing resistance to insurance approval of inpatient listing for PAO patients at the participating institution suggests that this changing tide is affecting PAO surgery. Purpose: To (1) investigate the proportion of PAOs various surgical listing classifications (outpatient, outpatient-overnight, inpatient, etc), (2) determine the incidence of subsequent denial/request for additional documentation for approval of inpatient stay after PAO, and (3) characterize the accuracy of preoperative patient listing classification as well as mean length of stay (LOS) and incidence of successful same-day discharge after PAO at a single institution. Study Design: Case series; Level of evidence, 3. Methods: A retrospective chart review was performed to identify all PAOs, performed by 4 participating surgeons, at a single academic institution over a 2-year period. The initial listing status as an outpatient-overnight or inpatient procedure was identified. Whether a preoperative peer review was required for approval of inpatient listings as well as if additional documentation was necessary to convert outpatient-overnight listings to inpatient stays were also recorded. Results: A total of 140 PAOs among 117 patients were performed with 25 (17.9%) initially listed as an inpatient stay and 115 (82.1%) listed as outpatient-overnight. Of the 25 PAOs listed as inpatient, 2 (8.0%) required a preoperative peer review process to justify or clarify listing status. The mean LOS was 1.9 ± 1.4 days with 55.7% (78/140) of PAOs staying ≥2 nights in the hospital. Only 6 PAOs (4.3%) went home the same day as surgery. Patients who underwent PAO with concomitant hip arthroscopy stayed on average 2.4 ± 1.2 days in comparison with 1.6 ± 1.4 days for those who underwent PAO alone ( P < .001). Of the 115 PAOs listed as an outpatient-overnight, 53 (46.1%) converted to an inpatient stay, all of which required service documentation to support conversion to inpatient status. Conclusion: Over half of PAOs performed resulted in an inpatient stay with patients spending ≥2 nights in the hospital. Additionally, all conversions from outpatient-overnight to inpatient required additional service documentation to support status conversion. Understanding trends in postoperative hospitalizations and LOS may allow for better informed partnerships between surgeons and insurance companies creating more efficient preauthorizations, billing practices, and expected patterns of patient care and discharge.

Background: Osteochondral allograft transplant and autograft transplant for femoral head defects have emerged as promising treatments for concomitant cartilage and subchondral bone injuries in young patients. Purpose: To evaluate the clinical and radiological outcomes of patients who underwent osteochondral allograft or autograft transplant for femoral head defects and identify any risk factors that may lead to conversion to total hip arthroplasty (THA). Study Design: Case series; Level of evidence, 4. Methods: All patients who underwent osteochondral allograft or autograft transplant for femoral head defects across 2 institutions were analyzed. Clinical outcomes were assessed at final follow-up with the modified Harris Hip Score (mHHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool (iHOT-12). Complications and reoperations were recorded. Patients were assessed radiographically preoperatively and at final follow-up for osteoarthritis using Tönnis grading. Results: A total of 27 patients were included in this study (19 osteochondral allograft transplant, 8 osteochondral autograft transplant). The mean follow-up for the allograft and autograft cohorts was 2.8 and 9.5 years, respectively. The mean defect size for patients who underwent allograft and autograft transplant was 2.8 × 2.1 cm and 1.6 × 1.0 cm, respectively. The mean mHHS, HOS-ADL, HOS-SSS, and iHOT-12 for the allograft cohort were 86.7, 92.8, 81.4, and 79.0, respectively, and for the autograft cohort were 87.6, 92.7, 83.1, and 82.0, respectively. No significant difference in outcomes was noted for patients who underwent femoral head allograft versus nonorthotopic femoral condyle allograft transplant. For the allograft cohort, 4 patients (21.1%) underwent conversion to THA at a mean of 1.9 years. Of the remaining 15 allograft patients, only 1 patient (6.7%) had radiographic osteoarthritis progression. None of the patients in the autograft cohort underwent conversion to THA. Conclusion: Osteochondral allograft and autograft transplant for femoral head defects demonstrated overall favorable clinical outcomes and rates of conversion to THA. Additionally, nonorthotopic femoral condyle allografts demonstrated similar outcomes to femoral head allografts. Both osteochondral allograft and autograft transplant should be considered for patients with focal femoral head defects.

Abstract Background: Intra-articular corticosteroid injections (ICSI) have been shown to be an effective symptomatic non-operative treatment for hip osteoarthritis (OA) and other joint-related pain. There has been recent dispute over the true risk of complications from ICSI specifically when injected into the hip. Avascular necrosis (AVN) of the femoral head has been reported to occur in up to 30.5% of patients after undergoing hip ICSI, and up to 50.6% of patients experiencing osteoarthritis progression in as little as 3 months following injection. Purpose: To analyze the current protocol of hip ICSIs performed by two fellowship-trained non-operative sports medicine physicians and assess the rate of femoral head avascular necrosis. We hypothesized that the rate of AVN will be less than what has been recently reported in the literature. Study Design: Retrospective chart review Methods: Patients that underwent at least one intra-articular corticosteroid hip injection by two fellowship trained non-operative sports medicine physicians at this institution were identified using an institutional database. Exclusion criteria included injections with contrast dye used for imaging, injections that administered orthobiologics to the intra-articular, and non-intra-articular injections. Procedure notes were reviewed for anesthetic and steroid type, dosage, and needle size. Each chart was screened for demographic information, post-injection infections, AVN diagnosis, and subsequent hip replacement. 10 patients were identified with an AVN diagnosis. Their MRNs were sent to a board-certified radiologist at the same medical institution. The radiologist was blinded to the patient’s chart and instructed to identify the first radiograph with evidence of AVN. Patients were excluded if the reviewer did not agree with the diagnosis as it appeared in the medical chart or the AVN developed post-traumatically. Results: 449 patients, 530 hips, underwent 1.8 ± 1.4 ICSIs and 16.3% underwent THA at an average of 2.2 ± 2.3 years following their first injection. Of the 530 hips that underwent ICSI, only 1 hip demonstrated findings of AVN on radiographs following the first injection, and this patient had been taking oral prednisone for over 20 years. Conclusions: Intra-articular corticosteroid injections are a relatively safe symptomatic treatment option for hip pain secondary to both OA and non-OA pathology to be considered when other non-operative treatment options have failed. While the use of steroids comes with an inherent risk of osteonecrosis and cartilage damage, these results demonstrate that, when performed properly with ultrasound guidance and sterile technique, the risk of femoral head avascular necrosis is minimal.