Background: The literature has given little attention to the nonoperative management of femoroacetabular impingement (FAI) syndrome despite a rapidly expanding body of research on the topic. Purpose: To perform a prospective study utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2013 and 2016, patients meeting the following criteria were prospectively recruited in a nonoperative FAI study: no prior hip surgery, groin-based pain, a positive impingement test, and radiographic FAI syndrome. The protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were then offered an image-guided intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Outcome scores were collected at 12 and 24 months. Statistical analysis was performed to identify risk factors for the need for operative treatment and to determine patient outcomes based on FAI type and treatment. Results: Ninety-three hips (n = 76 patients: mean age, 15.3 years; range, 10.4-21.4 years) were included in this study and followed for a mean ± SD 26.8 ± 8.3 months. Sixty-five hips (70%) were managed with physical therapy, rest, and activity modification alone. Eleven hips (12%) required a steroid injection but did not progress to surgery. Seventeen hips (18%) required arthroscopic management. All 3 groups saw similar improvements in modified Harris Hip Score ( P = .961) and nonarthritic hip score ( P = .975) with mean improvements of 20.3 ± 16.8 and 13.2 ± 15.5, respectively. Hips with cam impingement and combined cam-pincer impingement were 4.0 times more likely to meet the minimal clinically important difference in modified Harris Hip Score ( P = .004) and 4.4 times more likely to receive surgical intervention ( P = .05) than patients with pincer deformities alone. Participants in team sports were 3.0 times more likely than individual sport athletes to return to competitive activities ( P = .045). Conclusion: A majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of 2 years. Clinical Relevance: A nonoperative approach should be the first-line treatment for young active patients with symptomatic FAI syndrome.

Background: It is unclear what the optimal graft choice is for performing anterior cruciate ligament (ACL) reconstruction in a skeletally immature patient. Purpose: To evaluate outcomes and complications of skeletally immature patients undergoing transphyseal ACL reconstruction with a hamstring tendon autograft versus a quadriceps tendon autograft. Study Design: Cohort study; Level of evidence, 3. Methods: Between 2012 and 2016, 90 skeletally immature patients from a single institution underwent primary transphyseal ACL reconstruction with either a quadriceps tendon autograft or a hamstring tendon autograft based on surgeon preference (n = 3). Patient demographic, injury, radiographic, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation (SANE), Tegner activity score, pain, satisfaction, and complications such as graft tears and physeal abnormalities. Results: A total of 83 patients (56 hamstring tendon, 27 quadriceps tendon) were available for a minimum follow-up of 2 years or sustained graft failure. The mean age of the patients was 14.8 ± 1.4 years at the time of ACL reconstruction. No differences in chronological age, bone age, sex, patient size, or mechanism of injury were noted between groups. There were no differences in surgical variables, except that the quadriceps tendon grafts were larger than the hamstring tendon grafts (9.6 ± 0.6 mm vs 7.8 ± 0.7 mm, respectively; P < .001). Patient outcomes at a mean follow-up of 2.8 ± 0.9 years revealed no differences based on graft type, with mean Lysholm, SANE, pain, satisfaction, and Tegner scores of 96, 93, 0.6, 9.6, and 6.6, respectively, for the quadriceps tendon group and 94, 89, 0.9, 9.2, and 7.1, respectively, for the hamstring tendon group. While there were no physeal complications in either group, patients undergoing ACL reconstruction with a hamstring tendon autograft were more likely to tear their graft (21% vs 4%, respectively; P = .037). Conclusion: Skeletally immature patients undergoing ACL reconstruction can be successfully managed with either a quadriceps tendon autograft or a hamstring tendon autograft with good short-term outcomes, high rates of return to sport, and low rates of physeal abnormalities. The primary differences between grafts were that the quadriceps tendon grafts were larger and were associated with a lower retear rate. ACL reconstruction performed with a quadriceps tendon autograft may reduce early graft failure in skeletally immature patients.

Study Design. Cross-sectional study. Objective. To determine which factors spine surgery fellowship program directors (PDs) consider most important when ranking applicants. Summary of Background Data. Spine surgery is a popular orthopedic subspecialty. As such, the spine fellowship match process is highly competitive. Surveys of fellowship PDs in orthopedic sports medicine and hand surgery have demonstrated differing opinions regarding factors considered most important when ranking fellowship applicants. The factors considered important to spine surgery fellowship PDs have not been evaluated. Methods. A web-based questionnaire was sent to the PDs of all spine surgery fellowships participating in the San Francisco (SF) Match Program. The questions were designed to identify criteria considered most important in ranking spine surgery fellowship applicants. A list of 12 criteria was presented and PDs were asked to rank these in order of importance. A weighted score for each criterion was calculated using the following scale: 5 points for each criterion ranked 1st, 4 points for 2nd, 3 points for 3rd, 2 points for 4th, and 1 point for 5th. Results. Of the 73 PDs queried, 52 responded (71% response rate). The interview was the most important factor when ranking fellowship applicants. The other criteria deemed most important in order of weighted scoring were letters of recommendation and personal connections to the applicant and/or familiarity with the applicant's letter writer(s). Conclusion.Spine surgery fellowship PDs consider the interview, letters of recommendation, and personal connections with the applicant/letter writers to be the most important factors when ranking candidates. These results may be valuable to orthopedic residents and mentors of those pursuing fellowship training in spine surgery.

Background: The management of adolescents with acute first-time patellar dislocation with an associated loose body remains a debated topic. The rate of recurrent dislocation in these patients may be up to 61% if the medial patellofemoral ligament (MPFL) is repaired or not addressed surgically. To our knowledge, a prospective evaluation of MPFL reconstruction for adolescents with acute first-time patellar dislocation with an associated chondral or osteochondral loose body has not been previously performed. Purpose/Hypothesis: The purpose of this study was to analyze patients with a first-time patellar dislocation who required surgery for a loose body, comparing those who underwent MPFL repair or no treatment with those who underwent MPFL reconstruction during the index procedure. The hypothesis was that performing MPFL reconstruction would reduce the rate of recurrent instability and improve patient-reported outcomes compared with MPFL repair or no treatment. A secondary objective was to report outcomes of those patients who underwent reconstruction versus those who did not. Study Design: Case series; Level of evidence, 4. Methods: This was a prospective analysis of adolescents treated with MPFL reconstruction for acute first-time patellar dislocation with associated loose bodies between 2015 and 2017 at a single pediatric level 1 trauma center with minimum 2-year follow-up. Retrospective analysis was previously performed for a similar cohort of adolescents treated with MPFL repair or no treatment. Patient characteristic data, radiographic measurements, and surgical variables were compared. Primary outcome measures included recurrent subluxation or dislocation and the need for further stabilization procedures. Secondary outcomes included Kujala score, Single Assessment Numeric Evaluation score, patient satisfaction, and ability to return to sport. Results: A total of 76 patients were included, 30 in the MPFL reconstruction cohort and 46 in the MPFL repair or no-treatment cohort. The only difference noted in patient characteristic, radiographic, or surgical variables was a smaller Insall-Salvati ratio in the reconstruction group (1.29 vs 1.42; P = .011). Compared with MPFL repair or no treatment, MPFL reconstruction was associated with less recurrent instability (10.0% vs 58.7%; P < .001), fewer secondary procedures (6.7% vs 47.8%; P < .001), and more frequent return to sports (66.7% vs 39.1%; P = .003). No differences in patient-reported outcomes were noted. Conclusion: Performing concomitant MPFL reconstruction in adolescents with first-time patellar dislocation and an intra-articular loose body results in a 5-fold reduction in recurrent instability, reduces the need for subsequent surgery, and improves patients’ ability to return to sports compared with repairing or not treating the MPFL.

Background: There is a lack of midterm or long-term outcome data on nonoperative management of femoroacetabular impingement (FAI) syndrome in adolescents despite expanding research mostly focused on arthroscopic management. Purpose: To present 5-year outcome data utilizing a nonoperative protocol on a consecutive series of patients presenting to our clinic with FAI syndrome. Study Design: Cohort study, Level of evidence, 2. Methods: A total of 100 patients (62% female; mean age 15 years) who presented to the clinic for evaluation of hip pain and had at least 1 hip with a positive impingement sign were prospectively recruited. The management protocol consisted of an initial trial of rest, physical therapy, and activity modification. Patients who remained symptomatic were offered an intra-articular steroid injection. Patients with recurrent symptoms were then offered arthroscopic treatment. Patient-reported outcomes (PROs), including the modified Harris Hip Score (mHHS) and the Nonarthritic Hip Score (NAHS) were then collected at a mean 1, 2, and 5 years after the initial evaluation. Results: At enrollment, the mean mHHS and NAHS were 69.6 ± 12.9 and 75.5 ± 15.2, respectively. A total of 51 patients (n = 69 hips) were available at a mean 5-year follow-up, with the mean mHHS and NAHS of 89.5 ± 10.8 and 88.1 ± 12, respectively. There was no significant difference in the mHHS or the NAHS between activity modification and physical therapy, injection, or arthroscopic surgery groups at 5-year follow-up ( P > .6) and no difference in the proportion of hips meeting the minimal clinically important difference (MCID) for the mHHS based on treatment course ( P = .99). There was no significant difference in the mHHS or the NAHS between FAI types at any time point, or in the proportion of hips that met the MCID among FAI types ( P = .64). Also, 11 out of 12 hips that required surgery had surgery in less than 2 years. One hip underwent surgery at 5 years after the initial visit. There was no significant drop-off in the mHHS or the NAHS between the 2-year and 5-year time periods ( P > .3). Conclusion: Nonoperative management of FAI syndrome is effective in a majority of adolescent patients, with significant improvements in PROs persisting at a mean 5-year follow-up.

Background: Variables considered by hip and knee arthroplasty fellowship program directors (PDs) to select fellowship candidates are not well known. Methods: A web-based questionnaire containing 5 questions was developed and sent to all 92 adult reconstruction fellowship PDs via email. Three questions collected program information including the number of positions available, the number of candidates interviewed, and ranked annually. PDs were then given a list of 12 factors and asked to rank them in the order of importance. A weighted score for each factor was calculated using the following scale: 5 points each time a factor was ranked 1st, 4 points each time a factor was ranked 2nd, 3 points for each 3rd place rank, 2 points for each 4th place rank, and 1 point for each 5th place rank. PDs were also allowed to write in other factors they considered important when ranking fellowship candidates. Results: The overall response rate was 34.8% (32/92). Seventy-five percent of responding programs indicated that they interview between 21 and 40 applicants per year for their fellowship position(s). The interview was ranked as the most important variable in selecting applicants by 53.1% of responding PDs, followed by letters of recommendation (ranked first by 25% of PDs) and personal connections to the applicant and/or letter writer(s) (ranked first by 9% of PDs). A positive correlation was identified between the program size and an applicant's geographical ties to the city/town of the fellowship program (r s ¼ 0.472; P ¼ .006). Conclusions: According to hip and knee arthroplasty fellowship PDs, the interview, letters of recommendation, and personal connections to the applicant and/or letter writers are the most important factors considered in selecting arthroplasty fellowship candidates.

Background: Although anterior cruciate ligament (ACL) injuries are common in female soccer players, the optimal graft option for ACL reconstruction is currently unclear. Purpose/Hypothesis: To compare the outcomes of female soccer players after ACL reconstruction using either hamstring tendon autograft or bone–patellar tendon–bone (BTB) autograft. We hypothesized that there would be no difference in clinical outcome scores, return to sport, or retear rates between BTB and hamstring grafts in our study cohort. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective review of all skeletally mature adolescent female soccer players who underwent primary ACL reconstruction using either hamstring tendon or BTB autograft between 2013 and 2016. Demographic, injury, and surgical variables were documented. Outcome measures included the Lysholm score, Single Assessment Numeric Evaluation, Tegner activity score, and visual analog scales for pain and for satisfaction, as well as ability to return to sport. Results: Overall, 90 female soccer players met the inclusion criteria, of whom 79% (41 BTB and 30 hamstring) were available for a minimum 2-year follow-up or had a graft failure before the follow-up. The BTB group had a lower body mass index (mean ± SD, 23 ± 3 vs 25 ± 4; P = .02) and shorter postoperative follow-up time in months (mean ± SD, 37.4 vs 46.1; P ≤ .001); otherwise, no differences in demographic, injury, or surgical variables between groups were noted. Regarding outcome measures, the BTB group achieved a higher Tegner score (6.0 vs 4.2; P = .004), and there was no other difference between groups. Of the patients who did not return to soccer, 44.7% reported fear as the reason. Of the patients who did return to soccer, 31.9% sustained another ACL injury (retear or contralateral tear), with no differences in reinjury rates based on graft selection. Conclusion: Adolescent female soccer players undergoing ACL reconstruction had relatively high satisfaction and outcome scores independent of autograft choice. Notwithstanding, patients and families need to be counseled that less than half of patients will return to their preinjury level of sport and, if an athlete attempts to return, there is a high risk of further ACL injury.

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