Chhabra, Anikar

Background: The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities. Methods: A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools. Results: Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation. Conclusions: Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Purpose To systematically review the literature to examine current understanding of the meniscofemoral ligaments (MFLs), their function, their importance in clinical management, and known anatomical variants. Methods A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines using PubMed, EMBASE, and Cochrane databases. Studies were included if they reported on the biomechanical, radiographic, or arthroscopic evaluation of human MFLs, or if they reported on an anatomical variant. These were then categorized as cadaveric, radiographic, or clinical. Biomechanical, radiographic, patient‐reported, and functional outcomes data were recorded. Results Forty‐seven studies were included in the qualitative analysis, and 26 of them were included in the quantitative analysis. Of these, there were 15 cadaveric, 3 arthroscopic, and 9 radiographic studies that reported on the prevalence of MFLs. Overall, when looking at all modalities, the presence of either the anterior or posterior MFL (aMFL, pMFL) has been noted to be 70.8%, with it being the aMFL 17.4% and the pMFL 40.6%. The presence of both ligaments occurs in approximately 17.6% of individuals. Eleven reported on mean MFL length and thickness. When evaluating mean length in both men and women, the aMFL has been reported between 21.6 and 28.3 mm and the pMFL length in this population is between 23.4 and 31.2 mm. Five reported on cross‐sectional area. Nine additional papers report anatomical variants. Conclusions This review shows that there continues to be a variable incidence of MFLs reported in the literature, but our understanding of their function continues to broaden. A growing number of anatomic and biomechanical studies have demonstrated the importance of the MFLs in supporting knee stability. Specifically, the MFLs serve an important role in protecting the lateral meniscus and augmenting the function of the posterior cruciate ligament. Clinical Relevance Our findings will aid the clinician in both identifying and treating pathologies of the meniscofemoral ligaments.

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.

Purpose To analyze recent trends in orthopaedic surgery consolidation and quantify these changes temporally and geographically from 2012 to 2020. Methods We performed a retrospective cross‐sectional analysis of orthopaedic surgeon practice size in the United States using 2012 and 2020 data obtained from the Physician Compare database. Results Although we observed an increase from 21,216 unique orthopaedic surgeons in 2012 to 21,553 in 2020 (1.6% increase), the number of practices experienced a large decrease from 7,299 practices in 2012 to 5,829 in 2020 (20.1% decrease). The proportion of orthopaedic surgeons working in solo practices decreased from 13.2% (2,790) in 2012 to 7.4% (1,595) in 2020, and the proportion of orthopaedic surgeons working in groups sized 2 to 24 decreased from 35.3% (7,482) in 2012 to 22.2% (4,775) in 2020. In contrast, groups sized 25 to 99 have grown from 20.7% (4,387) of all orthopaedic surgeons to 23.4% (5,048) in 2020. Groups sized 100 to 499 have increased from 16.9% (3,593) in 2012 to 24.1% (5,190) in 2020, whereas groups sized 500 or greater have grown from 14% (2,964) in 2012 to 22.9% (4,945) in 2020. The number of unique group practices showed a significant decrease in the number of solo groups, which comprised 43.8% (3,200) of the total number of individual practices in 2012, decreasing to 32% (1,886) in 2020. All other groups increased in number and proportionally from 2012 to 2020. Conclusions This study shows that over the period from 2012 to 2020, there has been a substantial trend of orthopaedic surgeons shifting to increasing practice sizes, potentially indicating that more orthopaedic surgeons are working for large health care organizations rather than small independent practices. Clinical Relevance The impact of these changes should be examined to determine large‐scale effects on patient care, payment models, access, and outcomes, along with physician compensation, lifestyle, and satisfaction.

Purpose To examine and characterize extremely negative Yelp reviews of orthopedic sports surgeons in the United States. Methods A search for reviews was performed using the keywords “Orthopedic Sports Medicine” on Yelp.com for 8 major metropolitan areas. Single‐star reviews were isolated for analysis, and individual complaints were then categorized as clinical or nonclinical. The reviews were classified as surgical or nonsurgical. Results A total of 11,033 reviews were surveyed. Of these, 1,045 (9.5%) were identified as 1‐star, and 289 were ultimately included in the study. These reviews encompassed 566 total complaints, 133 (23%) of which were clinical, and 433 (77%) of which were nonclinical in nature. The most common clinical complaints concerned complications (32 complaints; 6%), misdiagnosis (29 complaints; 5%), and uncontrolled pain (21 complaints; 4%). The most common nonclinical complaints concerned physicians’ bedside manner (120 complaints; 21%), unprofessional staff (98 complaints; 17%), and finances (78 complaints; 14%). Patients who had undergone surgery wrote 47 reviews that resulted in 114 complaints (20.5% of total complaints), whereas nonsurgical patients were responsible for 242 reviews and a total of 452 complaints (81.3% of total complaints). The difference in the number of complaints by patients after surgery and patients without surgery was statistically significant ( P < 0.05) for all categories except for uncontrolled pain, delay in care, bedside manner of midlevel staff, and facilities. Conclusion Our study of extremely negative Yelp reviews found that 77% of negative complaints were nonclinical in nature. The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. Only 16% of 1‐star reviews were from surgical patients. Clinical Relevance Patients use online review platforms when choosing surgeons. A comprehensive understanding of factors affecting patient satisfaction and dissatisfaction is needed. The results of our study could be used to guide future quality‐improvement measures and to assist surgeons in maintaining favorable online reputations.

Abstract Arthroscopy in the posterior knee continues to improve as new techniques arise. Traditionally, posterior techniques included posteromedial and posterolateral portals. Although frequently used, these techniques do have some limitations. We propose the use of dual posteromedial portals for complex arthroscopy cases to improve access and instrumentation in the posterior knee. Applications include, but are not limited to, resection of tumors or masses in the posterior knee, meniscal posterior horn repair, ramp lesion repair, repair of posterior cruciate ligament avulsions, and use as accessory portals for arthroscopic posterior cruciate ligament reconstruction. We describe a technique for establishing dual posteromedial portals for complex arthroscopy in the posterior knee, specifically in relation to a case of a posterior knee mass biopsy and resection. Technique Video video See video under supplementary data.

Purpose To analyze and objectively measure the trends in inflation‐adjusted Medicare reimbursement rates for the 20 most commonly performed orthopaedic arthroscopic surgical procedures from 2000 to 2019. Methods The Centers for Medicare & Medicaid Services website was used to find the top 20 most commonly performed arthroscopic procedures using the Public Use File data file for calendar year 2017. By use of the Physician Fee Schedule Look‐Up Tool, national reimbursement averages were calculated from 2000‐2019 and data were analyzed. Averages were adjusted for inflation using the Consumer Price Index. Current Procedural Terminology codes that did not exist in 2000 were unable to be analyzed in this study. Results When adjusted for inflation, Medicare reimbursement for the 20 most commonly performed arthroscopic procedures from 2000‐2019 has decreased substantially (–29.81%). The mean Medicare reimbursement to physicians was $906 in 2000 and $632 in 2019. During this same period, the annual change in the adjusted mean reimbursement rate for all included arthroscopic procedures was –1.8% whereas the average compound annual growth rate was –1.9%. Conclusions This study shows that when adjusted for inflation, Medicare reimbursement to physicians has decreased by nearly 30% during the past 20 years for the most common arthroscopic procedures. Clinical Relevance This analysis will give orthopaedic surgeons and hospital administrators a better understanding of the financial trends surrounding one of the fastest‐growing techniques in surgery. Additionally, these financial‐trend data will be increasingly important as the population in the United States continues to age and new payment models are introduced.

Purpose To discuss the surgical outcomes of patients identified to have the wave sign without an accompanying labral tear treated with and without stabilization of the chondrolabral junction in conjunction with femoral osteoplasty. Methods A retrospective study was performed in patients with cartilage delamination (wave sign) treated with femoral osteoplasty alone (FO group) or femoral osteoplasty with chondrolabral stabilization (CLS group). Patient‐reported outcomes including the modified Harris Hip Score, Hip Outcome Score (HOS)–Activities of Daily Living, and HOS–Sports‐Specific Subscale were obtained at a minimum of 2 years postoperatively. Other outcomes included rates of revision hip arthroscopy and conversion to hip arthroplasty. Results The study consisted of 47 patients in the FO group and 38 in the CLS group. Both groups showed significant increases in all patient‐reported outcomes over the study period compared with preoperative values. The final modified Harris Hip Score was 72.8 ± 9.2 in the FO group and 79.9 ± 9.3 in the CLS group ( P < .001). The HOS–Activities of Daily Living in the FO and CLS groups was 81.4 ± 10.3 and 87.2 ± 7.5, respectively ( P < .001). There was no difference in the HOS–Sports‐Specific Subscale between the FO group (74.4 ± 10.3) and the CLS group (78.0 ± 14.6) at final follow‐up ( P = .198). Revision hip arthroscopy was required in 5 patients in the FO group (13%) and 3 in the CLS group (6.3%). No patient in either group required conversion to hip arthroplasty throughout the study period. Conclusions Chondrolabral stabilization in conjunction with femoral osteoplasty is an effective treatment in patients with the wave sign without labral tears. Level of Evidence Level III, retrospective cohort study.

» In documenting a patient encounter, the orthopaedic evaluation consists of 3 key components: “History,” “Physical Examination,” and “Medical Decision-Making.” » The level of service coded must be supported by the complexity of the problem, the care provided, and the documentation of the encounter. » Determining whether the patient is new or established is the first step in the evaluation and management (E/M) process and relies on same-practice/same-specialty rules. » Careful attention must be paid to documentation and coding to allow for appropriate care of the patient and efficient use of the orthopaedist’s time. The available step-by-step guidelines include all necessary criteria to accomplish this. » Continue to monitor for the U.S. Centers for Medicare & Medicaid Services (CMS) changes to stay up-to-date on changes in the guidelines.

➢ The coronavirus disease 2019 (COVID-19) crisis has disrupted health care in the United States and globally, and the ability to treat patients as we did in the prepandemic environment has changed. The safety of patients and providers, the avoidance of unnecessary exposure, and the cancellation of elective procedures have prompted the use of telemedicine. In addition, many large institutions are without a functioning videoconferencing platform and the use of telephone visits has become essential. ➢ Several important changes have been made by the Centers for Medicare & Medicaid Services to facilitate ease of access to telemedicine during the COVID-19 pandemic, including alternate place of service codes, visit time associated with evaluation and management services, and new Current Procedural Terminology codes for virtual visits with new patients. ➢ Although telemedicine visits do not allow for a hands-on physical examination, it is prudent for the medical provider to understand and learn the breadth of examination that may take place through an audio and video (when possible)-enabled virtual visit.