Citations

Background: Despite mounting clinical evidence for the utility of orthobiologics in nonoperative management of orthopaedic pathology, the market for orthobiologic therapies remains largely unregulated by the Food and Drug Administration, giving rise to a wide range of pricing for these therapeutics by different provider types. Purpose: To determine the availability and pricing for platelet-rich plasma (PRP), amniotic or adipose “stem cell,” and bone marrow aspirate concentrate (BMC) injections for the treatment of knee osteoarthritis among orthopaedic sports medicine and alternative providers (eg, chiropractic clinics and stand-alone “regenerative medicine” clinics) in a major metropolitan city. Study Design: Cross-sectional study. Methods: Orthopaedic sports medicine providers in the Chicagoland area were identified through the American Orthopaedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of North America (AANA) surgeon databases. Alternative clinics offering orthobiologic injections were systematically compiled using Yelp! and Google search listings and reviews. Clinics were contacted using a standardized telephone script. Data were collected for each site on the types of injections offered, whether price was disclosed over the telephone, the price of injections offered, and the source of stem cell injections if they were provided. Mann-Whitney U tests were used to compare the mean price between practices. F tests for equality of variances were used to compare the variability in prices between practice types. Results: A total of 25 unique orthopaedic sports medicine practices (comprising 80 AOSSM/AANA surgeons) and 40 alternative clinics offered PRP, stem cell, and/or BMC injections, as indicated over the telephone. There was no difference in likelihood of offering PRP ( P = .698) or BMC injections ( P = .340). However, alternative clinics were significantly more likely to offer stem cell injections ( P < .001). There was no difference in the willingness to disclose the price for PRP ( P = .269), stem cell injections ( P = .302), and BMC ( P = .528) or the source of what each clinic advertised as stem cell injections ( P = .630). The mean price for a single PRP injection was significantly higher ( P = .011) and significantly more variable ( F statistic = .139; P < .001) at alternative clinics. Similarly, the mean price for a single stem cell injection was significantly higher ( P < .001) and significantly more variable ( F statistic = 0.080; P = .025) at alternative clinics. Conclusion: This study demonstrates that orthobiologic knee injections are highly prevalent for in-clinic use within the Chicago metropolitan area, with PRP being the most commonly used therapeutic. When compared with orthopaedic sports medicine providers, alternative clinics were more likely to offer stem cell injections and charge a significantly greater and more variable amount per PRP and stem cell treatment.

Purpose To perform a prospective, double‐blind, randomized controlled trial to assess differences in integration and patient‐reported outcomes metrics (PROMs) of osteochondral allograft transplantation with and without bone marrow aspirate concentrate (BMAC) augmentation. Methods Patients (n = 36) undergoing osteochondral allograft transplantation of the knee were consented and enrolled in this prospective study. They were randomized to either iliac crest BMAC or sham incision groups and blinded to their allocation. Computerized tomography (CT) scans of the knee were obtained at 6 months postoperatively after the index transplantation and graded by the semiquantitative assessment CT osteochondral allograft system. PROMs, including the International Knee Documentation Committee and Knee injury and Osteoarthritis Outcome Score–Joint Replacement, were obtained at 6 months, 1 year, and 2 years postoperatively. Results On 6‐month postoperative CT scans, patients receiving BMAC‐treated grafts were more likely to have small cystic changes ( P = .01), with an associated trend toward reduction in large cyst formation ( P = .06), but equal osseous integration, graft signal density, and presence of discernible clefts and intra‐articular fragments. The BMAC group was less likely to undergo subsequent surgery for graft debridement or revision (5.3% vs 35.3%; P = .02). There were no significant differences in PROMs between the 2 groups preoperatively or postoperatively at 6 months, 1 year, or 2 years. Patients receiving BMAC trended toward a higher rate of achievement of Knee Documentation Committee and Knee injury and Osteoarthritis Outcome Score–Joint Replacement minimal clinically important difference (88% vs 55%; P = .076). Conclusions Patients receiving BMAC‐treated grafts were more likely to have small cystic changes and were less likely to undergo subsequent surgery for persistent or new symptoms after the index procedure. No difference in postoperative PROMs was shown at the 6‐month, 1‐year, and 2‐year follow‐ups between the 2 groups. Level of Evidence Level I, prospective, randomized controlled trial.

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.

Purpose To evaluate the differences in clinical outcomes and complication rates between open and arthroscopic iliopsoas (IP) tenotomy between 1998 and 2023 at our institution. Methods Patients who underwent arthroscopic iliopsoas fractional lengthening (IPFL) or open tenotomy for IP tendinitis following total hip arthroplasty (THA) between 1988 and 2023 were identified. Patients were excluded if they underwent revision IP tendon release, had additional concomitant procedures, or had less than a 24‐month postoperative follow‐up. Patient records were reviewed, and patient‐reported outcomes were collected via electronic survey. Results Fifty‐two patients (36 arthroscopic, 16 open) were followed for an average of 68.7 (24.0‐203.7) months. Overall surgery satisfaction was 7.9 (scale 0‐10) following arthroscopic IPFL and 6.0 following open tenotomy ( P = .178). Eighty‐six percent of patients reported improvement in their anterior groin pain following arthroscopic IPFL, compared to 45% following open tenotomy ( P = .065). In the arthroscopic cohort, 64% reported improved hip flexion strength, compared to 36% in the open cohort ( P = .158). Visual analog scale for pain at rest was lower following arthroscopic IPFL (1.1 ± 2.2 vs 3.3 ± 3.2, P = .0092), while pain with use did not differ between cohorts (3.1 ± 1.3 vs 2.6 ± 1.1, P = .786). There were no differences in postoperative Tegner (3.1 ± 1.3 vs 2.6 ± 1.1, P = .302), modified Harris Hip Score (77.0 ± 19.0 vs 69.2 ± 26.9, P = .073), or Single Assessment Numeric Evaluation (70.9 ± 28.7 vs 66.7 ± 31.8, P = .571) scores between arthroscopic and open cohorts. Revision THA rates did not differ following arthroscopic or open procedures (8.3% vs 25%, P = .104). Conclusions Patients have improved pain at rest following arthroscopic IPFL when compared to open tenotomy for IP tendinitis following THA. Overall complication and reoperation rates were low for both techniques. Level of Evidence Level III, retrospective cohort study.

Abstract As the prevalence of hip arthroscopy increases, management of capsular defects as well as capsulotomy closure has increasingly been recognized for their impact on recurrent symptoms in the young athletic hip. Several recent studies have shown that capsular closure at the time of primary hip arthroscopy improves both short‐ and long‐term patient‐reported outcomes, revision rates, and conversion to arthroplasty. Specifically, capsular insufficiency is a source of recurrent pain and microinstability. In this context, far medial labral tears pose a challenge for suture fixation, given the historic need of extending the interportal capsulotomy to obtain adequate trajectory for suture anchors and subsequent passage. Given the suboptimal stability consequences of extending the capsulotomy medially, here we present a novel approach for suture fixation of the medial labrum. This technique provides an effective method for suture fixation of the medial labrum, without necessitating extension of the interportal capsulotomy. Technique Video video See video under supplementary data.

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.

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 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.

» Femoroacetabular impingement (FAI) is the premature contact of the femoral head-neck junction with the superior acetabular rim during hip range of motion, which may further damage intra-articular soft tissue structures and lead to the accelerated development of osteoarthritis. » FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings, and is a common cause of hip pain in young patients that have a significant impact on patient hip-related function and quality of life. » The treatment of FAI syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy. For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term » In this article, we examine the available literature regarding the nonoperative treatment of FAI and provide insight into the effectiveness of current treatment modalities.

Abstract The ability of the knee to resist valgus stress is largely a result of the integrity of the superficial medial collateral ligament (MCL) and neighboring supporting structures (i.e., deep MCL, semimembranosus, and posterior oblique ligament). The MCL is known to have a robust healing capacity; consequently, the decision to proceed with operative versus nonoperative management of even grade III MCL tears is controversial. When it comes to operative management of these injuries, the decision to proceed with repair or reconstruction is nuanced because the chronicity and location of the MCL tear (i.e., proximal, midsubstance, or distal) largely determine which technique is appropriate. In distal MCL avulsions, including the so‐called Stener lesion, with good tissue quality, direct MCL repair has shown excellent mid‐term outcomes. Consequently, there is a growing need to understand different techniques to address MCL incompetence. In this article, we present a method for primary MCL repair using a washer post–suture post construct. Technique Video video See video under supplementary data.