Citations

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.

Background: Patients with persistent symptomatic iliopsoas tendonitis following total hip arthroplasty may benefit from iliopsoas fractional lengthening. We present an arthroscopic approach utilizing an air bursogram that provides safe and predictable access to the iliopsoas tendon for efficient tendon lengthening without violating the capsule or unintentional instrumentation of the nearby medial neurovascular bundle. Indications: Arthroscopic iliopsoas fractional lengthening is indicated for patients with clinical evidence of symptomatic iliopsoas tendonitis following total hip arthroplasty and have no radiographic evidence of frank acetabular malpositioning. A diagnosis of iliopsoas tendinitis amenable to surgical management can be established with substantial but nondurable relief following image-guided anesthetic injection to the iliopsoas bursa. Technique Description: Under fluoroscopic guidance, an air bursogram is employed in the anatomic plane of the iliopsoas tendon to accurately identify its course. This allows for hip portal placement with precise subsequent instrumentation. This technique is preferred in the setting of postarthroplasty anatomy because it avoids capsular violation and the challenge of working in an altered anatomic space with a nearby, medially based neurovascular bundle. Results: Arthroscopic and endoscopic approaches to iliopsoas release have been shown to provide excellent functional and patient-reported outcomes in >85% of patients, and several studies have shown that an arthroscopic approach not only provides a less invasive technique but also results in comparable or improved clinical outcomes with lower revision rates compared to open release or acetabular cup revision. Our technique for arthroscopic iliopsoas fractional lengthening using the air bursogram is both safe and reproducible and offers distinct advantages, including maintenance of an intact capsule, visual confirmation of the correct anatomic structure to be released, and percutaneous access with standard arthroscopic access cannulas without the need for hip distraction. Conclusions: Arthroscopic fractional iliopsoas lengthening is a minimally invasive and successful treatment option for patients with persistent groin pain after total hip arthroplasty, especially without substantial acetabular component malpositioning. This technique includes using an air bursogram to safely identify and navigate to the iliopsoas tendon without violating the hip capsule, thereby reducing the risk of inadvertent instrumentation of adjacent critical neurovascular structures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. Purpose: To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. Results: A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Conclusion: Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.

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.

Background There is a paucity of literature analyzing data for return to sport (RTS) and return to work (RTW) in the setting of direct anterior approach (DAA) total hip arthroplasty (THA). Objective The aims of this systematic review are to identify existing literature and to aggregate rates of RTS/RTW following DAA THA in a meta-analysis. Methods A query of major databases yielded 1819 initial studies. A random-effects model approach was implemented for meta-analysis. Moderator effects were assessed with respect to patient demographics and functional outcomes. Results Five studies reporting RTS after DAA THA were identified, representing a total of 204 patients with a mean age of 60.2±7.5 years and mean follow up of 31.8±9.5 months. Pooled rate of RTS was 76%(95% confidence interval [CI], 63%-86%;range 58%-100%). Pooled rate of return to the same sport was 77%(95%CI, 64%-86%;range of 62%-100%). Pooled rate of RTS to the same intensity was 58%(95%CI, 48%-68%;range of 41%-68%). Meta-regression demonstrated no significant correlations between independent variables and RTS characteristics. Three studies reported RTW rates. Rates of RTW within 3-months were 30%, 45%, and 60%. One study reported rate of RTW of 79% at 6-months and 87% at 12-months. One study demonstrated a mean time to RTW of 38±24.8 days. Conclusion Pooled rate of RTS is satisfactory following DAA THA and are comparable to rates of RTS aggregated without delineating surgical approach. Data supporting RTW rates following DAA THA limited, and thus more primary studies are needed to establish if this approach confers an advantage of faster RTS/RTW.

Background: The number of hip arthroscopies performed in the United States has grown significantly over the past several decades, with evolving indications and emerging techniques. Purposes: To (1) examine the evolution of hip arthroscopy at 3 tertiary referral centers between 1988 and 2022 and (2) quantify trends in patient demographics and procedures performed. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was performed of all patients undergoing hip arthroscopy at 3 academic centers between 1988 and 2022. Demographic data were collected using standardized forms and operative notes, and intraoperative images were manually reviewed for each patient to determine the specific procedures performed at the time of the hip arthroscopy. Surgical procedures were plotted over time to evaluate trends. Patients were divided into 3 time periods for comparison: early hip arthroscopy from 1988 to 2008, 2009 (the time of the first labral repair in our cohort) to 2015, and 2016 to 2022. Results: A total of 3000 patients (age, 35.7 ± 13.8 years; age range, 10-89 years; female sex, 2109 (70.3%); body mass index, 27.4 ± 6.3 kg/m 2 ) underwent arthroscopic hip procedures between 1988 and 2022. The mean number of cases increased from a mean of 3.2 per year in 1988-2008 to 285.9 per year in 2016-2022 ( P < .001). Labral treatment at the time of primary hip arthroscopy evolved from 100% debridement and 0% repair in 1988-2008 to 5.0% debridement, 94.0% repair, and 1.0% labral reconstruction in 2016-2022 ( P < .001). Cam resection increased from 4.1% in 1988-2008 to 86.9% in 2016-2022 ( P < .001). By 2022, 45 out of 325 cases (13.8%) were revisions. The rate of capsular repair at the time of primary hip arthroscopy increased from 0.0% in 1988-2008 up to 81.0% in 2016-2022. Conclusion: There has been a significant growth of hip arthroscopy volumes as well as a significant transition from use as a tool for diagnosis and labral debridement to procedures restoring native anatomy including labral repair, cam resection, capsular repair, periacetabular osteotomy, and gluteal repair.

Abstract As the prevalence of hip arthroscopy increases, hip capsular defects are increasingly recognized as a source of recurrent symptoms in the young athletic hip. The hip capsule is of substantial importance in providing joint stability and normal biomechanics. Several recent studies have demonstrated 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. Similarly, capsular insufficiency has been shown to be a source of recurrent pain and microinstability. Arthroscopic hip capsular management in the setting of chronic defects can be technically challenging, and far medial defects along the iliopsoas bursa are historically difficult to successfully repair because of challenging access and common lack of a proximal cuff of tissue for repair. We present an effective method for arthroscopic management of far medial hip capsular defects that consistently allows for reproducible capsular repair even in the absence of proximal capsular tissue. Technique Video video See video under supplementary data.

Objectives: The microvasculature of the human meniscus has been previously described by Arnoczky and Warren. However, to date the qualitative and quantitative extra-articular vascular anatomy of the medial meniscus has not yet been characterized. Therefore, the purpose of our study was to perform a qualitative and quantitative anatomic study of the extra-articular medial meniscal vasculature and to introduce the novel “medial meniscal artery” (MMA), potentially providing future guidelines for the treatment of meniscal pathology. Methods: Thirty-three unpaired frozen human cadaveric knees were dissected. The popliteal artery was identified and cannulated with an angiocatheter. The arteries were perfused with a red acrylic paint solution allowing for improved visualization. Artery dimensions and distances were measured using a digital caliper. Perfused specimens were imaged with Computed Tomography scanning and segmented using software to identify vessels and repeat artery measurements. Results: The MMA was consistently identified in all specimens. In 26 of 33 (82%) specimens, the MMA branched directly from the popliteal artery, while in 6, the MMA shared a common trunk with the inferior medial genicular artery (IMGA). The MMA was easily distinguishable from the superior MGA, inferior MGA, and MGA, given its direct course to the medial joint line with terminal branches to the posterior horn of the medial meniscus and deep to the semimembranosus tendon. The MMA exhibited a consistently smaller vessel diameter relative to the genicular arteries. Conclusions: This is the first study identifying and quantitively describing the MMA in the human knee. The MMA can be identified consistently on gross anatomic dissection in patients of varying demographics. The findings of this study will provide future avenues of study toward understanding the medial meniscus vascularization and the genesis of potential degenerative changes when vascularization is poor. This will help to further refine diagnostic and treatment options for meniscus revascularization and compartment preservation. Additionally, this study may help define safe zones in the knee during posterior approaches, as well as furthering the base of knowledge for emerging vascular procedures such as genicular artery embolization. Further research is needed to identify and characterize the artery in vivo and to determine the MMA’s role in meniscus preservation.

Background: Arthroscopic diagnosis and treatment of femoroacetabular pathology has experienced significant growth in the last 30 years; nevertheless, reduced utilization of orthopaedic procedures has been observed among the underrepresented population. Purpose/Hypothesis: The purpose of this study was to examine racial differences in case incidence rates, outcomes, and complications in patients undergoing hip arthroscopy. It was hypothesized that racial and ethnic minority patients would undergo hip arthroscopy at a decreased rate compared with their White counterparts but that there would be no differences in clinical outcomes. Study Design: Cross-sectional study. Methods: The State Ambulatory Surgery and Services Database and the State Emergency Department Database of New York were queried for patients undergoing hip arthroscopy between 2011 and 2017. Patients were stratified into White and racial and ethnic minority races, and intergroup comparisons were performed for utilization over time, total charges billed per encounter, 90-day emergency department (ED) visits, and revision hip arthroscopy. Temporal trends in the utilization of hip arthroscopy were identified, and racial differences in secondary outcomes were analyzed with a semiparametric method known as targeted maximum likelihood estimation (TMLE) backed by a library of machine learning algorithms. Results: A total of 9745 patients underwent hip arthroscopy during the study period, with 1081 patients of minority race (11.1%). White patients underwent hip arthroscopy at 5.68 (95% CI, 4.98-6.48) times the incidence rate of racial and ethnic minority patients; these incidence rates grew annually at a ratio of 1.11 in White patients compared with 1.03 in racial and ethnic minority patients ( P < .001). Based on the TMLE, racial and ethnic minority patients were significantly more likely to incur higher costs ( P < .001) and visit the ED within 90 days ( P = .049) but had negligible differences in reoperation rates at a 2-year follow-up ( P = .53). Subgroup analysis identified that higher likelihood for 90-day ED admissions among racial and ethnic minority patients compared with White patients was associated with Medicare insurance ( P = .002), median income in the lowest quartile ( P = .012), and residence in low-income neighborhoods ( P = .006). Conclusion: Irrespective of insurance status, racial and ethnic minority patients undergo hip arthroscopy at a lower incidence and incur higher costs per surgical encounter.

Abstract Osteochondromas are benign bone tumors that result in an osseous projection along with a hyaline cartilage cap that most commonly form around the knee. Typically, they are asymptomatic, however with continued growth, symptoms may arise such as pain, mechanical symptoms, or neurovascular compression due to contact with neighboring structures resulting in the need for surgical management. The presented arthroscopic technique described herein is a safe, effective, and reproducible method for excision of benign, metaphyseal, distal femoral osteochondromas. Technique Video video See video under supplementary data.