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Objectives: To evaluate return-to-sport (RTS) rates and patient reported outcome measures (PROMs) following hip arthroscopy for femoroacetabular impingement (FAI) in active football players with a minimum of 5-years follow-up. Methods: All active football players who underwent hip arthroscopy for FAI from 2010-2019 were identified. Preoperative radiographic measures including lateral center edge angle, Tönnis angle, alpha angle, and acetabular depth were obtained. Patients were evaluated for post-operative RTS and revision surgery data at final follow-up. Modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), HOS Activities of Daily Living (HOS-ADL), HOS Sports Specific Subscale (HOS-Sports), Tegner Activity Scores, Visual Analogue Scale (VAS) for pain, and surgery satisfaction were collected at a minimum 5-year follow-up. Descriptive and comparative statistical analysis was performed using R software (version 4.4.1). Results: Sixty-six hips from 53 male patients were included. The mean age was 20.4 ± 6.4 years and mean BMI was 27.3 ± 6.6 kg/m² (Table 1). Mean follow-up was 8.7 ± 2.8 years. The majority (60%) were high school players and 19% were college players. Figure 1 displays the most commonly affected positions which included wide receiver (32%), defensive lineman (26%), and tight end or offensive lineman (16%). There were 11 bilateral cases and 2 revisions. The mean lateral center edge angle was 31.6º ± 6.4, the mean Tönnis angle was 5.0º ± 5, and the mean alpha angle was 63.2º ± 12.7. There was significant improvement in all PROMs from baseline to a minimum 5-year follow-up (p<0.04). Fifty-four percent of athletes returned to football postoperatively and the average overall surgery satisfaction rating was 8.1/10. Among those who didn’t return, 14% cited hip-related reasons, while 67% cited non-hip related reasons such as priorities changing or graduating (Figure 2). Athletes who returned to football had significantly higher mean HOS-ADL (p=0.049), HOS-Sport (p=0.042), and Tegner level before surgery (p=0.023) compared to those who did not return (Table 2). Conclusions: Football players undergoing hip arthroscopy for FAI demonstrate significant improvements in outcome scores at a minimum 5-year follow-up with a moderate return-to-sport rate. Athletes who are able to return to football report higher patient reported outcomes compared to those who do not. Player position may also influence incidence and outcomes. Although football players demonstrate significant improvements following hip arthroscopy, the moderate RTS rates highlights the demanding nature of the sport and need for improved perioperative counseling.

Objectives: Periacetabular osteotomy (PAO) is utilized for the treatment of hip dysplasia, with a growing trend towards hip arthroscopy at the time of PAO or in a planned, staged manner prior to PAO in order to address intra-articular pathology such as labral tears. For patients with persistent or new pain following isolated PAO, a subset undergo unplanned, primary hip arthroscopy. To date, there is a paucity of available evidence regarding the risk factors for and outcomes of unplanned hip arthroscopy for persistent or new pain after PAO. The purpose of this study was to determine demographic and radiographic characteristics of patients undergoing hip arthroscopy for persistent pain after PAO and also to compare radiographic parameters, surgical characteristics, and postoperative PROMs between patients that underwent hip arthroscopy following PAO and a demographically similar group of controls without acetabular dysplasia that underwent primary hip arthroscopy. Methods: An institutional database of 3014 hip arthroscopies performed between 1988 and 2022 was reviewed for patients having undergone unplanned (i.e. non-staged) first-time hip arthroscopy after PAO. These patients were propensity-matched on a 1:2 ratio with demographically similar, non-dysplastic patients undergoing primary hip arthroscopy with labral repair. All patients were contacted at final-follow-up to collect outcomes including subsequent procedures, progression to THA, and patient-reported outcome measures (PROMs), including modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT), Tegner Activity Scores, Visual Analogue Scale (VAS) for pain, and surgery satisfaction. Demographics, radiographic characteristics, and postoperative outcomes were compared. All statistical analysis and Kaplan-Meier survival curve analysis was performed using R software (version 4.4.1). Results: We identified 22 hips in 21 patients (17 female, 4 male; age: 24.6 ± 8.5 years; BMI: 29.3 ± 7.4 kg/m²) who underwent first-time arthroscopy after ipsilateral PAO and were followed for a mean of 7.2 ± 2.8 years (Table 1). The median post-PAO LCEA was 28° (IQR: 24.6 – 31.7) and the mean Tönnis angle was 4.2° ± 5.9. The median time from the date of PAO to date of subsequent hip arthroscopy was 1.6 years (IQR: 1.1 - 3.4). Compared to the control group, there was a significantly lower rate of femoral osteochondroplasty (50% vs, 86%, p < 0.01), as well as trends towards lower rate of labral repair (77% vs. 95% p = 0.11), and higher rate of capsular repair (64% vs. 75%, p = 0.34). No differences were found between the PAO and control groups in any of the postoperative PROMs (Table 2). Among the PAO patients, 3 (20%) progressed to total hip arthroplasty (THA) compared to 1 (9%) in the control group (p=0.62). Conclusions: Hip arthroscopy after prior PAO was associated with postoperative improvements in pain and moderate rates of conversion to THA. When patients undergoing hip arthroscopy following PAO were compared to a demographically similar matched cohort of nondysplastic hips who underwent primary hip arthroscopy without a prior PAO, similar postoperative outcome scores were observed. This data provides valuable counselling information for clinicians discussing hip arthroscopy in the setting of patients with persistent pain following PAO.

Abstract Objective This study aims to better characterize the long‐term neurological quality of life (QOL) outcomes (using the Neuro‐QOL scale) in survivors of new onset refractory status epilepticus (NORSE), including its subtype febrile infection‐related epilepsy syndrome (FIRES), and provide guidance for psychological and social support strategies. Methods Utilizing data from a multicenter prospective study of NORSE/FIRES led by Yale University, we enrolled patients who completed the validated, patient‐reported Neuro‐QOL scale at least once at 3–6 months ( n = 37), 12 months ( n = 29), 24 months ( n = 23), or ≥36 months ( n = 9) following discharge. The Neuro‐QOL scale assesses physical, mental, and social health in patients with neurological disorders. QOL impairment (QOL‐I) scores were calculated, with higher scores indicating greater impairment. T ‐scores enabled comparisons with reference populations. Results In adults, median QOL‐I improved from 44.1% at 3–6 months to 37.6% at 36+ months. Paired analysis showed significant improvement in QOL‐I between 3–6 and 24 months ( p = .016), with specific improvements in communication, satisfaction with social roles, fatigue, and mobility. Greater improvement was also observed for participation in social roles (5.5‐point T ‐score gain) compared to the reference population, suggesting meaningful change. A gradual improvement in overall QOL‐I scores was also observed in pediatric participants, despite a modest sample size ( n = 5 with data at 3–6 and 12 months). Measures of fatigue and anxiety persisted in adults, and cognitive difficulties persisted in both adults and children. In adults, longer status epilepticus duration and intensive care unit stay were associated with poorer QOL. Additionally, a higher number of antiseizure medications was associated with more depression, cognitive impairments, and perceived stigma. Significance These findings highlight the potential for recovery following an acute episode of NORSE, although many patients continue to face challenges requiring ongoing support, and the clinical meaning of the reported QOL improvement remains unclear. Furthermore, the findings underscore the importance of strategic multidisciplinary support systems in the years following discharge.

Background: Treatment decisions in patients with anterior cruciate ligament (ACL) injuries are influenced by multiple factors, such as the desire to return to sports or symptomatic instability. Identifying the differential treatment effect of ACL reconstruction (ACLR) compared with nonoperative management on a patient-specific level can inform surgical decision-making. Hypothesis: Unsupervised machine learning can identify distinct patient subgroups based on outcome achievement after ACL injury, and ACLR will exert a protective effect on the development of posttraumatic osteoarthritis (PTOA) over nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: A longitudinal populational registry identified patients with ACL injuries from 1990 to 2016 with a minimum 7.5-year follow-up. An unsupervised random forest algorithm was utilized to develop and validate patient subgroups. Treatment effects of ACLR on outcomes were analyzed using a machine learning causal inference estimator. Patient subgroup membership was incorporated into a multivariable logistic regression to identify factors predictive of optimal outcomes. Results: A total of 923 patients (785 primary ACLR, 138 nonoperative) were included. The random forest algorithm arrived at an optimal partition of 2 subgroups, with 653 patients in the optimal outcome subgroup (368 male [56.4%]; mean age, 26.0 ± 10.2 years; mean body mass index [BMI], 26.5 ± 4.30) and 270 patients in the suboptimal outcome subgroup (152 male [56.3%]; mean age, 35.0 ± 10.1 years; mean BMI, 30.5 ± 5.54). The latter group demonstrated significantly increased rates of secondary meniscal injury, development of symptomatic PTOA, and progression to total knee arthroplasty (TKA) at the final follow-up (all P < .01). In the optimal outcome subgroup, ACLR had significantly protective treatment effects on the risk of secondary meniscal injury (average treatment effect [ATE], 61%), contralateral ACL injury (ATE, 8%), symptomatic PTOA (ATE, 16%), and progression to TKA (ATE, 6%) (all P < .01). Conversely, in the suboptimal outcome subgroup, ACLR only protected against symptomatic PTOA (ATE, 11%) and progression to TKA (ATE, 8%) (both P < .01). Conclusion: Two clinically meaningful subgroups were identified from retrospectively collected data and found to experience differential treatment responses after ACL injuries. ACLR decreased the rate of development of PTOA and TKA in both subgroups but was not as effective in preventing secondary meniscal injuries or contralateral ACL injuries in patients who were older, heavier, or had concomitant medial meniscus injuries.

Abstract Arthrofibrosis of the knee is a difficult‐to‐manage complication after meniscoligamentous knee injuries, traumatic injuries with articular extension, and surgeries to treat these conditions. Treatment protocols for the management of postoperative arthrofibrosis exhaust nonoperative therapies before proceeding to the operating room for lysis of adhesions (LOA). Although LOA restores range of motion in most cases, a recurrence of arthrofibrosis is possible when postoperative therapy protocols are not strictly followed. Limited treatment options exist in the setting of recalcitrant arthrofibrosis. Revision arthroscopic LOA may be performed in this scenario. This revision procedure places neurovascular anatomy in the posterior compartment at risk. Performing a posterior capsule release in the arthroscopic management of recalcitrant arthrofibrosis is challenging but important to optimize recovery of range of motion. This Technical Note and accompanying video present a stepwise approach to LOA that demonstrates a safe method for performing an arthroscopic posterior capsule release in these challenging cases. Technique Video video See video under supplementary data.

Abstract Hip chondral defects often are encountered at the time of hip arthroscopy and can result in substantial pain and dysfunction. With the evolution of cell‐based techniques, there is growing interest in single‐stage, arthroscopic treatment of such chondral lesions. Arthroscopic orthobiologic delivery remains technically challenging, given the constrained and concave nature of the acetabulum and the need to perform instrumentation taking into account nearby structures such as the articular surface, hip capsule, and labrum. In this Technical Note, we describe our preferred method for arthroscopic delivery of orthobiologics at the time of single‐stage cartilage repair, which allows for needle‐based transcapsular, translabral access of hip chondral defects for both the acetabulum and femoral head. Technique Video video See video under supplementary data.

Abstract Introduction: Periacetabular osteotomy (PAO) is a complex procedure historically requiring inpatient stay. There is increased emphasis for these to be performed on an outpatient basis by insurance companies. The purpose of this study was to investigate the proportion of various surgical listing classifications (outpatient, outpatient-overnight, inpatient), the incidence of subsequent denial/request for additional documentation for approval of inpatient stay, and to characterize the average length of stay (LOS) following PAO. Methods: A retrospective chart review was performed to identify all PAOs, performed by four participating surgeons, at a single academic institution over a two-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 amongst 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 average LOS was 1.9 ± 1.4 days with 55.7% (78/140) of PAOs staying two or more nights in the hospital. Only 6 PAOs (4.3%) went home the same day as surgery. Of the 115 PAOs listed as an outpatient-overnight, 53 (46.1%) converted to an inpatient stay. Conclusion: Over half of PAOs performed required inpatient stay beyond outpatient-overnight status. Preoperative peer-to-peer review for inpatient stay approval was modestly frequent (8% of inpatient listings), and all conversions to inpatient required additional service documentation to support status conversion. Understanding trends in postoperative hospitalizations and LOS might allow for better informed partnerships between surgeons and insurance companies creating more efficient pre-authorizations, billing practices, and expected patterns of patient care and discharge.

Abstract Background: Osteochondral allograft and autograft transplantation for femoral head defects have emerged as promising treatments for concomitant cartilage and subchondral bone injuries in young patients. The purpose of this study was to evaluate the clinical and radiological outcomes of patients who underwent osteochondral allograft or autograft transplantation for femoral head defects and access any risk factors that may lead to conversion to THA. Methods: All patients who underwent osteochondral allograft or autograft transplantation for femoral head defects were analyzed. All patients had symptomatic femoral head osteochondral defects identifiable on advanced imaging such as computed tomography or magnetic resonance imaging. 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). Additionally, patients were assessed radiographically preoperatively and at a final postoperative visit using anterior-posterior and lateral radiographs for osteoarthritis using Tönnis grading. Results: A total of 27 patients were included in this study (19 osteochondral allograft transplantation, 8 osteochondral autograft transplantation). The overall mean follow-up was 4.7 years. The average mHHS, HOS-ADL, HOS-SSS, and iHOT-12 for the allograft cohort were 86.7, 92.8, 81.4, and 79.0, respectively, while for the autograft cohort it was 87.6, 92.7, 83.1, and 82.0, respectively. For the allograft cohort, there were a total of 5 reoperations (26.3%) consisting of 4 THA at a mean of 1.9 years and 1 trochanteric osteotomy nonunion at 0.7 year. For the remaining allograft patients who did not undergo treatment failure, only one (6.7%) had radiographic osteoarthritis progression. None of the patients in the autograft cohort underwent THA. Overall, conversion to THA was 14.8%. Conclusion: Osteochondral allograft and autograft transplantation for femoral head defects demonstrated overall favorable clinical outcomes and conversion to THA at mean 5-year follow-up and should be considered for patients with focal femoral head defects.

Abstract Periprosthetic fractures of the lesser trochanter may migrate proximally and result in anterior mechanical irritation and impingement with hip flexion refractory to comprehensive conservative management. In such cases, patients may benefit from arthroscopic resection of the displaced lesser trochanteric fragment. We present a minimally invasive, arthroscopic approach with initial access through an air bursogram. This technique can be performed percutaneously, with standard access cannulas, without the need for additional disposable instrumentation or large cannulas. In such a way, reproducible arthroscopic instrumentation can be provided for safe and efficient fragment removal while remaining cognizant of the nearby medial neurovascular bundle. Technique Video video See video under supplementary data.

Abstract Meniscal root tears have been shown to significantly impact tibiofemoral mechanics and contribute to accelerated development of osteoarthritis. A common finding in conjunction with a meniscal root tear is extrusion of the meniscus. Meniscal extrusion is an independent risk factor for tibiofemoral cartilage loss and the progression of osteoarthritis. Meniscus centralization was first introduced to directly address extrusion alongside root repair techniques. To date, reported techniques for meniscus centralization generally involve anchoring the meniscus directly to the tibia in some fashion, which can limit the normal anatomic motion of the meniscus. We present a technique for meniscus centralization that aims to maintain natural meniscal motion by utilizing the meniscotibial ligaments. Technique Video video See video under supplementary data.