Citations

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA. Purpose: To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes. Results: A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years [range, 6.5-41.0 years]) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort ( P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients ( P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio [HR], 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01). Conclusion: At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.

Abstract Clinical recognition and surgical treatment of patellofemoral instability has evolved dramatically over the past 3 decades. However, few patellofemoral patients present with an isolated medial patellofemoral ligament (MPFL) tear. Rather, patients often demonstrate patella alta, increased tibial tubercle to trochlear groove (TT‐TG) distance, dysplasia, coronal malalignment, or combinations thereof. Given this, concomitant procedures such as tibial tubercle osteotomy (TTO) have become increasingly popularized, given their ability to anteriorize, medialize, and even distalize the patella to correct tracking. It is generally recommended that concurrent TTO be considered with primary medial patellofemoral ligament reconstruction (MPFLR) in patients with closed physes whose TT‐TG distance is larger than 17 to 20 mm. MPFLR + TTO is generally safe and may decrease risk of revision surgery when compared with isolated MPFLR in properly indicated patients. However, it important to measure both knee rotation angle and tibial tubercle lateralization on magnetic resonance imaging, as both factors influence TT‐TG. In patients in whom abnormal knee rotation angle is felt to be the primary driver of TT‐TG, surgeons should proceed with caution when considering concomitant TTO. The pen may be mightier than the sword, but the osteotome may be mightier yet than the scalpel.

Objectives: Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has been increasingly used in the past thirty years with interventions resulting in improved hip function and ultimate delay of hip arthroplasty in a minimally invasive manner. Unfortunately, previous investigations have observed decreased rates of access, utilization of, and outcomes following orthopedic interventions such as hip arthroplasty in underrepresented patients. The purpose of this study is to examine racial differences in procedural rates, outcomes, and complications in patients undergoing hip arthroscopy. Methods: The State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) of New York were queried for patients undergoing hip arthroscopy from 2011 to 2017. The primary outcomes investigated were utilization over time, total charges billed per encounter, 90-day emergency department visits, and revision hip arthroscopy. Patients were stratified into White and non-White race, and intergroup differences were evaluated with descriptive statistics. Subgroup analysis was performed with linear mixed-effects models to identify significant interactions between race and individual variables that contributed to any differences in the outcomes of interest. Temporal trends in utilization of hip arthroscopy and concomitant procedures between the two groups were analyzed with Poisson regression modeling. Finally, targeted maximum likelihood estimation (TMLE) was performed to provide nonparametric estimates of the specific differences in the outcomes studied using machine learning ensembles while controlling for patient risk factors. Results: A total of 9,745 patients underwent hip arthroscopy during the study period, with 1,081 patients of non-White race (11.9%). Results of Poisson regression demonstrated an annual increase of 1.11 in the incidence rate of hip arthroscopy among White patients, compared to 1.03 for non-White patients (p<0.001), with this disparity projected to increase by 2040. Based on TMLE utilizing an ensemble of machine learning models, non-White patients were significantly more likely to incur higher costs (OR: 1.30, 95% CI: 1.24-1.37, p<0.001) and visit the emergency department within 90-days (OR: 1.09, 95% CI: 1.01, 1.18, p=0.05), but had negligible differences in reoperation rates at 90 days to 2 years (OR: 1.13, 95% CI: 0.78-1.63, p=0.53). Subgroup analysis identified higher likelihood for 90-day emergency department admissions among non-White patients compared to White patients, which were significantly compounded by Medicare insurance (OR: 2.95, 95% CI 1.46-5.95, p=0.002), median income in the lowest quartile (OR: 1.84, 95% CI: 1.2-2.61, p=0.012), and residence in low-income neighborhoods (OR: 2.05, 95% CI: 1.31-3.2, p=0.006). Subgroup analysis for charges billed and reoperation did not identify significant findings. Conclusions: Hip arthroscopy remains an increasingly utilized surgical technique for the treatment of a myriad of hip disorders. Unfortunately, racial disparities exist and are worsening over time. Irrespective of insurance status, non-white patients undergo hip arthroscopy at a lower rate, incur higher costs, and more frequently experience unexpected returns to the emergency department. Improved initiatives to improve the disparity in access to and outcomes following hip arthroscopy must be addressed to further its utility for all patients.

Objectives: The purpose of this study was to assess return to play (RTP), patient-reported outcomes (PRO), and reoperation rates following patellofemoral stabilization surgeries (PSS) for recurrent patellar instability (RPI) in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of an RPI and subsequent PSS at a single institution between 2000 and 2020 were identified. Primary PSS ranged from MPFL reconstruction (n = 31; 50%) or MPFL repair (n = 22; 33.5%), and other PSS (n = 9; 14.5%) in the form of tibial tubercle osteotomy (TTO), lateral retinaculum release (LRR), and medial retinaculum reefing (MRR). Exclusion criteria included revision PSS, or concomitant anterior cruciate ligament reconstruction or multi ligament knee injury. All patients were contacted for determination of reinjury rates, current sport status, and PROs. Surgical failure defined as subsequent patellar dislocation despite operative management or need for secondary PSS. Results: Ultimately, 62 knees in 56 wrestlers were included at a mean follow-up time of 6.6 years (range, 2.0 – 18.8 years). RTP occurred in 55.3% of wrestlers at a mean of 8.8 ± 6.7 months. Among the PSS no differences were observed between rates of RTP (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). Recurrent patellar instability was the most common complication in 21% of knees. Among PSS types, MPFL reconstruction had the lowest rate of RPI (6.5% vs. 27.3% vs. 55.6%; P = .005), and surgical failure (9.7% vs. 31.8% vs. 55.6%; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared to MPFL repair and other PSS up to 10 years after the index surgery (90.3% vs. 64.1% vs. 27.8%; P = .048). Conclusions: Recurrent patellar instability remains a concern for competitive wrestlers after PSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared to other PSS up to 10 years after surgery. [Table: see text]

Objectives: Desirable outcomes following surgery for anterior shoulder instability (ASI) include a multitude of functional and clinical functions, yet it remains uncertain if all of these outcomes are simultaneously achievable (i.e. can patients have full motion and no instability; does excellent stability coincide with stiffness?). The purpose of this study was to employ unsupervised machine learning techniques to define the actual "optimal observed outcome” for patients undergoing surgical treatment for ASI and to identify predictors of obtaining this outcome. Methods: Patients <40 years with an initial diagnosis of ASI from 1994 -2016 were included. Four unsupervised machine learning clustering algorithms were evaluated to partition subjects into “optimal observed outcome” or “suboptimal outcome” based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan-Meier survival curves; multivariate stepwise logistic regression evaluated variable prognostic value. Results: 200 patients with a mean follow-up of 11 years were included. 146 (64%) obtained the “optimal observed outcome”, characterized by significantly (P <0.001) lower rates of: recurrent postoperative pain (23% vs 52%), recurrent instability (12% vs 41%), revision surgery (10% vs 24%), progression to osteoarthritis (OA) (5% vs. 19%), and mildly restricted motion (161° vs. 168°). Stepwise multivariate logistic regression identified time from initial instability to presentation (OR: 0.96, 95% CI: 0.92-0.98) and habitual instability (OR: 0.17, 95%CI: 0.04-0.77) as negative predictors of “observed optimal outcome”. Increased rate of subluxation over frank dislocation pre-operatively (OR: 1.30, 95% CI: 1.02-1.65) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusions: Following surgical treatment for ASI, an appropriate “optimal observed outcome” can be defined as: minimal postoperative pain, absence of recurrent instability, low rates of revision surgery, absence of OA, and increased ROM. This “optimal observed outcome” was achieved in over 2/3rds of the cohort and this work demonstrated the synergistic relationship of these. The most significant predictors included shorter time to presentation and history of subluxations over frank dislocations pre-operatively. This definition of the “optimal observed outcome” may be more appropriate for surgical decision making and setting appropriate expectations. [Table: see text][Table: see text]

Purpose The purposes of this study were to determine the incidence and key characteristics of meniscus injuries in professional baseball players, assess current treatment strategies, determine the return to play rates at any level (RTP) and at the same level (RSL), and identify prognostic factors that predict injury severity. Methods After approval from the Major League Baseball (MLB) Research Committee and our institutional review board, the MLB Health and Injury Tracking System was used to identify meniscus injuries occurring across MLB and Minor League Baseball (MiLB) from 2011 to 2017. Analyzed injuries occurred during normal baseball activity in a player who was active on an MLB or MiLB roster and resulted in at least 1 day missed. Results A total of 293 professional baseball players sustained 314 meniscus injuries from 2011 to 2017 (7 years) for a mean of 44.9 injuries/y. Pitchers were the most injured position (31.8%), followed by infielders (26.4%). Catchers and infielders missed the most median number of days (50 days). When comparing injuries to landing leg vs push‐off leg in pitchers, injury to the push‐off leg resulted in significantly more days missed per injury compared to the lead leg (59.6 vs 39.9 days, P = .048). Overall, RTP was 93.0%, while RSL was 84.4%. Conclusions Over 7 professional baseball seasons, 314 meniscus injuries occurred in 293 players. Pitchers and catchers were most injured, and overall, the number of meniscal injuries per year declined while the percentage of injuries that required surgery increased over time. High rates of RTP were observed. Level of Evidence Level IV, therapeutic case series.

Purpose To use unsupervised machine learning clustering to define the “optimal observed outcome” after surgery for anterior shoulder instability (ASI) and to identify predictors for achieving it. Methods Medical records, images, and operative reports were reviewed for patients <40 years old undergoing surgery for ASI. Four unsupervised machine learning clustering algorithms partitioned subjects into “optimal observed outcome” or “suboptimal outcome” based on combinations of actually observed outcomes. Demographic, clinical, and treatment variables were compared between groups using descriptive statistics and Kaplan‐Meier survival curves. Variables were assessed for prognostic value through multivariate stepwise logistic regression. Results Two hundred patients with a mean follow‐up of 11 years were included. Of these, 146 (64%) obtained the “optimal observed outcome,” characterized by decreased: postoperative pain (23% vs 52%; P < 0.001), recurrent instability (12% vs 41%; P < 0.001), revision surgery (10% vs 24%; P = 0.015), osteoarthritis (OA) (5% vs 19%; P = 0.005), and restricted motion (161° vs 168°; P = 0.001). Forty‐one percent of patients had a “perfect outcome,” defined as ideal performance across all outcomes. Time from initial instability to presentation (odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.92‐0.98; P = 0.006) and habitual/voluntary instability (OR = 0.17; 95% CI, 0.04‐0.77; P = 0.020) were negative predictors of achieving the “optimal observed outcome.” A predilection toward subluxations rather than dislocations before surgery (OR = 1.30; 95% CI, 1.02‐1.65; P = 0.030) was a positive predictor. Type of surgery performed was not a significant predictor. Conclusions After surgery for ASI, 64% of patients achieved the “optimal observed outcome” defined as minimal postoperative pain, no recurrent instability or OA, low revision surgery rates, and increased range of motion, of whom only 41% achieved a “perfect outcome.” Positive predictors were shorter time to presentation and predilection toward preoperative subluxations over dislocations. Level of Evidence Level IV, retrospective cohort.

Background: Medial meniscus posterior root tears (MMPRTs) cause pain and dysfunction and are associated with poor clinical outcomes with nonoperative management at short-term follow-up. However, little is known about the long-term natural history of these tears. Purpose: The purpose of this study was to (1) provide an update to a previous minimum 2-year study on the natural progression of these tears and (2) evaluate long-term patient-reported and radiographic outcomes. Study Design: Case series (prognosis); Level of evidence, 4. Methods: A retrospective review was performed on a cohort of patients with untreated MMPRTs, diagnosed between 2005 and 2013, who were followed clinically using International Knee Documentation Committee (IKDC), visual analog scale for pain, and Tegner activity scores as well as radiographically at a minimum 10-year follow-up. Failure was defined as conversion to arthroplasty or a severely abnormal subjective IKDC score <75.4. Results: Overall, 5 (10%) of the original 52 patients with minimum 2-year outcomes were subsequently lost to follow-up. The remaining 47 patients (21 male, 26 female) were followed for a mean of 14 ± 2 years (range, 11-18 years). At final follow-up, 25 patients (53%) had progressed to total knee arthroplasty, 8 (17%) were deceased, and 14 (30%) had not progressed to total knee arthroplasty. The mean IKDC and Tegner activity scores for the 14 patients with remaining MMPRTs were 51.6 ± 22.2 and 3.1 ± 1.1, respectively, and the mean visual analog scale score was 4.4 ± 3.0. Radiographically, the mean Kellgren-Lawrence grade progressed from 1.2 ± 0.7 at baseline to 2.6 ± 0.5 at final follow-up ( P < .001). At a minimum 10-year follow-up, 37 of 39 living patients (95%) had failed nonoperative treatment. Conclusion: Poor clinical and radiographic outcomes were associated with the nonoperative treatment of degenerative MMPRTs at long-term follow-up. This study provides a valuable update on the natural history and long-term prognosis of nonoperatively treated MMPRTs.

AbstractPurposeIdentifying predictive factors for all‐cause reoperation after anterior cruciate ligament reconstruction could inform clinical decision making and improve risk mitigation. The primary purposes of this study are to (1) determine the incidence of all‐cause reoperation after anterior cruciate ligament reconstruction, (2) identify predictors of reoperation after anterior cruciate ligament reconstruction using machine learning methodology, and (3) compare the predictive capacity of the machine learning methods to that of traditional logistic regression.MethodsA longitudinal geographical database was utilized to identify patients with a diagnosis of new anterior cruciate ligament injury. Eight machine learning models were appraised on their ability to predict all‐cause reoperation after anterior cruciate ligament reconstruction. Model performance was evaluated via area under the receiver operating characteristics curve. To explore modeling interpretability and radiomic feature influence on the predictions, we utilized a game‐theory‐based method through SHapley Additive exPlanations.ResultsA total of 1400 patients underwent anterior cruciate ligament reconstruction with a mean postoperative follow‐up of 9 years. Two‐hundred and eighteen (16%) patients experienced a reoperation after anterior cruciate ligament reconstruction, of which 6% of these were revision ACL reconstruction. SHapley Additive exPlanations plots identified the following risk factors as predictive for all‐cause reoperation: diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. XGBoost was the best‐performing model (area under the receiver operating characteristics curve of 0.77) and outperformed logistic regression in this regard.ConclusionsAll‐cause reoperation after anterior cruciate ligament reconstruction occurred at a rate of 16%. Machine learning models outperformed traditional statistics and identified diagnosis of systemic inflammatory disease, distal tear location, concomitant medial collateral ligament repair, higher visual analog scale pain score prior to surgery, hamstring autograft, tibial fixation via radial expansion device, younger age at initial injury, and concomitant meniscal repair as predictive risk factors for reoperation. Pertinent negatives, when compared to previous studies, included sex and timing of surgery. These models will allow surgeons to tabulate individualized risk for future reoperation for patients undergoing anterior cruciate ligament reconstruction.Level of evidenceIII.

Background: The extent to which recurrent patellar instability (RPI) affects wrestlers has not been thoroughly examined. Purpose: To assess return to wrestling (RTW), patient-reported outcomes, and reoperation rates after patellofemoral stabilization surgery (PFSS) for RPI in a cohort of competitive wrestlers. Study Design: Cohort study; Level of evidence, 3. Methods: All competitive wrestlers with a history of RPI and subsequent PFSS performed at a single institution between 2000 and 2020 were identified. Primary PFSS procedures included medial patellofemoral (MPFL) reconstruction (n = 31; 50%); MPFL repair (n = 22; 35.5%); or other PFSS (n = 9; 14.5%), such as tibial tubercle osteotomy, lateral retinacular release, and/or medial retinacular reefing. Exclusion criteria included revision PFSS or concomitant anterior cruciate ligament reconstruction or multiligament knee injury. Surgical failure was defined as subsequent patellar dislocation despite operative management or need for secondary PFSS. Results: Ultimately, 62 knees in 56 wrestlers with a mean age of 17.0 years (range, 14.0-22.8 years) were included at a mean follow-up of 6.6 years (range, 2.0-18.8 years). RTW occurred in 55.3% of wrestlers at a mean ± SD 8.8 ± 6.7 months. Among PFSS types, no differences were observed in rates of RTW ( P = .676), postoperative pain ( P = .176), Tegner activity level ( P = .801), International Knee Documentation Committee ( P = .378), Lysholm ( P = .402), or Kujala scores ( P = .370). RPI was the most common postoperative complication (n = 13; 21.0%). MPFL reconstruction had the lowest rate of RPI (6.5% vs 27.3% [repair] vs 55.6% [other]; P = .005) and surgical failure (9.7% vs 31.8% [repair] vs 55.6% [other]; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared with MPFL repair and other PFSS up to 10 years after the index surgery (90.3% vs 64.1% vs 27.8%; P = .048). Conclusion: RPI remains a concern for competitive wrestlers after PFSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared with other PFSS procedures at up to 10 years after surgery.