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PURPOSE: To prospectively compare pain intensity and patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only. METHODS: Sixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n = 30) or control group (group C, n = 31). Two patients in group C were excluded because of miscommunication. All patients were administered 40 mg of parecoxib intravenously prior to induction of anesthesia. SSNB and ANB were performed after general anesthesia in group N, whereas no nerve block was performed in group C. Pain intensity was compared before surgery, as well as immediately, 24 hours, and 2 weeks after surgery. PROs, including the Oxford Shoulder Score, University of California-Los Angeles shoulder score, and Single Assessment Numeric Evaluation score, were compared before and 6 months after surgery. RESULTS: The numerical rating scale (NRS) score for resting pain was significantly lower in group N (4.9 ± 3.1 vs 7.6 ± 2.5, P < .001) immediately after surgery, but no difference was noted 24 hours after surgery. The resting pain NRS score 2 weeks after surgery was significantly lower in group N (1.4 ± 1.6 vs 2.7 ± 2.7, P = .03), but the scores for movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after surgery in both groups, but there was no difference between the 2 groups. CONCLUSIONS: The addition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after surgery. LEVEL OF EVIDENCE: Level II, prospective randomized controlled trial.

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BACKGROUND: Ultrasonographic structural abnormalities are regarded as one of the risk factors of elbow injuries. Elbow injuries are commonly associated with decreased shoulder/elbow range of motion (ROM). The purpose of this study is to determine the relationship between shoulder/elbow ROM and elbow ultrasonographic structural abnormalities in Taiwan high school baseball players. METHODS: A total of 533 Taiwan high school baseball players were enrolled. Physical examinations including measurements on shoulder/elbow ROM and elbow sonographic examinations were performed and recorded by professional physicians. The analyses were conducted in three subgroups according to their defensive position because the training programs were different. All players pooled, pitchers-only, and fielders-only, due to several demographic differences among these subgroups. In all the subgroups, univariate analyses were conducted separately for participants with and those without elbow ultrasonographic structural abnormalities, and then multivariate analyses were conducted to identify factors significantly related. The odds ratios (ORs) were used to estimate the risk of elbow ultrasonographic structural abnormalities. RESULTS: Demographic data showed that pitchers had taller body height (P < 0.001) and greater elbow flexion/extension ROM (P < 0.001). When all players were pooled, significant risk factors included started playing baseball at an younger age (OR = 1.202; 95% CI = 1.064-1.357; P = 0.003), longer experience of official baseball (OR = 1.154; 95% CI = 1.038-1.283; P = 0.008), lower total shoulder rotation angle (OR = 1.007; 95% CI = 1.000-1.014; P = 0.050), and less total elbow arm angle (OR = 1.052; 95% CI = 1.017-1.088; P = 0.003) For pitchers, significant risk factors included longer experience of official baseball (OR = 1.342; 95% CI = 1.098-1.640; P = 0.004), lower total shoulder rotation angle (OR = 1.016; 95% CI = 1.004-1.027; P = 0.006), and lower total elbow arm angle (OR = 1.075; 95% CI = 1.024-1.129; P = 0.004) (Table 5). There were no significant risk factors for elbow structural abnormalities in fielders. CONCLUSION: For Taiwan high school pitchers, longer official baseball experience, decreased shoulder total rotational angle, and decreased elbow total flexion/extension angle, were related to ultrasonographic structural abnormalities in elbows.

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BACKGROUND: The timing to start passive or active range of motion (ROM) after arthroscopic rotator cuff repair remains unclear. This systematic review and meta-analysis evaluated early versus delayed passive and active ROM protocols following arthroscopic rotator cuff repair. The aim of this study is to systematically review the literature on the outcomes of early active/passive versus delayed active/passive postoperative arthroscopic rotator cuff repair rehabilitation protocols. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) published up to April 2022 comparing early motion (EM) versus delayed motion (DM) rehabilitation protocols after arthroscopic rotator cuff repair for partial and full-thickness tear was conducted. The primary outcome was range of motion (anterior flexion, external rotation, internal rotation, abduction) and the secondary outcomes were Constant-Murley score (CMS), Simple Shoulder Test Score (SST score) and Visual Analogue Scale (VAS). RESULTS: Thirteen RCTs with 1,082 patients were included in this study (7 RCTs for early passive motion (EPM) vs. delayed passive motion (DPM) and 7 RCTs for early active motion (EAM) vs. delayed active motion (DAM). Anterior flexion (1.40, 95% confidence interval (CI), 0.55-2.25) and abduction (2.73, 95%CI, 0.74-4.71) were higher in the EPM group compared to DPM. Similarly, EAM showed superiority in anterior flexion (1.57, 95%CI, 0.62-2.52) and external rotation (1.59, 95%CI, 0.36-2.82), compared to DAM. There was no difference between EPM and DPM for external rotation, retear rate, CMS and SST scores. There was no difference between EAM and DAM for retear rate, abduction, CMS and VAS. CONCLUSION: EAM and EPM were both associated with superior ROM compared to the DAM and DPM protocols. EAM and EPM were both safe and beneficial to improve ROM after arthroscopic surgery for the patients with small to large sized tears.

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Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

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BACKGROUND: Posterior tibial plateau fractures can lead to significant posttraumatic instability if not treated properly. It remains unclear which surgical approach achieves better patient outcomes. The objective of this systematic review and meta-analysis was to assess postoperative outcomes in patients undergoing anterior, posterior, or combined approach for posterior tibial plateau fractures. METHODS: The PubMed, Embase, Web of Science, The Cochrane Library, and Scopus were searched for studies published before October 26, 2022, comparing anterior, posterior, or combined approaches for posterior tibial plateau fractures. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Outcomes included complications, infections, range of motion (ROM), operation time, union rates, and functional scores. Significance was set at p < 0.05. Meta-analysis was conducted with STATA software. RESULTS: In total, 29 studies with a total of 747 patients were included for quantitative and qualitative analysis. Compared with other approaches, the posterior approach for posterior tibial plateau fractures was associated with a better ROM and shorter operative time. The complication rates, infection rates, union time, and hospital for special surgery (HSS) scores were not significantly different between surgical approaches. CONCLUSIONS: The posterior approach for posterior tibial plateau fractures offers advantages such as improved ROM and shorter operative time. However, there are concerns regarding prone positioning in patients with medical or pulmonary comorbidities and indications in polytrauma cases. Further prospective studies are needed to determine the optimal approach for these fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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PURPOSE: Our study aimed to determine the impact of a novel technique of anesthesia administration on the clinical outcomes and complications in geriatric patients with severe systemic disease undergoing hip surgery. METHODS: We retrospectively identified patients aged > 65 years with severe systemic disease that was a constant of life [American Society of Anesthesiologists (ASA) IV] who underwent surgery for hip fracture between January 2018 and January 2020. The patients were divided into two groups: Group I [fascia iliaca compartment block plus propofol-based total intravenous anesthesia (FICB + TIVA)] and Group II [general anesthesia (GA)]. The primary outcomes were 30-day and 1-year mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, postoperative morbidity, Visual Analog Scale score, and consumption of analgesics. RESULTS: There was no significant difference in the 30-day mortality (5 vs. 3.8%, p = 0.85) and 1-year mortality (15 vs. 12%, p = 0.73) between the groups. Group I had significantly lower ICU requirements (p = 0.01) and shorter lengths of ICU stay (p < 0.001) and hospital stay (p < 0.001). Moreover, a smaller proportion of patients in Group I required postoperative morphine or oral opiates. CONCLUSION: Geriatric patients who underwent hip surgery under FICB + TIVA required fewer ICU admissions, shorter lengths of ICU and hospital stay, and had lesser postoperative opioid consumption than those who were under GA. Hence, we recommend the novel FICB + TIVA technique for hip fracture surgery in geriatric patients with poor general health status and high surgical risks (ASA IV).

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BACKGROUND: Sufficient distraction of the hip is the key to a safe central compartment (CC) approach in hip arthroscopy. However, an adequate distraction gap has not been scientifically identified. PURPOSE: To determine the sufficient amount of distraction that could predict a successful CC access as well as to identify the risk factors for a failed or difficult CC access. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients who underwent hip arthroscopy by a single surgeon between January 2018 and April 2019 were prospectively enrolled. We analyzed gaps of the hip on 4 C-arm fluoroscopic images: nondistraction, preoperative manual traction, preoperative maximal traction (without distension), and intraoperative maximal traction (at the end of CC procedures in a successful CC approach or after peripheral compartment procedures in a failed or difficult CC approach). A failed CC approach was defined as failure in introducing the anterolateral portal to the CC under arthroscopic control; a difficult CC approach was defined as the presence of an incomplete diagnostic round in the CC because of a small distraction. The amount of distraction was evaluated by the ratio of the distracted gap to the undistracted gap. Patients were classified into the successful CC access group (group 1) and the failed/difficult CC access group (group 2). The amount of distraction, demographic characteristics, and preoperative radiographic parameters were compared between the groups. RESULTS: A total of 240 patients were included in this study. Group 1 consisted of 205 patients (113 males and 92 females; mean ± SD age, 34.5 ± 11.4 years), and group 2 consisted of 35 patients (27 males and 8 females; age, 32.5 ± 11.2 years). The preoperative joint space width was not significantly different between group 1 (mean ± SD, 3.89 ± 0.83 mm) and group 2 (3.68 ± 0.68 mm). The ratio of the amount of distraction at lateral gaps under all traction conditions was significantly greater in group 1 compared with group 2 (1.50 ± 0.54 vs 1.26 ± 0.35, respectively, under preoperative manual traction; 2.84 ± 0.76 vs 2.03 ± 0.63 under preoperative maximal traction; 3.36 ± 0.96 vs 2.50 ± 0.79 under intraoperative maximal traction). An increase of the lateral gap by >2.2 times (P < .001) under preoperative maximal traction and by >2.7 times (P < .001) under intraoperative maximal traction could predict successful CC access. Male sex (odds ratio [OR], 2.94; P = .017) and increased lateral center-edge angle (OR, 1.08 for every 1° increase; P = .004) were significant risk factors for failed/difficult CC access. CONCLUSION: An increase of the lateral gap by >2.2 times during an unsterile traction test without joint distension could predict successful CC access. Male sex and increased lateral center-edge angle were risk factors for a failed or difficult CC access.

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Background: There is limited research investigating the diagnostic strength of 3-dimensional computed tomography (3D-CT) and multidirectional CT arthrography (CTA) for femoroacetabular impingement (FAI) and related hip lesions. Purpose: To evaluate the diagnostic strength of combined 3D-CT and CTA in patients with FAI and related hip lesions by comparing it with hip arthroscopic surgery findings. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: This study included patients who were suspected of having FAI and related hip lesions and who underwent a combination of 3D-CT and CTA and subsequent hip arthroscopic surgery between December 2013 and December 2017. The CT and intraoperative arthroscopic findings were recorded and compared. The sensitivity, specificity, and accuracy of 3D-CT for FAI and those of CTA for related hip lesions were calculated. Results: A total of 114 patients with 114 hips were included in our study. There were 101 patients with positive findings and 13 patients with negative findings for FAI (including cam, pincer, and combined morphology) according to 3D-CT. The sensitivity, specificity, and accuracy of 3D-CT for FAI were 91.58%, 57.14%, and 89.47%, respectively. The sensitivity, specificity, and accuracy of CTA for labral tears were 94.64%, 100.00%, and 94.73%, respectively. For acetabular cartilage defects, the sensitivity, specificity, and accuracy of CTA were 60.71%, 91.37%, and 76.31%, respectively. For femoral cartilage defects, the sensitivity, specificity, and accuracy of CTA were 82.22%, 76.81%, and 78.94%, respectively. Conclusion: The study results indicated that 3D-CT was able to provide excellent accuracy for FAI compared with hip arthroscopic surgery findings. In addition, multidirectional CTA demonstrated promising diagnostic strength for hip lesions such as labral tears and chondral defects.

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PURPOSE: In the setting of acetabular dysplasia, the increased translational motion of the femur may damage the labrum and cartilage, as well as stretch the capsule. The purpose of the study was to investigate the relationship between the acetabular coverage and the capsular stiffness by assessing the distension of anterior and posterior joint recesses on the hip computed tomography arthrography. METHODS: One hundred thirty-three patients (138 hips) with a median age of 36 years (range 18-50 years) who received the computed tomography arthrography for evaluation of nonarthritic hip pain in our institute between 2015 and 2017 were retrospectively reviewed. The maximal distance between the anterior/posterior capsule and the anterior femoral head-neck junction/posterior femoral head on the axial imaging of computed tomography arthrography was defined as the width of anterior/posterior joint recess. The width of anterior/posterior joint recess was adjusted with the diameter of the femoral head and was then compared between acetabular dysplasia (lateral center-edge angle < 25°), normal acetabulum (lateral center-edge angle between 25 and 39°), and deep acetabulum (lateral center-edge angle > 39°). In addition, the standard univariate linear regression analysis was used to investigate the relationship between the adjusted width of anterior/posterior joint recess and anterior/posterior coverage of the hip, determined by the anterior/posterior wall index. RESULTS: The adjusted width of posterior joint recess was significantly greater in the acetabular dysplasia group than the normal acetabulum and deep acetabulum groups (p < 0.01 and p = 0.02, respectively). There was no significant difference of the adjusted width of anterior joint recess between the groups (n.s.). The adjusted width of posterior joint recess had a significant but weak negative correlation with the anterior wall index (r = - 0.25, p < 0.001), and no correlation with the posterior wall index (r = - 0.0004, n.s.). There was no significant correlation between the adjusted width of anterior joint recess and the anterior/posterior wall index (r = 0.05, n.s./r = 0.07, n.s.). CONCLUSIONS: The distension of posterior capsule on the computed tomography arthrography was significantly greater in acetabular dysplasia. In addition, there was a significant but weak negative correlation between the distension of posterior capsule and the anterior coverage of the hip. It indicated a looser posterior capsule was observed in a dysplastic hip. The relevance of posterior capsular laxity to clinical outcomes warrants further investigation. Given the fact that the distension of anterior capsule was not significantly higher in acetabular dysplasia, the need of anterior capsular plication in a dysplastic hip should be carefully evaluated. LEVEL OF EVIDENCE: Level III.

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INTRODUCTION: The best treatment for Rockwood type V acromioclavicular (AC) joint dislocation is unknown. HYPOTHESIS: Hook plate augmented with suture anchor (HA) may have different clinical and radiological results than hook plate alone (H), and arthroscopically assisted TightRope (TR) techniques in treating acute type V AC joint dislocations. MATERIAL AND METHODS: This retrospective study included 71 patients with acute type V AC joint dislocations between December 2010 and August 2018. Patients were categorized into three groups: H group (n=22), HA group (n=23) and TR group (n=26). We measured the coracoclavicular distance (CCD) differences and CCD ratio compared to uninjured side pre-operatively, immediately post-operatively, at 3-month and 2-year after operation. Clinical outcomes were assessed as well at the same time points. Loss of correction was determined by the CCD difference and ratio between surgical and uninjured sides. RESULTS: The mean age and follow-up period were 41.8±24.7 years and 30.2±4.3 months, respectively. No significant differences were found in the demographic data between the three groups. The HA group presented a trend of less overcorrection but without significance compared with the H group at immediately post-operation, 3-month, and 2-year follow-up. (CCD difference: -2.4mm vs. -3.7mm, -1.6mm vs. -1.8, and 0.2mm vs -1.9mm, CCD ratio: 67.7% vs. 40.9%, 79.3% vs. 70.1%, and 100.6% vs. 86.5%, respectively). The HA group also had significantly less loss of correction compared with the TR group at 3-month and 2-year after the operation (CCD difference: -1.6mm vs. 1.6mm, 0.2mm vs. 2.4mm; CCD ratio: 79.3% vs. 122.2%, 100.6% vs. 136.1%, all p<0.05). All three methods achieved significant improvement in function and pain without inter-group differences. No coracoid-related or tunnel complications occurred. DISCUSSION: The hook plate alone, and hook plate with suture anchor augmentation techniques provided less residual vertical instability compared to TightRope fixation at 2-year follow-up. The patient-reported functional outcomes were promising and comparable among the three groups. LEVEL OF EVIDENCE: III, Retrospective comparative therapeutic trial.

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A 16-year-old right-handed male pitcher had a first-time right anterior shoulder dislocation during a baseball game. X-ray and MRI revealed no apparent glenoid bone loss or Hill-Sachs lesion, but an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion with mild posterolateral decompression of the humerus head. His instability severity index score (ISIS score) was 5 with an on-track lesion. He had an arthroscopic Bankart repair using two all-suture anchors and returned to pitching 6 months after the index surgery. However, he had an unstable sensation after 50 pitches during a game one year postoperatively. This time, he presented with a significant Hill-Sachs lesion and a recurrent APLSA lesion. His ISIS score was 6 with an on-tract lesion. During the arthroscopic examination, the previous suture was stable, while anterior capsuloligament tissues were dislodged from sutures, and a Hill-Sachs lesion was observed. This time, a revision arthroscopic Bankart repair and Remplissage procedure were done on him with four double-loaded soft tissue anchors. Pitchers often develop more external rotation in their throwing arm because of a repetitive stretch of the anterior shoulder capsule and ligaments during pitching. The decrease in external rotation after surgery may limit the pitching speed of the pitcher, making a return to play (RTP) more difficult. There is still a paucity of best evidence to revise a failed arthroscopic Bankart repair in the dominant arm of a pitcher. Arthroscopic Bankart repair and Remplissage procedure have gained increasing popularity because they can provide a stable shoulder without harvesting the coracoid. The Latarjet procedure provides a high RTP rate; however, we did not perform it in the revision surgery and decided to revise the Bankart lesion again on its own with a Remplissage procedure, even with his ISIS score being 6 before the revision surgery. A salvage Latarjet procedure is left as a bailout procedure.

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Shoulder arthroscopy is a mature and widely used treatment to deal with various shoulder disorders. It enables faster recovery and decreases postoperative complications. However, some complications related to shoulder arthroscopy cannot be neglected because they could be life threatening. We presented three cases of various clinical manifestations of pneumothorax after shoulder arthroscopy. The first case was a 65-year-old female who underwent arthroscopic rotator cuff repair under general anesthesia and interscalene nerve block in the beach-chair position. The second case was a 58-year-old male undergoing arthroscopic rotator cuff repair and reduction in glenoid fracture under general anesthesia in the lateral decubitus position. The third case was a 62-year-old man receiving arthroscopic rotator cuff repair under general anesthesia in the lateral decubitus position. Each case's operation time was 90, 240, and 270 min. The pressure of the irrigation pumping system was 30, 50, and 70 mmHg, respectively. The second and third cases did not undergo interscalene nerve block. Although the incidence of pneumothorax following shoulder surgery and interscalene nerve block was only 0.2%, it is one of the most life-threatening complications following shoulder arthroscopy. In these cases, multifactorial factors, including patient positioning, interscalene nerve block, long surgical time, size of rotator cuff tears, and the pressure of the irrigation and suction system, can be attributed to the occurrence of pneumothorax. It is crucial to fully comprehend the diagnosis and management of pneumothorax to reduce the risk for patients receiving shoulder arthroscopy.

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We present a surgical technique combining arthroscopic-assisted lower trapezius tendon (LTT) transfer with autologous semitendinosus tendon and long head of biceps tendon (LHBT) superior capsule reconstruction (SCR) for massive irreparable posterosuperior rotator cuff tears. The patients are placed in the beach-chair position with the ipsilateral lower leg prepared simultaneously. After both tendons are harvested, 1 limb of a semitendinosus graft is fixed with the LTT via a Krakow suture. The LHBT is then fixed by an anchor 5 to 8 mm posterior to the bicipital groove and tenotomized distally. The transverse humeral ligament is released afterward to provide better visualization. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove, and drilled posteriorly until it exits at the infraspinatus footprint. Next, 4.5- and 8-mm cannulated drills are used sequentially to create a humeral tunnel. A shuttle suture passed through infraspinatus fascia in the back brings the EndoButton and looped semitendinosus graft from posterior to anterior of the humerus, until the EndoButton flips and is fixed inside the bicipital groove. The shoulder is placed in 45° abduction and 30° external rotation. The free limb of semitendinosus tendon is then sutured with LTT with the desired tension.

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The objective of this study is to compare the clinical outcomes after arthroscopic hip labral repair in athletes and non-athletes. The design of this study is a retrospective comparative study. The setting of this study is an institutional study. One hundred and sixteen patients of hip labral tears who underwent arthroscopic labral repair were included. Eighty-five of these patients met the inclusion/exclusion criteria (25 athletes and 60 non-athletes). Hip labral tears underwent arthroscopic labral repair. The main outcome measures are as follows: visual analog scale (VAS) and modified Harris Hip Score (mHHS) 2 years postoperatively and the rate of return to sports at previous level. There was no significant difference in the gender, alpha angle, lateral center-edge angle between the two groups, except for the mean age (19.3 versus 42.2, P < 0.001), Marx activity rating scale (MARS) (14.6 versus 6.8, P < 0.001) and University of California, Los Angeles (UCLA) activity rating scale (9.6 versus 5.0, P < 0.001). The intraoperative findings were similar in the two groups. The VAS scores and mHHS both showed a significant improvement after surgery in both groups (VAS improvement 3.6 and mHHS improvement 22.4 in the athlete group; VAS improvement 3.9 and mHHS improvement 25.0 in the non-athlete group, all P < 0.001). There was no difference in VAS improvement or mHHS improvement between the athlete and non-athlete groups. All the patients in the athlete group return to sports at previous level 6 months after the operation. The mean time of return to sports at previous level was 5.4 months. Both athletes and non-athletes demonstrate significant VAS and mHHS improvement following arthroscopic labral repair. The VAS scores improvement and mHHS improvement were similar in the athlete and non-athlete groups after arthroscopic labral repair.

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PURPOSE: To identify the relationship between the alpha angle and the severity of chondrolabral separation as well as acetabular rim chondral damage in symptomatic cam-type femoroacetabular impingement (FAI) with or without focal pincer-type FAI. METHODS: Patients who received hip arthroscopy under the diagnosis of symptomatic cam-type FAI between January 2018 and August 2018 were identified in a prospectively collected database. Patients were excluded if preoperative lateral center-edge angle <25°, lateral center-edge angle ≥40°, Tönnis grade >1, with previous surgery on the affected hip, or with concomitant synovial disease. The chondrolabral junction was classified into intact chondrolabral junction, stable chondrolabral separation and unstable chondrolabral separation. The classification of acetabular rim chondral damage was modified from the MAHORN (Multicenter Arthroscopy of the Hip Outcomes Research Network) classification: normal/softening, bubble, pocket, flap, and exposed bone. The relationship between the hip morphology and severity of chondrolabral junction and acetabular rim chondral damage was assessed. RESULTS: A total of 71 patients with the mean age of 33.2 ± 11.0 years were included. Preoperative alpha angles on anteroposterior (AP) or Lauenstein view positively correlated with the severity of acetabular rim chondral damage (P = .028 and P = .016, respectively). A significant increment of the alpha angle between 2 consecutive grades of acetabular rim chondral damage was 7.1° (P = .001) on AP view and 5.2° on Lauenstein view (P = .001). The cut-off values for predicting advanced acetabular rim chondral damage (pocket, flap or bony exposure) were an AP alpha angle of 70° (P = .025) and a Lauenstein alpha angle of 57° (P = .003). There was no significant association between the alpha angle and the severity of chondrolabral separation. CONCLUSIONS: In patients with symptomatic cam-type FAI with or without focal pincer-type FAI, greater preoperative alpha angles on AP and Lauenstein views can predict more severe acetabular chondral damage. LEVEL OF EVIDENCE: Level III.

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INTRODUCTION: Early synovectomy is considered as the main treatment of pigmented villonodular synovitis (PVNS) of the hip in young patients with preserved cartilage. The purpose of the study is to evaluate outcomes of arthroscopic management for PVNS of the hip. METHODS: Patients who underwent primary hip arthroscopy for the treatment of histology-confirmed PVNS by the senior author between January 2012 and December 2016 were retrospectively reviewed. We excluded patients who had less than 1-year follow-up or had undergone primary surgeries with other surgeons and then received revision hip arthroscopic procedures by the senior author. The recurrence of PVNS and postoperative condition of affected hip were assessed by follow-up magnetic resonance imaging (MRI). Patient-reported outcomes of modified Harris hip score (mHHS) and 12-item International Hip Outcome Tool (iHOT-12) were collected at latest follow-up. RESULTS: Nine patients (2 males, 7 females) with a mean age of 24.3 ± 11.2 years (range 14-44 years) were included in this study. Localized PVNS was observed in four patients, and diffuse PVNS was observed in five patients. No patient presented with advanced osteochondral destruction. Five patients received single adjuvant radiosynoviorthesis. No patient had evidence of recurrence based on follow-up MRI. Patient-reported outcomes were obtained in eight patients at mean 55.8 ± 26.1 months (range 24-84 months) after the index surgery. The mean mHHS was 94.6 ± 4.9 (range 84.7-100) and the mean iHOT-12 was 93.3 ± 20.2 (range 50-120). No patient needed secondary surgery during the follow-up period. CONCLUSION: Arthroscopic subtotal synovectomy can offer favorable short to mid-term outcomes in the treatment of hip PVNS in case of no advanced osteochondral damage at presentation.

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Superior capsule reconstruction (SCR) can be performed using fascia lata, dermal allograft, and long head of the biceps tendon (LHBT). We present a Technical Note combining dermal allograft and autologous LHBT, reconstructing the superior capsule's actual anatomical thickness and augmenting with single-stranded LHBT. The glenoid side consists of intact LHBT insertion and is covered with dermal allograft. The lateral side comprises posteriorly transpositioned LHBT, dermal allograft, and repairable remnant cuff. First, 1 suture-based anchor is used to fix the biceps 5 to 8 mm posterior to the bicipital groove, and tenotomy is done distal to it, while the glenoid side of the biceps is preserved. Second, 2 suture-based anchors are used to fix the dermal allograft at the glenoid side by 1 double-pulley and 2 mattress sutures. Third, 2 SwiveLock anchors are used to fix allograft's lateral side by 2 reverse mattress sutures. The tension and coverage of the graft can be determined by the position of the SwiveLock anchors. In this way, fewer anchors are needed than the conventional dermal allograft SCR and larger footprint coverage can be achieved than LHBT SCR. A better spacer effect may be achieved by combining both biological grafts' thickness, mimicking the intact shoulder's true anatomy.

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This study evaluated the outcomes of arthroscopic surgery for the treatment of external snapping hip at 2- to 10-year follow-ups. Eighteen patients with refractory external snapping hip treated by arthroscopic surgery were enrolled in this prospective study. All patients underwent unsuccessful conservative treatment for more than 3 months before surgery. We made diamond-shaped defects on the iliotibial band and resected peripheral fibrosis tissues for iliotibial band release with an arthroscopic approach. The visual analog scale (VAS), modified Harris hip score and return to previous level of activity were evaluated as functional outcomes. In addition, residual discomfort or the presentation of complications was also investigated. The average follow up period was 7 years. The modified Harris hip score increased from 70.08 preoperatively to 93.14 postoperatively, and the VAS score decreased from 3.67 preoperatively to 1.17 2 weeks after the operation and declined to 0.33 at the last follow-up. Neither recurrence of snaps nor complications were recorded. Two patients complained of a tight sensation with tenderness after exertion. Our clinical outcomes were compatible with those of previous studies, and no long-term complications were noted, even with a relatively longer follow-up period than what was reported in previous studies. Arthroscopic surgery is a safe and effective treatment that can provide promising long-term clinical outcomes for patients with refractory external snapping hip.

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OBJECTIVES: This study aimed to evaluate the prognostic factors of reoperation after plate fixation for midshaft clavicle fracture and compare outcomes of dynamic compression plates (DCP) and pre-contoured locking plates. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: We recruited 274 consecutive patients who underwent plate fixation for midshaft clavicle fracture from 2007 to 2017 and completed at least 1 year of follow-up. INTERVENTION: 235 patients underwent surgery with DCP, while 39 patients were treated with locking plate. MAIN OUTCOME MEASUREMENTS: We reviewed the possible variables of secondary surgeries, and documented complications from the medical records. Patients with a DCP or locking plate were further divided for outcome comparisons. RESULTS: 150 (54.7%) patients underwent reoperation after the initial surgery, and plate removal represented the major etiology. On multivariate analysis, superficial wound infection and prominent implant were identified as significant risk factors for reoperation, while aging, locking plate usage, and higher body mass index (BMI) were protective factors (all P < 0.05). The locking plate featured a significantly decreased implant removal rate (7.7% vs. 60.9%, P < 0.05). CONCLUSIONS: Patients with risk factors for superficial wound infection or a prominent implant tended to require a secondary operation after surgery for midshaft clavicle fracture, while aging, pre-contoured locking plate usage, and higher BMI decreased the risk. Compared with DCP, patients with locking plates tended to have better prognosis and significantly lower implant removal rates. LEVEL OF EVIDENCE: Prognostic III.

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PURPOSE: To analyze the current approaches and clinical outcomes in the surgical management of concomitant mild acetabular dysplasia and femoroacetabular impingement (FAI). METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) method, the PubMed and Medline databases were searched in March 2019 for studies that reported on surgical outcomes in hips with concomitant mid acetabular dysplasia and FAI. Studies published in English that focused on the surgical outcomes after hip arthroscopy, open surgery, or periacetabular osteotomy of concomitant acetabular dysplasia and FAI, in which the lateral center-edge angle of all subjects was between 15° and 25°, were included. Articles that included subjects with lateral center-edge angle <15°, with a minimum follow-up duration <1 year, had <5 subjects, or were not original articles were excluded. RESULTS: The initial search yielded 748 studies, and 5 studies met the inclusion criteria. All these 5 studies focused on hip arthroscopic treatment for patients with concomitant mild acetabular dysplasia and FAI. Three studies had level III evidence, whereas 2 studies had level IV evidence. The mean patient age range across the studies was 29.8 to 49.6 years, and the female-to-male ratio was 1.14. Improved patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport, modified Harris Hip Score, Short Form-12 Physical Component Summary, Western Ontario and McMaster Universities Osteoarthritis Index) at a minimum 2-year follow-up were obtained in 4 of the 5 studies. Two of these 4 studies had a comparative cohort of patients with FAI with normal acetabular coverage, and there was no significant difference in the postoperative outcomes and secondary procedure rate between patients with mild acetabular dysplasia and those with normal acetabular coverage. CONCLUSIONS: This systematic review indicates that improved patient-reported outcomes can be obtained with hip arthroscopy in the treatment of concomitant mild acetabular dysplasia and FAI at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

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