Contrast-induced acute kidney injury (CI-AKI) is an important consideration in patients undergoing cardiac catheterization. There has been a continuous strive to decrease morbidity and improve procedural safety. This review will address the pathophysiology, predictors, and clinical management of CI-AKI with a concise overview of the pathophysiology and a suggested association with left atrial appendage closure. Minimizing contrast administration and intravenous fluid hydration are the cornerstones of an effective preventive strategy. A few adjunctive pharmacotherapies hold promise, but there are no consensus recommendations on prophylactic therapies.

Background: Osteoarthritis (OA) of the hip is a debilitating condition associated with inferior outcomes in patients undergoing hip arthroscopy. To provide symptom relief and improve outcomes in these patients, bone marrow aspirate concentrate (BMAC) has been applied as an adjuvant therapy with the hope of halting progression of cartilage damage. The current study examined the clinical efficacy of BMAC application in patients undergoing arthroscopic acetabular labral repair by comparing patient-reported outcome measures (PROMs) between groups with and without BMAC application.Methods: Patients who received BMAC during arthroscopic acetabular labral repair from December 2016 to June 2019 were compared with a control cohort that underwent the same procedure but did not receive BMAC from November 2013 to November 2016. Patients in both cohorts were asked to prospectively complete PROMs prior to surgery and at 3, 6, 12, and 24-month follow-up intervals; those who completed the PROMs at enrollment and the 12-month follow-up were included in the study. An a priori subgroup analysis was performed among patients with moderate cartilage damage (Outerbridge grade 2 or 3). The analyses were adjusted for any differences in baseline factors between groups.Results: Sixty-two patients with BMAC application were compared with 62 control patients without BMAC application.When compared with the no-BMAC cohort, the BMAC cohort did not report significantly different mean International Hip Outcome Tool-33 (iHOT-33) scores at any postoperative time point. However, when patients with moderate cartilage damage were compared across groups, the BMAC cohort reported significantly greater mean (95% confidence interval) scores than the no-BMAC cohort at the 12-month (78.6 [72.4 to 84.8] versus 69.2 [63.3 to 75.2]; p = 0.035) and 24month (82.5 [73.4 to 91.6] versus 69.5 [62.1 to 76.8]; p = 0.030) follow-up. Similarly, these patients reported greater score improvements at 12 months (37.3 [30.3 to 44.3] versus 25.4 [18.7 to 32.0]; p = 0.017) and 24 months (39.6 [30.4 to 48.7] versus 26.4 [19.1 to 33.8]; p = 0.029).Conclusions: Patients with moderate cartilage injury undergoing arthroscopic acetabular labral repair with BMAC application reported significantly greater functional improvements when compared with similar patients without BMAC application.Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Despite advances in techniques to repair acetabular labral tears, mitigating damage to acetabular cartilage and the chondrolabral junction is an ongoing chal-lenge for orthopaedic surgeons 1,2 . Since moderate-to-severe osteoarthritis (OA) has been associated with inferior outcomes for patients undergoing hip arthroscopy [3][4][5][6] , there is a great need Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G751).

Background: Many of the current rehabilitation programs for patients undergoing hip arthroscopy fail to consider the progression of soft tissue healing and inflammation that can be heightened due to aggressive therapy to the operative hip in the immediate postoperative period. Hypothesis: It was hypothesized that introducing conservative physical therapy (PT) preoperatively along with a slow progression to return to activity using a structured, patient-guided postoperative program would improve patient outcomes. Study Design: Case series; Level of evidence, 4. Methods: The authors conducted a retrospective review of patients who received a hip arthroscopy, were at least 18 years old, and who had completed the following patient-reported outcomes (PROs) at 1-year follow-up: modified Harris Hip Score (mHHS), Hip Outcome Score, Nonarthritic Hip Score, International Hip Outcome Tool-33, and Lower Extremity Functional Scale. Patients who underwent previous surgery on the ipsilateral hip and those with cartilage erosion down to exposed subchondral bone (Outerbridge grade 4) were excluded. Paired-samples t tests were used to compare the change in PRO scores at 3-month, 6-month, and 1-year follow-up, and the percentage of patients who achieved minimal clinically important difference (MCID) and substantial clinical benefit (SCB) thresholds on the mHHS were stratified according to their Outerbridge grade (0-3). Results: Overall, 202 patients (53% female, 47% male) were included in the analysis. Significant improvement was seen from 3 to 6 months on all PRO measures and from 6 months to 1 year on all but the mHHS ( P < .05 for all except the mHHS). A significantly smaller percentage of patients with Outerbridge grade 3 cartilage damage achieved the MCID and SCB on the mHHS compared with those with grade 0, both at 6 months (grade 3 vs 0: 20% vs 63.2% [MCID]; 18.0% vs 52.6% [SCB]; both P = .03) and 1 year (grade 3 vs 0: 22.0% vs 57.9% [MCID]; 14.0% vs 52.6% [SCB]; both P < .05). Conclusion: A structured, patient-guided PT protocol after arthroscopic acetabular labral repair can significantly improve postoperative outcomes.

Background: There is a paucity of literature on arthroscopic capsular autograft labral reconstruction. Purpose: To report midterm functional outcomes for patients undergoing acetabular labral repair with capsular autograft labral reconstruction. Study Design: Case series; Level of evidence, 4. Methods: This is a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by the senior surgeon between March 2013 and August 2018. The inclusion criteria for this study were adult patients aged 18 years or older who underwent primary hip arthroscopy for arthroscopic capsular autograft labral reconstruction. Exclusion criteria were <2 years of postoperative follow-up, elective disenrollment from study before 2-year follow-up, or repeat ipsilateral hip surgery before 2-year follow-up. Intraoperatively, patients underwent capsular autograft hip labral reconstruction if they were found to have a labrum with hypoplastic tissue (width <5 mm), complex tearing, or frank degeneration of native tissue. Clinical outcome data consisted of patient-reported outcome measures. Results: A total of 97 hips (94 patients) met the inclusion criteria with a mean final follow-up of 28.2 months (95% CI, 26.0-30.4). Patients had a mean age of 39.0 years (95% CI, 36.8-41.2) with a mean body mass index of 25.8 (95% CI, 24.9-26.7). When compared with baseline (40.4 [95% CI, 36.7-44.2]), the mean international Hip-Outcome Tool-33 (iHOT-33) scores were significantly greater at 3-month (60.9 [95% CI, 56.8-64.9]; P < .001), 6-month (68.8 [95% CI, 64.7-72.9]; P < .001), 12-month (73.2 [95% CI, 68.9-77.5]; P < .001), and final (76.6 [95% CI, 72.4-80.8]; P < .001) follow-up. At 2-year follow-up, 76.3%, 65.5%, and 60.8% of patients’ iHOT-33 scores exceeded clinically meaningful outcome thresholds for minimally clinically important difference (MCID), patient-acceptable symptomatic state, and substantial clinical benefit, respectively. Conclusions: In this study of 97 hips undergoing arthroscopic labral repair with capsular autograft labral reconstruction, we found favorable outcomes that exceeded the MCID thresholds in the majority of patients at a mean 28.2 months’ follow-up. Future studies should compare outcomes between this technique and other methods of autograft and allograft reconstruction to determine differences in patient-reported outcomes, donor-site morbidity, and complications.

Background: The optimal treatment strategy for patients with full-thickness chondral flaps undergoing hip arthroscopy is controversial. Purpose: To compare functional outcomes of patients who underwent bone marrow aspirate concentrate (BMAC) application with those of patients who underwent microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective case series of prospectively collected data on patients who underwent arthroscopic acetabular labral repair by 1 surgeon between June 2014 and April 2020. The inclusion criteria for this study were age ≥18 years, preoperative radiographs of the pelvis, arthroscopic acetabular labral repair, exposed subchondral bone with overlying chondral flap seen at the time of hip arthroscopy, microfracture or BMAC to address this lesion, and completed patient-reported outcome measures (PROMs) (International Hip Outcome Tool–33 [iHOT-33], Hip Outcome Score–Activities of Daily Living [HOS-ADL], Hip Outcome Score–Sports Subscale [HOS-Sport], modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) at enrollment and 12-month follow-up. Clinical outcomes were assessed using PROM scores. Results: A total of 81 hips with full-thickness chondral flaps were included in this study: 50 treated with BMAC and 31 treated with microfracture. There were no significant differences between groups in age, sex, body mass index, tear size, radiographic osteoarthritis, or radiographic femoroacetabular impingement. In the BMAC cohort, all PROM scores improved significantly from preoperatively to follow-up: 41.7 to 75.6 for iHOT-33, 67.6 to 91.0 for HOS-ADL, 41.5 to 72.3 for HOS-Sport, 59.4 to 87.2 for mHHS, and 6.2 to 2.2 for VAS pain ( P < .001 for all). In the microfracture cohort, the score improvements were 48.0 to 65.1 for iHOT-33 ( P = .001), 80.5 to 83.3 for HOS-ADL ( P = .275), 59.2 to 62.4 for HOS-Sport ( P = .568), 70.4 to 78.3 for mHHS ( P = .028), and 4.9 to 3.6 for VAS pain ( P = .036). Regarding clinically meaningful outcomes, 77.6% of the BMAC group and 50.0% of the microfracture group met the minimal clinically important difference for iHOT-33 at the 12-month follow-up ( P = .013). Conclusion: Patients with full-thickness chondral flaps at the time of hip arthroscopy experienced greater improvements in functional outcome scores at the 12-month follow-up when treated with BMAC as opposed to microfracture.

Background: Arthroscopic treatment for labral tears includes debridement and repair. Long-term studies have failed to demonstrate a difference between these treatments in terms of conversion to total hip arthroplasty (THA). Purpose: To investigate 2 different labral treatments, debridement and repair, using an adjusted analysis to evaluate long-term conversion to THA. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective cohort study of patients who underwent hip arthroscopy by a single surgeon between April 2007 and October 2014. Postoperative follow-up information included conversion to THA, patient satisfaction, and patient-reported outcome measures (modified Harris Hip Score; Hip Outcome Score, Activities of Daily Living and Sports Specific subscales; International Hip Outcome Tool; Nonarthritic Hip Score; and Lower Extremity Functional Scale). Results: Of the 204 hips included in the study, 99 (48.5%) underwent labral repair, and 105 (51.5%) underwent debridement. In total, 28 (13.7%) of the 204 patients underwent conversion to THA within 10 years after hip arthroscopy (labral repair: 5 [5.0%] vs labral debridement: 23 [21.9%]). Labral repair was associated with a significantly lower risk of conversion to THA compared with debridement (hazard ratio [HR] = 0.24; 95% CI, 0.07-0.74; P = .014). Additional factors associated with risk of conversion to THA included older age at the time of arthroscopy (HR = 1.06 per year; 95% CI, 1.02-1.11; P = .002) and Tönnis grade (HR = 2.39; CI, 1.14-5.41; P = .026). Abrasion chondroplasty, acetabuloplasty, body mass index, Outerbridge grade, and radiographic femoroacetabular impingement were not found to be significantly associated with risk of THA. No significant difference in patient satisfaction was found between treatment groups, and for patients who did not convert to THA, there was no difference in mean patient-reported outcome scores at final follow-up. Conclusion: Patients who underwent labral repair were less likely to convert to THA compared with patients who underwent labral debridement, despite adjustment for differences in baseline patient characteristics and preexisting pathology. Additional factors associated with a lower rate of hip survival were older age and osteoarthritis at the time of hip arthroscopy.

We herein report a case of a 55-year-old female with an unusual case of post-operative kratom withdrawal. The patient’s withdrawal symptoms subsequently contributed to complications and admission to the intensive care unit. Features of this case are discussed, alongside the management of kratom withdrawal and the implications of supplementation with unregulated herbal medications.

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