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Background: The most reliable suture technique for capsular closure after a capsulotomy remains unknown. Purpose: To determine which suture technique best restores native stability after a 5-cm interportal capsulotomy. Study Design: Controlled laboratory study. Methods: Ten human cadaveric hip specimens were tested using a 6-degrees-of-freedom robotic arm in 7 states: intact, capsular laxity, 5-cm capsulotomy, standard suture, shoelace, double shoelace, and Quebec City slider (QCS). Rotational range of motion (ROM) was measured across 9 tests: flexion, extension, abduction, abduction at 45° of flexion, adduction, external rotation, internal rotation, anterior impingement, and log roll. Distraction (ie, femoral head translation [FHT]) was measured across a range of flexion and abduction angles. Results: When compared with the native state, the 5-cm capsulotomy state showed the largest laxity increases on all tests, specifically in external rotation ROM (+13.4°), extension ROM (+11.5°), and distraction FHT (+4.5 mm) ( P < .001 for all). The standard suture technique was not significantly different from the 5-cm capsulotomy on any test and demonstrated significantly more flexion ROM than the double shoelace suture (+1.41°; P = .049) and more extension ROM (+5.51°; P = .014) and external rotation ROM (+6.03°; P = .021) than the QCS. The standard suture also resulted in significantly higher distraction FHT as compared with the shoelace suture (+1.0 mm; P = .005), double shoelace suture (+1.4 mm; P < .001), and QCS (+1.1 mm; P = .003). The shoelace, double shoelace, and QCS techniques significantly reduced hip laxity when compared with the 5-cm capsulotomy state, specifically in external rotation ROM (respectively, –8.1°, –7.8°, and –10.2°), extension ROM (–6.3°, –7.3°, and –8.1°), and distraction FHT (–1.8, –2.2, and –1.9 mm) ( P ≤ .003 for all). These 3 techniques restored native stability (no significant difference from intact) on some but not all tests, and no significant differences were observed among them on any test. Conclusion: Hip capsule closure with the standard suture technique did not prevent postoperative hip instability after a 5-cm capsulotomy, and 3 suture techniques were found to be preferable; however, none perfectly restored native stability at time zero. Clinical Relevance: The shoelace, double shoelace, and QCS suture techniques are recommended when closing the hip capsule.

Background: Synovial mesenchymal stem cells (MSCs) have high proliferative potential and are considered an excellent source for stem cell therapy. Purposes: To isolate MSCs from the synovium of ankle joints in patients with chronic lateral ankle instability (CLAI) and to compare the characteristics of MSCs derived from the synovium anterior to the talus with those from the surrounding anterior talofibular ligament (ATFL) synovium. Study Design: Controlled laboratory study. Methods: The synovium was harvested from 2 locations in the ankle, the synovium anterior to the talus and the surrounding ATFL synovium, of 14 patients who underwent arthroscopic ATFL repair for CLAI without osteochondral lesions of the talus (OLTs). Synovial fluid was also harvested. MSCs were isolated from both types of synovial tissue, as well as synovial fluid. The number of MSCs in the synovium and their viability, proliferation, colony-forming units, and potential to differentiate into adipose, bone, and cartilage tissues were determined and compared between groups. Additionally, real-time polymerase chain reaction was used to assess the differentiation capacity of adipose, bone, and cartilage tissues from both samples. The Wilcoxon signed rank test was used to compare the sample weight, number of colonies, number of nucleated cells per colony, yield obtained, and phenotypic characteristics of MSCs derived from different locations of the synovium. Results: No significant differences were observed in the sample weight ( P = .051), number of nucleated cells per milligram ( P = .272), number of colonies ( P = .722), and yield obtained ( P = .099) between the 2 groups. MSCs could not be isolated from synovial fluid. The frequency of oil red O–positive adipogenic colonies ( P = .028) and the expression of the adipsin gene ( P < .05) were significantly increased in the cells from the synovium anterior to the talus compared to those in the cells from the surrounding ATFL synovium. However, chondrogenic and osteogenic potentials were not significantly different between the 2 groups. Conclusion: Synovial MSCs obtained from the ankle joint had self-renewal and multilineage differentiation potential, although the adipogenesis potential of MSCs from the synovium anterior to the talus was superior to that from the surrounding ATFL synovium. Clinical Relevance: Both the adipose synovium and fibrous synovium in the ankle joints of patients with CLAI may be a good source of MSCs for stem cell therapy applications, whereas synovial fluid appeared unsuitable.

Background: The onset of the coronavirus disease 2019 (COVID-19) pandemic has presented unforeseeable challenges to the orthopaedic community, especially arthroplasty and sports medicine subspecialities, as many surgeries were deemed nonessential and delayed. Although there is a glimpse of hope with the approval and distribution of vaccines, daily case numbers and death tolls continue to rise at the time of this review. Purpose: To summarize the available literature on the management of elective sports medicine and arthroplasty procedures in the outpatient setting to gather a consolidated source of information. Study Design: Scoping review; Level of evidence, 5. Methods: A scoping review of 3 databases (PubMed, Embase, and OVID Medline) was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. All retrospective and prospective analyses, systematic reviews and meta-analyses, expert opinions, and societal guidelines were included for review, with 29 articles meeting the inclusion criteria. Results: Guidance for resumption of elective arthroplasty and sports medicine surgery and patient selection during the COVID-19 pandemic focuses on resource availability, patient fitness, and time sensitivity of the procedure, with patient and surgical team safety as the highest priority. Telemedicine and other innovative technology can be used to continue patient care during periods of delayed surgery through monitoring disease progression and offering nonoperative management options. Conclusion: While the current societal recommendations provide guidance on safety protocols and patient prioritization, each orthopaedic practice must consider its unique situation and use evidence-based medicine when determining surgical timing and patient selection.

Background: The cleft sign (CS) and bone marrow edema (BME) are considered magnetic resonance imaging (MRI) findings signifying a pubic pathology, which is associated with groin pain; however, their relationship with bony morphology related to femoroacetabular impingement (FAI) has not been established. Purpose: To investigate the prevalence of CS and BME in symptomatic patients with acetabular labral tears and assess their possible association with bone morphology and sport-specific activities. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study enrolled 418 patients (469 hips) undergoing hip arthroscopic surgery for labral tears. Also included were patients with labral tears in the setting of either hip dysplasia or borderline hip dysplasia who were undergoing endoscopic shelf acetabuloplasty combined with hip arthroscopic labral repair, cam osteoplasty, and capsular plication. All patients were screened for superior CS (SCS), inferior CS (ICS), and BME of the ipsilateral side of the pubis using 3-T MRI. We measured the following angles: lateral center edge (LCE), Sharp, Tönnis, vertical-central-anterior, and alpha. Then, we evaluated the relationship between patient characteristics and abnormal findings on MRI scans (preoperatively vs 1 year postoperatively). Results: An overall 397 hips were included: 200 in men and 197 in women (mean ± SD age, 35.3 ± 16.0 years). There were hips in 214 athletes (53.9%) and hips in 183 nonathletes (46.1%). MRI findings revealed SCS, ICS, and BME in 18 (4.5%), 13 (3.3%), and 34 hips (8.6%), respectively. Abnormal MRI findings at the pubis were seen more often in athletes than nonathletes (23.8% vs 3.3%), and contact sports athletes had the most frequent abnormalities. There was no SCS in patients with an LCE angle Conclusion: In patients with labral tears, CS and BME were seen more frequently in athletes versus nonathletes, especially contact athletes with FAI-related bony abnormalities. More than 60% of abnormal MRI pubis findings resolved after arthroscopic treatment of FAI.

Background: Based on previous studies, it is difficult to discern whether patients who have femoroacetabular impingement (FAI) with borderline developmental dysplasia of the hip (BDDH) would benefit from arthroscopy when compared with patients without BDDH. Purpose: To evaluate the existing comparative literature on arthroscopic findings, procedures, patient-reported outcomes (PROs), and failures in patients who have FAI with BDDH compared with those without BDDH. Study Design: Systematic review; Level of evidence, 3. Methods: The PubMed, Embase, and Ovid databases were searched for studies published up to August 31, 2019, that reported outcomes after arthroscopy to treat patients who had FAI with BDDH. Included studies were required to have patients diagnosed with FAI and BDDH who were treated arthroscopically and compared with control patients (FAI without BDDH). Arthroscopic findings, PROs, and revision or total hip arthroplasty (THA) conversion rates were compared between groups. Results: Included in the review were 4 articles (933 patients). Patients who had FAI with BDDH were defined as having a lateral center-edge angle (LCEA) of either 18° to 25° or 20° to 25°; for control patients, the maximum LCEA was 40°. Across the studies, there were 224 patients who had FAI with BDDH compared with 709 control patients; the mean follow-up time ranged from 21.6 to 31.3 months among the groups. Improvements were shown across all PROs in each study. Random-effects meta-analysis indicated no statistically significant differences in postoperative PROs, the risk for revision surgery, or conversion to THA between the patients who had FAI with versus without BDDH. Conclusion: The results of the current review indicated that hip arthroscopy produced similar short-term outcomes between patients who had FAI with versus without BDDH.

Objectives: Microfracture (MFx) technique is the most commonly used first-line treatment for cartilage injuries; however, it has been shown to have inferior long-term clinical outcomes as the repaired tissue is predominantly fibrocartilage. Bone Marrow Aspirate Concentrate (BMAC) treatment has been shown to enhance the healing ability of cartilage repair, superior to MFx treatment alone, although chondral defect filling was achieved with fibrocartilage or “hyaline-like” cartilage. Therefore, new therapeutic strategies to further improve cartilage healing following defects are in need. Fisetin (FIS) is a compound with antioxidant, anti-inflammatory, and senolytic activity capable of eliminating senescent cells systemically. Previous studies have reported that FIS attenuates the progression of osteoarthritis and osteoporosis in aged mice, however, whether FIS treatment improves the quality of repaired cartilage in MFx-treated acute osteochondral defects augmented with BMAC has not yet been investigated. We hypothesized that FIS or autologous BMAC, or a combination of the two, would enhance MFx procedure both histologically and mechanically in the repair of osteochondral defects in a rabbit model. Methods: All surgical procedures were performed by an experienced orthopaedic surgeon and followed Institutional IACUC approved protocols. Sixty-four skeletally mature New Zealand White rabbits at seven months old were used in this study. Animal procedure: Before surgery, bone marrow aspirate was collected through the iliac crests in each rabbit under anesthesia and processed via a two-step centrifugation method to prepare BMAC. After exposing the bilateral knee joints through the medial parapatellar approach, osteochondral defects (diameter: 5 mm, depth: 2 mm) were created bilaterally in the patellar groove of each rabbit, followed by the MFx procedure (5 holes with 2 mm depth) to allow bleeding at each MFx hole as previously described (Fig.1). BMACs were injected into the left knee joint as an autograft immediately after closing the joint capsule in all rabbits, with the right knee as a control (no BMAC transplantation). Rabbits were then randomly divided into 4 groups (N=8/group): MFx alone, MFx+FIS, MFx+BMAC and MFx+FIS+BMAC. FIS-treated rabbits were given FIS orally via drinking water at a dose of 20 mg/kg/day daily from immediately after surgery until euthanasia. Rabbits were sacrificed at 6 and 12 weeks post-op. The macroscopic appearance was evaluated using the International Cartilage Repair Society (ICRS) macroscopic assessment grading. ΜicroCT and histology: Microcomputed tomography (μCT) was performed to evaluate subchondral bone healing. Cartilage healing was assessed histologically on de-calcified tissue at 6 and 12 weeks post-op (H&E, Safranin O, and Alcian blue) and with immunohistochemistry for collagen II and p16. Regenerated cartilage was scored using the Modified O’Driscoll ICRS grading system (max 27 points). Biomechanical tests: The strength of the regenerated cartilage was analyzed by measuring the instantaneous elastic modulus of the regenerated cartilage in each group of samples collected at 12 weeks. (N=6/group). Results: Macroscopic assessment and μCT: At both 6 and 12 weeks postoperatively, MFx+BMAC and MFx+FIS+BMAC groups scored significantly higher than MFx alone group in the ICRS macroscopic evaluation. ( p < 0.01, Fig. 2 A, D and Fig. 3 A, D). At both 6- and 12-week time points after surgery, μCT showed favorable healing of the bone defect in MFx+FIS, MFx+BMAC, and MFx+FIS+BMAC groups compared to MFx alone group. (Fig. 2 B and Fig. 3 B). Histology: At both 6- and 12- week time points, the Modified O’Driscoll score was significantly higher in the MFx+BMAC and MFx+FIS+BMAC groups than in the MFx alone group ( p Conclusions: Our results showed that BMAC treatment enhanced the healing of MFx-treated osteochondral defects, macroscopically, biomechanically, and histologically, compared to MFx alone. Furthermore, FIS treatment improved MFx-treated cartilage repair, and its combined use with BMAC led to significantly higher quality cartilage regeneration with stronger mechanical properties. Oxidative stress, which is one of the inducers of cell senescence, has been noted as the primary factor contributing to age-related changes in cartilage homeostasis, function, and response to injury. Given the increase in SOD1 expression commensurate with p16 reduction in the FIS-treated group (Figs 2-3), our results suggest that FIS may improve cartilage healing via reducing cellular senescence. These results support the clinical use of FIS combined with BMAC to enhance the effect of MFx in the repair of osteochondral defects and highlight cellular senescence as a novel therapeutic target for cartilage repair following injury. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]

Background:The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH.Purpose:To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH.Study Design:Systematic review; Level of evidence, 4.Methods:Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH.Results:A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures.Conclusion:There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.

Background: Knowledge of clinical outcomes and return to artistic activities after endoscopic shelf acetabuloplasty (ESA) for acetabular dysplasia in artistic athletes is lacking. Hypothesis: Hip arthroscopic surgery including ESA will enable artistic athletes to return to their activities with a high success rate, significantly improved acetabular coverage, and preserved joint cartilage. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 28 hips in 23 female artistic athletes (14 ballet, 9 rhythmic gymnastics, 4 dance, and 1 baton twirling) who underwent arthroscopic labral preservation, capsular plication, and ESA. Their mean age was 25.8 ± 10.2 years. Preoperatively, all patients had generalized joint laxity (Beighton score, 7.1 ± 1.8). We evaluated preoperative and postoperative radiographs and outcome scores including the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), International Hip Outcome Tool 12 (iHOT-12), Vail Hip Score (VHS), and Hip Outcome Score–Sports (HOS— Sports). Statistical analysis was performed using paired t tests and Bonferroni correction. Results: The mean follow-up was 32.5 ± 12.5 months. The mean lateral center-edge angle significantly increased from preoperatively (15.7° ± 5.3°) to postoperatively (39.8° ± 8.2°; P < .001) and at the final follow-up (33.7° ± 8.6°; P < .001). The vertical-center-anterior angle significantly improved from preoperatively (16.2° ± 8.8°) to final follow-up (33.6° ± 8.0°; P < .001). All hips maintained a Tönnis grade of 0 or 1 at the final follow-up. Overall, 20 patients (87%) were able to return to their preinjury level. All outcome scores improved from preoperatively to postoperatively: mHHS, from 68.5 ± 18.1 to 88.3 ± 18.5; NAHS, from 50.8 ± 17.7 to 69.0 ± 11.4; iHOT-12, from 36.9 ± 19.3 to 75.2 ± 19.8; VHS, from 53.8 ± 13.7 to 79.4 ± 19.4; and HOS--Sports, from 59.9 ± 17.0 to 79.6 ± 21.3 ( P < .001 for all). In total, 3 patients could not return to artistic activities as the result of postoperative deep gluteal syndrome. Conclusion: ESA concomitant with labral repair, cam osteoplasty, and capsular plication to treat dysplastic hips in patients with joint laxity enabled artistic athletes to return to their activities with a high success rate.