Citations

» 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.

Background: Hip arthroscopy has been shown to be effective in athletes who have femoral acetabular impingement and labral tearing. The effect of complete capsular closure versus nonclosure on return to play is unknown. Hypothesis: Complete capsular closure after hip arthroscopy would lead to a higher rate and faster return to sports in high-level athletes. Study Design: Cohort study; Level of evidence, 3. Methods: A nonrandomized retrospective review was performed of high school, collegiate, and professional athletes undergoing hip arthroscopy by a single high-volume hip arthroscopic surgeon. Athletes were divided into those undergoing complete capsular closure (CC group) and non–capsular closure (NC group) after hip arthroscopy. Rate and time to return to play were determined between the 2 groups. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were obtained at a minimum of 2 years. Results: A total of 111 athletes with a minimum 2-year follow-up were included in the study. There were 62 in the CC group and 49 in the NC group. A higher percentage of athletes in the CC group returned to play compared with that in the NC group (90.3% vs 75.5%, respectively; P = .03). The CC group returned to play at a mean ± SD of 4.7 ± 1.9 months compared with 5.8 ± 2.6 months in the NC group ( P < .001). Patients in the CC group met the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS patient-reported outcomes at higher percentages: mHHS, 98.3% vs 87.7% for CC vs NC, respectively ( P = .02); HOS-ADL, 98.3% vs 87.7% ( P = .02); and HOS-SSS, 96.7% vs 89.7% ( P = .13). The difference between groups was statistically significant for mHHS and HOS-ADL. Conclusion: Complete capsular closure after hip arthroscopy was associated with faster return to play and a higher rate of return compared with that of nonclosure of the capsule in this sample population of high-level athletes. At a minimum 2-year follow-up, complete capsular closure was associated with significantly higher patient-reported outcomes compared with those of nonclosure in athletes who underwent hip arthroscopy.

➢ 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.

Abstract Isolated patellofemoral arthritis is a common debilitating condition in adults older than 40 years of age. Surgical options such as patellofemoral arthroplasty exist for those who failed to respond to nonoperative treatment. However, early patellofemoral arthroplasty techniques often resulted in poor outcomes due to mal‐tracking and malalignment of components. Robotic‐assisted surgery recently has been introduced as an alternative to classic patellofemoral arthroplasty, with the potential to improve the anatomical fit and reproducibility of implant positioning. We present the technique for minimally invasive robotic‐assisted patellofemoral arthroplasty system. Technique Video video See video under supplementary data.

Background: Hip and groin injuries are common in competitive soccer players and have been shown to be significant sources of time loss. There are few studies describing the epidemiology of hip and groin injuries in female National Collegiate Athletic Association (NCAA) soccer players. Purpose: To describe the epidemiology of hip and groin injuries in women’s collegiate soccer players. Study Design: Descriptive epidemiology study. Methods: The NCAA Injury Surveillance System/Program (ISS/ISP) was analyzed from 2004 through 2014 for data related to hip and groin injuries in female collegiate soccer players. Injuries and athlete-exposures (AEs) were reported by athletic trainers. Data were stratified by time of season, event type, injury type, treatment outcome, time loss, and player field position. Results: Between 2004 and 2014, there were 439 recorded hip or groin injuries in female soccer players and an overall rate of injury of 0.57 per 1000 AEs. Injuries were 12.0 times more likely to occur during the preseason (4.41/1000 AEs) as opposed to during the regular season (0.37/1000 AEs) (injury rate ratio [IRR], 12.01; 95% confidence interval [CI], 9.92-14.55) or postseason (0.38/1000 AEs) (IRR, 11.55; 95% CI, 7.06-18.91). Rates of injury were similar during the regular season and postseason (IRR, 0.96; 95% CI, 0.59-1.58). Rates of injury were higher during competition (0.69/1000 AEs) than during practice (0.52/1000 AEs) (IRR, 1.33; 95% CI, 1.08-1.63). Most injuries were new (87.5%; n = 384) and unlikely to recur (12.5%; n = 55). Conclusion: Hip and groin injuries in female NCAA soccer players are uncommon, and fortunately, most players return to play quickly without recurrence. Future prospective studies should evaluate the effectiveness of strength and conditioning programs in preventing these injuries.

Background: Hip arthroscopy is a safe and effective mechanism for treating femoroacetabular impingement symptoms in high level athletes. Bilateral symptoms occur in a subset of this population. Purpose: To discuss outcomes of bilateral hip arthroscopy in high-level athletes and compare a standard staged timeline for bilateral hip arthroscopic surgery versus an accelerated timeline. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all staged bilateral hip arthroscopies was performed on high-level athletes over a 3-year period. Patients were categorized into cohorts based upon when the second procedure was performed (4-6 weeks after the index procedure or >6 weeks after the index procedure). Exclusion criteria included any prior hip surgery, advanced arthritis, previous pelvic or femoral fracture, or inflammatory arthropathy. Demographics, radiographic measurements, operative reports of procedures performed, and patient-reported outcomes (Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sport Specific Subscale, modified Harris Hip Score, return to sports, return to same level of play) were compared between groups at 6-month, 1-year, and 2-year intervals, with the Student t test used for continuous data and a chi-square test used for categorical data. Results: 50 patients were identified: 22 in the accelerated surgery (AS) group and 28 in the standard surgery (SS) group. Age and number of collegiate participants were greater in the AS group, whereas the number of high school participants and the time away from sports were higher in the SS group. Preoperative alpha angles were significantly larger among the AS group, but no differences were found in postoperative alpha angles, center edge angles, or Tönnis grades. No significant difference was seen in patient-reported outcomes between the 2 groups at 6-month, 1-year, and 2-year follow-up. Conclusion: Bilateral hip arthroscopy performed 4 to 6 weeks apart is a safe and effective treatment option for athletes with bilateral femoroacetabular impingement and labral tears; the procedures entail a high rate of return to sports, return to the same level of sports, and decreased time lost from sports. This information could be useful for an athlete deciding on whether to proceed with bilateral hip arthroscopy and deciding on the timing for the procedures.

Background: Capsular management during hip arthroscopy remains controversial. Studies evaluating this topic consist mostly of retrospective comparative reviews of prospectively gathered data on a large series of patients. Purpose/Hypothesis: The purpose was to perform a prospective randomized trial to comparatively assess 3 commonly performed capsular management techniques. It was hypothesized that capsular closure during hip arthroscopy would result in superior outcomes when compared with unclosed capsulotomy management techniques. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients (N = 150) who had hip arthroscopy with labral repairs and femoral osteoplasties performed by the senior author were randomly assigned into 3 groups at the time of their surgery: T-capsulotomy without closure (TC), interportal capsulotomy without closure (IC), and interportal capsulotomy with closure (CC). All patients underwent labral repair and femoral osteoplasty. Patient-reported outcomes were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Other outcomes obtained included the need for future hip surgery. Results: Patient demographics, preoperative patient-reported outcomes, and radiographic measurements were similar among all 3 groups. Revision hip arthroscopy was performed in 5 TC cases, 2 IC cases, and 1 CC case ( P = .17). Conversion to hip arthroplasty occurred in 4 patients in the TC group and none in the IC and CC groups ( P = .02). The CC group showed higher modified Harris Hip Score (mHHS) and Hip Outcome Score–Activities of Daily Living (HOS-ADL) at the 2-year follow-up when compared with the IC group ( P = .003 and P < .001, respectively). When compared with the TC group, the CC group demonstrated superior mHHS (86.2 vs 76), HOS-ADL (85.6 vs 76.8), and HOS-SSS (Hip Outcome Score–Sports-Specific Subscale; 74.4 vs 65.3) at the final 2-year follow-up ( P < .001). At the 2-year follow-up, the IC group had a higher mHHS (81.7 vs 76), HOS-ADL (82 vs 76.8), and HOS-SSS (71.4 vs 65.3; P > .001) as compared with the TC group. Conclusion: Patients undergoing complete capsular closure during hip arthroscopy showed improved patient-reported and surgical outcomes when compared with those with unrepaired T-capsulotomy or interportal capsulotomy. These results suggest that repair after capsulotomy may be a favorable arthroscopic capsular management technique.

Purpose The purpose of this investigation is to assess the incidence of rotator cuff tears in cases of calcific tendonitis and evaluate for differences in the incidences of rotator cuff tears by magnetic resonance imaging (MRI) between calcific lesions of different morphology, size, or location. Methods This single‐center study involved a retrospective chart review searching for patients from January 2010 to April 2017 with a diagnosis of calcific tendonitis of the shoulder based on review of all MRI reads done on patients with shoulder pain. Anteroposterior radiographic and MRI studies were reviewed by a musculoskeletal radiologist to assess calcific tendonitis morphology, size, distance from cuff insertion, and any rotator cuff tear. An additional radiologist evaluated calcific tendonitis size, morphology, and location to evaluate the reliability of these variables. Results In the final cohort of 318 shoulders with calcific tendonitis, the incidence of concomitant rotator cuff tears was 56%. Of all 177 tears, 164 (93%) were partial‐thickness and 13 (7%) were complete. Type III calcification morphology (cloudy with soft contour) was most frequently associated with rotator cuff tears and demonstrated an increased odds of tear by a factor of 1.8 (CI 95% 1.1‐2.9).There was no statistical difference regarding calcification size or location prognosticating rotator cuff tears or tear thickness. Intraclass correlation coefficients for calcification size, morphology, and location were 0.78, 0.30, and 0.50, respectively. Conclusions The incidence of rotator cuff tears in cases of calcific tendonitis in this cohort of patients who underwent MRI is higher than previously reported. Cloudy‐appearing calcified lesions showed a significant association with rotator cuff tears with an odds ratio of 1.8. Specific locations or sizes of calcified lesions do not appear to be reliable factors to predict concomitant rotator cuff tears. Interobserver agreement for these radiographic variables ranged from fair to substantial and prompt a cautious interpretation of these results. Level of Evidence IV Retrospective Case Series.

Purpose To define a distraction distance (pull length) cut‐off that would differentiate those patients with hip microinstability and those without the disorder, called the Pull‐Out Test. Methods In total, 100 consecutive patients undergoing hip arthroscopy were included in the study. Patients were separated into a hip microinstability group (HMI) and non‐hip microinstability group (NHI) based on the results of Beighton's score, the abduction–extension–external rotation test, hip extension–external rotation examination, and the prone instability test. Inclusion criteria were patients with an magnetic resonance imaging‐proven labral tear who did not respond to conservative treatment and underwent hip arthroscopy. Exclusion criteria included those patients undergoing revision hip arthroscopy, had a previous surgery on the ipsilateral hip, or had severe arthritis in the hip. The Pull‐Out Test was performed before surgery with the hip in 30° of abduction and the foot in 30° of external rotation. A blinded examiner places gross axial traction on the leg until a firm end point is reached. The distraction distance between the femoral head and acetabulum is the pull length. Results In total, 32 patients made up the HMI group whereas 68 patients were in the NHI group. The average pull length for the NHI group was 0.9 ± 0.1 cm and 1.7 ± 0.4 cm for the HMI group ( P < .001). Subtracting the standard deviation from the HMI group average, when defined a cut off for hip microinstability as 1.3 cm. Using this value, we found the Pull‐Out Test to have a sensitivity of 0.91 and specificity of 0.96. The positive predictive value for the Pull Test was 0.91 and the negative predictive value 0.97. Conclusions The Pull‐Out Test is a useful test in identifying and confirming the presence of hip microinstability in patients undergoing hip arthroscopy. A pull‐length of 1.3 cm or greater is consistent with the presence of microinstability with a specificity of 94% and a sensitivity of 96%. Level of Evidence Level IV, diagnostic, case‐control study.

Background: Lumbar spine injuries (LSIs) are common in both men’s and women’s National Collegiate Athletic Association (NCAA) basketball players and can frequently lead to reinjuries and persistent pain. Purpose: To describe the epidemiology of an LSI in collegiate men’s and women’s basketball during the 2009-2010 through 2013-2014 academic years. Study Design: Descriptive epidemiology study. Methods: The incidence and characteristics of LSIs were identified utilizing the NCAA Injury Surveillance Program (ISP). Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in 1 NCAA-sanctioned practice or competition. Incidence rate ratios (IRRs) were then calculated to compare the rates of injury between season, event type, mechanism, injury recurrence, and time lost from sport. Results: The NCAA ISP reported 124 LSIs from an average of 28 and 29 men’s and women’s teams, respectively. These were used via validated weighting methodology to estimate a total of 5197 LSIs nationally. The rate of LSIs in women was 2.16 per 10,000 AEs, while men suffered LSIs at a rate of 3.47 per 10,000 AEs. Men were 1.61 times more likely to suffer an LSI compared with women. In men, an LSI was 3.48 times more likely to occur in competition when compared with practice, while in women, an LSI was 1.36 times more likely to occur in competition than in practice. Women suffered the highest LSI rate during the postseason, while the highest rate in men was during the regular season. The majority of both female (58.9%; n = 1004) and male (73.1%; n = 2353) athletes returned to play within 24 hours of injury. Conclusion: To date, this is the largest study to characterize LSIs in NCAA basketball and provides needed information on the prevalence and timing of these injuries. The majority of injuries in both sexes were new, and most athletes returned to play in less than 24 hours. Injury rates were highest during competition in both sexes.