Hassebrock, Jeffrey D.

Purpose To evaluate the rates of lateral femoral cutaneous nerve (LFCN) injury in patients who underwent a direct anterior approach (DAA) total hip arthroplasty (THA) with and without previous hip arthroscopy. Methods We retrospectively investigated consecutive DAA THAs performed by a single surgeon. These cases were grouped into patients with and without a history of previous ipsilateral hip arthroscopy. LFCN sensation was assessed during the initial follow‐up (6 weeks) and 1‐year (or most recent) follow‐up visits. The incidence and character of LFCN injury was compared between the 2 groups. Results In total, 166 patients underwent a DAA THA with no previous hip arthroscopy, and 13 had a history of previous arthroscopy. Of the 179 total patients who underwent THA, 77 experienced some form of LFCN injury at initial follow‐up (43%). The rate of injury for the cohort with no previous arthroscopy was 39% (n = 65/166) on initial follow‐up, whereas the rate of injury for the cohort with a history of previous ipsilateral arthroscopy was 92% (n =12/13) on initial follow‐up ( P < .001). In addition, although the difference was not significant, 28% (n = 46/166) of the group without history of previous arthroscopy and 69% (n = 9/13) of the group with a history of previous arthroscopy had continued symptoms of LFCN injury at most recent follow‐up. Conclusions In this study, patients who underwent hip arthroscopy before an ipsilateral DAA THA were at increased risk of LFCN injury compared with patients who underwent a DAA THA without a previous hip arthroscopy. At final follow‐up of patients with initial LFCN injury, symptoms resolved in 29% (n = 19/65) of patients with no previous hip arthroscopy and 25% (n = 3/12) of patients with previous hip arthroscopy. Level of Evidence Level III, case–control study.

Purpose To compare the 5‐year clinical and functional outcomes of the soft‐tissue quadriceps tendon (QT) with those of the hamstring tendon (HT) autograft. Methods A retrospective review of patients undergoing anterior cruciate ligament reconstruction using either soft‐tissue QT or double‐tendon HT autograft with at least 5 years of follow‐up was conducted. Surgical technique included anteromedial portal creation for the femoral tunnel and transtibial technique for the tibia. Graft fixation was achieved with interference composite screws for the QT and combination of interference composite screw and suture button for the HT cohort. The 2 groups were compared for differences in outcomes, including International Knee Documentation Committee (IKDC) score, Lysholm score, return to sport, and complications. Results A total of 37 patients with QT autograft and 46 HT autografts were included in the study, with a mean follow up of 69.9 months and 70.9 months, respectively. The QT group demonstrated a larger graft size on average (9.64 mm vs 7.90 mm, P < .001). The IKDC and Lysholm scores were similar between the 2 groups at 2‐years’ postoperatively. At 5 years’ postoperatively, the QT group demonstrated significantly greater IKDC ( P = .018) and Lysholm ( P = .007) scores. The cohorts demonstrated similar rates of achieving minimal clinically important difference thresholds at both 2 and 5 years’ postoperatively. The 2 groups also demonstrated comparable rates of return to sport, time to return, and postoperative complications. Conclusions Although the QT autograft demonstrated increased patient‐reported outcome scores when compared with the HT at 5 years’ postoperatively, there was no clinically significant difference between the cohorts at 2 or 5 years’ postoperatively. The QT autograft is an effective alternative to HT autograft with noninferior results to the HT autograft at mid‐term follow‐up. Level of Evidence III, retrospective comparison study.

Purpose To investigate the characteristics of shoulder and elbow fellowship directors (FDs). Methods FDs for shoulder and elbow fellowship programs in the United States were identified. Demographic, educational, and professional background data were collected from available curricula vitarum, institutional biographies, and the Scopus database. Data collected included age, sex, race/ethnicity, training locations, graduation years, advanced degrees, current institutional information, and personal research H‐index. Results Thirty current orthopaedic shoulder and elbow FDs were identified. The mean Scopus H‐index was 25.5. The mean age of FDs was 52.1 years. In total, 29 FDs (96.7%) were male and 1 (3.3%) was female. In addition, 25 of the 30 (83.3%) were White (83.3%), 4 were Asian, and 1 (3.3%) was Hispanic. Two (6.7%) had a military affiliation. Mean time from fellowship training graduation to FD appointment was 13.5 years. Mean number of years as FD was 6.1 years, whereas the number of years tenure with an FD‐affiliated institution was 13.0 years. Mean calendar years for completion of orthopaedic residency training and fellowship training were 1998 and 2000, respectively. The residencies that produced the most future FDs were Hospital of the University of Pennsylvania (n = 2) and University of Nebraska Medical Center/Creighton University Health Foundation (n = 2). The fellowship that produced the most future FDs was Columbia University (n = 6). Moderate correlation was found between age and Scopus H‐index (r = 0.48; P = .04) and years as FD and Scopus H‐index (r = 0.42; P = .03). Conclusions Women and minorities are under‐represented in leadership positions in shoulder and elbow surgery. Shoulder and elbow FDs have the highest H‐index of any subspecialty reported in the orthopaedic literature. Research productivity is an important qualification when considering the characteristics of shoulder and elbow FDs. Clinical Relevance Fellowship directors can have a profound influence on current and future orthopaedic surgeons. It is important to identify the traits that characterize current fellowship directors to have a better understanding of who we choose as leaders in our field.

Background: Social media and online resources have been used in graduate medical education for years. In addition to an official residency program website, many orthopaedic surgery programs have an established social media presence to interact, educate, and engage with prospective applicants. The role of social media in orthopaedic surgery has significantly expanded in recent years. Despite its increasing use, the specific impact of social media on orthopaedic surgery residency applicants remains unknown. Methods: Applicants to the home institution's orthopaedic surgery residency program were sent an optional online survey during the 2020 to 2021 application cycle. No incentive was provided in exchange for participation. Results: Of 812 orthopaedic surgery applicants, 650 (80%) completed the survey. Program-based social media is widely accessed by applicants. Instagram is used by most applicants (61.9%), and nearly a third (28.7%) rely on it as their main resource when researching prospective residency programs. The majority (66.9%) agreed that social media can be successfully used to inform and interact with applicants. Most of the applicants (60.6%) also reported that social media had a positive impact on their perception of the associated program. Only 5.7% of respondents indicated that social media had a negative influence. The most effective uses of social media seem to be in allowing a program to display its culture and transparency. Conclusion: Social media plays a substantial role in the orthopaedic surgery residency application process, and its use continues to grow. Programs can use it to effectively engage with and inform prospective applicants. The impact of social media is positive on most of the applicants. Instagram is the preferred social media platform used by applicants, and nearly one-third rely on it as their main resource when researching programs. Investing time and resources into a social media presence seems to be a worthwhile pursuit for orthopaedic surgery programs as an important piece to a well-rounded recruitment effort of modern orthopaedic surgery applicants.

Abstract Recurrent instability associated with glenoid bone loss is a commonly encountered problem after anterior shoulder dislocation. Surgical management with bony augmentation can be achieved with several allograft or autograft options. Fixation strategies also vary, including screw, suture button, or suture anchor fixation. Concerns exist regarding screw fixation because of the technical difficulty of a medial portal establishment, as well as the potential for graft osteolysis. Suture button fixation for osteochondral graft fixation has been previously described. However, no description of graft fixation using suture anchors exists. We describe an arthroscopic technique for glenoid augmentation using distal tibial allograft with suture anchor fixation. Technique Video video See video under supplementary data.

Background: Although there is some evidence that cannabinoid (CBD) products may provide a therapeutic effect for musculoskeletal pain, little is known about the usage patterns or their prevalence of use in orthopaedic sports medicine patients. Purpose: To report the prevalence and perceived self-efficacy of CBD products in patients evaluated in an orthopaedic sports medicine clinic. Study Design: Descriptive epidemiology study. Level of evidence, 2. Methods: The study population consisted of new patients who visited an orthopaedic surgery sports medicine clinic at a large academic center for consultation with a surgeon between August 2020 and March 2021. All patients were asked to complete a survey that assessed perceived pain and effectiveness of CBD products and other nonsurgical treatment modalities using the Single Assessment Numeric Evaluation score (range, 0-100) and the Numeric Pain Rating Scale (NRS). Descriptive factors were collected via chart review. Descriptive statistics were used to characterize the data. Results: Overall, 823 patients completed the survey (45.4% female; mean age, 51 years [range, 18-87 years]; mean body mass index, 28.9 [range, 17.2-58.4]). Body areas involved included 285 shoulders, 44 elbows, 76 hips, 276 knees, 58 ankles, and 77 other. Of these patients, 19% (152/823) endorsed the use of CBD products before their initial evaluation. The mean NRS for pain was significantly different between non-CBD users and CBD users (5.6 vs 6.1; P = .029). CBD users were significantly more likely to have tried other nonoperative modalities compared with nonusers, including nonsteroidal anti-inflammatory drugs (79.6% vs 69.8%; P = .032), bracing (44.7% vs 34.6%; P = .024), steroid injections (38.8% vs 21.6%; P < .001), and physical therapy (54% vs 36.1%; P < .001). In addition, 30.9% of CBD utilizers reported marijuana use compared with 2.8% of non-CBD users ( P < .001) for management of their pain. Conclusion: In the current study, 19% of patients had used CBD products to manage joint-related issues. Sports medicine providers should be aware of this high incidence of usage and the potential interactions CBD products may have with other treatment modalities. Further studies are needed to assess the effectiveness of CBD as a therapeutic agent and the specific interactions it has with other drugs and other forms of treatment.

Purpose To use the National Collegiate Athletic Association Injury Surveillance Program (NCAA‐ISP) from the 2009‐2010 through the 2014‐2015 seasons to report lumbar spine injury rates, characteristics, and time lost from sport in soccer players. Methods Characteristics of lumbar spine injuries by season, competition/practice, and time lost from sport were determined using the NCAA‐ISP database. Rates of injury were calculated as the number of injuries divided by the number of athlete exposures (AEs). AEs are any athlete participation in a competition or practice. Incidence rate ratios (IRRs) were calculated to compare rates between event types and time of season. Injury proportion ratios (IPRs) were used to evaluate differences in injury rates between men and women. Results The NCAA‐ISP estimated 4,464 LSIs over 5 years. The rate of LSI in men was 2.1/10,000 AEs and 3.0/10,000 AEs in women. Women were 1.43 times more likely to suffer an LSI compared to men. Women were 2.15 times as likely to suffer an LSI in competition compared to in practice while men were 1.10 times as likely. Women were 2.15 times as likely to be injured in the preseason compared to the regular season, while men were 3.76 times as likely. Non‐contact injuries were the most common cause of lumbar spine injuries (LSIs) in men (35%); however, contact injuries were more common in women (33%). Most athletes both male (57%) and female (59%) returned to play within 24 hours. Conclusion This study provides information on the characteristics of LSIs in NCAA soccer. The overall injury rate to the lumbar spine is relatively low. Injury rates are highest in the preseason and in competition. Women suffer from more recurrent LSI’s than men, and men acquired more injuries through non‐contact mechanisms. More than one‐half of athletes returned to sport within 24 hours.

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm 2 (95% CI, 13.3-14.7 cm 2 ), while the mean area visible via an open approach was 2.1 cm 2 (95% CI, 0.5-3.6 cm 2 ). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

Purpose To examine and analyze Medicare reimbursement rates from 2000 to 2020 for orthopaedic foot and ankle procedures. Methods The 20 most used orthopaedic foot and ankle surgical procedures were gathered from the Centers for Medicare & Medicaid Services website using the Medicare Provider Utilization and Payment Data Public Use File 2017. The reimbursement data for each code were gathered from The Physician Fee Schedule Look‐Up Tool from Centers for Medicare & Medicaid Services. The reimbursement values were adjusted for inflation to 2020 U.S. dollars using the consumer price index. Results The average inflation‐adjusted reimbursement for included procedures decreased by 30% from 2000 to 2020. The greatest mean decreases were observed for “correction of hallux valgus” (–47%) and “partial excision of foot bone” (–41%). The procedures with the smallest mean decreases were observed in “treatment of “Amputation of toe” (–19%) and “closed treatment of metatarsal fracture” (–7%). Conclusions From 2000 to 2020, Inflation‐adjusted Medicare reimbursement for foot and ankle surgery decreased by 30%. Level of Evidence IV; economic analysis.

Background: In patients with femoroacetabular impingement, preoperative diagnostic injections are commonly used to establish a diagnosis of intra-articular pathology. In some cases, intra-articular steroid injections are also used for therapeutic purposes. Purpose/Hypothesis: The purpose of this study was to determine if a positive response to intra-articular steroid injection was predictive of superior outcomes after hip arthroscopy to determine if the response to intra-articular steroid injection was predictive of outcomes after hip arthroscopy. It was hypothesized that a positive response to a preoperative hip injection would be predictive of improved short- to midterm outcomes after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective study of 208 patients who elected to have ultrasound-guided intra-articular steroid injection before they underwent hip arthroscopy between January 2016 and December 2016. Patients were divided into 2 groups: those who showed improvement in pain after the injection (steroid responder group) and those who showed no response (nonresponder group). The authors compared the preoperative and 2-year postoperative patient-reported outcomes (modified Harris Hip Score [mHHS] and Hip Outcome Score–Activities of Daily Living [HOS-ADL]) and radiographic findings between groups. Clinical endpoints, including rates of revision and conversion to total hip arthroplasty, were also reviewed. Results: There were 88 patients in the nonresponder group and 120 patients in the responder group, with no significant between-group differences in preoperative descriptive variables. The responder group had significantly higher 2-year mHHS and HOS-ADL, pre- to postoperative change in mHHS and HOS-ADL, percentage of patients achieving the patient acceptable symptomatic state (PASS) on the mHHS, and percentage of patients reaching the minimum clinically important difference and the PASS on the HOS-ADL. There was no difference in Tönnis grade, acetabular labrum articular disruption grade, revision rate, or conversion to total hip arthroplasty between the 2 groups. Conclusion: The response to preoperative intra-articular injection did aid in predicting 2-year patient-reported outcomes of hip arthroscopy for femoroacetabular impingement. Overall, the result of a preoperative intra-articular injection can be a helpful clinical tool for surgical decision-making and counseling patients on expected outcomes after hip arthroscopy.