Clinical Focus

  • Orthopaedic Surgery
  • Sports Medicine
  • Hip Arthroscopy
  • Elbow Surgery
  • Ligament Reconstruction
  • Knee Surgery
  • Knee Arthroscopy
  • Shoulder Surgery
  • Shoulder Dislocation
  • Hip Impingement
  • Labral Tears
  • Shoulder Impingement Syndrome
  • Thrower's Shoulder
  • Thrower's Elbow
  • Knee Injuries
  • Elbow Arthroscopy
  • Arthroscopy

Academic Appointments

Administrative Appointments

  • Board Member, Chair Council of Delegates, American Orthopaedic Society for Sports Medicine (2012 - 2014)
  • Past President, International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) (2017 - 2019)
  • Past President, International Society for Hip Arthroscopy (ISHA) (2015 - 2016)
  • Chief Orthopaedic Consultant, Women's Tennis Association (WTA) (2011 - Present)

Honors & Awards

  • American Heart Association Student Research Fellowship, American Heart Association (1982)
  • Honor Student Society, UC Berkeley (1979-1983)
  • Magna Cum Laude, UC Berkeley (1983)
  • Best Resident's Paper, 3RD Place, Am. Acad. Ped., Orthop. Section (1990)
  • Best Resident's Paper, 1ST Place, Western Orthopaedic Association (1993)
  • Best Clinical Science Fellow's Paper, 1ST Place, University of Pittsburgh (1994)
  • American College of Sports Medicine (ACSM) Clinical Exchange Scholar, American College of Sports Medicine (ACSM) (2001)
  • American Orthopaedic Society for Sports Medicine (AOSSM) International Traveling Fellow, American Orthopaedic Society for Sports Medicine (AOSSM) (2002)
  • Irving Glick Award, Physician of the Year, Sanex WTA Tour (2001)
  • Guest Reviewer, Aircast Foundation Granting Board (2004)

Boards, Advisory Committees, Professional Organizations

  • President, International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (2017 - 2019)
  • Vice President, International Society for Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (2013 - 2017)
  • Vice President, International Society of Hip Arthroscopy (2014 - 2015)
  • President, International Society of Hip Arthroscopy (2015 - 2016)
  • Editorial Board, American Journal of Sports Medicine (2002 - Present)
  • Deputy Editor, Journal of Hip Preservation Surgery (2014 - Present)
  • Board Member, Chair, Council of Delegates, American Orthopaedic Society for Sports Medicine (2012 - 2014)

Professional Education

  • Board Certification: American Board of Orthopaedic Surgery, Orthopaedic Surgery (2017)
  • Internship: UCLA Registrar (1988) CA
  • Fellowship: University of Pittsburgh (1994) PA
  • Board Certification: American Board of Orthopaedic Surgery, Sports Medicine (2007)
  • Medical Education: Duke University School of Medicine (1987) NC
  • MD, University of Pittsburgh, Sports Med. & Shoulder Surgery (1994)
  • MD, UCLA, Orthopaedic Surgery (1993)
  • M.D., Duke University (1987)

Community and International Work

  • Evaluation of Hip Kinematic in Cadaver Model, Stanford



    Partnering Organization(s)

    Rizzoli Institute



    Ongoing Project


    Opportunities for Student Involvement


  • PreOp 3D Computer Simulation Improve Clinical Outcomes of Arthroscopic Surgery for FAI, Stanford, London


    Hip Arthroscopy and FAI

    Partnering Organization(s)


    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Dr. Safran is the Chief of the Division of Sports Medicine and Fellowship Director of Sports Medicine, Professor of Orthopaedic Surgery. Dr. Safran specializes in Sports Medicine and arthroscopic and ligament reconstructive surgery on the shoulder, elbow, hip and knee. He is a diplomat at the American Board of Orthopaedic Surgery and member of such prestigious societies such as: The American Orthopaedic Society for Sports Medicine, the ACL Study Group, the American Shoulder and Elbow Surgeons Society, the Herodicus Society, the Multicenter of Arthroscopic Hip Surgery Outcomes Research Network, the Multicenter Orthopaedic Outcomes Network, and the Society of Tennis Medicine and Science in addition to the American College of Sports Medicine. Dr. Safran’s practice focuses on arthroscopic management of hip problems as well as articular cartilage regeneration, shoulder surgery and athletic shoulder and elbow problems. He is actively involved in research in these areas. Dr. Safran graduated from the University of California, Berkeley; Medical School was at Duke University; Residency at Uuniversity of California, Los Angeles; and Sports Medicine and Shoulder Surgery Fellowship from the University of Pittsburgh. He has served as a team physician for many collegiate teams since 1993, in addition to being actively involved with professional tennis and as a consultant for the NBA Players Association and NHL Players Association. Dr. Safran has authored or co-authored more than 200 scientific articles, 75 book chapters and seven books on sports medicine as it relates to the shoulder, elbow, knee, hip as well as tennis injuries and biomechanics cartilage research. Prior to coming to Stanford in the Spring of 2007, Dr. Safran has been in different practices, including being the Chief of Sports Medicine at the University of California, San Francisco (UCSF), where he also served as a team physician for the University of California, Berkeley. He is on the editorial board of many journals, including the American Journal of Sports Medicine, Journal of Hip Preservation Surgery and the Journal of ISAKOS.


  • Does PreOperative 3D Computer Simulation Improve Clinical Outcomes of Arthroscopic Surgery for FAI, Stanford University and London, England (June 30, 2013 - 12/31/2015)

    This is a prospective, randomized, multicenter study, involving Stanford and London, England evaluating the efficacy of pre-operative planning for femoroacetabular (FAI) arthroscopic surgery using novel computer simulation software (from the Netherlands) to plan surgery for patients with FAI


    Stanford University and London, England

  • Evaluation of Hip Kinematic in Cadaver Model, Stanford University and Rizzoli Institute, Bologna, Italy (2007 - 2007)

    This was a study of hip kinematics performed at Stanford University and the PAlo Alto Veteran's Administration Hospital / Bone and Joint Research Center, using technology developed at the Rizzoli Institute in Bologna, Italy. Cadaveric hips were studied to better understand hip function and motion.


    Stanford University and Bologna, Italy

2021-22 Courses

All Publications

  • Biologics in professional and Olympic sport: a scoping review. The bone & joint journal Murray, I. R., Makaram, N. S., Rodeo, S. A., Safran, M. R., Sherman, S. L., McAdams, T. R., Murray, A. D., Haddad, F. S., Abrams, G. D. 2021; 103-B (7): 1189-1196


    AIMS: The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes.METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and Arksey and O'Malley frameworks were followed. A three-step search strategy identified relevant published primary and secondary studies, as well as grey literature. The identified studies were screened with criteria for inclusion comprising clinical studies evaluating the use of biologic therapies in professional and Olympic athletes, systematic reviews, consensus statements, and conference proceedings. Data were extracted using a standardized tool to form a descriptive analysis and a thematic summary.RESULTS: A total of 202 studies were initially identified, and 35 met criteria for the scoping review; 33 (94.3%) were published within the last eight years, and 18 (51.4%) originated from the USA. Platelet rich plasma was the most studied biologic therapy, being evaluated in 33 (94.3%) studies. Ulnar collateral ligament and hamstring injuries were the conditions most studied (nine (25.7%) studies and seven (20.0%) studies, respectively). Athletes most frequently participated in baseball, soccer, and American football. Only two (5.7%) studies were level 1 evidence, with interpretation and comparison between studies limited by the variations in the injury profile, biologic preparations, and rehabilitation protocols.CONCLUSION: There is diverse use of biologic therapies in the management of musculoskeletal injuries in professional and Olympic athletes. There is currently insufficient high-level evidence to support the widespread use of biologic therapies in athletes. Further research priorities include the development of condition/pathology-specific preparations of biologic therapies, and of outcome measures and imaging modalities sufficiently sensitive to detect differences in outcomes, should they exist. Cite this article: Bone Joint J2021;103-B(7):1189-1196.

    View details for DOI 10.1302/0301-620X.103B7.BJJ-2020-2282.R1

    View details for PubMedID 34192936

  • Nonsurgical Versus Surgical Management of Femoroacetabular Impingement: What Does the Current Best Evidence Tell Us. The Journal of the American Academy of Orthopaedic Surgeons Gao, I. n., Safran, M. R. 2020; Publish Ahead of Print


    Controversy exists as to the management of femoroacetabular impingement (FAI). When nonsurgical management of symptomatic FAI fails, surgical management is generally indicated. However, many groups with a stake in patient care (particularly payors) have insisted on higher levels of evidence. Recently, there have been several Level I studies published, comparing physical therapy (PT) with hip arthroscopy in the management of symptomatic FAI. All of these studies have used outcomes tools developed and validated for patients with nonarthritic hip pain (the International Hip Outcome Tool). Most highest level evidence confirms that although patients with FAI do benefit from PT, patients who undergo surgical management for FAI with hip arthroscopy benefit more than those who undergo PT (mean difference in the International Hip Outcome Tool 6.8 [minimal clinically important difference 6.1], P = 0.0093). Future large prospective studies are needed to evaluate the effect on the outcomes when there is a delay in surgical management in symptomatic individuals, assess whether FAI surgery prevents or delays osteoarthritis, and determine the role of other advanced surgical techniques.

    View details for DOI 10.5435/JAAOS-D-20-00571

    View details for PubMedID 33351525

  • Contributions of the Capsule and Labrum to Hip Mechanics in the Context of Hip Microinstability ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Johannsen, A. M., Ejnisman, L., Behn, A. W., Shibata, K., Thio, T., Safran, M. R. 2019; 7 (12)
  • The evolution of femoroacetabular impingement surgical management as a model for introducing new surgical techniques. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Ohlin, A., Coughlin, R. P., Ahlden, M., Samuelsson, K., Malchau, H., Safran, M. R., Ayeni, O. R., Sansone, M. 2019


    Introducing new surgical techniques and concepts can be difficult. There are many hurdles to overcome initially, such as the learning curve, equipment and technique development, before a standard of care can be established. In the past, new surgical techniques have been developed, and even widely accepted, before any scientific evaluation has been made. At that stage, it may be too late properly to evaluate the effectiveness of treatments, as the objectiveness and/or randomisation process may be obstructed. Since the introduction of evidence-based medicine (EBM), there have been high standards of scientific rigour to prove the efficacy of treatments. Based on the nature of evidence-based acceptance, innovations cannot be subjected to this final process before their evolution process is complete and, as a result, there is a need for the staged scientific development of new surgical techniques that should be adopted. This paper presents a model for this kind of stepwise introduction based on the actual evolution of FAI syndrome surgery. By following a scientific algorithmic methodology, new surgical techniques and concepts can be introduced in a stepwise manner to ensure the evidence-based progression of knowledge.

    View details for PubMedID 30949748

  • The Role of Anterior Capsular Laxity in Hip Microinstability A Novel Biomechanical Model AMERICAN JOURNAL OF SPORTS MEDICINE Johannsen, A. M., Behn, A. W., Shibata, K., Ejnisman, L., Thio, T., Safran, M. R. 2019; 47 (5): 1151–58
  • The Role of Anterior Capsular Laxity in Hip Microinstability: A Novel Biomechanical Model. The American journal of sports medicine Johannsen, A. M., Behn, A. W., Shibata, K., Ejnisman, L., Thio, T., Safran, M. R. 2019: 363546519827955


    BACKGROUND:: Hip microinstability is an increasingly recognized source of hip pain and disability. Although the clinical entity has been well described, the pathomechanics of this disease remain poorly understood.PURPOSE/HYPOTHESIS:: The purpose of this study was to determine the role of capsular laxity in atraumatic hip microinstability. Our hypothesis was that cyclic stretching of the anterior hip capsule would result in increased hip range of motion and femoral head displacement.STUDY DESIGN:: Controlled laboratory study.METHODS:: In this study, 7 hip specimens met inclusion criteria (age, 18-46 years). Specimens were stripped of all soft tissue, aligned, cut, and potted by use of a custom jig. A materials testing system was used to cyclically stretch the anterior hip capsule in extension and external rotation while rotating about the mechanical axis of the hip. A motion tracking system was used to record hip rotation and displacement of the femoral head relative to the acetabulum in the anterior-posterior, medial-lateral, and superior-inferior directions. Testing was conducted at baseline, after venting, and after capsular stretching.RESULTS:: With the hip in anatomic neutral alignment, cyclic stretching of the anterior hip capsule resulted in increased hip rotation ( P < .001). Femoral head displacement significantly increased relative to the vented state in the medial-lateral ( P < .001), anterior-posterior ( P = .013), and superior-inferior ( P = .036) planes after cyclic stretching of the anterior hip capsule.CONCLUSION:: The anterior hip capsule plays an important role in controlling hip rotation and femoral head displacement. This study is the first to display significant increases in femoral head displacement through a controlled cyclic stretching protocol of the anterior hip capsule.CLINICAL RELEVANCE:: This study is directly applicable to the treatment of atraumatic hip microinstability. The results quantitatively define the relative importance of the hip capsule in controlling femoral head motion. This allows for a better understanding of the pathophysiological process of hip microinstability and serves as a platform to develop effective surgical techniques for treatment of this disease.

    View details for PubMedID 30865838

  • International Expert Consensus on a Cell Therapy Communication Tool: DOSES. The Journal of bone and joint surgery. American volume Murray, I. R., Chahla, J. n., Safran, M. R., Krych, A. J., Saris, D. B., Caplan, A. I., LaPrade, R. F. 2019; 101 (10): 904–11


    The lack of a standardized system for describing cell therapies acts as a barrier to advancement in clinical and basic research and practice. The aim of this study was to establish an international expert consensus on strategies to improve standardization and transparency when describing cell therapies. The secondary aim was to develop a consensus among experts on the contents of a standardized tool for describing cell therapies.The need for expert consensus on strategies to improve cell therapy communication was confirmed at the American Academy of Orthopaedic Surgeons/National Institutes of Health Optimizing Clinical Use of Biologics Symposium in 2018. A working group of 6 experts convened an international consensus process involving clinicians and basic scientists using validated Delphi methodology. This iterative process was used to define statements on communication of cell therapies and develop a standardized tool for describing cell therapies.Thirty-four experts completed 3 rounds survey with use of the Delphi process. After 3 rounds, 27 statements relating to existing nomenclature, solutions to improve communication, ideal characteristics of a framework, mandatory elements of a new framework, and future work to facilitate application reached consensus with >80% agreement and <5% disagreement. Consensus was reached on the contents of a tool for improving standardization and transparency when describing cell therapies. This tool, dubbed "DOSES," is based on the reporting of 5 core items: donor (i.e., autologous, allogeneic, xenogeneic), origin of tissue, separation from other cell types/preparation method, exhibited cell characteristics associated with behavior, and the site of delivery.This study has established expert consensus on the communication of cell therapies. The DOSES tool has been developed to improve standardization and transparency in describing cell therapies.The DOSES tool for describing cell therapies can be utilized by researchers, clinicians, regulators, and industry professionals to improve standardization and transparency when describing cell therapies. The use of this tool may allow clinicians and patients to better understand the characteristics of current and future cell preparations.

    View details for DOI 10.2106/JBJS.18.00915

    View details for PubMedID 31094982

  • Microinstability of the Hip-Gaining Acceptance JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Safran, M. R. 2019; 27 (1): 12–22
  • Hip Arthroscopy - State of the Art in 2018 SPORTS MEDICINE AND ARTHROSCOPY REVIEW Nathani, A., Safran, M. R. 2018; 26 (4): 185–89
  • Hip Arthroscopy - State of the Art in 2018. Sports medicine and arthroscopy review Nathani, A., Safran, M. R. 2018; 26 (4): 185–89


    The field of hip arthroscopy has undergone considerable change in the past 25 years and continues to evolve at a rapid pace. Lessons from the early complications and challenges of hip arthroscopy have led to improved safety and refinement of instrumentation and techniques. The pathophysiology of hip injuries is better understood, and advances in surgical technique have helped expand indications, particularly as a shift from pathology resection to anatomic repair and reconstructive procedures has occurred. As the field has progressed, longitudinal outcome studies are now available to help judge efficacy. The purpose of this review is to highlight the past 30 years of hip arthroscopy, the current practice trends, and future directions of the field.

    View details for PubMedID 30395065

  • Knotless Anchors in Acetabular Labral Repair: A Biomechanical Comparison. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Safran, M. R., Behn, A. W., Botser, I. B., Mardones, R. 2018


    PURPOSE: To analyze the failure mechanism, stiffness, and pullout strength of acetabular knotless suture anchors.METHODS: Seven suture anchors were tested in high-density (0.48g/cc) synthetic blocks. The anchors were implanted perpendicular to the bone block. The anchor's suture(s) were tied around a loop of 8 high-strength nonabsorbable sutures and pulled in line with the anchor at a rate of 1mm/s until failure. The following knotless anchors were tested: Stryker Knotilus 3.5, Arthrex Pushlock 2.9, Linvatec PopLok 2.8, Linvatec PopLok 3.3, ArthroCare SpeedLock HIP (3.4-mm), and Smith & Nephew Bioraptor Knotless 2.9. The standard knot tying Smith & Nephew Bioraptor 2.9mm served as a baseline for comparison.RESULTS: Stiffness was highest in the Pushlock, the SpeedLock HIP, and Knotilus. At 1mm displacement, the SpeedLock HIP exhibited significantly higher load than all other anchors, excluding the Pushlock and PopLok 3.3 (P≤.012 for all comparisons). Excluding the SpeedLock HIP and Knotilus, the Pushlock displayed significantly higher load than all other anchors at 2-mm displacement (P ≤ .015 for all comparisons). Maximum load was the highest for the Knotilus and Bioraptor knotted anchor (P < .001 compared with all other anchors).CONCLUSIONS: All knotless suture anchors used in hip arthroscopy, except for the Knotilus 3.5, failed by suture pullout from the anchor. The 2 anchors with the highest maximum load, the Knotilus 3.5 and knotted Bioraptor 2.9, failed by suture failure; however, these anchors displayed the lowest stiffness and load at 1mm displacement among all anchors tested. Stiffness and loads at clinically relevant displacements, not maximum load alone, may be most important in predicting anchor clinical performance during the early phases of labral healing.CLINICAL RELEVANCE: Knotless suture anchors tend to fail by suture pullout from the anchor, yet the stiffness of these constructs suggests that minimal displacement of the repair will occur under physiologic loads.

    View details for PubMedID 30473457

  • Microinstability of the Hip-Gaining Acceptance. The Journal of the American Academy of Orthopaedic Surgeons Safran, M. R. 2018


    The hip has generally been considered an inherently stable joint. However, the femoral head moves relative to the acetabulum. Although the bones are primarily important in hip stability, the importance of the soft tissues has recently been demonstrated. Symptomatic microinstability of the hip is defined as extraphysiologic hip motion that causes pain with or without symptoms of hip joint unsteadiness and may be the result of bony deficiency and/or soft-tissue damage or loss. Recent work has helped improve the ability to identify microinstability patients preoperatively. Initial management begins with activity modification and strengthening of the periarticular musculature. Failing nonsurgical management, surgical intervention can be beneficial, focusing on treatment of the underlying cause of microinstability, as well as associated intra-articular pathology. Bony deficiency may be treated with a redirectional osteotomy, whereas those with adequate bony coverage may be treated with capsular plication, capsular reconstruction, and/or labral reconstruction.

    View details for PubMedID 30475277

  • The Cliff Sign: A New Radiographic Sign of Hip Instability ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Packer, J. D., Cowan, J. B., Rebolledo, B. J., Shibata, K. R., Riley, G. M., Finlay, A. K., Safran, M. R. 2018; 6 (11): 2325967118807176


    The preoperative diagnosis of hip microinstability is challenging. Although physical examination maneuvers and magnetic resonance imaging findings associated with microinstability have been described, there are limited reports of radiographic features. In patients with microinstability, we observed a high incidence of a steep drop-off on the lateral edge of the femoral head, which we have named the "cliff sign."(1) To determine the relationship of the cliff sign and associated measurements with intraoperative microinstability and (2) to determine the interobserver reliability of these measurements.Cohort study (diagnosis); Level of evidence, 2.A total of 115 consecutive patients who underwent hip arthroscopy were identified. Patients with prior hip surgery, Legg-Calve-Perthes disease, fractures, pigmented villonodular synovitis, or synovial chondromatosis were excluded, resulting in the inclusion of 96 patients in the study. A perfect circle around the femoral head was created on anteroposterior pelvis radiographs. If the lateral femoral head did not completely fill the perfect circle, it was considered a positive cliff sign. Five additional measurements relating to the cliff sign were calculated. The diagnosis of microinstability was made intraoperatively by the (1) amount of traction required to distract the hip, (2) lack of hip reduction after initial traction release following joint venting, or (3) intraoperative findings consistent with hip microinstability. Continuous variables were analyzed through use of unpaired t tests and discrete variables with Fisher exact tests. Interobserver reliability (n = 3) was determined for each measurement.Overall, 89% (39/44) of patients with microinstability had a cliff sign, compared with 27% of patients (14/52) without instability (P < .0001). Conversely, 74% of patients with a cliff sign had microinstability, while only 12% of patients without a cliff sign had instability (P < .0001). In women younger than 32 years with a cliff sign, 100% (20/20) were diagnosed with instability. No differences were found in any of the 5 additional measurements. Excellent interobserver reliability was found for the presence of a cliff sign and the cliff angle measurement.We have identified a radiographic finding, the cliff sign, that is associated with the intraoperative diagnosis of hip microinstability and has excellent interobserver reliability. Results showed that 100% of young women with a cliff sign had intraoperative microinstability. The cliff sign may be useful in the preoperative diagnosis of hip microinstability.

    View details for PubMedID 30480017

  • Surgical Decision Making for Acetabular Labral Tears: An International Perspective ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Herickhoff, P., Safran, M. 2018; 6 (9): 2325967118797324


    Studies comparing acetabular labral repair with debridement have generally demonstrated better clinical outcomes with repair. However, it is not clear whether hip arthroscopic surgeons agree on the indications for labral repair and debridement, bringing the generalizability of these (and future) studies into question.To investigate surgical decision making for acetabular labral tears, with a specific focus on indications for repair or debridement, by performing an international survey of hip arthroscopic surgeons.Cross-sectional study.A total of 35 hip arthroscopic surgeons from around the world were invited to participate in this survey study. Surgeons selected the factors that they consider when deciding to repair or debride acetabular labral tears. For each variable selected, computerized adaptive logic prompted additional questions to better define how that variable affects decision making. Six deidentified intraoperative videos of a variety of labral tears were included to determine the level of agreement between the experts on which labral tears are repairable.The survey response rate was 86%. A majority (77%) of hip arthroscopic surgeons selected the intraoperative appearance of the labrum as the most important factor affecting their decision making. Specific factors affecting surgical decision making included pattern of the labral tear (73% of surgeons), ossification of the labrum (70%), magnetic resonance imaging findings (70%), patient age (63%), activity level (57%), radiographic findings (53%), calcification of the labrum (50%), and thickness of the labrum (47%). Three intraoperative videos had ≥90% agreement for labral repair, while the other 3 had ≤76% agreement.The intraoperative appearance of the labrum is the most important factor affecting surgical decision making. However, different surgeons viewing the same tear arthroscopically may select different treatments. The indications to repair a torn acetabular labrum are highly variable among hip arthroscopic surgeons.

    View details for PubMedID 30263897

  • There Is a Significant Discrepancy Between "Big Data" Database and Original Research Publications on Hip Arthroscopy Outcomes: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Sochacki, K. R., Jack, R. A., Safran, M. R., Nho, S. J., Harris, J. D. 2018; 34 (6): 1998–2004


    The purpose of this study was to compare (1) major complication, (2) revision, and (3) conversion to arthroplasty rates following hip arthroscopy between database studies and original research peer-reviewed publications.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, SportDiscus, and Cochrane Central Register of Controlled Trials were searched for studies that investigated major complication (dislocation, femoral neck fracture, avascular necrosis, fluid extravasation, septic arthritis, death), revision, and hip arthroplasty conversion rates following hip arthroscopy. Major complication, revision, and conversion to hip arthroplasty rates were compared between original research (single- or multicenter therapeutic studies) and database (insurance database using ICD-9/10 and/or current procedural terminology coding terminology) publishing studies.Two hundred seven studies (201 original research publications [15,780 subjects; 54% female] and 6 database studies [20,825 subjects; 60% female]) were analyzed (mean age, 38.2 ± 11.6 years old; mean follow-up, 2.7 ± 2.9 years). The database studies had a significantly higher age (40.6 + 2.8 vs 35.4 ± 11.6), body mass index (27.4 ± 5.6 vs 24.9 ± 3.1), percentage of females (60.1% vs 53.8%), and longer follow-up (3.1 ± 1.6 vs 2.7 ± 3.0) compared with original research (P < .0001 for all). Ninety-seven (0.6%) major complications occurred in the individual studies, and 95 (0.8%) major complications occurred in the database studies (P = .029; relative risk [RR], 1.3). There was a significantly higher rate of femoral neck fracture (0.24% vs 0.03%; P < .0001; RR, 8.0), and hip dislocation (0.17% vs 0.06%; P = .023; RR, 2.2) in the database studies. Reoperations occurred at a significantly higher rate in the database studies (11.1% vs 7.3%; P < .001; RR, 1.5). There was a significantly higher rate of conversion to arthroplasty in the database studies (8.0% vs 3.7%; P < .001; RR, 2.2).Database studies report significantly increased major complication, revision, and conversion to hip arthroplasty rates compared with original research investigations of hip arthroscopy outcomes.Level IV, systematic review of Level I-IV studies.

    View details for PubMedID 29477605

  • Biologics in hip preservation ANNALS OF JOINT Ejnisman, L., Safran, M. R. 2018; 3 (6)
  • Complication Rates for Hip Arthroscopy Are Underestimated: A Population-Based Study. Arthroscopy Truntzer, J. N., Hoppe, D. J., Shapiro, L. M., Abrams, G. D., Safran, M. 2017


    To identify major and minor complication rates associated with hip arthroscopy from a payer-based national database and compare with the rates reported in the existing literature.Patients who underwent hip arthroscopy between 2007 and 2014 were identified using PearlDiver, a publicly available database. Rates of major and minor complications, as well as conversion to total hip arthroscopy (THA), were determined by using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9), codes. Incidence rates of select major complications across the entire database were used as a comparison group. Statistical significance was set at P < .05.Of 18 million patients screened from 2007 to 2014, a total of 2,581 hip arthroscopies were identified. The rates of major and minor complications within a 1-year postoperative period were 1.74% and 4.22%, respectively. Complications included heterotopic ossification (2.85%), bursitis (1.23%), proximal femur fracture (1.08%), deep vein thrombosis (0.79%), and hip dislocation (0.58%). The rate of conversion to THA within 1 year was 2.85%. When compared to rates in the general population, the relative risks [RRs] of requiring a THA (age <50 years, RR = 57.66, P < .001; age >50 years, RR = 22.05, P < .001), sustaining a proximal femur fracture (age <50 years, RR = 18.02, P < .001; age >50 years, RR = 2.23, P < .001), or experiencing a hip dislocation (RR 19.60, P < .001) at 1 year after hip arthroscopy were significantly higher in all age groups.Higher major complication rates after hip arthroscopy were observed using a national payer-based database than previously reported in the literature, especially in regard to hip dislocations and proximal femur fractures. Rates of total hip arthroplasty were similar to prior studies, whereas the rates of revision hip arthroscopy were higher.Level IV, case series.

    View details for DOI 10.1016/j.arthro.2017.01.021

    View details for PubMedID 28259588

  • Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Horner, N. S., Ekhtiari, S., Simunovic, N., Safran, M. R., Philippon, M. J., Ayeni, O. R. 2017; 33 (2): 464–U562


    To (1) report clinical outcomes, complication rates, and total hip arthroplasty (THA) conversion rates for patients age 40 or older who underwent hip arthroscopy, and (2) report any age-related predictors of outcome identified in the literature.MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data were abstracted from eligible studies. No meta-analysis was performed because of heterogeneity amongst studies.Seventeen studies were included in this review comprising 16,327 patients, including 9,954 patients age 40 or older. All studies reported statistically significant improvements in outcomes after hip arthroscopy for femoral osteochondroplasty, labral repair, or unspecified indications. In patients 40 or older who underwent labral debridement, these improvements were not clinically significant. Obesity and osteoarthritic changes predicted poorer outcomes. Only 1 of 3 studies directly comparing the 2 groups found that patients 40 or older had a significantly less improvement in a standardized hip outcome score than patients under 40 after hip arthroscopy, but all found that patients 40 or older had significantly higher rates of THA conversion. The rate of conversion to THA was 18.1% for patients 40 or older, 23.1% for patients over 50, and 25.2% for patients over 60 with a mean of 25.0 months to THA.Indications for hip arthroscopy including femoral osteochondroplasty and labral repair resulted in clinically significant improvements in patients 40 or older in most research studies examined in this review, whereas labral debridement did not produce clinically significant improvements postoperatively in the same studies. In these studies, the rate of conversion to THA is higher than in patients under 40 and increases with each decade of life, with many individual studies showing a significant increase in the rate of THA conversion. Hip arthroscopy may be suitable for some patients 40 or older, but patient selection is key and patients should be informed of the higher risk of conversion to THA.Level IV, systematic review of Level III and IV studies.

    View details for PubMedID 27625005

  • Cyclic and Load to Failure Properties of All-Suture Anchors in Synthetic Acetabular and Glenoid Cancellous Bone. Arthroscopy Douglass, N. P., Behn, A. W., Safran, M. R. 2017


    To evaluate the cyclic displacement, maximum load to failure, and failure mode of multiple all-suture anchors (ASAs) in 2 different densities of sawbones cancellous bone substitute.Anchors tested included the Suturefix Ultra 1.7 mm, JuggerKnot 1.45 mm (No. 1 and No. 2 MaxBraid) and 2.9 mm, Y-Knot Flex 1.3 mm and 1.8 mm, Iconix 1, 2, 25, and 3, Q-Fix 1.8 mm, and Bioraptor 2.3 PK. The Bioraptor served as a non-all-suture-based control. Seven to eleven anchors were tested in both 20 and 30 pounds per cubic foot (pcf) test blocks that were chosen to simulate glenoid and acetabular cancellous bone, respectively. After a 40 N deployment force, anchors were cyclically loaded at 0.5 Hz from 10 to 50 N and then 10 to 100 N for 200 cycles each. Surviving specimens were pulled to failure at 10 mm/s. Displacement, stiffness, maximum load, and failure mode were recorded. Welch t-tests and Welch analysis of variance with Games-Howell post hoc tests were used for statistical analysis.In higher density blocks, 11 of 12 anchors had significantly (P < .05) higher maximum loads to failure, and 8 anchors showed significantly lower post-cyclic displacement. The Q-Fix 1.8 displayed the lowest post-cyclic displacement in both densities (0.1 ± 0.2 mm, mean ± standard deviation, in both densities). All other groups exhibited at least 2.8 mm and 0.6 mm post-cyclic displacement in 20 and 30 pcf, respectively. The Bioraptor did not survive cyclic testing in 20 pcf and had 0.6 ± 0.3 mm post-cyclic displacement in 30 pcf.ASAs show better fixation in higher density synthetic bone. The cyclic displacement and maximum load of ASAs vary widely depending on anchor design and bone density. Most anchors fail by suture anchor pullout. In general, the Bioraptor 2.3 PK outperformed ASAs in higher density test blocks with mixed results in lower density test blocks.ASAs show mixed results compared with a traditional suture anchor. They perform better in higher density bone substitute.

    View details for DOI 10.1016/j.arthro.2016.11.022

    View details for PubMedID 28132809

  • Evaluation of the sealing function of the acetabular labrum: an in vitro biomechanical study. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Signorelli, C., Bonanzinga, T., Lopomo, N., Zaffagnini, S., Marcacci, M., Safran, M. 2017; 25 (1): 62-71


    To quantitatively evaluate the biomechanical sealing function of an intact labrum and the effect of labral-chondral separation, cerclage suture labral repair, vertical mattress suture repair and partial labrectomy on distraction load and hip joint centre (HJC) displacement.Eight fresh-frozen cadaveric hips were tested using a navigation system for intra-operative kinematic analysis. A six-axis load cell was used to measure the manually applied force when performing the tests: hip pivoting movement and distraction. The HJC displacement that occurred during the distraction test has been evaluated in correspondence of seven different values of applied force. During the pivoting motion, the maximum value of HJC displacement was evaluated. Five different conditions were tested: labrum intact, labral-chondral separation, vertical mattress suture repair, cerclage suture repair, and partial labrectomy.With regard to HJC displacement using at fixed value of force, the paired sample t test underscored the statistically significant differences (p < 0.05) for each of the five tested conditions among themselves. Only the comparison of intact versus labral-chondral separation was not significantly different. During pivoting motion, a statistically significantly greater displacement was identified after labrectomy when compared with the cerclage suture repair (p = 0.03) and vertical mattress repair (p < 0.01) in medial-lateral direction. Along proximal-distal direction, a significant lower displacement after labrectomy was identified when compared to the cerclage suture repair (p = 0.03). Performing the pivoting motion at the extreme ranges of motion demonstrated a higher value of displacement after labrectomy when compared with all the previously tested conditions.These results suggest that labral repair is important in the function of the hip and that the vertical mattress suture technique may be better than the cerclage suture repair.

    View details for DOI 10.1007/s00167-015-3851-x

    View details for PubMedID 26572634

  • Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Ekhtiari, S., de Sa, D., Haldane, C. E., Simunovic, N., Larson, C. M., Safran, M. R., Ayeni, O. R. 2017; 25 (1): 9–23


    Hip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy.MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria.Eighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2-82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients).Technical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear.Level IV, systematic review of level I-IV Studies.

    View details for PubMedID 28120020

  • Is there a distinct pattern to the acetabular labrum and articular cartilage damage in the non-dysplastic hip with instability? KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Shibata, K. R., Matsuda, S., Safran, M. R. 2017; 25 (1): 84-93


    The purpose of this study was to determine whether or not there is a distinct pattern of injury to the acetabular labrum and/or cartilage in the hip with instability without bony dysplasia.Surgical records and intra-operative images of consecutive patients who underwent primary hip arthroscopy for femoroacetabular impingement (FAI) and/or hip instability by the senior author from April 2007 to December 2014 were retrospectively reviewed. Pathological changes were documented and charted on a novel diagram of the acetabulum, and classified into eight patterns corresponding to the lesion's location and size. In patients who had acetabular chondroplasty treatment, the width of the cartilage lesion was recorded.A total of 953 hips in 886 patients were included, and patients who met our inclusion/exclusion criterion were grouped into an Instability-Only group (45 hips), an Instability-Dysplasia group (12 hips), as well as Pincer-FAI, Cam-FAI, and Combined-FAI groups consisting of 100, 54, and 269 hips, respectively. In the Instability-Only group, 42.2 % of the chondral and labral lesions demonstrated a "Straight-Anterior" pattern, which proportion was statistically significantly different compared with Pincer-FAI (p < 0.000), Cam-FAI (p = 0.0002), and Combined-FAI (p < 0.000) groups. In Instability-Only patients, only 15.6 % of the lesions had an "Anterior to Lateral" pattern, a significantly lower proportion (p < 0.000) compared with the FAI groups. Also 11.1 % of the lesions demonstrated a "Lateral" pattern, which is a significantly greater proportion compared with Pincer-FAI (p < 0.000) and Combined-FAI (p < 0.000) groups. The mean width of the cartilage lesions for the Instability-Only group was 2.9 mm, which was significantly shallower than for the other FAI groups (p < 0.000).A significant predilection of "Straight-Anterior" or "Lateral" location of labral and/or cartilage damage was observed in the hip with instability, while there was shallow width of articular cartilage damage in these patients. These results suggest that there is a distinctive labral and cartilage damage pattern for hips with instability without inherent bony dysplasia.Diagnostic study, Level IV.

    View details for DOI 10.1007/s00167-016-4342-4

    View details for Web of Science ID 000395078100013

  • Hip instability treated with arthroscopic capsular plication KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Kalisvaart, M. M., Safran, M. R. 2017; 25 (1): 24-30


    Atraumatic microinstability of the hip is felt to be a cause of intra-articular pathology, particularly tears of the anterior labrum. The purpose of this study is to evaluate a consecutive series of patients with atraumatic hip microinstability that resulted in anterior labral and cartilage pathology, treated with hip arthroscopy and capsular plication without any associated bony procedures.Thirty-two patients underwent hip arthroscopy and suture capsular plication for the treatment of hip instability without concomitant bony resections of the acetabulum or proximal femur between November 2009 and November 2012 and were followed for a minimum of 12 months. Patients were clinically evaluated preoperatively and again at 3, 6, 12, 24, and 36 months postoperatively with the modified Harris hip score (mHHS) and iHOT score in some patients (as this was introduced late in the study). Comparison was made evaluating centre-edge angle, Tönnis angle, physical examination findings, and demographics on outcome.There was significant improvement in the mean mHHS from 67 (SD = 8.7) to 97 (SD = 4.7) and iHOT score from 41 (SD = 18.3) to 85 (SD = 10.1) at final follow-up. When comparing patients with mild hip dysplasia to patients without hip dysplasia, there was no significant difference in clinical outcome at any point in follow-up. There was no significant association between patient age, duration of preoperative symptoms, previous ipsilateral hip arthroscopy, nature of onset of symptoms, centre-edge angle, Tönnis angle, or preoperative physical examination findings with clinical outcome at final follow-up.Isolated arthroscopic suture capsular plication performed for the treatment of hip instability resulted in improved patient pain and function at a minimum of 1-year follow-up.

    View details for DOI 10.1007/s00167-016-4377-6

    View details for Web of Science ID 000395078100004

    View details for PubMedID 27885395

  • Magnetic Resonance Imaging of Asymptomatic Knees in Collegiate Basketball Players: The Effect of One Season of Play. Clinical journal of sport medicine Pappas, G. P., Vogelsong, M. A., Staroswiecki, E., Gold, G. E., Safran, M. R. 2016; 26 (6): 483-489


    To determine the prevalence of abnormal structural findings using 3.0-T magnetic resonance imaging (MRI) in the asymptomatic knees of male and female collegiate basketball players before and after a season of high-intensity basketball.Institutional review board-approved prospective case series.Asymptomatic knees of 24 NCAA Division I collegiate basketball players (12 male, 12 female) were imaged using a 3.0-T MRI scanner before and after the end of the competitive season. Three subjects did not undergo scanning after the season.Images were evaluated for prepatellar bursitis, fat pad edema, patellar and quadriceps tendinopathy, bone marrow edema, and articular cartilage and meniscal injury.Every knee imaged had at least 1 structural abnormality both preseason and postseason. A high preseason and postseason prevalence of fat pad edema (75% and 81%), patellar tendinopathy (83% and 90%), and quadriceps tendinopathy (75% and 90%) was seen. Intrameniscal signal change was observed in 50% preseason knees and 62% of postseason knees, but no discrete tears were found. Bone marrow edema was seen in 75% and 86% of knees in the preseason and postseason, respectively. Cartilage findings were observed in 71% and 81% of knees in the preseason and postseason, respectively. The cartilage injury score increased significantly in the postseason compared with the preseason (P = 0.0009).A high prevalence of abnormal knee MRI findings was observed in a population of asymptomatic young elite athletes. These preliminary data suggest that high-intensity basketball may have potentially deleterious effects on articular cartilage.

    View details for PubMedID 27347867

  • Arthroscopic Shoulder Surgery in Female Professional Tennis Players: Ability and Timing to Return to Play. Clinical journal of sport medicine Young, S. W., Dakic, J., Stroia, K., Nguyen, M. L., Safran, M. R. 2016: -?


    To assess the outcome and time to return to previous level of competitive play after shoulder surgery in professional tennis players.Retrospective case series.Tertiary academic centre.The records of all female tennis players on the Women's Tennis Association (WTA) professional circuit between January 2008 and June 2010 were reviewed to identify players who underwent shoulder surgery on their dominant (serving) shoulder.Primary outcomes were the ability and time to return to professional play and if they were able to return to their previous level of function as determined by singles ranking. Preoperative and postoperative singles rankings were used to determine rate and completeness of return to preoperative function.During the study period, 8 professional women tennis players from the WTA tour underwent shoulder surgery on their dominant arm. Indications included rotator cuff debridement or repair, labral reconstruction for instability or superior labral anterior posterior lesion, and neurolysis of the suprascapular nerve. Seven players (88%) returned to professional play. The mean time to return to play was 7 months after surgery. However, only 25% (2 of 8) players achieved their preinjury singles rank or better by 18 months postoperatively. In total, 4 players returned to their preinjury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years postoperatively.In professional female tennis players, a high return to play rate after arthroscopic shoulder surgery is associated with a prolonged and often incomplete return to previous level of performance. Thus, counseling the patient to this fact is important to manage expectations.Level IV-Case Series.

    View details for PubMedID 27347868

  • Biomechanical Implications of Corrective Surgery for FAI: An Evidence-based Review SPORTS MEDICINE AND ARTHROSCOPY REVIEW Sampson, J. D., Safran, M. R. 2015; 23 (4): 169-173


    Femoroacetabular impingement (FAI) has been identified as a potential cause of hip osteoarthritis. The goal of FAI surgery is to relieve pain, and hopefully delay or prevent osteoarthritis of the hip. Several studies have now demonstrated favorable clinical outcomes after arthroscopic and open surgical correction of symptomatic FAI. The concept is restoration of normal hip anatomy may result in improved biomechanical function and kinematics of the hip, which may prevent or delay the progression of osteoarthritis. Although many clinical studies demonstrate restoration of "normal" anatomy, there are few studies evaluating improvement of biomechanics and function. To date, only 5 studies have been published in the English literature that study biomechanics and/or kinematics of the hip both preoperatively and postoperatively. At this point in the understanding of FAI, critical analysis of the literature suggests that FAI surgery can improve several parameters of biomechanical hip function. However, the impact of these improved biomechanics on the natural history and progression of degenerative changes in patients that are treated for symptomatic FAI has not been demonstrated.

    View details for DOI 10.1097/JSA.0000000000000092

    View details for PubMedID 26524550

  • The etiology of primary femoroacetabular impingement: genetics or acquired deformity? JOURNAL OF HIP PRESERVATION SURGERY Packer, J. D., Safran, M. R. 2015; 2 (3): 249–57


    The etiology of primary femoroacetabular impingement (FAI) remains controversial. Both genetic and acquired causes have been postulated and studied. While recent studies suggest that genetic factors may have a role in the development of FAI, there is no conclusive evidence that FAI is transmitted genetically. Currently, the most popular theory for the development of cam-type deformities is that a repetitive injury to the proximal femoral physis occurs during a critical period of development. There is a correlation between a high volume of impact activities during adolescence and the development of cam-type deformities. Multiple studies have found a high prevalence of FAI in elite football, ice hockey, basketball and soccer players. In this article, we review the current literature relating to the etiology of primary FAI.

    View details for PubMedID 27011846

  • High Incidence of Infraspinatus Muscle Atrophy in Elite Professional Female Tennis Players AMERICAN JOURNAL OF SPORTS MEDICINE Young, S. W., Dakic, J., Stroia, K., Nguyen, M. L., Harris, A. H., Safran, M. R. 2015; 43 (8): 1989-1993


    Isolated infraspinatus muscle atrophy is common in overhead athletes, who place significant and repetitive stresses across their dominant shoulders. Studies on volleyball and baseball players report infraspinatus atrophy in 4% to 34% of players; however, the prevalence of infraspinatus atrophy in professional tennis players has not been reported.To investigate the incidence of isolated infraspinatus atrophy in professional tennis players and to identify any correlations with other physical examination findings, ranking performance, and concurrent shoulder injuries.Cross-sectional study; Level of evidence, 3.A total of 125 professional female tennis players underwent a comprehensive preparticipation physical health status examination. Two orthopaedic surgeons examined the shoulders of all players and obtained digital goniometric measurements of range of motion (ROM). Infraspinatus atrophy was defined as loss of soft tissue bulk in the infraspinatus scapula fossa (and increased prominence of dorsal scapular bony anatomy) of the dominant shoulder with clear asymmetry when compared with the contralateral side. Correlations were examined between infraspinatus atrophy and concurrent shoulder disorders, clinical examination findings, ROM, glenohumeral internal rotation deficit, singles tennis ranking, and age.There were 65 players (52%) with evidence of infraspinatus atrophy in their dominant shoulders. No wasting was noted in the nondominant shoulder of any player. No statistically significant differences were seen in mean age, left- or right-hand dominance, height, weight, or body mass index for players with or without atrophy. Of the 77 players ranked in the top 100, 58% had clinical infraspinatus atrophy, compared with 40% of players ranked outside the top 100. No associations were found with static physical examination findings (scapular dyskinesis, ROM glenohumeral internal rotation deficit, postural abnormalities), concurrent shoulder disorders, or compromised performance when measured by singles ranking.This study reports a high level of clinical infraspinatus atrophy in the dominant shoulder of elite female tennis players. Infraspinatus atrophy was associated with a higher performance ranking, and no functional deficits or associations with concurrent shoulder disorders were found. Team physicians can be reassured that infraspinatus atrophy is a common finding in high-performing tennis players and, if asymptomatic, does not appear to significantly compromise performance.

    View details for DOI 10.1177/0363546515588177

    View details for Web of Science ID 000358892400026

    View details for PubMedID 26078449

  • Microinstability of the hip-it does exist: etiology, diagnosis and treatment JOURNAL OF HIP PRESERVATION SURGERY Kalisvaart, M. M., Safran, M. R. 2015; 2 (2): 123–35


    Symptomatic hip microinstability is now recognized as a potential cause of pain and disability in young patients. Causes of hip microinstability include underlying bony or soft tissue abnormalities and iatrogenic injuries of the hip capsule; however, many patients lack a clear underlying etiology. Treatment usually begins with an extensive course of non-operative management with an emphasis on activity modification and physical therapy. Surgical intervention should focus on treatment of the underlying cause as well as any associated intra-articular pathology. In many cases, arthroscopic suture plication can be considered when bony deficiency is not the cause. In this article, we will review the spectrum of symptomatic hip microinstability with a focus on the relevant anatomy, etiology, diagnosis and various treatment options.

    View details for PubMedID 27011829

  • Biochemical and Cellular Assessment of Acetabular Chondral Flaps Identified During Hip Arthroscopy ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Hariri, S., Truntzer, J., Smith, R. L., Safran, M. R. 2015; 31 (6): 1077-1083


    To analyze chondral flaps debrided during hip arthroscopy to determine their biochemical and cellular composition.Thirty-one full-thickness acetabular chondral flaps were collected during hip arthroscopy. Biochemical analysis was undertaken in 21 flaps from 20 patients, and cellular viability was determined in 10 flaps from 10 patients. Biochemical analysis included concentrations of (1) DNA (an indicator of chondrocyte content), (2) hydroxyproline (an indicator of collagen content), and (3) glycosaminoglycan (an indicator of chondrocyte biosynthesis). Higher values for these parameters indicated more healthy tissue. The flaps were examined to determine the percentage of viable chondrocytes.The percentage of acetabular chondral flap specimens that had concentrations within 1 SD of the mean values reported in previous normal cartilage studies was 38% for DNA, 0% for glycosaminoglycan, and 43% for hydroxyproline. The average cellular viability of our acetabular chondral flap specimens was 39% (SD, 14%). Only 2 of the 10 specimens had more than half the cells still viable. There was no correlation between (1) the gross examination of the joint or knowledge of the patient's demographic characteristics and symptoms and (2) biochemical properties and cell viability of the flap, with one exception: a degenerative appearance of the surrounding cartilage correlated with a higher hydroxyproline concentration.Although full-thickness acetabular chondral flaps can appear normal grossly, the biochemical properties and percentage of live chondrocytes in full-thickness chondral flaps encountered in hip arthroscopy show that this tissue is not normal.There has been recent interest in repairing chondral flaps encountered during hip arthroscopy. These data suggest that acetabular chondral flaps are not biochemically and cellularly normal. Although these flaps may still be valuable mechanically and/or as a scaffold in some conductive or inductive capacity, further study is required to assess the clinical benefit of repair.

    View details for DOI 10.1016/j.arthro.2015.01.010

    View details for Web of Science ID 000355636500012

    View details for PubMedID 25749531

  • Femoral Neck Stress Fractures and Imaging Features of Femoroacetabular Impingement PM&R Goldin, M., Anderson, C. N., Fredericson, M., Safran, M. R., Stevens, K. J. 2015; 7 (6): 584-592


    Prior literature has suggested an association between the radiographic signs of femoroacetabular impingement (FAI) and femoral neck stress fractures (FNSF) or femoral neck stress reactions (FNSR). At the time of the writing of this article, no study has described the association of FAI and FNSF/FNSR along with the need for surgical intervention and outcomes.To determine the prevalence of radiographic features of FAI in patients diagnosed with FNSF.Retrospective case series.Tertiary care, institutional setting.A medical records search program (Stanford Translational Research Integrated Database Environment, Stanford University, California) was used to retrospectively search for patients 18-40 years old with a history of FNSF or FNSR. The records were obtained from the period July 25, 2003, to September 23, 2011.For assessment of risk factors, plain radiographs and magnetic resonance imaging studies were reviewed for features of cam or pincer FAI. Medical records were reviewed to determine whether patients required operative intervention.Incidence of abnormal alpha (α) angle, abnormal anterior offset ratio, abnormal femoral head-neck junction, coxa profunda, positive crossover sign, and abnormal lateral center-to-edge angle.Twenty-one female and 3 male participants (mean age 27 years, range 19-39 years) were identified with magnetic resonance imaging evidence of femoral neck stress injury. Cam morphology was seen in 10 patients (42%). Pincer morphology could be assessed in 18 patients, with coxa profunda in 14 (78%) and acetabular retroversion in 6 (14%). Features of combined pincer and cam impingement were observed in 4 patients (17%). Seven patients (29%) had operative intervention, with 3 (12%) requiring internal fixation of their femoral neck fractures, and all had radiographic evidence of fracture union after surgery. Four patients (17%) had persistent symptoms after healing of their FNSF with conservative treatment and eventually required surgery for FAI, 3 had no pain at final follow-up 1 year post-surgery, and one patient was lost to follow-up.The results of the current study suggest that patients in the general population with femoral neck stress injuries have a higher incidence of bony abnormalities associated with pincer impingement, including coxa profunda and acetabular retroversion, although it is unclear whether pincer FAI is a true risk factor in the development of FNSF.

    View details for DOI 10.1016/j.pmrj.2014.12.008

    View details for Web of Science ID 000356053400005

    View details for PubMedID 25591871

  • RESTORATION OF THE SEAL FUNCTION OF THE ACETABULAR LABRUM: IN VITRO STUDY JOURNAL OF MECHANICS IN MEDICINE AND BIOLOGY Signorelli, C., Lopomo, N., Colle, F., Bontempi, M., Visani, A., Zaffagnini, S., Marcacci, M., Safran, M. R. 2015; 15 (2)
  • Hip Range of Motion and Association With Injury in Female Professional Tennis Players AMERICAN JOURNAL OF SPORTS MEDICINE Young, S. W., Dakic, J., Stroia, K., Nguyen, M. L., Harris, A. H., Safran, M. R. 2014; 42 (11): 2654-2658


    Adequate hip range of motion is required for the transfer of energy from the lower to the upper extremity along the kinetic chain. Repetitive rotational stresses in the lower extremities during tennis may lead to sport-specific range of motion adaptations, which may increase the risk of injury to other joints along the kinetic chain.To assess whether such range of motion adaptations occur in the hip, and if so, to identify whether they are associated with injury.Cross-sectional study; Level of evidence, 3.A total of 125 female professional tennis players, the majority of whom were ranked in the top 200 World Tennis Association singles rankings, underwent a comprehensive preparticipation physical health status examination. Hip range of motion was assessed using a digital inclinometer and side-to-side differences in rotational parameters calculated, and associations with previous injuries were identified.A history of an abdominal strain was reported by 10% of players, and there was an association between abdominal strains and the presence of hip flexion contractures (odds ratio, 6.1; P = .006). Hip flexion contractures were bilateral in 85% of those found, affected only the nondominant side in 9%, and affected only the dominant side in 6%. We were unable to identify any specific side-to-side rotational adaptations in the dominant or nondominant hips, and no association between loss of hip range of motion and shoulder, lower back, hip, knee, or ankle injuries was found.We report an association in female professional tennis players between abdominal strains and flexion contractures of the hip with iliopsoas tightness. We did not find evidence of specific hip adaptations in rotational range of motion. If hip flexion contractures are found on clinical examination, a stretching program may be indicated. Further studies are required to assess whether such a program can reduce the risk of abdominal injury.

    View details for DOI 10.1177/0363546514548852

    View details for Web of Science ID 000344658000018

    View details for PubMedID 25214532

  • A quantitative assessment of the insertional footprints of the hip joint capsular ligaments and their spanning fibers for reconstruction CLINICAL ANATOMY Telleria, J. J., Lindsey, D. P., Giori, N. J., Safran, M. R. 2014; 27 (3): 489-497


    Quantitative descriptions of the hip joint capsular ligament insertional footprints have been reported. Using a three-dimensional digitizing system, and computer modeling, the area, and dimensions of the three main hip capsular ligaments and their insertional footprints were quantified in eight cadaveric hips. The iliofemoral ligament (ILFL) attaches proximally to the anterolateral supra-acetabular region (mean area = 4.2 cm(2)). The mean areas of the ILFL lateral and medial arm insertional footprints are 4.8 and 3.1 cm(2), respectively. The pubofemoral ligament (proximal footprint mean area = 1.4 cm(2)) blends with the medial ILFL anteriorly and the proximal ischiofemoral ligament (ISFL) distally without a distal bony insertion. The proximal and distal ISFL footprint mean areas are 6.4 and 1.2 cm(2), respectively. The hip joint capsular ligaments have consistent anatomic and insertional patterns. Quantification of the ligaments and their attachment sites may aid in improving anatomic repairs and reconstructions of the hip joint capsule using open and/or arthroscopic techniques.

    View details for DOI 10.1002/ca.22272

    View details for Web of Science ID 000332794400033

    View details for PubMedID 24293171

  • Ischiofemoral impingement of the hip: a novel approach to treatment KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Safran, M., Ryu, J. 2014; 22 (4): 781-785


    Ischiofemoral impingement (IFI) is an uncommon source of hip pain recently described in the non-surgical hip, associated with decreased space between the lesser trochanter and the ischium. There are no reports in the English literature of surgical treatment of this problem. We describe a case of IFI in a 19-year-old female who failed conservative management and underwent endoscopic surgical intervention to increase the space between her ischium and proximal femur. More than 2 years later, the patient is doing very well with an improvement of her iHOT score of 53 points to 85.

    View details for DOI 10.1007/s00167-013-2801-8

    View details for Web of Science ID 000333157000012

    View details for PubMedID 24346740

  • Biomechanical analysis of three tennis serve types using a markerless system. British journal of sports medicine Abrams, G. D., Harris, A. H., Andriacchi, T. P., Safran, M. R. 2014; 48 (4): 339-342


    PURPOSE: The tennis serve is commonly associated with musculoskeletal injury. Advanced players are able to hit multiple serve types with different types of spin. No investigation has characterised the kinematics of all three serve types for the upper extremity and back. METHODS: Seven NCAA Division I male tennis players performed three successful flat, kick and slice serves. Serves were recorded using an eight camera markerless motion capture system. Laser scanning was utilised to accurately collect body dimensions and data were computed using inverse kinematic methods. RESULTS: There was no significant difference in maximum back extension angle for the flat, kick or slice serves. The kick serve had a higher force magnitude at the back than the flat and slice as well as larger posteriorly directed shoulder forces. The flat serve had significantly greater maximum shoulder internal rotation velocity versus the slice serve. Force and torque magnitudes at the elbow and wrist were not significantly different between the serves. CONCLUSIONS: The kick serve places higher physical demands on the back and shoulder while the slice serve demonstrated lower overall kinetic forces. This information may have injury prevention and rehabilitation implications.

    View details for DOI 10.1136/bjsports-2012-091371

    View details for PubMedID 22936411

  • Arthroscopic Management of Protrusio Acetabuli ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Safran, M. R., Epstein, N. P. 2013; 29 (11): 1777-1782


    The purpose of this study was to evaluate 4 hips with symptomatic protrusio acetabuli treated arthroscopically for symptomatic pincer-type femoroacetabular impingement in 3 patients aged younger than 40 years.Four hips in 3 patients, all active women, aged 26 to 37 years, with hip pain and radiographic evidence of protrusio acetabuli and a center-edge angle (CEA) of 50° or more, were studied and followed up for a minimum of 2.5 years. Each of these patients underwent arthroscopic anterior and lateral acetabuloplasty, partial labrectomy, synovectomy, and chondroplasty. Follow-up included evaluation with the modified Harris Hip Score (mHHS), radiographs, and clinical history and examination.Patient 1 had bilateral hip surgeries. The right hip was followed up for 63 months, and the CEA improved from 67° to 60°, with an mHHS score improvement by 60.4 points. The CEA for the left hip improved from 63° to 53° at 61 months' follow-up, and the mHHS improved by 43.9 points. Both hips had a final mHHS of 100 points. Patient 3, followed up for 28 months, had a final mHHS of 100 points, 32 points better than preoperatively, whereas the CEA improved from 51° to 44°. Patient 3, a 26-year-old with preoperative radiographically apparent arthritis, had a final mHHS of 87 points, 35 points better than preoperatively, and the CEA improved from 50° to 42° at 32 months' follow-up. All 3 patients were happy with their outcomes.In this small case series, arthroscopic acetabuloplasty showed reduced symptoms and improved function in 3 patients with protrusio aged younger than 40 years at a minimum of 2.5 years' follow-up.Level IV, therapeutic case series.

    View details for DOI 10.1016/j.arthro.2013.08.003

    View details for Web of Science ID 000326133700013

    View details for PubMedID 24209674

  • ACL Reconstruction in Patients Aged 40 Years and Older A Systematic Review and Introduction of a New Methodology Score for ACL Studies AMERICAN JOURNAL OF SPORTS MEDICINE Brown, C. A., McAdams, T. R., Harris, A. H., Maffulli, N., Safran, M. R. 2013; 41 (9): 2181-2190


    Treatment of the anterior cruciate ligament (ACL)-deficient knee in older patients remains a core debate.To perform a systematic review of studies that assessed outcomes in patients aged 40 years and older treated with ACL reconstruction and to provide a new methodological scoring system that is directed at critical assessment of studies evaluating ACL surgical outcomes: the ACL Methodology Score (AMS).Systematic review.A comprehensive literature search was performed from 1995 to 2012 using MEDLINE, EMBASE, and Scopus. Inclusion criteria for studies were primary ACL injury, patient age of 40 years and older, and mean follow-up of at least 21 months after reconstruction. Nineteen studies met the inclusion criteria from the 371 abstracts from MEDLINE and 880 abstracts from Scopus. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, and Tegner activity scores), joint stability measures (Lachman test, pivot-shift test, and instrumented knee arthrometer assessment), graft type, complications, and reported chondral or meniscal injury were evaluated in this review. A new methodology scoring system was developed to be specific at critically analyzing ACL outcome studies and used to examine each study design.Nineteen studies describing 627 patients (632 knees; mean age, 49.0 years; range, 42.6-60.0 years) were included in the review. The mean time to surgery was 32.0 months (range, 2.9-88.0 months), with a mean follow-up of 40.2 months (range, 21.0-114.0 months). The IKDC, Lysholm, and Tegner scores and knee laxity assessment indicated favorable results in the studies that reported these outcomes. Patients did not demonstrate a significant difference between graft types and functional outcome scores or stability assessment. The mean AMS was 43.9 ± 7.2 (range, 33.5-57.5). The level of evidence rating did not positively correlate with the AMS, which suggests that the new AMS system may be able to detect errors in methodology or reporting that may not be taken into account by the classic level of evidence rating.Patients aged 40 years and older with an ACL injury can have satisfactory outcomes after reconstruction. However, the quality of currently available data is still limited, such that further well-designed studies are needed to determine long-term efficacy and to better inform our patients with regard to expected outcomes.

    View details for DOI 10.1177/0363546513481947

    View details for Web of Science ID 000325714200028

    View details for PubMedID 23548805

  • Applications of computer navigation in sports medicine knee surgery: an evidence-based review. Current reviews in musculoskeletal medicine Young, S. W., Safran, M. R., Clatworthy, M. 2013; 6 (2): 150-157


    Computer-assisted surgery (CAS) has been investigated in a number of sports medicine procedures in the knee. Current barriers to its widespread introduction include increased costs, duration, and invasiveness of surgery. Randomized trials on the use of CAS in anterior cruciate ligament reconstruction have failed to demonstrate a clinical benefit. Data on CAS use in high tibial osteotomy are more promising; however, long-term studies are lacking. CAS has a number of research applications in knee ligament surgery, and studies continue to explore its use in the treatment of osteochondral lesions. This article reviews the applications of CAS in sports medicine knee surgery and summarizes current literature on clinical outcomes.

    View details for DOI 10.1007/s12178-013-9166-y

    View details for PubMedID 23483407

  • Risk of sciatic nerve traction injury during hip arthroscopy—is it the amount or duration? An intraoperative nerve monitoring study. journal of bone and joint surgery. American volume Telleria, J. J., Safran, M. R., Harris, A. H., Gardi, J. N., Glick, J. M. 2012; 94 (22): 2025-2032


    Using intraoperative nerve monitoring we prospectively studied the prevalence, pattern, and predisposing factors for sciatic nerve traction injury during hip arthroscopy.The transcranial motor (tcMEP) and/or somatosensory (SSEP) evoked potentials of seventy-six patients undergoing hip arthroscopy in the lateral position were recorded. Changes in the posterior tibial and common peroneal nerves were evaluated to assess the effects of the amount and duration of traction on nerve function. Sixteen subjects were excluded because of incomplete data. Nerve dysfunction was defined as a 50% reduction in the amplitude of SSEPs or tcMEPs or a 10% increase in the latency of the SSEPs; nerve injury was defined as a clinically apparent sensory or motor deficit. Traction time and weight were continuously monitored with use of a custom foot-plate tensiometer.Of sixty patients (thirty-one female and twenty-nine male, with a mean age of thirty-seven years [range, sixteen to sixty-one years]), thirty-five (58%) had intraoperative nerve dysfunction and four (7%) sustained a clinical nerve injury. The average maximum traction weight (and standard deviation) for patients who did and those who did not have nerve dysfunction or injury was 38.1 ± 7.8 kg (range, 22.7 to 56.7 kg) and 32.9 ± 7.9 kg (range, 22.7 to 45.4 kg), respectively. The odds of a nerve event increased 4% with every 0.45-kg (1-lb) increase in the traction amount (age/sex-adjusted; p=0.043; odds ratio, 1.04; 95% confidence interval, 1.01 to 1.08). The average total traction time for patients who did and those who did not have nerve dysfunction was 95.9 ± 41.9 minutes (range, forty-two to 240 minutes) and 82.3 ± 35.4 minutes (range, thirty-eight to 160 minutes), respectively, and an increase in traction time did not increase the odds of a nerve event (p = 0.201). Age and sex were not significant risk factors.The prevalence of nerve changes seen with monitoring of SSEPs and tcMEPs is greater than what is clinically identified. The maximum traction weight, not the total traction time, is the greatest risk factor for sciatic nerve dysfunction during hip arthroscopy. This study did not identify a discrete threshold of traction weight or traction time that increased the odds of nerve dysfunction.

    View details for PubMedID 23052834

  • Arthroscopic Rotator Cuff Repair-Traditional Anchor Techniques OPERATIVE TECHNIQUES IN SPORTS MEDICINE Cheung, E. V., Safran, M. R. 2012; 20 (3): 213-219
  • The Development and Validation of a Self-Administered Quality-of-Life Outcome Measure for Young, Active Patients With Symptomatic Hip Disease: The International Hip Outcome Tool (iHOT-33) ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Mohtadi, N. G., Griffin, D. R., Pedersen, M. E., Chan, D., Safran, M. R., Parsons, N., Sekiya, J. K., Kelly, B. T., Werle, J. R., Leunig, M., McCarthy, J. C., Martin, H. D., Byrd, J. W., Philippon, M. J., Martin, R. L., Guanche, C. A., Clohisy, J. C., Sampson, T. G., Kocher, M. S., Larson, C. M. 2012; 28 (5): 595-U214


    The purpose of this study was to develop a self-administered evaluative tool to measure health-related quality of life in young, active patients with hip disorders.This outcome measure was developed for active patients (aged 18 to 60 years, Tegner activity level ≥ 4) presenting with a variety of symptomatic hip conditions. This multicenter study recruited patients from international hip arthroscopy and arthroplasty surgeon practices. The outcome was created using a process of item generation (51 patients), item reduction (150 patients), and pretesting (31 patients). The questionnaire was tested for test-retest reliability (123 patients); face, content, and construct validity (51 patients); and responsiveness over a 6-month period in post-arthroscopy patients (27 patients).Initially, 146 items were identified. This number was reduced to 60 through item reduction, and the items were categorized into 4 domains: (1) symptoms and functional limitations; (2) sports and recreational physical activities; (3) job-related concerns; and (4) social, emotional, and lifestyle concerns. The items were then formatted using a visual analog scale. Test-retest reliability showed Pearson correlations greater than 0.80 for 33 of the 60 questions. The intraclass correlation statistic was 0.78, and the Cronbach α was .99. Face validity and content validity were ensured during development, and construct validity was shown with a correlation of 0.81 to the Non-Arthritic Hip Score. Responsiveness was shown with a paired t test (P ≤ .01), effect size of 2.0, standardized response mean of 1.7, responsiveness ratio of 6.7, and minimal clinically important difference of 6 points.We have developed a new quality-of-life patient-reported outcome measure, the 33-item International Hip Outcome Tool (iHOT-33). This questionnaire uses a visual analog scale response format designed for computer self-administration by young, active patients with hip pathology. Its development has followed the most rigorous methodology involving a very large number of patients. The iHOT-33 has been shown to be reliable; shows face, content, and construct validity; and is highly responsive to clinical change. In our opinion the iHOT-33 can be used as a primary outcome measure for prospective patient evaluation and randomized clinical trials.

    View details for DOI 10.1016/j.arthro.2012.03.013

    View details for Web of Science ID 000303456000004

    View details for PubMedID 22542433

  • Labral Tears EVIDENCE-BASED ORTHOPEDICS Hariri, S., Eijer, H., Safran, M. R., Bhandari, M. 2012: 879–91
  • Kinematics Differences Between the Flat, Kick, and Slice Serves Measured Using a Markerless Motion Capture Method ANNALS OF BIOMEDICAL ENGINEERING Sheets, A. L., Abrams, G. D., Corazza, S., Safran, M. R., Andriacchi, T. P. 2011; 39 (12): 3011-3020


    Tennis injuries have been associated with serving mechanics, but quantitative kinematic measurements in realistic environments are limited by current motion capture technologies. This study tested for kinematic differences at the lower back, shoulder, elbow, wrist, and racquet between the flat, kick, and slice serves using a markerless motion capture (MMC) system. Seven male NCAA Division 1 players were tested on an outdoor court in daylight conditions. Peak racquet and joint center speeds occurred sequentially and increased from proximal (back) to distal (racquet). Racquet speeds at ball impact were not significantly different between serve types. However, there were significant differences in the direction of the racquet velocity vector between serves: the kick serve had the largest lateral and smallest forward racquet velocity components, while the flat serve had the smallest vertical component (p < 0.01). The slice serve had lateral velocity, like the kick, and large forward velocity, like the flat. Additionally, the racquet in the kick serve was positioned 8.7 cm more posterior and 21.1 cm more medial than the shoulder compared with the flat, which could suggest an increased risk of shoulder and back injury associated with the kick serve. This study demonstrated the potential for MMC for testing sports performance under natural conditions.

    View details for DOI 10.1007/s10439-011-0418-y

    View details for Web of Science ID 000296507000014

    View details for PubMedID 21984513

  • Diagnosis and Management of Ulnar Collateral Ligament Injuries in Throwers CURRENT SPORTS MEDICINE REPORTS Freehill, M. T., Safran, M. R. 2011; 10 (5): 271-278


    Although ulnar collateral ligament (UCL) injuries are reported most commonly in baseball players (especially in pitchers), these also have been observed in other throwing sports including water polo, javelin throw, tennis, and volleyball. This article reviews the functional anatomy and biomechanics of the UCL with associated pathophysiology of UCL injuries of the elbow of the athlete participating in overhead throwing. Evaluation, including pertinent principles in history, physical examination, and imaging modalities, is discussed, along with the management options.

    View details for DOI 10.1249/JSR.0b013e31822d4000

    View details for Web of Science ID 000294685000005

    View details for PubMedID 23531973

  • Musculoskeletal injuries in the tennis player MINERVA ORTOPEDICA E TRAUMATOLOGICA Abrams, G. D., Safran, M. R. 2011; 62 (4): 311-329
  • Evaluation of formal methods in hip joint center assessment: An in vitro analysis CLINICAL BIOMECHANICS Lopomo, N., Sun, L., Zaffagnini, S., Giordano, G., Safran, M. R. 2010; 25 (3): 206-212


    The hip joint center is a fundamental landmark in the identification of lower limb mechanical axis; errors in its location lead to substantial inaccuracies both in joint reconstruction and in gait analysis. Actually in Computer Aided Surgery functional non-invasive procedures have been tested in identifying this landmark, but an anatomical validation is scarcely discussed.A navigation system was used to acquire data on eight cadaveric hips. Pivoting functional maneuver and hip joint anatomy were analyzed. Two functional methods - both with and without using the pelvic tracker - were evaluated: specifically a sphere fit method and a transformation techniques. The positions of the estimated centers with respect to the anatomical center of the femoral head, the influence of this deviation on the kinematic assessment and on the identification of femoral mechanical axis were analyzed.We found that the implemented transformation technique was the most reliable estimation of hip joint center, introducing a - Mean (SD) - difference of 1.6 (2.7) mm from the anatomical center with the pelvic tracker, whereas sphere fit method without it demonstrated the lowest accuracy with 25.2 (18.9) mm of deviation. Otherwise both the methods reported similar accuracy (<3mm of deviation).The functional estimations resulted in the best case to be in an average of less than 2mm from the anatomical center, which corresponds to angular deviations of the femoral mechanical axis smaller than 1.7 (1.3) degrees and negligible errors in kinematic assessment of angular displacements.

    View details for DOI 10.1016/j.clinbiomech.2009.11.008

    View details for Web of Science ID 000275986300004

    View details for PubMedID 20006913

  • The Pattern and Technique in the Clinical Evaluation of the Adult Hip: The Common Physical Examination Tests of Hip Specialists ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Martin, H. D., Kelly, B. T., Leunig, M., Philippon, M. J., Clohisy, J. C., Martin, R. L., Sekiya, J. K., Pietrobon, R., Mohtadi, N. G., Sampson, T. G., Safran, M. R. 2010; 26 (2): 161–72


    The purpose of this study was to systematically evaluate the technique and tests used in the physical examination of the adult hip performed by multiple clinicians who regularly treat patients with hip problems and identify common physical examination patterns.The subjects included 5 men and 6 women with a mean age (+/-SD) of 29.8 +/- 9.4 years. They underwent physical examination of the hip by 6 hip specialists with a strong interest in hip-related problems. All examiners were blind to patient radiographs and diagnoses. Patient examinations were video recorded and reviewed.It was determined that 18 tests were most frequently performed (>or=40%) by the examiners, 3 standing, 11 supine, 3 lateral, and 1 prone. Of the most frequently performed tests, 10 were performed more than 50% of the time. The tests performed in the supine position were as follows: flexion range of motion (ROM) (percentage of use, 98%), flexion internal rotation ROM (98%), flexion external rotation ROM (86%), passive supine rotation test (76%), flexion/adduction/internal rotation test (70%), straight leg raise against resistance test (61%), and flexion/abduction/external rotation test (52%). The tests performed in the standing position were the gait test (86%) and the single-leg stance phase test (77%). The 1 test in the prone position was the femoral anteversion test (58%).There are variations in the testing that hip specialists perform to examine and evaluate their patients, but there is enough commonality to form the basis to recommend a battery of physical examination maneuvers that should be considered for use in evaluating the hip.Patients presenting with groin, abdominal, back, and/or hip pain need to have a basic examination to ensure that the hip is not overlooked. A comprehensive physical examination of the hip will benefit the patient and the physician and serve as the foundation for future multicenter clinical studies.

    View details for DOI 10.1016/j.arthro.2009.07.015

    View details for Web of Science ID 000274300100007

    View details for PubMedID 20141979

  • Case Reports: Unusual Cause of Shoulder Pain in a Collegiate Baseball Player CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Ligh, C. A., Schulman, B. L., Safran, M. R. 2009; 467 (10): 2744-2748


    The objective of reporting this case was to introduce a unique cause of shoulder pain in a high-level Division I NCAA collegiate baseball player. Various neurovascular causes of shoulder pain have been described in the overhead athlete, including quadrilateral space syndrome, thoracic outlet syndrome, effort thrombosis, and suprascapular nerve entrapment. All of these syndromes are uncommon and frequently are missed as a result of their rarity and the need for specialized tests to confirm the diagnosis. This pitcher presented with nonspecific posterior shoulder pain that was so severe he could not throw more than 50 feet. Eventually, intermittent axillary artery compression with the arm in abduction resulting from hypertrophy of the pectoralis minor and scalene muscles was documented by performing arteriography with the arm in 120 degrees abduction. MRI-MR angiographic evaluation revealed no anatomic abnormalities. The patient was treated successfully with a nonoperative rehabilitation program and after 6 months was able to successfully compete at the same level without pain.

    View details for DOI 10.1007/s11999-009-0962-z

    View details for Web of Science ID 000269926400036

    View details for PubMedID 19588212

    View details for PubMedCentralID PMC2745474

  • The role of the elbow musculature, forearm rotation, and elbow flexion in elbow stability: An in vitro study JOURNAL OF SHOULDER AND ELBOW SURGERY Seiber, K., Gupta, R., McGarry, M. H., Safran, M. R., Lee, T. Q. 2009; 18 (2): 260-268


    The goal of this study was to define the relative passive contributions of the major muscle groups about the elbow to varus-valgus stability and to determine whether these contributions vary with forearm rotation and elbow flexion. Fourteen cadaveric upper extremities were tested with a custom elbow testing device. The biceps, brachialis, and triceps muscles were loaded to simulate passive tension. The origins and insertions of the remaining muscles that cross the elbow were left intact to assess the contributions of their passive tension to elbow stability. For each specimen, varus-valgus laxity was measured at 30 degrees , 50 degrees , and 70 degrees of elbow flexion with the forearm in full supination, pronation, and neutral rotation, yielding 9 total positions of assessment. Six specimens (series 1) were tested for varus-valgus laxity after the following sequence of conditions: (1) unloaded biceps, brachialis, and triceps; (2) loaded biceps, brachialis, and triceps; (3) release of lateral elbow muscle tension; (4) release of medial elbow muscle tension; and (5) transection of the anterior bundle of the ulnar collateral ligament (UCL). Eight specimens (series 2) were assessed under the same conditions, only with the order of the last 2 conditions reversed for further comparison. Release of the lateral muscles alone increased varus-valgus laxity by a mean of 0.6 degrees to 1.4 degrees , but this was statistically significant only at positions of forearm pronation in series 1 (P < .012) and only at 2 of 9 positions in series 2 (30 degrees of flexion in pronation and 50 degrees of flexion in neutral rotation, P < .049). Release of the medial muscles alone caused a further increase in varus-valgus laxity by a mean of 0.5 degrees to 1.2 degrees , but this was only statistically significant at 30 degrees , 50 degrees , and 70 degrees of flexion in supination (P < .014) and 70 degrees of flexion in pronation (P = .044) in series 1 and only at 30 degrees , 50 degrees , and 70 degrees of flexion in supination in series 2 (P < .046). Release of the anterior bundle of the UCL resulted in a statistically significant increase in elbow varus-valgus laxity at all elbow and forearm positions by a mean of 1.8 degrees to 3.2 degrees (P < .001). Unloading the biceps, triceps, and brachialis caused significant increases in varus-valgus laxity at most elbow testing positions, independent of the position of forearm rotation (P < .046). Thus, the medial elbow musculature and lateral elbow musculature affect total elbow varus-valgus stability to roughly equal magnitudes, and the anterior bundle of the UCL affects stability to over twice the magnitude of either muscle group. The medial elbow musculature mostly affects elbow stability with the arm in supination and the lateral musculature in pronation, where the passive tension in the respective muscles is increased. Furthermore, the medial elbow musculature provided stability to the elbow when the forearm was supinated even with a deficient anterior bundle of the UCL, emphasizing its role as a secondary stabilizer.

    View details for DOI 10.1016/j.jse.2008.08.004

    View details for Web of Science ID 000263692600018

    View details for PubMedID 19046641

  • Elbow valgus laxity may result in an overestimation of apparent shoulder external rotation during physical examination AMERICAN JOURNAL OF SPORTS MEDICINE Mihata, T., Safran, M. R., McGarry, M. H., Abe, M., Lee, T. Q. 2008; 36 (5): 978-982


    The contributions of the scapulothoracic articulation and spine when measuring shoulder range of motion have been well described; however, the effect of elbow valgus laxity has not.Increased elbow valgus laxity affects the assessment of shoulder external rotation measured during physical examination at 90 degrees of elbow flexion.Controlled laboratory study.Seven cadaveric upper extremities were tested with an elbow valgus laxity-testing device. Shoulder external rotation was assessed with 2.8 N . m of external torque by measuring a change in the angle of the forearm axis at 90 degrees of elbow flexion. Elbow valgus laxity was measured in degrees of valgus angulation with 1.5 N . m of valgus torque with the humerus fixed. Shoulder external rotation and elbow valgus laxity were recorded at each of the following conditions: (1) intact, (2) after splitting the pronator muscles and venting the capsule, (3) after cutting the posterior band of the anterior oblique ligament of the ulnar collateral ligament, and (4) after cutting the anterior oblique ligament completely.After the posterior band of the anterior oblique ligament of the ulnar collateral ligament was cut, apparent shoulder external rotation and elbow valgus laxity were increased by 4.1 degrees +/- 1.7 degrees (P < .01) and 3.1 degrees +/- 1.3 degrees (P < .001), respectively, when compared with the intact condition. Complete cutting of the anterior oblique ligament resulted in an apparent increased shoulder external rotation and an increased elbow valgus laxity of 11.0 degrees +/- 1.1 degrees (P < .001) and 9.1 degrees +/- 1.2 degrees (P < .001), respectively, when compared with the intact condition.Shoulder external rotation as assessed by physical examination, which was defined as the angle of the forearm axis, as well as elbow valgus laxity, was significantly increased after the anterior oblique ligament of the ulnar collateral ligament was cut, although the glenohumeral joint condition was not changed.Elbow valgus laxity may cause an overestimation of shoulder external rotation on clinical examination of the shoulder.

    View details for DOI 10.1177/0363546507313086

    View details for Web of Science ID 000255752900022

    View details for PubMedID 18272796

  • Interobserver agreement in the classification of rotator cuff tears using magnetic resonance imaging AMERICAN JOURNAL OF SPORTS MEDICINE Spencer, E. E., Dunn, W. R., Wright, R. W., Wolf, B. R., Spindler, K. P., McCarty, E., Ma, C. B., Jones, G., Safran, M., Holloway, B., Kuhn, J. E. 2008; 36 (1): 99-103


    Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease.Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears.Cohort study (diagnosis); Level of evidence, 3.Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived.Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was -0.11.Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

    View details for DOI 10.1177/0363546507307504

    View details for Web of Science ID 000251875900011

    View details for PubMedID 17932406

  • Surgical treatment of lateral epicondylitis: A systematic review CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Lo, M. Y., Safran, M. R. 2007: 98-106


    For the minority of people with lateral epicondylitis who do not respond to nonoperative treatment, surgical intervention is an option, but confusion exists because of the plethora of options. The surgical techniques for treating lateral epicondylitis can be grouped into three main categories: open, percutaneous, and arthroscopic. Our primary question was whether there was clear evidence suggesting one of these three approaches was superior in relieving pain, restoring strength, or reducing time to return to work. A 2002 Cochrane Collaboration Database review found no conclusions could be drawn regarding the efficacy of operative treatment given the lack of controlled trials. Although there is not enough literature to conduct a meta-analysis, we systematically reviewed the available literature to address our questions. Although there are advantages and disadvantages to each procedure, no technique appears superior by any measure. Therefore, until more randomized, controlled trials are done, it is reasonable to defer to individual surgeons regarding experience and ease of procedure.

    View details for DOI 10.1097/BLO.0b013e3181483dc4

    View details for Web of Science ID 000250100300017

    View details for PubMedID 17632419

  • The role of arthroscopy in the treatment of glenohumeral arthritis SPORTS MEDICINE AND ARTHROSCOPY REVIEW Safran, M. R., Baillargeon, D. 2004; 12 (2): 139-145
  • A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Lai, C. H., Shapiro, L. M., Amanatullah, D. F., Chou, L. B., Gardner, M. J., Hu, S. S., Safran, M. R., Kamal, R. N. 2021


    PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians.METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted.RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and(3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care.CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

    View details for DOI 10.1007/s11136-021-02972-5

    View details for PubMedID 34510335

  • Infographic: Biologics in professional and Olympic sport: a scoping review. The bone & joint journal Murray, I. R., Makaram, N. S., Rodeo, S. A., Safran, M. R., Sherman, S. L., McAdams, T. R., Murray, A. D., Haddad, F. S., Abrams, G. D. 2021; 103-B (7): 1187-1188
  • Biologics in professional and Olympic sport: a scoping review BONE & JOINT JOURNAL Murray, I. R., Makaram, N. S., Rodeo, S. A., Safran, M. R., Sherman, S. L., McAdams, T. R., Murray, A. D., Haddad, F. S., Abrams, G. D. 2021; 103B (7): 1189-1196
  • There is no definite consensus on the adequate radiographic correction in arthroscopic osteochondroplasty for femoroacetabular impingement: a systematic review and meta-analysis. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Cohen, D., Khan, A., Kay, J., Slawaska-Eng, D., Almasri, M., Simunovic, N., Duong, A., Safran, M. R., Ayeni, O. R. 2021


    PURPOSE: The purpose of this study is to evaluate and define what is considered an adequate radiographic correction in arthroscopic osteochondroplasty for FAI and to secondarily assess how radiographic outcomes relate to patient reported outcomes and complications.METHODS: The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until January 2021. Studies were screened by two reviewers independently and in duplicate for studies reporting on post-operative radiographic outcomes in arthroscopic osteochondroplasty for FAI. Data on radiographic outcomes as well as data reporting functional outcomes and complications were recorded. A meta-analysis was used to combine the mean pre- and post-operative radiographic outcomes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score.RESULTS: The most commonly reported radiographic outcome was the alpha angle with a pooled mean post-operative angle of 44° (95% CI 41°-46°), and mean pre- to post-surgical difference of -19° (-22 to -16, I2=96%), followed by the LCEA with a pooled mean post-operative angle of 30° (95% CI 29-31) and mean difference after surgery of -4° (-6 to -1, I2=97%,). Eleven studies reported on the correlation between radiographic and clinical outcomes with no consistent consensus correlation found amongst the included studies. Similarly, six studies correlated radiographic outcomes with conversion to THA with no consistent consensus correlation found amongst the included studies.CONCLUSION: Based on this review, the main conclusion is that there is no consensus definition on the optimal radiographic correction for FAI and there was no consistent correlation between radiographic correction and functional outcomes. However, based on the uniform improvement in functional outcomes, this review suggests a post-operative alpha angle target of 44° with a correction target of 19° and LCEA target of 30° with a correction target of 3°.LEVEL OF EVIDENCE: IV.

    View details for DOI 10.1007/s00167-021-06645-1

    View details for PubMedID 34173836

  • Return to sport following anterior cruciate ligament reconstruction: the argument for a multimodal approach to optimise decision-making: current concepts. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Chona, D., Eriksson, K., Young, S. W., Denti, M., Sancheti, P. K., Safran, M., Sherman, S. 2021


    Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective-breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play-to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete's readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.Level of evidence: level V.

    View details for DOI 10.1136/jisakos-2020-000597

    View details for PubMedID 34088854

  • Concomitant Osteotomy Reduces Risk of Reoperation Following Cartilage Restoration Procedures of the Knee: A Matched Cohort Analysis. Cartilage Calcei, J. G., Varshneya, K., Sochacki, K. R., Safran, M. R., Abrams, G. D., Sherman, S. L. 2021: 19476035211011515


    OBJECTIVE: The objective of this study is to compare the (1) reoperation rates, (2) 30-day complication rates, and (3) cost differences between patients undergoing isolated autologous chondrocyte implantation (ACI) or osteochondral allograft transplantation (OCA) procedures alone versus patients with concomitant osteotomy.STUDY DESIGN: Retrospective cohort study, level III.DESIGN: Patients who underwent knee ACI (Current Procedural Terminology [CPT] 27412) or OCA (CPT 27415) with minimum 2-year follow-up were queried from a national insurance database. Resulting cohorts of patients that underwent ACI and OCA were then divided into patients who underwent isolated cartilage restoration procedure and patients who underwent concomitant osteotomy (CPT 27457, 27450, 27418). Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using ICD-9-CM codes. The cost per patient was calculated.RESULTS: A total of 1,113 patients (402 ACI, 67 ACI + osteotomy, 552 OCA, 92 OCA + osteotomy) were included (mean follow-up of 39.0 months). Reoperation rate was significantly higher after isolated ACI or OCA compared to ACI or OCA plus concomitant osteotomy (ACI 68.7% vs. ACI + osteotomy 23.9%; OCA 34.8% vs. OCA + osteotomy 16.3%). Overall complication rates were similar between isolated ACI (3.0%) and ACI + osteotomy (4.5%) groups and OCA (2.5%) and OCA + osteotomy (3.3%) groups. Payments were significantly higher in the osteotomy groups at day of surgery and 9 months compared to isolated ACI or OCA, but costs were similar by 2 years postoperatively.CONCLUSIONS: Concomitant osteotomy at the time of index ACI or OCA procedure significantly reduces the risk of reoperation with a similar rate of complications and similar overall costs compared with isolated ACI or OCA.

    View details for DOI 10.1177/19476035211011515

    View details for PubMedID 33969740

  • A Single Injection of Amniotic Suspension Allograft is Safe and Effective for Treatment of Mild to Moderate Hip Osteoarthritis: A Prospective Study. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Meadows, M., Elisman, K., Nho, S., Mowry, K., Safran, M. 2021


    PURPOSE: The purpose of our study was to examine the effects of a commercially available amniotic suspension allograft (ASA) (ReNuTM, Organogenesis, Canton, MA) in a patient population with moderate osteoarthritis of the hip.METHODS: Ten patients with symptomatic hip osteoarthritis, defined as Tonnis grade 1 or 2 on radiographic examination, were prospectively enrolled. Each patient received a single image-guided injection of ASA into the hip joint. Patient-reported outcomes measures, including the iHOT12, mHHS, and SANE scores were recorded at baseline, 6 months, and 12 months post-injection. A linear regression model was performed to detect differences in outcome scores from baseline.RESULTS: Nine patients had complete 12-month data available for analysis. One patient failed treatment and underwent arthroplasty at 2 months post-injection. The cohort includes 5 males and 4 females, ages 47-67. iHOT scores demonstrated a significant improvement between baseline and 12 months (p = 0.02). SANE scores demonstrated a significant difference between baseline and 6 months (p < 0.01), as well as between baseline and 12 months (p < 0.01). mHHS scores demonstrated a significant difference between baseline and 6 months (p = 0.02) and between baseline and 12 months (p = 0.01). There were no major adverse events in the course of the study period.CONCLUSION: This study demonstrates promising results for relief of pain and improvement in patient-reported outcomes with intra-articular ASA in patients with moderate osteoarthritis of the hip for up to one year, though the exact mechanism of action remains unknown.

    View details for DOI 10.1016/j.arthro.2021.04.034

    View details for PubMedID 33940131

  • High Specialization among Female Youth Soccer Players Is Associated with an Increased Likelihood of Serious Injury. Medicine and science in sports and exercise Xiao, M., Lemos, J. L., Hwang, C. E., Sherman, S. L., Safran, M. R., Abrams, G. D. 2021


    PURPOSE: To assess the associations between serious injury (> 3-month time loss) and level of specialization among high-level female soccer players and to compare the specialization and college commitment ages of female youth soccer players to Division I college and professional soccer athletes.METHODS: Youth, college, and professional female soccer players in the United States playing in the top league at each level were recruited to complete an anonymous online survey. The survey collected information about player demographics, soccer specialization and training patterns, history of serious injuries from soccer, and perceptions surrounding soccer specialization. Comparisons between groups were performed using 2-sample t-tests, chi-squared analyses, and multiple logistic regression models controlling for differences in age. A p-value of less than 0.05 was set as significant.RESULTS: A total of 1,018 (767 youth, 251 college/professional) athletes completed the survey. Serious injuries affected 23.6% of youth and 51.4% of college/professional athletes. Anterior cruciate ligament (ACL) tears were more prevalent in college/professional players compared to youth athletes (18.3% vs 4.0%; p < 0.001). Highly specialized youth athletes (66.5%) were more likely to have sustained a serious injury from soccer compared to athletes with low specialization (Odds Ratio (OR) = 2.28 [1.38-3.92]; p=0.008) but not moderate specialization (OR = 1.37 [0.83-2.27]; p=0.43). A higher proportion of youth athletes specialized at a young age (< 10 years) compared to college/professional players (44.2% vs 25.9%; p < 0.001).CONCLUSION: High specialization in female youth soccer players is associated with an increased likelihood of sustaining a serious injury. Current youth soccer players are specializing earlier and committing to play college soccer at a younger age compared to when current college and professional players did.

    View details for DOI 10.1249/MSS.0000000000002693

    View details for PubMedID 33927169

  • Evaluation of Athletes with Hip Pain. Clinics in sports medicine Calcei, J. G., Safran, M. R. 2021; 40 (2): 221–40


    Hip pain is a common complaint in athletes and can result in a significant amount of time lost from sport. Diagnosis of the source of hip pain can be a clinical challenge because of the deep location of the hip and the extensive surrounding soft tissue envelope. Establishing whether the source of hip pain is intra-articular or extra-articular is the first step in the process. A thorough history and a consistent and comprehensive physical examination are the foundation for the proper management of athletes with hip pain.

    View details for DOI 10.1016/j.csm.2020.11.001

    View details for PubMedID 33673883

  • Arthroscopic Repair of the Hip Abductor Musculotendinous Unit: The Effect of Microfracture on Clinical Outcomes. The American journal of sports medicine Kocaoglu, B., Paksoy, A. E., Cerciello, S., Ollivier, M., Seil, R., Safran, M. 2021: 363546521999678


    BACKGROUND: Endoscopic surgical repair has become a common procedure for treating patients with hip abductor tendon tears. Considering that retear rates are high after the repair of gluteus medius and minimus tendons, exploring alternative strategies to enhance structural healing is important.PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the effect of adding microfracture to single-row repair (SR) on outcomes after the surgical repair of gluteus medius and minimus tendons and compare with SR and double-row repair (DR) without microfracture. We hypothesized that microfracture of the trochanteric footprint with SR would lead to superior clinical outcomes and lower clinically evident retear rates compared with SR and DR without the addition of microfracture.STUDY DESIGN: Cohort study; Level of evidence, 3.METHODS: A total of 50 patients who underwent primary arthroscopic repair of hip gluteus medius and minimus tendon tears were investigated. Patients were divided into 3 groups: DR, 16 patients; SR, 14 patients; and SR with microfracture (SRM), 20 patients. Patients were evaluated with a visual analog scale (VAS) for pain as well as the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport Specific (HOS-SS), and modified Harris Hip Score (mHHS) both preoperatively and at a minimum 2-year follow-up (mean, 30 months).RESULTS: Among the SR, SRM, and DR groups, the greatest decrease in VAS scores and increase in mHHS, HOS-ADL, and HOS-SS scores were seen in the SRM group, and all the differences were significant (P < .001 to P = .006). The abductor tendon retear rates were 31.3%, 35.7%, and 15.0% in the DR, SR, and SRM groups, respectively. Retear rates were lower in the SRM group compared with the SR and DR groups (P = .042); however, there was no significant difference between the SR and DR groups (P = .32) in terms of retear rates.CONCLUSION: Endoscopic SR with microfracture was a safe, practical, and effective technique and had the potential advantage of enhancing biological healing at the footprint. The addition of microfracturing the trochanteric footprint significantly lowered the retear rate and provided better functional outcomes than SR and DR without microfracture.

    View details for DOI 10.1177/0363546521999678

    View details for PubMedID 33793365

  • Combinatorial mechanical gradation and growth factor biopatterning strategy for spatially controlled bone-tendon-like cell differentiation and tissue formation NPG ASIA MATERIALS Wang, D., Ker, D., Ng, K., Li, K., Gharaibeh, B., Safran, M., Cheung, E., Campbell, P., Weiss, L., Yang, Y. 2021; 13 (1)
  • In Response to COVID-19: Current Trends in Orthopaedic Surgery Sports Medicine Fellowships. Orthopaedic journal of sports medicine Liles, J. L., Danilkowicz, R., Dugas, J. R., Safran, M., Taylor, D., Amendola, A. N., Herzog, M., Provencher, M. T., Lau, B. C. 2021; 9 (2): 2325967120987004


    Background: The COVID-19 (SARS-COV-2) pandemic has brought unprecedented challenges to the health care system and education models. The reduction in case volume, transition to remote learning, lack of sports coverage opportunities, and decreased clinical interactions have had an immediate effect on orthopaedic sports medicine fellowship programs.Purpose/Hypothesis: Our purpose was to gauge the response to the pandemic from a sports medicine fellowship education perspective. We hypothesized that (1) the COVID-19 pandemic has caused a significant change in training programs, (2) in-person surgical skills training and didactic learning would be substituted with virtual learning, and (3) hands-on surgical training and case numbers would decrease and the percentage of fellows graduating with skill levels commensurate with graduation would decrease.Study Design: Cross-sectional study.Methods: In May 2020, a survey was sent to the fellowship directors of all 90 orthopaedic sports medicine fellowships accredited by the Accreditation Council for Graduate Medical Education; it included questions on program characteristics, educational lectures, and surgical skills. A total of 37 completed surveys (41%) were returned, all of which were deidentified. Responses were compiled and saved on a closed, protected institutional server.Results: In a majority of responding programs (89%), fellows continued to participate in the operating room. Fellows continued with in-person clinical visits in 65% of programs, while 51% had their fellows participate in telehealth visits. Fellows were "redeployed" to help triage and assist with off-service needs in 21% of programs compared with 65% of resident programs having residents rotate off service. Regarding virtual education, 78% of programs have used or are planning to use platforms offered by medical societies, and 49% have used or are planning to use third-party independent education platforms. Of the 37 programs, 30 reported no in-person lectures or meetings, and there was a sharp decline in the number of programs participating in cadaver laboratories (n = 10; 27%) and industry courses (n = 6; 16%).Conclusion: Virtual didactic and surgical education and training as well as telehealth will play a larger role in the coming year than in the past. There are effects to fellows' exposure to sports coverage and employment opportunities. The biggest challenge will be how to maintain the element of human interaction and connect with patients and trainees at a time when social distancing is needed to curb the spread of COVID-19.

    View details for DOI 10.1177/2325967120987004

    View details for PubMedID 33623801

  • Effects of the Competitive Season and Off-Season on Knee Articular Cartilage in Collegiate Basketball Players Using Quantitative MRI: A Multicenter Study. Journal of magnetic resonance imaging : JMRI Rubin, E. B., Mazzoli, V. n., Black, M. S., Young, K. n., Desai, A. D., Koff, M. F., Sreedhar, A. n., Kogan, F. n., Safran, M. R., Vincentini, D. J., Knox, K. A., Yamada, T. n., McCabe, A. n., Majumdar, S. n., Potter, H. G., Gold, G. E. 2021


    Injuries to the articular cartilage in the knee are common in jumping athletes, particularly high-level basketball players. Unfortunately, these are often diagnosed at a late stage of the disease process, after tissue loss has already occurred.To evaluate longitudinal changes in knee articular cartilage and knee function in National Collegiate Athletic Association (NCAA) basketball players and their evolution over the competitive season and off-season.Longitudinal, multisite cohort study.Thirty-two NCAA Division 1 athletes: 22 basketball players and 10 swimmers.Bilateral magnetic resonance imaging (MRI) using a combined T1ρ and T2 magnetization-prepared angle-modulated portioned k-space spoiled gradient-echo snapshots (MAPSS) sequence at 3T.We calculated T2 and T1ρ relaxation times to compare compositional cartilage changes between three timepoints: preseason 1, postseason 1, and preseason 2. Knee Osteoarthritis Outcome Scores (KOOS) were used to assess knee health.One-way variance model hypothesis test, general linear model, and chi-squared test.In the femoral articular cartilage of all athletes, we saw a global decrease in T2 and T1ρ relaxation times during the competitive season (all P < 0.05) and an increase in T2 and T1ρ relaxation times during the off-season (all P < 0.05). In the basketball players' femoral cartilage, the anterior and central compartments respectively had the highest T2 and T1ρ relaxation times following the competitive season and off-season. The basketball players had significantly lower KOOS measures in every domain compared with the swimmers: Pain (P < 0.05), Symptoms (P < 0.05), Function in Daily Living (P < 0.05), Function in Sport/Recreation (P < 0.05), and Quality of Life (P < 0.05).Our results indicate that T2 and T1ρ MRI can detect significant seasonal changes in the articular cartilage of basketball players and that there are regional differences in the articular cartilage that are indicative of basketball-specific stress on the femoral cartilage. This study demonstrates the potential of quantitative MRI to monitor global and regional cartilage health in athletes at risk of developing cartilage problems.2 Technical Efficacy Stage: 2.

    View details for DOI 10.1002/jmri.27610

    View details for PubMedID 33763929

  • Knee arthroscopy: evidence for a targeted approach. British journal of sports medicine LaPrade, R. F., Spalding, T., Murray, I. R., Chahla, J., Safran, M. R., Larson, C. M., Faucett, S. C., von Bormann, R., Brophy, R. H., Maestu, R., Krych, A. J., Firer, P., Engebretsen, L. 2020

    View details for DOI 10.1136/bjsports-2020-103742

    View details for PubMedID 33288619

  • Author response to 'Regarding the study by Packer et al.' Journal of hip preservation surgery Packer, J. D., Safran, M. R. 2020; 7 (4): 787

    View details for DOI 10.1093/jhps/hnab012

    View details for PubMedID 34377522

  • The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement. Journal of hip preservation surgery Takla, A., O'Donnell, J., Voight, M., Byrd, T., Dienst, M., Martin, R. R., Philippon, M. J., Enseki, K., Andrade, T., Safran, M., Christoforetti, J. J., Martin, H., Grant, L., Campbell, A., Ryan, M., Tyler, T., McGovern, R. P., Bizzini, M., Kohlrieser, D. 2020; 7 (4): 631-642


    The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.

    View details for DOI 10.1093/jhps/hnaa043

    View details for PubMedID 34377507

  • Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial. Clinical orthopaedics and related research Mariano, D. J., Liu, A., Eppler, S. L., Gardner, M. J., Hu, S., Safran, M., Chou, L., Amanatullah, D. F., Kamal, R. N. 2020


    BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs.QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions?METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement.RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71.CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL.LEVEL OF EVIDENCE: Level II, therapeutic study.

    View details for DOI 10.1097/CORR.0000000000001582

    View details for PubMedID 33239521

  • Platelet-Rich Plasma Augmentation for Isolated Arthroscopic Meniscal Repairs Leads to Significantly Lower Failure Rates: A Systematic Review of Comparative Studies. Orthopaedic journal of sports medicine Sochacki, K. R., Safran, M. R., Abrams, G. D., Donahue, J., Chu, C., Sherman, S. L. 2020; 8 (11): 2325967120964534


    Background: Studies have reported relatively high failure rates of isolated meniscal repairs. Platelet-rich plasma (PRP) has been suggested as a way to increase growth factors that enhance healing.Purpose: To compare (1) meniscal repair failures and (2) patient-reported outcomes after isolated arthroscopic meniscal repair augmented with and without PRP.Study Design: Systematic review; Level of evidence, 3.Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Multiple databases were searched for studies that compared outcomes of isolated arthroscopic meniscal repair augmented with PRP versus without PRP in human patients. Failures and patient-reported outcome scores were reported for each study and compared between groups. Study heterogeneity was assessed using I 2 for each outcome measure before meta-analysis. Study methodological quality was analyzed. Continuous variable data were reported as mean and standard deviation from the mean. Categorical variable data were reported as frequency with percentage. All P values were reported with significance set at P < .05.Results: Five articles were analyzed (274 patients [110 with PRP and 164 without PRP]; 65.8% male; mean age, 29.1 ± 4.6 years; mean follow-up, 29.2 ± 22.1 months). The risk of meniscal repair failure ranged from 4.4% to 26.7% for PRP-augmented repairs and 13.3% to 50.0% for repairs without PRP. Meniscal repairs augmented with PRP had significantly lower failure rates than repairs without PRP (odds ratio, 0.32; 95% CI, 0.12-0.90; P = .03). One of the 5 studies reported significantly higher outcomes in the PRP-augmented group versus the no-PRP group for the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) (P < .05 for all). The remaining 4 studies reported no significant difference between groups with regard to outcomes for the IKDC, Lysholm knee scale, visual analog scale for pain, or Tegner activity level.Conclusion: Although the studies were of mostly of low quality, isolated arthroscopic meniscal repairs augmented with PRP led to significantly lower failure rates (10.8% vs 27.0%; odds ratio, 0.32; P = .03) as compared with repairs without PRP. However, most studies reported no significant differences in patient-reported outcomes.

    View details for DOI 10.1177/2325967120964534

    View details for PubMedID 33283008

  • Biomechanics and physical examination of the posteromedial and posterolateral knee: state of the art JOURNAL OF ISAKOS JOINT DISORDERS & ORTHOPAEDIC SPORTS MEDICINE Swinford, S. T., LaPrade, R., Engebretsen, L., Cohen, M., Safran, M. 2020; 5 (6): 378-388
  • Comparison of Autologous Chondrocyte Implantation and Osteochondral Allograft Transplantation of the Knee in a Large Insurance Database: Reoperation Rate, Complications, and Cost Analysis. Cartilage Sochacki, K. R., Varshneya, K., Calcei, J. G., Safran, M. R., Abrams, G. D., Donahue, J., Chu, C., Sherman, S. L. 2020: 1947603520967065


    OBJECTIVE: To compare (1) the reoperation rates, (2) risk factors for reoperation, (3) 30-day complication rates, and (4) cost differences between autologous chondrocyte implantation (ACI) and osteochondral allograft transplantation (OCA) of the knee in a large insurance database.DESIGN: Subjects who underwent knee ACI (Current Procedural Terminology [CPT] code 27412) or OCA (CPT code 27415) with minimum 2-year follow-up were queried from a national insurance database. Reoperation was defined by ipsilateral knee procedure after index surgery. Multivariate logistic regression models were built to determine the effect of independent variables (age, sex, tobacco use, obesity, diabetes, and concomitant osteotomy) on reoperation rates. The 30-day complication rates were assessed using ICD-9-CM codes. The cost of the procedures per patient was calculated. Statistical comparisons were made. All P values were reported with significance set at P < 0.05.RESULTS: A total of 909 subjects (315 ACI and 594 OCA) were included (mean follow-up 39.2 months). There was a significantly higher reoperation rate after index ACI compared with OCA (67.6% vs. 40.4%, P < 0.0001). Concomitant osteotomy at the time of index procedure significantly reduced the risk for reoperation in both groups (odds ratio [OR] 0.2, P < 0.0001 and OR 0.2, P = 0.009). The complication rates were similar between ACI (1.6%) and OCA (1.2%) groups (P = 0.24). Day of surgery payments were significantly higher after ACI compared with OCA (P = 0.013).CONCLUSIONS: Autologous chondrocyte implantation had significantly higher reoperation rates and cost with similar complication rates compared with OCA. Concomitant osteotomy significantly reduced the risk for reoperation in both groups.

    View details for DOI 10.1177/1947603520967065

    View details for PubMedID 33106002

  • Assessment of the reliability of a non-invasive elbow valgus laxity measurement device. Journal of experimental orthopaedics Seiber, K., Bales, C., Worner, E., Lee, T., Safran, M. R. 2020; 7 (1): 74


    PURPOSE: The purpose of this study was to assess the reliability of a new objective measurement tool to measure the valgus stress laxity of the ulnar collateral ligament (UCL) of the elbow, the "Elbow Tester". The anterior oblique portion of the ulnar collateral ligament (UCL) of the elbow is the primary static restraint to valgus stress during the overhead throwing motion. The main research question was if the "Elbow Tester" that we have developed was reliable and reproducible for further use in research and daily practice.METHODS: Three different examiners tested both elbows of 11 volunteers for UCL laxity. Each elbow was tested 5 times using a standard 2Nm valgus load, and 3 times using a manual maximum valgus load. One examiner tested the volunteers again 1 week later. The outcomes of elbow valgus laxity were compared between examiners. The intraobserver reliability was assessed using an intraclass correlation coefficient (ICC) and interobserver reliability was also assessed with a mixed model repeated ANOVA test.RESULTS: The device demonstrated a high level of intraobserver reliability with both the 2Nm valgus force and manual maximum valgus force, using a minimum of three trials as determined by an ICC>0.9 for all examiners. The interobserver reliability was moderate using the 2Nm valgus load with an ICC value of 0.72 and significant different outcomes of elbow valgus laxity amongst examiners (p<0.01). A high interobserver reliability (ICC value of 0.90) was observed using manual maximum valgus force and no differences between outcomes (p>0.53).CONCLUSION: The noninvasive valgus elbow tester demonstrates high interobserver and intraobserver reliability using manual maximum valgus force and can be used for further research and daily practice.

    View details for DOI 10.1186/s40634-020-00290-2

    View details for PubMedID 32989568

  • Surgeon practice patterns for pre-soaking ACL tendon grafts in vancomycin: a survey of the ACL study group. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Xiao, M., Sherman, S. L., Safran, M. R., Abrams, G. D. 2020


    PURPOSE: To survey members of The ACL study group to determine the current practice patterns surrounding the technique of pre-soaking ACL grafts in vancomycin.METHODS: A web-based questionnaire was distributed to members of the ACL Study Group. Questions included the use of vancomycin solution for graft soaking during ACL reconstruction, their protocol for soaking the graft, vancomycin concentration utilized, graft choices, and concerns with the technique.RESULTS: Sixty-six (57%) ACL surgeons completed the survey. Approximately one-third (37.9%) of respondents currently pre-soak their ACL grafts in vancomycin prior to implantation, with 60% of these surgeons being from Europe. Seventy-six percent have adopted this practice within the past 5years. The majority of surgeons wrap the graft in a vancomycin-soaked gauze prior to implantation (56%), soak for a variable amount of time before implantation (56%), use a concentration of 5mg/mL (68%), and soak hamstring grafts (92%). Concerns included the mechanical properties of the graft (35%), cost of vancomycin (23%), availability (12%), and antibiotic resistance (9%).CONCLUSION: This survey demonstrates that 37.9% of ACL study group members currently utilize vancomycin to pre-soak ACL tendon grafts as a means to decrease post-operative infection risk, with the majority of surgeons having implemented this practice within the past 5years. The biggest concern towards using vancomycin was the mechanical properties of the graft after soaking.LEVEL OF EVIDENCE: IV.

    View details for DOI 10.1007/s00167-020-06265-1

    View details for PubMedID 32902684

  • The Effect of Resection Size in the Treatment of Cam-Type Femoroacetabular Impingement in the Typical Patient With Hip Arthroscopy: A Biomechanical Analysis. The American journal of sports medicine Bonano, J. C., Johannsen, A., Mardones, R. M., Fithian, A., Storaci, H., Tam, K., Safran, M. R. 2020: 363546520952774


    BACKGROUND: Arthroscopic osteochondroplasty may improve range of motion and relieve pain in patients with symptomatic hip impingement. Femoral neck fracture is a risk of this procedure because of the weakening of the proximal femur. To our knowledge, there are no biomechanical studies in young human cadaveric bone evaluating the effect of osteochondroplasty on femoral neck strength.PURPOSE/HYPOTHESIS: The purpose was to evaluate loads to fracture in young human cadavers after resection depths of 25% and 40% at the head-neck junction. We hypothesized that both depths will maintain ultimate loads to failure above previously published loads, as well as above physiologic weightbearing loads.STUDY DESIGN: Descriptive laboratory study.METHODS: Cadaveric proximal femoral specimens (6 matched pairs, under the age of 47 years) were divided into 2 groups: 25% or 40% of the diameter at the head-neck junction was resected. The length of the resection was 2 cm and the width of the resection was determined by the length of the anterolateral quadrant at the head-neck junction in all cases. A compressive load was applied directly to the femoral head. Peak load, stiffness, and energy to fracture were compared between groups.RESULTS: The average peak load to fracture after 25% resection (7347 N) was significantly higher than after the 40% resection (5892 N) (P = .010). The average energy to fracture was also significantly higher in the 25% resection group (30.2 J vs 19.2 J; P = .007). The average stiffness was higher in the 25% group, although not statistically significant (P = .737).CONCLUSION: Resection depths of 25% and 40% at the anterolateral quadrant of the femoral head-neck junction may be safe at previously described functional loads such as standing and walking in the age range more typically seen in patients undergoing hip arthroscopy. Loads to fracture were significantly higher than previously reported using older cadaveric specimens.CLINICAL RELEVANCE: Currently, most surgeons limit weightbearing after femoral osteochondroplasty in part because of risk of femoral neck fracture. Given the higher observed loads to fracture, young patients could possibly bear weight sooner after surgery, although postoperative protocols should be individualized based on patient age, weight, bone density, amount of bone resected, concomitant procedures, and potential compliance with activity restrictions.

    View details for DOI 10.1177/0363546520952774

    View details for PubMedID 32881582

  • Rationale for the Use of Orthobiologics in Sports Medicine OPERATIVE TECHNIQUES IN SPORTS MEDICINE Makaram, N. S., Safran, M. R., Abrams, G. D., Sherman, S. L., Murray, I. R. 2020; 28 (3)
  • The Importance of Concordance Between Patients and Their Subspecialists ORTHOPEDICS Shah, R. F., Mertz, K., Gil, J. A., Eppler, S. L., Amanatullah, D., Yao, J., Chou, L., Steffner, R., Safran, M., Hu, S. S., Kamal, R. N. 2020; 43 (5): 315-+


    Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient-physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient-physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315-319.].

    View details for DOI 10.3928/01477447-20200818-01

    View details for Web of Science ID 000608158400032

    View details for PubMedID 32931591

  • Costs, Complications, and Reoperations Associated With Primary Arthroscopic Rotator Cuff Repair With or Without Acromioplasty and/or Biceps Tenodesis. Arthroscopy, sports medicine, and rehabilitation Varshneya, K., Safran, M. R., Sherman, S. L., Abrams, G. D. 2020; 2 (4): e369–e376


    Purpose: To evaluate the reoperations, complications, and costs up to 5 years following arthroscopic rotator cuff repair (RCR) alone, with acromioplasty (acro), with biceps tenodesis (BT), or with both acro and BT.Methods: We queried the MarketScan database to identify patients who underwent RCR from 2007 to 2016. Patients were stratified into groups based on concomitant procedures (acro and/or BT) performed on the same day as index RCR. Reoperations, complications, and costs were followed for 5 years post-index procedure. Patients without laterality codes were excluded. A multivariate logistic regression analysis was used to control for confounding factors.Results: This study identified 147,838 patients (mean age, 53.1 years; standard deviation, 8.3 years) who underwent primary RCR. Patients were stratified into 4 groups: (1) RCR only, (2) RCR+ acro, (3) RCR+ BT, and (4) RCR+ acro+ BT. Patients in the RCR only group experienced the highest rate of unadjusted overall postoperative complications (17.2%) versus the other groups (RCR+ acro 16.4%, RCR+ BT 15.1%, RCR+ acro+ BT 16.2%, P < .0161). The RCR only group also experienced a significantly greater number of reoperations on the ipsilateral shoulder (P < .0001), whereas the RCR+ acro+ BT had the highest costs at all timepoints. In the regression analysis, there was no significant differences between complications and reoperations between any groups. After adjusting for covariates, the performance of a BT with an RCR and acromioplasty led to increased costs (odds ratio, 1.47, 1.37-1.59, P < .001).Conclusions: Concomitant biceps tenodesis does lead to higher total healthcare costs, both in the shorter and longer terms. When adjusting for confounding factors, the performance of concomitant biceps tenodesis with rotator cuff repair does not lead to a difference in postoperative complication rate or risk for revision surgery.Level of Evidence: Level IV, economic analysis.

    View details for DOI 10.1016/j.asmr.2020.05.010

    View details for PubMedID 32875302

  • Bone marrow lesions: etiology and pathogenesis at the hip. Journal of hip preservation surgery Munsch, M. A., Safran, M. R., Mai, M. C., Vasileff, W. K. 2020; 7 (3): 401–9


    Bone marrow lesions (BML) are painful changes in subchondral bone which can be reliably identified on magnetic resonance imaging and have been identified in patients suffering from hip osteoarthritis (OA) and related conditions. Created via repetitive microdamage at the articular surface and dysregulated subchondral healing, BML have been linked to traumatic, inflammatory, degenerative, metabolic and neoplastic processes. While BML are known to be a common pathology throughout the body, BML at the hip have not been extensively studied in comparison to those at the knee. Due to the hip's unique biomechanical architecture, function and loading, and independent risk factors leading to hip OA, hip BMLs must be independently understood. The identification of BML in the setting of a pre-osteoarthritic condition may provide a target for treatment and prevention of joint degeneration. By continuing to define and refine the relationships between BML, subchondral bone cysts and OA, prevention, diagnosis and treatment of OA could shift, leading to an improved quality of life and increased longevity of individuals' native hips.

    View details for DOI 10.1093/jhps/hnaa056

    View details for PubMedID 33948196

  • A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial. Medical decision making : an international journal of the Society for Medical Decision Making Mertz, K., Shah, R. F., Eppler, S. L., Yao, J., Safran, M., Palanca, A., Hu, S. S., Gardner, M., Amanatullah, D. F., Kamal, R. N. 2020: 272989X20943520


    Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

    View details for DOI 10.1177/0272989X20943520

    View details for PubMedID 32744134

  • Nonoperative Treatment of Psoas Tendon Avulsion in a Professional Athlete: A Case Report and Evidence Based Review. JBJS case connector Ejnisman, L. n., Andrade-Silva, F. B., Pontin, P. A., Ottoni, J. J., Magliocca, G. D., Safran, M. R. ; 10 (2): e0490


    A 36-year-old male professional soccer player sustained an acute left hip injury during a tournament game while defending the goal. Magnetic resonance imaging demonstrated a complete avulsion of the iliopsoas tendon from the left trochanter. The patient was treated nonoperatively, and after 10 weeks, he was able to return to full activity. After 1 year of follow-up, the patient was completely asymptomatic, and was still playing professional soccer without flexion strength deficit.In this professional soccer athlete, nonoperative treatment of complete psoas avulsion resulted in a good functional outcome and successful return to play.

    View details for DOI 10.2106/JBJS.CC.18.00490

    View details for PubMedID 32649129

  • Linked Double-Row Equivalent Arthroscopic Rotator Cuff Repair Leads to Significantly Improved Patient Outcomes. Orthopaedic journal of sports medicine Endo, A., Hoogervorst, P., Safranek, C., Sochacki, K. R., Safran, M. R., Sherman, S. L., Donahue, J. 2020; 8 (7): 2325967120938311


    Background: Biomechanical studies have demonstrated that arthroscopic rotator cuff repair using a linked double-row equivalent construct results in significantly higher load to failure compared with conventional transosseous-equivalent constructs.Purpose: To determine the patient-reported outcomes (PROs), reoperation rates, and complication rates after linked double-row equivalent rotator cuff repair for full-thickness rotator cuff tears.Study Design: Case series; Level of evidence, 4.Methods: Consecutive patients who underwent linked double-row equivalent arthroscopic rotator cuff repair with minimum 2-year follow-up were included. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score at final follow-up. Secondary outcomes included the Simple Shoulder Test (SST), shortened Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, visual analog scale (VAS), reoperations, and complications. Clinical relevance was defined by the minimally clinically important difference (MCID). Comparisons on an individual level that exceeded MCID (individual-level scores) were deemed clinically relevant. Comparisons between preoperative and postoperative scores were completed using the Student t test. All P values were reported with significance set at P < .05.Results: A total of 42 shoulders in 41 consecutive patients were included in this study (21 male patients [51.2%]; mean age, 64.5 ± 11.9 years; mean follow-up, 29.7 ± 4.5 months). All patients (100%) completed the minimum 2-year follow-up. The rotator cuff tear measured on average 15.2 ± 8.9 mm in the coronal plane and 14.6 ± 9.8 mm in the sagittal plane. The ASES score improved significantly from 35.5 ± 18.2 preoperatively to 93.4 ± 10.6 postoperatively (P < .001). The QuickDASH (P < .001), SST (P < .001), and VAS (P < .001) scores also significantly improved after surgery. All patients (42/42 shoulders; 100%) achieved clinically relevant improvement (met or exceeded MCID) on ASES and SST scores postoperatively. There were no postoperative complications (0.0%) or reoperations (0.0%) at final follow-up.Conclusion: Arthroscopic repair of full-thickness rotator cuff tears with the linked double-row equivalent construct results in statistically significant and clinically relevant improvements in PRO scores with low complication rates (0.0%) and reoperation rates (0.0%) at short-term follow-up.

    View details for DOI 10.1177/2325967120938311

    View details for PubMedID 32728593

  • Snapping of the Sciatic Nerve and Sciatica Provoked by Impingement Between the Greater Trochanter and Ischium: A Case Report. JBJS case connector Hatem, M., Martin, H. D., Safran, M. R. 2020; 10 (3): e2000014


    CASE: A 64-year-old woman developed worsening sciatica associated with snapping at the hip over a period of 4 years. The physical examination and dynamic ultrasound revealed the snapping of the sciatic nerve (SN) provoked by impingement between the greater trochanter (GT) and the ischium. Additional imaging studies demonstrated hyperintense signal in the SN at the hip, sagittal imbalance, decreased ischiofemoral space, and increased femoral torsion.CONCLUSION: Snapping and entrapment of the SN provoked by impingement between the GT and the ischium should be considered in the differential diagnosis of snapping hip and/or sciatica.

    View details for DOI 10.2106/JBJS.CC.20.00014

    View details for PubMedID 32773704

  • Capsular thinning on magnetic resonance arthrography is associated with intra-operative hip joint laxity in women. Journal of hip preservation surgery Packer, J. D., Foster, M. J., Riley, G. M., Stewart, R., Shibata, K. R., Richardson, M. L., Boutin, R. D., Safran, M. R. 2020; 7 (2): 298–304


    Hip microinstability is a recognized cause of hip pain in young patients. Intra-operative evaluation is used to confirm the diagnosis, but limited data exist associating magnetic resonance arthrography (MRA) findings with hip microinstability. To determine if a difference exists in the thickness of the anterior joint capsule and/or the width of the anterior joint recess on MRA in hip arthroscopy patients with and without an intra-operative diagnosis of hip laxity. Sixty-two hip arthroscopy patients were included in the study. Two musculoskeletal radiologists blinded to surgical results reviewed the MRAs for two previously described findings: (i) anterior joint capsule thinning; (ii) widening of the anterior joint recess distal to the zona orbicularis. Operative reports were reviewed for the diagnosis of joint laxity. In all patients with and without intra-operative laxity, there were no significant differences with either MRA measurement. However, twenty-six of 27 patients with intra-operative laxity were women compared with 11 of 35 patients without laxity (P<0.001). In subgroup analysis of women, the intra-operative laxity group had a higher rate of capsular thinning compared with the non-laxity group (85% versus 45%; P=0.01). A 82% of women with capsular thinning also had intra-operative laxity, compared with 40% without capsular thinning (P=0.01). There were no differences regarding the width of the anterior joint recess. In this study, there was an association between capsular thinning and intra-operative laxity in female patients. Measuring anterior capsule thickness on a pre-operative MRA may be useful for the diagnosis of hip microinstability.

    View details for DOI 10.1093/jhps/hnaa018

    View details for PubMedID 33163215

  • The evolution of femoroacetabular impingement surgical management as a model for introducing new surgical techniques KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Ohlin, A., Coughlin, R. P., Ahlden, M., Samuelsson, K., Malchau, H., Safran, M. R., Ayeni, O. R., Sansone, M. 2020; 28 (4): 1333–40
  • There is poor accuracy in documenting the location of labral and chondral lesions observed during hip arthroscopy. Journal of experimental orthopaedics Hariri, S., Sochacki, K. R., Harris, A. S., Safran, M. R. 2020; 7 (1): 4


    PURPOSE: To determine and compare the accuracy and interobserver reliability of the different methods for localizing acetabular labral, acetabular chondral, and femoral head chondral lesions with hip arthroscopy .METHODS: Three cadaver hips were placed in the supine position. Three labral, three femoral chondral, and six acetabular chondral lesions were made in each cadaver using electrocautery. Six surgeons classified the lesions according to different classification systems (clock-face, geographic, Method-G) using hip arthroscopy and standardized portals. Identification of each lesion was performed after conclusion of the study through open dissection and surgical hip dislocation to be used as the "gold-standard." Accuracy was calculated as the number of correct answers divided by total number of responses for a given system. The interobserver reliability was calculated using the kappa coefficient. The different classification methods were compared. All P values were reported with significance set at P<0.05.RESULTS: The clock-face method had an accuracy of 74% (95% CI, 60%-85%) and interobserver reliability of 0.19 (95% CI, 0.11-0.26) while the geographic method had an accuracy of 50% (95% CI, 36%-64%) and interobserver reliability of 0.21 (95% CI, 0.05-0.31) for acetabular labral lesion identification (P>0.05). The acetabular chondral lesion identification accuracy was 56% (95% CI, 46%-65%) for Method G, 66% (95% CI, 56%-75%) for Method G-simp, and 63% (95% CI, 53%-72%) for the geographic system (P>0.05) with an interobserver reliability of 0.31 (95% CI, 0.27-0.35), 0.34 (95% CI, 0.28-0.40), and 0.40 (95% CI, 0.34-0.45), respectively (P>0.05). Femoral chondral lesion identification accuracy was 74% (95% CI, 60%-85%) for Method G, 43% (95% CI, 29%-57%) for the geographic method, and 59% (95% CI, 45%-72%) for the geographic-simp system with interobserver reliability of 0.37 (95% CI, 0.27-0.47), 0.34 (95% CI, 0.28-0.40), and 0.40 (95% CI, 0.29-0.51), respectively (P>0.05). Method G was significantly more accurate than the geographic system (P=0.001).CONCLUSIONS: There was poor to fair accuracy and interobserver reliability of the reporting systems for localization of labral, acetabular chondral, and femoral chondral lesions encountered during hip arthroscopy. The study suggests there is a need for a new method that is easy to use, reliable, reproducible and accurate.

    View details for DOI 10.1186/s40634-020-0221-5

    View details for PubMedID 32008125

  • Reoperation Rates following Meniscus Transplantation using the Truven Database. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Sochacki, K. R., Varshneya, K. n., Safran, M. R., Abrams, G. D., Donahue, J. n., Wang, T. n., Sherman, S. L. 2020


    The purpose of this study was to determine the (1) reoperation rate and (2) 30-day complication rate in a large insurance database.The Truven Database was queried for subjects that underwent meniscus allograft transplantation (CPT code 29868) in the outpatient setting with minimal two year follow up. Patients without confirmed laterality and patients that underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using ICD-9-CM codes.284 patients (mean age of 26.2 ± 10.4 years old and 49.6% females) were included in this study with mean follow up of 43.2 ± 19.2 months. One hundred and sixty seven subjects (58.8%) undergoing meniscus allograft transplantation underwent reoperation at an average of 11.9 ± 12.2 months postoperatively. There was a low number of subjects that required ipsilateral unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) postoperatively (0.7% and 1.1%, respectively). The overall 30-day complication rate following meniscus allograft transplantation was 1.4%.Patients undergoing meniscus allograft transplantation have a 58.8% reoperation rate at final follow up with low (1.4%) 30-day complication rates in a large insurance database.

    View details for DOI 10.1016/j.arthro.2020.06.031

    View details for PubMedID 32645340

  • Risk of Subsequent Knee Arthroplasty After Sports Medicine Procedures. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Enweze, L. C., Varshneya, K. n., Sherman, S. L., Safran, M. R., Abrams, G. D. 2020; 4 (8): e2000125


    Approximately 10% of men and 13% of women older than the age of 60 are affected by symptomatic osteoarthritis of the knee. Anatomic repair or reconstruction after knee injury has been a central tenet of surgical treatment to reduce the risk of osteoarthritis. The purpose of this study was to examine common sports medicine procedures of the knee and determine the proportion of patients who subsequently undergo total knee arthroplasty (TKA).The MarketScan database was queried from the period of January 2007 through December 2016. Patients were identified, who underwent a procedure of the knee, as defined by Current Procedural Terminology codes relating to nonarthroplasty procedures of the knee. Patients in whom laterality could not be confirmed or underwent another ipsilateral knee procedure before TKA were excluded from this study. The primary outcome of this study was the overall rate of TKA after index knee surgery. Time from index procedure to TKA was a secondary outcome. A multivariate regression analysis was used to control for covariates such as age, sex, and comorbidity status.A total of 843,749 patients underwent one of the 13 common sports medicine procedures of the knee. The procedure with the highest unadjusted rate of subsequent TKA was arthroscopic osteochondral allograft (5.81%), whereas anterior cruciate ligament (ACL) reconstruction with meniscus repair demonstrated the lowest rate of subsequent TKA (0.01%). When adjusting for confounding factors, the regression analysis identified meniscal transplantation (odds ratio [OR] = 3.06, P < 0.0001) as having the highest risk of subsequent TKA, followed by osteochondral autograft (OR = 1.74, P = 0.0424) and arthroscopic osteochondral allograft (OR = 1.49, P < 0.0001). ACL reconstruction with meniscus repair (OR = 0.02, P < 0.0001), ACL reconstruction alone (OR = 0.17, P < 0.0001), ACL with meniscectomy (OR = 0.20, P < 0.0001), and meniscal repair (OR = 0.65, P < 0.0001) had the lowest rate of subsequent TKA. ACL reconstruction with meniscus repair had the longest period from index procedure to TKA at 2827 days.ACL reconstruction and meniscus preservation demonstrated an extremely low rate of conversion to TKA when compared with patients who needed salvage interventions such as meniscus and cartilage transplantation. None of the salvage interventions delayed the need for a TKA. Meniscal transplantation had the highest risk of all procedures of going on to a TKA.

    View details for DOI 10.5435/JAAOSGlobal-D-20-00125

    View details for PubMedID 32852917

  • The prevalence of femoroacetabular impingement anatomy in Division 1 aquatic athletes who tread water Journal of Hip Preservation Surgery Langner, J. L., Black, M. S., MacKay, J. W., Hall, K. E., Safran, M. R., Kogan, F., Gold, G. E. 2020; 0: 1-9


    Femoroacetabular impingement (FAI) is a disorder that causes hip pain and disability in young patients, particularly athletes. Increased stress on the hip during development has been associated with increased risk of cam morphology. The specific forces involved are unclear, but may be due to continued rotational motion, like the eggbeater kick. The goal of this prospective cohort study was to use magnetic resonance imaging (MRI) to identify the prevalence of FAI anatomy in athletes who tread water and compare it to the literature on other sports. With university IRB approval, 20 Division 1 water polo players and synchronized swimmers (15 female, 5 male), ages 18-23 years (mean age 20.7 ± 1.4), completed the 33-item International Hip Outcome Tool and underwent non-contrast MRI scans of both hips using a 3 Tesla scanner. Recruitment was based on sport, with both symptomatic and asymptomatic individuals included. Cam and pincer morphology were identified. The Wilcoxon Signed-Rank/Rank Sum tests were used to assess outcomes. Seventy per cent (14/20) of subjects reported pain in their hips yet only 15% (3/20) sought clinical evaluation. Cam morphology was present in 67.5% (27/40) of hips, while 22.5% (9/40) demonstrated pincer morphology. The prevalence of cam morphology in water polo players and synchronized swimmers is greater than that reported for the general population and at a similar level as some other sports. From a clinical perspective, acknowledgment of the high prevalence of cam morphology in water polo players and synchronized swimmers should be considered when these athletes present with hip pain.

    View details for DOI 10.1093/jhps/hnaa009

    View details for PubMedCentralID PMC7605769

  • Relationship of the Medial Patellofemoral Ligament Origin on the Distal Femur to the Distal Femoral Physis: A Systematic Review. The American journal of sports medicine Sochacki, K. R., Shea, K. G., Varshneya, K. n., Safran, M. R., Abrams, G. D., Donahue, J. n., Sherman, S. L. 2020: 363546520904685


    The relationship between the medial patellofemoral ligament (MPFL) and the distal femoral physis has been reported in multiple studies.To determine the distance from the MPFL central origin on the distal femur to the medial distal femoral physis in skeletally immature participants.Systematic review.A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched for studies investigating the anatomic origin of the MPFL on the distal femur and its relationship to the medial distal femoral physis in skeletally immature participants. Study methodological quality was analyzed with the Anatomical Quality Assessment tool, with studies categorized as low risk, high risk, or unclear risk of bias. Continuous variable data were reported as mean ± SD. Categorical variable data were reported as frequency with percentage.Seven articles were analyzed (298 femurs, 53.7% male patients; mean age, 11.7 ± 3.4 years). There was low risk of bias based on the Anatomical Quality Assessment tool. The distance from the MPFL origin to the distal femoral physis ranged from 3.7 mm proximal to the physis to 10.0 mm distal to the physis in individual studies. Six of 7 studies reported that the MPFL origin on the distal femur lies distal to the medial distal femoral physis in the majority of specimens. The MPFL originated distal to the medial distal femoral physis in 92.8% of participants at a mean distance of 6.9 ± 2.4 mm.The medial patellofemoral ligament originates distal to the medial distal femoral physis in the majority of cases at a mean proximal-to-distal distance of 7 mm distal to the physis. However, this is variable in the literature owing to study design and patient age and sex.

    View details for DOI 10.1177/0363546520904685

    View details for PubMedID 32109145

  • Soaking of Autologous Tendon Grafts in Vancomycin Before Implantation Does Not Lead to Tenocyte Cytotoxicity. The American journal of sports medicine Xiao, M. n., Leonardi, E. A., Sharpe, O. n., Sherman, S. L., Safran, M. R., Robinson, W. H., Abrams, G. D. 2020: 363546520951815


    Surgical site infections (SSIs) after anterior cruciate ligament (ACL) reconstruction procedures are an unfortunate complication. Soaking grafts in vancomycin before implantation has been reported to reduce the incidence of postoperative SSI after ACL reconstruction. There is potential for vancomycin to compromise graft integrity because of tenocyte toxicity.To examine the in vitro toxicity of varying doses of vancomycin on human tenocytes.Controlled laboratory study.Human patellar tenocytes were isolated and expanded in vitro. Tenocytes in culture were exposed to vancomycin at 5 different concentrations (400, 1600, 3200, 6400, and 12,800 μg/mL) and 3 time intervals (2, 6, and 24 hours). The control for all series was tenocyte exposure to only culture medium for each time interval. After treatment, a 10% Cell Counting Kit-8 solution in cellular growth medium was applied to the cells to examine cytotoxicity. A live/dead assay was used to assess tenocyte viability through fluorescence microscopy and flow cytometry. Results were analyzed statistically using multivariable logistic regression models with Tukey honest significant difference post hoc tests.Vancomycin did not cause significant changes in tenocyte viability after 2 and 6 hours of incubation at any concentration between 0 and 12,800 µg/mL. Incubation with vancomycin for 24 hours led to a significant decrease in cell viability at higher concentrations.Tenocytes derived from human patellar tendons exposed to relatively high concentrations of vancomycin for short periods of time do not demonstrate significant cell death and toxicity.Exposing tendons to vancomycin for a short period of time, such as before ACL reconstruction, is not likely to cause tenocyte toxicity because of vancomycin administration.

    View details for DOI 10.1177/0363546520951815

    View details for PubMedID 32898431

  • Definitions of Return to Sport After Hip Arthroscopy: Are We Speaking the Same Language and Are We Measuring the Right Outcome? Orthopaedic journal of sports medicine Chona, D. V., Bonano, J. C., Ayeni, O. R., Safran, M. R. 2020; 8 (9): 2325967120952990


    Return to sport is a commonly studied outcome of hip arthroscopy that is relevant to both patients and providers. There exists substantial variability in criteria used to define successful return to sport.To review and evaluate the definitions used in the literature so as to establish a single standard to enable comparison of outcomes in future studies.Systematic review; Level of evidence, 4.The PubMed, MEDLINE, and Embase databases were searched from inception to June 1, 2019, for studies relating to hip arthroscopy and return to sport. Articles included were those that met the following criteria: (1) contained 2 or more patients, (2) studied patients 18 years of age and older, (3) reported postoperative outcomes after hip arthroscopy, (4) clearly defined return to play, and (5) were written in English. Excluded articles (1) reported outcomes for nonoperative or open treatments, (2) did not clearly define return to play, or (3) were review articles, meta-analyses, or survey-based studies. Return-to-play definitions and additional metrics of postoperative performance and outcome were recorded.A total of 185 articles were identified, and 28 articles were included in the final review, of which 18 involved elite athletes and 10 involved recreational athletes. Of articles studying elite athletes, 6 (33%) defined return to play as participation in regular or postseason competition, 3 (17%) extended the criteria to the preseason, and 2 (11%) used participation in sport-related activities and training. The remaining 7 (39%) reported rates of return to the preoperative level of competition but did not specify preseason versus regular season. All 10 articles evaluating recreational athletes defined return to play based on patient-reported outcomes. Four (40%) did so qualitatively, while 6 (60%) did so quantitatively.There exists significant variability in criteria used to define successful return to sport after hip arthroscopy, and these criteria differ among elite and recreational athletes. For elite athletes, return to the preoperative level of competition is most commonly used, but there exists no consensus on what type of competition-regular season, preseason, or training-is most appropriate. For recreational athletes, patient-reported data are most commonly employed, although there are clear differences between authors on the ways in which these are being used as well.

    View details for DOI 10.1177/2325967120952990

    View details for PubMedID 33015214

    View details for PubMedCentralID PMC7509720

  • Significantly Lower Infection Risk For ACL Grafts Pre-Soaked in Vancomycin Compared to Un-Soaked Grafts: A Systematic Review and Meta-analysis. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Xiao, M. n., Sherman, S. L., Safran, M. R., Abrams, G. D. 2020


    To compare post-operative infection rates following ACL reconstruction performed with grafts pre-soaked in vancomycin versus those without vancomycin.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for therapeutic level I-III studies that compared outcomes of pre-soaking ACL grafts with vancomycin versus without vancomycin in human patients. Included graft types were tendon autografts or allografts, and studies documenting infection with a minimum follow-up of 30 days were included. Postoperative infection rates and knee-specific patient reported outcome scores were extracted from each study and compared between groups. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) and Modified Coleman Methodology Score (MCMS). Infection rates and re-tear rates were pooled and weighted for meta-analysis using a random-effects model. All P values were reported with an alpha level of 0.05 set as significant.The initial search yielded 144 articles (44 duplicates, 100 screened, 29 full-text review). Ten articles (21,368 subjects [7,507 vancomycin and 13,861 no vancomycin], 67% males, mean age 29.5 + 1.5 years old) were included and analyzed. Eight of the 10 studies included only autografts, with 94.5% of grafts being hamstring autografts. Soaking grafts in vancomycin resulted in significantly fewer infections (0.013% vs 0.77%; OR 0.07 [0.03, 0.18], p < 0.001). Only two studies included patient reported outcomes, and both demonstrated no difference in International Knee Documentation Committee (IKDC) scores one year after surgery for patients with grafts pre-soaked in vancomycin compared to without vancomycin.Soaking ACL tendon grafts with vancomycin prior to implantation is associated with a nearly 15 times decrease in odds of infection compared to grafts not soaked in vancomycin. There were few studies that investigated patient reported outcomes and re-tear rates after soaking ACL grafts in vancomycin.

    View details for DOI 10.1016/j.arthro.2020.12.212

    View details for PubMedID 33359822

  • Administrative Databases Utilized for Sports Medicine Research Demonstrate Significant Differences in Underlying Patient Demographics and Resulting Surgical Trends. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Xiao, M. n., Donahue, J. n., Safran, M. R., Sherman, S. L., Abrams, G. D. 2020


    To discern differences between the PearlDiver and MarketScan databases with regards to patient demographics, costs, re-operations, and complication rates for isolated meniscectomy.We queried the PearlDiver Humana Patient Records Database and the IBM® MarketScan® Commercial Claims and Encounters database for all patients who had record of meniscectomy denoted by CPT-29880 or CPT-29881 codes between January 1, 2007 and December 31, 2016. Those that had any other knee procedure at the same time as the meniscectomy were excluded, and the first instance of isolated meniscectomy was recorded. Patient demographics, Charlson Comorbidity Index (CCI), reoperations, 30- and 90-day complication rates, and costs were collected from both databases. Pearson's χ2 test with Yate's continuity correction and the student t-test were used to compare the two databases, and an alpha value of 0.05 was set as significant.We identified 441,147 patients with isolated meniscectomy from the MarketScan database (0.36% of total database), approximately 10 times the number of patients (n = 49,924; 0.20% of total database) identified from PearlDiver. The PearlDiver population was significantly older (median age: 65-69) than the MarketScan cohort, where all patients were younger than 65 (median age: 52; p < 0.001). Average CCI was significantly lower for MarketScan (0.172, SD: 0.546) compared to PearlDiver (1.43, SD: 2.05; p < 0.001), even when restricting the PearlDiver cohort to patients under 65 (1.02, SD: 1.74; p < 0.001). The PearlDiver < 65 sub-cohort also had increased 30- (RR: 1.53 (1.40-1.67)) and 90-day (RR: 1.56 (1.47-1.66)) post-operative complications compared to MarketScan. Overall, laterality coding was more prevalent in the PearlDiver database.For those undergoing isolated meniscectomy, the MarketScan database comprised an overall larger and younger cohort of patients with fewer comorbidities, even when examining only subjects under 65 years of age.Level III, retrospective comparative study.

    View details for DOI 10.1016/j.arthro.2020.09.013

    View details for PubMedID 32966865

  • Comparing Meniscectomy and Meniscal Repair: A Matched Cohort Analysis Utilizing a National Insurance Database. The American journal of sports medicine Sochacki, K. R., Varshneya, K. n., Calcei, J. G., Safran, M. R., Abrams, G. D., Donahue, J. n., Sherman, S. L. 2020: 363546520935453


    Meniscal repair leads to improved patient outcomes compared with meniscectomy in small case series.To compare the reoperation rates, 30-day complication rates, and cost differences between meniscectomy and meniscal repair in a large insurance database.Cohort study; Level of evidence, 3.A national insurance database was queried for patients who underwent meniscectomy (Current Procedural Terminology [CPT] code 29880 or 29881) or meniscal repair (CPT code 29882 or 29883) in the outpatient setting and who had a minimum 2-year follow-up. Patients without confirmed laterality and patients who underwent concomitant ligament reconstruction were excluded. Reoperation was defined by ipsilateral knee procedure after the index surgery. The 30-day postoperative complication rates were assessed using the International Classification of Diseases, 9th Revision, Clinical Modification codes. The cost of the procedures per patient was calculated. Propensity score matching was utilized to create matched cohorts with similar characteristics. Statistical comparisons of cohort characteristics, reoperations, postoperative complications, and payments were made. All P values were reported with significance set at P < .05.A total of 27,580 patients (22,064 meniscectomy and 5516 meniscal repair; mean age, 29.9 ± 15.1 years; 41.2% female) were included in this study with a mean follow-up of 45.6 ± 21.0 months. The matched groups were similar with regard to characteristics and comorbidities. There were significantly more patients who required reoperation after index meniscectomy compared with meniscal repair postoperatively (5.3% vs 2.1%; P < .001). Patients undergoing meniscectomy were also significantly more likely to undergo any ipsilateral meniscal surgery (P < .001), meniscal transplantation (P = .005), or total knee arthroplasty (P = .001) postoperatively. There was a significantly higher overall 30-day complication rate after meniscal repair (1.2%) compared with meniscectomy (0.82%; P = .011). The total day-of-surgery payments was significantly higher in the repair group compared with the meniscectomy group ($7094 vs $5423; P < .001).Meniscal repair leads to significantly lower rates of reoperation and higher rates of early complications with a higher total cost compared with meniscectomy in a large database study.

    View details for DOI 10.1177/0363546520935453

    View details for PubMedID 32667826

  • Does Injection of Hyaluronic Acid Protect Against Early Cartilage Injury Seen After Marathon Running? A Randomized Controlled Trial Utilizing High-Field Magnetic Resonance Imaging. The American journal of sports medicine Nathani, A., Gold, G. E., Monu, U., Hargreaves, B., Finlay, A. K., Rubin, E. B., Safran, M. R. 2019: 363546519879138


    BACKGROUND: Previous studies have shown that runners demonstrate elevated T2 and T1rho values on magnetic resonance imaging (MRI) after running a marathon, with the greatest changes in the patellofemoral and medial compartment, which can persist after 3 months of reduced activity. Additionally, marathon running has been shown to increase serum inflammatory markers. Hyaluronic acid (HA) purportedly improves viscoelasticity of synovial fluid, serving as a lubricant while also having chondroprotective and anti-inflammatory effects.PURPOSE/HYPOTHESIS: The purpose was to investigate whether intra-articular HA injection can protect articular cartilage from injury attributed to marathon running. The hypothesis was that the addition of intra-articular HA 1 week before running a marathon would reduce the magnitude of early cartilage breakdown measured by MRI.STUDY DESIGN: Randomized controlled trial; Level of evidence, 2.METHODS: After institutional review board approval, 20 runners were randomized into receiving an intra-articular injection of HA or normal saline (NS) 1 week before running a marathon. Exclusionary criteria included any prior knee injury or surgery and having run >3 prior marathons. Baseline 3-T knee MRI was obtained within 48 hours before the marathon (approximately 5 days after injection). Follow-up 3-T MRI scans of the same knee were obtained 48 to 72 hours and 3 months after the marathon. The T2 and T1rho relaxation times of articular cartilage were measured in 8 locations-the medial and lateral compartments (including 2 areas of each femoral condyle) and the patellofemoral joint. The statistical analysis compared changes in T2 and T1rho relaxation times (ms) from baseline to immediate and 3-month postmarathon scans between the HA and NS groups with repeated measures analysis of variance.RESULTS: Fifteen runners completed the study: 6 women and 2 men in the HA group (mean age, 31 years; range, 23-50 years) and 6 women and 1 man in the NS group (mean age, 27 years; range, 20-49 years). There were no gross morphologic MRI changes after running the marathon. Postmarathon studies revealed no statistically significant changes between the HA and NS groups in all articular cartilage areas of the knee on both T2 and T1rho relaxation times.CONCLUSION: Increased T2 and T1rho relaxation times have been observed in marathon runners, suggesting early cartilage injury. The addition of intra-articular HA did not significantly affect relaxation times in all areas of the knee when compared with an NS control.

    View details for DOI 10.1177/0363546519879138

    View details for PubMedID 31634003

  • The Association of Financial Distress With Disability in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Mertz, K., Eppler, S. L., Thomas, K., Alokozai, A., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. N. 2019; 27 (11): e522–e528


    INTRODUCTION: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?METHODS: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.RESULTS: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.CONCLUSIONS: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.LEVEL OF EVIDENCE: Level III prospective cohort.

    View details for DOI 10.5435/JAAOS-D-18-00252

    View details for PubMedID 31125323

  • Congenital internal rotation deformity of the distal femur presenting as patellofemoral instability and pain JOURNAL OF ISAKOS JOINT DISORDERS & ORTHOPAEDIC SPORTS MEDICINE Zhang, X., Attenello, J., Safran, M. R., Lowenberg, D. W. 2019; 4 (2): 93-97
  • Increased Prevalence of Concomitant Psychiatric Diagnoses Among Patients Undergoing Hip Arthroscopic Surgery ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Iglinski-Benjamin, K. C., Xiao, M., Safran, M. R., Abrams, G. D. 2019; 7 (1)
  • Can the FEAR Index Be Used to Predict Microinstability in Patients Undergoing Hip Arthroscopic Surgery? The American journal of sports medicine Truntzer, J. N., Hoppe, D. J., Shapiro, L. M., Safran, M. R. 2019: 363546519876105


    Atraumatic hip instability, or microinstability, is a challenging diagnosis for clinicians to make. Several radiographic parameters have been proposed to help identify patients with instability as a means to direct treatment. The Femoro-epiphyseal Acetabular Roof (FEAR) index was recently offered as a parameter to predict instability in a borderline dysplastic population.To evaluate the FEAR index in a series of predominantly nondysplastic patients undergoing hip arthroscopic surgery to determine if it can accurately predict patients with diagnosed microinstability at the time of surgery.Cohort study (diagnosis); Level of evidence, 2.A consecutive series of 200 patients undergoing hip arthroscopic surgery were evaluated for microinstability intraoperatively. Microinstability was diagnosed based on previously published criteria. Retrospectively, radiographic parameters were measured including the lateral center edge angle of Wiberg (LCEA), Tönnis angle, physeal scar angle, and FEAR index. Patients were excluded if they previously had any type of bony procedures performed, underwent prior open hip surgery or total hip arthroplasty of the ipsilateral hip, had osteoarthritis (Tönnis grade >1), or had any radiographic features of moderate-to-severe acetabular dysplasia including an LCEA <18°.After applying exclusion criteria, 167 hips in 150 patients were analyzed. Based on an intraoperative assessment, 96 hips (57.5%) were considered stable, and 71 hips (42.5%) had signs of microinstability (unstable group). Patients in the unstable group had fewer radiographic findings of femoroacetabular impingement and higher rates of borderline dysplasia. All 4 measured angles were found to have excellent interobserver agreement. The FEAR index was significantly more positive in the unstable group compared with the stable group (-7.8° vs -11.3°, respectively; P = .004). A more positive FEAR index was also found in patients meeting intraoperative criteria for instability, with the exception of chondral wear pattern. Unstable nondysplastic patients (LCEA ≥25°, Tönnis angle ≤10°) also were found to have higher FEAR index values (-9.0° vs -12.0°, respectively; P = .012). A FEAR index cut-off of -5.0° was associated with a specificity of 92.4% and accuracy of 69.4% for predicting instability in a nondysplastic population.The FEAR index was validated to improve the recognition of unstable patients preoperatively across a population with both borderline dysplastic and nondysplastic features.

    View details for DOI 10.1177/0363546519876105

    View details for PubMedID 31603694

  • A Contemporary Look at the Evaluation and Treatment of Adult Borderline and Frank Hip Dysplasia. The American journal of sports medicine Kraeutler, M. J., Safran, M. R., Scillia, A. J., Ayeni, O. R., Garabekyan, T. n., Mei-Dan, O. n. 2019: 363546519881411


    Adult hip dysplasia is often diagnosed according to the lateral center-edge angle (LCEA). Patients with frank hip dysplasia (LCEA <20°) traditionally require treatment with bony realignment through a periacetabular osteotomy (PAO) and/or derotational femoral osteotomy, while patients with borderline hip dysplasia (BHD) present a challenging treatment dilemma, as it remains unknown when they should be treated with hip arthroscopy and/or a PAO.To perform a narrative review to report the differences in hip morphology and clinical outcomes between adult patients with frank hip dysplasia and BHD.Narrative review.A systematic search of the literature was conducted through the Medline, EMBASE, and Cochrane databases with the search phrase borderline hip dysplasia.The search identified 305 articles, of which 48 were considered relevant to this study after screening of titles and abstracts. Four articles discussed new radiographic means of evaluating adult hip dysplasia, 16 articles analyzed morphology of dysplastic hips, and 28 articles described the clinical outcomes of patients with frank hip dysplasia or BHD treated with hip arthroscopy and/or PAO. Because the level of evidence obtained from this search was not adequate for systematic review or meta-analysis, a current concepts review on the diagnosis, hip morphology, and clinical outcomes of patients with frank hip dysplasia or BHD is presented.Adult hip dysplasia is most commonly diagnosed based on the LCEA; however, the LCEA is an unreliable sole marker for dysplasia, and additional radiographic parameters should be utilized. Furthermore, specific pathology identified on imaging and/or during hip arthroscopy can provide clues to a surgeon when the diagnosis is inconclusive according to history and physical examination alone. While the data support that patients with frank dysplasia are best treated with PAO, there is no such preferred treatment for patients with BHD, who have a wide spectrum of instability. Selective use of arthroscopic labral and capsular treatment alone may provide good results in carefully chosen patients with BHD, while some may end up requiring a bony realignment procedure.

    View details for DOI 10.1177/0363546519881411

    View details for PubMedID 31725329

  • (B) altered hip biomechanics and the muscles INTRODUCING THE CORE: DEMYSTIFYING THE BODY OF AN ATHLETE Safran, M. R., Sampson, J., Meyers, W. C. 2019: 303–8
  • Contributions of the Capsule and Labrum to Hip Mechanics in the Context of Hip Microinstability. Orthopaedic journal of sports medicine Johannsen, A. M., Ejnisman, L. n., Behn, A. W., Shibata, K. n., Thio, T. n., Safran, M. R. 2019; 7 (12): 2325967119890846


    Hip microinstability and labral pathology are commonly treated conditions with increasing research emphasis. To date, there is limited understanding of the biomechanical effects of the hip capsule and labrum on controlling femoral head motion.The purpose of this study was to determine the relative role of anterior capsular laxity and labral insufficiency in atraumatic hip microinstability. Our hypotheses were that (1) labral tears in a capsular intact state will have a minimal effect on femoral head motion and (2) the capsule and labrum work synergistically in controlling hip stability.Controlled laboratory study.Twelve paired hip specimens from 6 cadaveric pelvises (age, 18-41 years) met the inclusion criteria. Specimens were stripped of all soft tissue except the hip capsule and labrum, then aligned, cut, and potted using a custom jig. A materials testing system was used to cyclically stretch the anterior hip capsule in extension and external rotation, while rotating about the mechanical axis of the hip. Labral insufficiency was created with a combined radial and chondrolabral tear under direct visualization. A motion tracking system was used to record hip internal-external rotation and displacement of the femoral head relative to the acetabulum in the anterior-posterior, medial-lateral, and superior-inferior directions. Testing variables included baseline, postventing, postcapsular stretching, and postlabral insufficiency.When comparing the vented state with each experimental pathologic state, increases in femoral head motion were noted in both the capsular laxity state and the labral insufficiency state. The combined labral insufficiency and capsular laxity state produced statistically significant increases (P < .001) in femoral head translation compared with the vented state in all planes of motion.Both the anterior capsule and labrum play a role in hip stability. In this study, the anterior hip capsule was the primary stabilizer to femoral head translation, but labral tears in the setting of capsular laxity produced the most significant increases in femoral head translation.This study provides a physiologic biomechanical assessment of the hip constraints in the setting of hip microinstability. It also sheds light on the importance of the hip capsule in the management of labral tears. Our study demonstrates that labral tears in isolation provide minimal changes in femoral head translation, but in the setting of a deficient capsule, significant increases in femoral head translation are seen, which may result in joint-related symptoms.

    View details for DOI 10.1177/2325967119890846

    View details for PubMedID 31903404

    View details for PubMedCentralID PMC6931148

  • Increased Prevalence of Concomitant Psychiatric Diagnoses Among Patients Undergoing Hip Arthroscopic Surgery. Orthopaedic journal of sports medicine Iglinski-Benjamin, K. C., Xiao, M. n., Safran, M. R., Abrams, G. D. 2019; 7 (1): 2325967118822451


    Active patients with musculoskeletal pain are not immune to psychological or psychiatric disease. Observations suggest that patients undergoing hip arthroscopic surgery may have an increased prevalence of comorbid psychiatric conditions.Patients undergoing hip arthroscopic surgery have an increased prevalence of concomitant psychiatric diagnoses compared with the general population as well as those undergoing anterior cruciate ligament (ACL) reconstruction.Case-control study; Level of evidence, 3.A retrospective review of a medical claims database spanning from 2007 to 2016 was utilized to identify patients with a Current Procedural Terminology (CPT) code indicating that they had undergone hip arthroscopic surgery. This group was then dichotomized to those with or without an International Classification of Diseases, 9th Revision (ICD-9) and 10th Revision (ICD-10) diagnosis code indicating a psychological or psychiatric condition at any time before hip arthroscopic surgery or up to 2 years after hip arthrscopic surgery. As a control, ICD-9 and ICD-10 diagnosis codes for psychological or psychiatric conditions were determined in patients without a CPT code for hip arthroscopic surgery (general population) as well as for 2 surgical groups: those undergoing ACL reconstruction and those undergoing shoulder stabilization surgery. Prevalence was determined in all groups and compared using chi-square analysis.There were 22,676,069 patients in the database, with 2428 undergoing hip arthroscopic surgery. Those undergoing hip arthroscopic surgery had a 3-fold increased prevalence of concomitant psychiatric diagnoses compared with the general population (52% vs 17%, respectively; P < .0001). There was a significant difference in the prevalence of psychiatric diagnoses in the hip arthroscopic surgery group between male and female patients (46% vs 56%, respectively; P = .0061), with depression and anxiety being the 2 most common comorbid conditions. Those undergoing hip arthroscopic surgery also had a significantly increased prevalence of concomitant psychiatric diagnoses versus those undergoing ACL reconstruction (52% vs 28%, respectively; P < .0001) as well as those undergoing shoulder stabilization surgery (52% vs 42%, respectively; P < .0001).Patients undergoing hip arthroscopic surgery had an increased prevalence of comorbid psychiatric conditions compared with the general population as well as those undergoing ACL reconstruction or shoulder stabilization surgery. Depression and anxiety were the most prevalent concomitant psychiatric diagnoses.

    View details for PubMedID 30719482

  • Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process. The Journal of the American Academy of Orthopaedic Surgeons Lynch, T. S., Minkara, A. n., Aoki, S. n., Bedi, A. n., Bharam, S. n., Clohisy, J. n., Harris, J. n., Larson, C. n., Nepple, J. n., Nho, S. n., Philippon, M. n., Rosneck, J. n., Safran, M. n., Stubbs, A. J., Westermann, R. n., Byrd, J. W. 2019


    Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols.The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting.Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants.We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

    View details for DOI 10.5435/JAAOS-D-18-00041

    View details for PubMedID 31181030

  • Knotless Anchors in Acetabular Labral Repair: A Biomechanical Comparison ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Safran, M. R., Behn, A. W., Botser, I. B., Mardones, R. 2019; 35 (1): 70-+
  • Evolution of a Posttraumatic Femoral Head Bone Cyst: A Case Study and Surgical Management. Orthopaedic journal of sports medicine Ziino, C. n., Safran, M. R. 2019; 7 (7): 2325967119859287

    View details for DOI 10.1177/2325967119859287

    View details for PubMedID 31309125

    View details for PubMedCentralID PMC6604125

  • Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018; 476 (9): 1859–65
  • A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In-Office Diagnostic Arthroscopy With Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Gill, T. J., Safran, M., Mandelbaum, B., Huber, B., Gambardella, R., Xerogeanes, J. 2018; 34 (8): 2429–35


    The purpose of this study was to compare the efficacy, accuracy, and safety of in-office diagnostic arthroscopy with magnetic resonance imaging (MRI) and surgical diagnostic arthroscopy.A prospective, blinded, multicenter, clinical trial was performed on 110 patients, ages 18 to 75 years, who presented with knee pain. The study period was April 2012 to April 2013. Each patient underwent a physical examination, an MRI, in-office diagnostic imaging, and a diagnostic arthroscopic examination in the operating room. The attending physician completed clinical report forms comparing the in-office arthroscopic examination and surgical diagnostic arthroscopy findings on each patient. Two blinded experts, unaffiliated with the clinical care of the study's subjects, reviewed the in-office arthroscopic images and MRI images using the surgical diagnostic arthroscopy images as the "control" group comparison. Patients were consecutive, and no patients were excluded from the study.In this study, the accuracy, sensitivity, and specificity of in-office arthroscopy was equivalent to surgical diagnostic arthroscopy and more accurate than MRI. When comparing in-office arthroscopy with surgical diagnostic arthroscopy, all kappa statistics were between 0.766 and 0.902. For MRI compared with surgical diagnostic arthroscopy, kappa values ranged from a low of 0.130 (considered "slight" agreement) to a high of 0.535 (considered "moderate" agreement). The comparison of MRI to in-office arthroscopy showed very similar results as the comparison of MRI with surgical diagnostic arthroscopy, ranging from a low kappa of 0.112 (slight agreement) to a high of 0.546 (moderate agreement). There were no patient-related or device-related complications related to the use of in-office arthroscopy.Needle-based diagnostic imaging that can be used in the office setting is statistically equivalent to surgical diagnostic arthroscopy with regard to the diagnosis of intra-articular, nonligamentous knee joint pathology. In-office diagnostic imaging can provide a more detailed and accurate diagnostic assessment of intra-articular knee pathology than MRI. Based on the study results, in-office diagnostic imaging provides a safe, accurate, real-time, minimally invasive diagnostic modality to evaluate intra-articular pathology without the need for surgical diagnostic arthroscopy or high-cost imaging.Level II, comparative prospective trial.

    View details for DOI 10.1016/j.arthro.2018.03.010

    View details for Web of Science ID 000440402600040

    View details for PubMedID 29804955

  • What is the fate of scientific abstracts presented at the International Society for Hip Arthroscopy meetings? JOURNAL OF HIP PRESERVATION SURGERY Nwachukwu, B. U., Boddapati, V., Fu, M. C., Rebolledo, B. J., Ranawat, A. S., Safran, M. R. 2018; 5 (2): 157–61


    Publication rates for general sports medicine society meetings have been studied but little is known about the publication rate for subspecialty sports medicine meetings. The purpose of this study was to determine the publication rates of abstracts presented at the annual meeting of the International Society for Hip Arthroscopy (ISHA) from 2011 to 2014. A database of abstracts presented at the annual meetings of ISHA was compiled. Abstracts that reached manuscript publication were determined using a PubMed search of the Medline database and Google Scholar. Statistical analyses were primarily descriptive. A total of 220 podium abstracts and 454 posters were presented at ISHA annual meetings from 2011 to 2014. Of the 220 podium presentations, 118 (53.6%) were eventually published with 91.5% of these being published within 3 years. Of the 454 posters, 182 (40.1%) were published with 95.6% being published in 3 years. Podium presentations had a significantly higher publication rate (P < 0.001). Published podium and poster presentations were most frequently published in the Journal of Arthroscopy and Related Research (podium: 24.6%; poster: 28.6%). The overall publication rate of scientific abstracts presented at the Annual ISHA meeting approximates that of general sports medicine society meetings. Podium presentations are significantly more likely to be published than scientific research presented as poster. These findings may highlight the scientific and educational merit of content presented. Continued attention is needed to maintain and improve the quality of abstracts presented at ISHA meetings.

    View details for PubMedID 29876132

  • Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018


    BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

    View details for PubMedID 29965894

  • Functionally Graded, Bone- and Tendon-Like Polyurethane for Rotator Cuff Repair ADVANCED FUNCTIONAL MATERIALS Ker, D., Wang, D., Behn, A., Wang, E., Zhang, X., Zhou, B., Mercado-Pagan, A., Kim, S., Kleimeyer, J., Gharaibeh, B., Shanjani, Y., Nelson, D., Safran, M., Cheung, E., Campbell, P., Yang, Y. 2018; 28 (20)


    Critical considerations in engineering biomaterials for rotator cuff repair include bone-tendon-like mechanical properties to support physiological loading and biophysicochemical attributes that stabilize the repair site over the long-term. In this study, UV-crosslinkable polyurethane based on quadrol (Q), hexamethylene diisocyante (H), and methacrylic anhydride (M; QHM polymers), which are free of solvent, catalyst, and photoinitiator, is developed. Mechanical characterization studies demonstrate that QHM polymers possesses phototunable bone- and tendon-like tensile and compressive properties (12-74 MPa tensile strength, 0.6-2.7 GPa tensile modulus, 58-121 MPa compressive strength, and 1.5-3.0 GPa compressive modulus), including the capability to withstand 10 000 cycles of physiological tensile loading and reduce stress concentrations via stiffness gradients. Biophysicochemical studies demonstrate that QHM polymers have clinically favorable attributes vital to rotator cuff repair stability, including slow degradation profiles (5-30% mass loss after 8 weeks) with little-to-no cytotoxicity in vitro, exceptional suture retention ex vivo (2.79-3.56-fold less suture migration relative to a clinically available graft), and competent tensile properties (similar ultimate load but higher normalized tensile stiffness relative to a clinically available graft) as well as good biocompatibility for augmenting rat supraspinatus tendon repair in vivo. This work demonstrates functionally graded, bone-tendon-like biomaterials for interfacial tissue engineering.

    View details for PubMedID 29785178

  • Effects of Vitamin D on Skeletal Muscle and Athletic Performance. The Journal of the American Academy of Orthopaedic Surgeons Abrams, G. D., Feldman, D., Safran, M. R. 2018; 26 (8): 278–85


    Vitamin D is known to be important for calcium homeostasis and bone metabolism. It also has important direct effects on skeletal muscle. Unlike authentic vitamins, which cannot be synthesized in the body, vitamin D is produced in the skin using sunlight. Through its nuclear receptor (ie, vitamin D receptor) located throughout the body, including skeletal muscle, vitamin D initiates genomic and nongenomic pathways regulating multiple actions, including myocyte proliferation and growth. In some studies, vitamin D supplementation has been shown to increase muscle strength, particularly in people who are vitamin D deficient. Higher serum levels of vitamin D are associated with reduced injury rates and improved sports performance. In a subset of the population, vitamin D appears to play a role in muscle strength, injury prevention, and sports performance.

    View details for PubMedID 29561306

  • Effects of Vitamin D on Skeletal Muscle and Athletic Performance JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Abrams, G. D., Feldman, D., Safran, M. R. 2018; 26 (8): 278–85
  • Predictors of Clinically Suspected Intra-articular Hip Symptoms and Prevalence of Hip Pathomorphologies Presenting to Sports Medicine and Hip Preservation Orthopaedic Surgeons ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Larson, C. M., Safran, M. R., Brcka, D. A., Vaughn, Z. D., Giveans, M., Stone, R. M. 2018; 34 (3): 825–31


    The first purpose of the study was to evaluate the prevalence of various radiographic parameters and pathomorphologies for patients presenting with the diagnosis of hip pain. The second purpose of this study was to identify those pathomorphologies and radiographic parameters that were predictive of clinically suspected intra-articular and hip joint-related symptoms.A total of 998 hips (499 patients, 228 males, 271 females, mean age 38 years) presented to 2 orthopaedic surgeons with the diagnosis of hip pain. Patients were retrospectively identified as intra-articular and hip joint-related symptoms or extra-articular and non-hip joint-related symptoms based on history, examination, injection response, and diagnosis listed on clinical notes. A detailed morphologic evaluation of anteroposterior and 45° modified Dunn lateral radiographs of both hips was performed for all patients.The presence of at least 1 finding consistent with femoroacetabular impingement (FAI) was noted in 96.6% of patients (89.9% of hips) and was bilateral in 83%. The prevalence of dysplasia was 10.6% in patients (6.7% of hips) and was bilateral in 2.8%. Cam-type morphology was more common in males (P < .001). Profunda and protrusio were more common in females (P < .001). Acetabular retroversion was more common in males (P = .02). Fifty-seven percent of hips (564/998) were diagnosed clinically with intra-articular and hip joint related symptoms. Cam-type FAI, mixed-type FAI, increasing alpha angle, and increasing Tönnis grade were independent predictors of clinically suspected intra-articular and hip joint symptoms (P < .001), whereas isolated Pincer-type morphology was not.FAI is highly prevalent (96.6%) and frequently bilateral (83%) in patients presenting to an orthopaedic clinic with hip pain. Cam-type morphology and acetabular retroversion are more frequent in men, whereas profunda and protrusio are more frequent in women. Cam-type morphology, increasing alpha angle (larger cam morphology), and increasing Tönnis grade were highly predictive of clinically suspected intra-articular symptoms, whereas isolated pincer-type morphology was not.Level III, case-control study.

    View details for DOI 10.1016/j.arthro.2017.09.030

    View details for Web of Science ID 000426498300035

    View details for PubMedID 29100773

  • Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Haldane, C. E., Ekhtiari, S., de Sa, D., Simunovic, N., Safran, M., Randelli, F., Duong, A., Farrokhyar, F., Ayeni, O. R. 2018; 34 (1): 321-+


    The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature.The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria.Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives.The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation.Level IV, systematic review of Level II through IV studies.

    View details for PubMedID 28969946

  • Incorporating Hip Arthroscopy Into A Practice. Instructional course lectures Safran, M. R., Bedi, A. n., Byrd, J. W., Guanche, C. A., Ilizaliturri, V. n., Lynch, T. S., Martin, H. D., Matsuda, D. K., McCarthy, J. C., Philippon, M. J., Sampson, T. G., Suarez-Ahedo, C. n. 2018; 67: 453–72


    Hip arthroscopy is one of the most rapidly growing areas in orthopaedic surgery because of increased awareness of nonarthritic hip pathologies, advanced imaging modalities, and advanced techniques to reproducibly manage nonarthritic hip pathologies within a deep soft-tissue envelope and a constrained joint. In addition, more academic medical centers are providing residents with education on hip arthroscopy, and many hip preservation fellowships and courses are helping increase awareness of nonarthritic hip pathologies. Nonarthritic hip pathologies currently managed via hip arthroscopy include nonrepairable labral lesions, femoroacetabular impingement, hip instability, and hip fractures. Periarticular hip pathologies currently managed via endoscopy include greater trochanteric pain syndrome, tendinopathy and tears of the gluteus medius and minimus, partial and complete hamstring avulsions, and sciatic nerve entrapment. Ischiofemoral impingement may be addressed endoscopically via the deep gluteal space. Orthopaedic surgeons should understand the role and safety of hip arthroscopy in the pediatric population, specifically in the management of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and septic arthritis of the hip. The efficacy of hip arthroscopy is limited, and hip arthroscopy is relatively contraindicated in patients with osteoarthritis and hip dysplasia. Complications can occur and likely are underreported in patients who undergo hip arthroscopy. Orthopaedic surgeons should understand practical issues associated with incorporating hip arthroscopy into a practice, including the difficult learning curve associated with hip arthroscopy and the reluctance of some payors to reimburse procedures performed arthroscopically because hip arthroscopy is a relatively new technology.

    View details for PubMedID 31411432

  • Diagnostic Accuracy of 3 Physical Examination Tests in the Assessment of Hip Microinstability ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Hoppe, D. J., Truntzer, J. N., Shapiro, L. M., Abrams, G. D., Safran, M. R. 2017; 5 (11)
  • Cervical spine disease in surgeons performing arthroscopy or laparoscopy. Archives of environmental & occupational health Norheim, E. P., Black, M. H., Ngor, E. W., Shi, J. M., Safran, M. R., Navarro, R. A. 2017: 1–9


    Minimal research exists regarding cervical spine disorders in surgeons who perform endoscopy. A confidential on-line survey regarding neck pain (NP), spine disease (SD), and radiculopathy/myelopathy (R/M) was sent to 722 surgeons from a managed, group-based health care system. 415 responded. 361 had endoscopy experience, of whom 24.4% had NP, 20.8% SD, and 3.9% R/M. Most respondents were less than 50years of age (62.3%), and male (65.7%). Significant risk factors for NP included older age and female, whereas OB/Gyn specialty, increased age and job stress were for SD. After adjusting for age and gender, significant risk factors for NP and SD included greater surgeon experience. After also adjusting for job stress, significant risk factors for SD included increased surgeon experience and higher frequency of endoscopies. No association was found between use of digital OR. Endoscopy appears to place surgeons at higher risk of cervical disease.LEVEL OF EVIDENCE: Level 3.

    View details for DOI 10.1080/19338244.2017.1392277

    View details for PubMedID 29035681

  • Quality Measures in Orthopaedic Sports Medicine: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Abrams, G. D., Greenberg, D. R., Dragoo, J. L., Safran, M. R., Kamal, R. N. 2017; 33 (10): 1896–1910


    To report the current quality measures that are applicable to orthopaedic sports medicine physicians.Six databases were searched with a customized search term to identify quality measures relevant to orthopaedic sports medicine surgeons: MEDLINE/PubMed, EMBASE, the National Quality Forum (NQF) Quality Positioning System (QPS), the Agency for Healthcare Research and Quality (AHRQ) National Quality Measures Clearinghouse (NQMC), the Physician Quality Reporting System (PQRS) database, and the American Academy of Orthopaedic Surgeons (AAOS) website. Results were screened by 2 Board-certified orthopaedic surgeons with fellowship training in sports medicine and dichotomized based on sports medicine-specific or general orthopaedic (nonarthroplasty) categories. Hip and knee arthroplasty measures were excluded. Included quality measures were further categorized based on Donabedian's domains and the Center for Medicare and Medicaid (CMS) National Quality Strategy priorities.A total of 1,292 quality measures were screened and 66 unique quality measures were included. A total of 47 were sports medicine-specific and 19 related to the general practice of orthopaedics for a fellowship-trained sports medicine specialist. Nineteen (29%) quality measures were collected within PQRS, with 5 of them relating to sports medicine and 14 relating to general orthopaedics. AAOS Clinical Practice Guidelines (CPGs) comprised 40 (60%) of the included measures and were all within sports medicine. Five (8%) additional measures were collected within AHRQ and 2 (3%) within NQF. Most quality measures consist of process rather than outcome or structural measures. No measures addressing concussions were identified.There are many existing quality measures relating to the practice of orthopaedic sports medicine. Most quality measures are process measures described within PQRS or AAOS CPGs.Knowledge of quality measures are important as they may be used to improve care, are increasingly being used to determine physician reimbursement, and can inform future quality measure development efforts.

    View details for PubMedID 28655476

  • Hip arthroscopy in the United States: an update following coding changes in 2011 JOURNAL OF HIP PRESERVATION SURGERY Truntzer, J. N., Shapiro, L. M., Hoppe, D. J., Abrams, G. D., Safran, M. R. 2017; 4 (3): 250–57


    The purpose of this study is to define the incidence of hip arthroscopy-related procedures in the United States prior to and following 2011 and to determine if the rise in incidence has coincided with an increase in the complexity and diversity of procedures performed. Patients who underwent hip arthroscopy were identified from a publicly available US database. A distinction was made between 'traditional' and 'extended' codes. CPT-29999 (unlisted arthroscopy) was considered extended and counted only if associated with a hip pathology diagnosis. Codes directed toward femoroacetabular impingement pathology were also considered extended codes and were analyzed separately based on increased technical skill. Unpaired student t-tests and z-score tests were performed. From 2007 to 2014, there were a total of 2581 hip arthroscopies performed in the database (1.06 cases per 10 000 patients). The number of hip arthroscopies increased 117% from 2007 to 2014 (P < 0.001) and 12.5% from 2011 to 2014 (P = 0.045). Hip arthroscopies using extended codes increased 475% from 2007 to 2014 (P < 0.001) compared to 24% for traditional codes (P < 0.001). Codes addressing femoroacetabular impingement (FAI) pathology increased 55.7% between 2011 to 2014 (P < 0.001). The ratio of labral repair to labral debridement in patients younger than 50 years exceeded >1.0 starting in 2011 (P < 0.001). The total number of hip arthroscopies in addition to the complexity and diversity of hip arthroscopy procedures performed in the United States continues to rise. FAI-based procedures and labral repairs are being performed more frequently in younger patients, likely reflecting both improved technical ability and current evidence-based research.

    View details for PubMedID 28948037

  • Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE) KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Arrigoni, P., Cucchi, D., D'Ambrosi, R., Butt, U., Safran, M. R., Denard, P., Randelli, P. 2017; 25 (7): 2255–63


    Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain.Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated.At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408).Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition.III.

    View details for PubMedID 28341879

  • Open treatment of dysplasia-other than PAO: does it have to be a PAO? JOURNAL OF HIP PRESERVATION SURGERY Shibata, K. R., Matsuda, S., Safran, M. R. 2017; 4 (2): 131–44


    Hip dysplasia is a developmental disorder that results in anatomic abnormalities in which the acetabular coverage is insufficient. In the absence of severe degenerative changes, younger active patients with these symptomatic structural abnormalities are increasingly managed with joint-preserving operations. Historically there have been numerous reconstructive pelvic osteotomies. In recent years, the Bernese periacetabular osteotomy (PAO) has become the preferred osteotomy by many surgeons. Even so, as our understanding of the hip advances and new diagnostic and treatment techniques are developed, we sought to put a focus on the long-term results of augmental osteotomies and pelvic osteotomies other than the PAO, to see if any of these surgeries still have a place in the current algorithm of treatment for the dysplastic hip. As the longevity of the treatment is the focal point for joint preservation surgeries for the dysplastic hip, these authors have searched databases for articles in the English literature that reported results of long-term follow-up with a minimum of 11-year survivorship after surgical treatment of developmental dysplasia of the hip. Reconstruction osteotomies for the dysplastic hip are intended to restore normal hip anatomy and biomechanics, improve symptoms and prevent degenerative changes, in this manuscript each procedure is independently assessed on the ability to achieve these important characteristics.

    View details for DOI 10.1093/jhps/hnv028

    View details for Web of Science ID 000424558400003

    View details for PubMedID 28630734

    View details for PubMedCentralID PMC5467430

  • Decreased Synovial Inflammation in Atraumatic Hip Microinstability Compared With Femoroacetabular Impingement. Arthroscopy Abrams, G. D., Luria, A., Sampson, J., Madding, R. A., Robinson, W. H., Safran, M. R., Sokolove, J. 2017; 33 (3): 553-558


    To compare the inflammatory profile of hip synovial tissue in those with atraumatic microinstability to patients with femoroacetabular impingement (FAI).Patients with cam and mixed-type FAI (FAI group) and patients with hip instability underwent sampling of the anterolateral synovium. Demographic data, intraoperative measurements, and functional outcome scores (International Hip Outcomes Tool and Short Form-12) were recorded. Cryosections were stained and examined under light microscopy as well as confocal fluorescent microscopy for anti-CD45 (common leukocyte antigen), anti-CD31 (endothelial), and anti-CD68 (macrophage) cell surface markers. A grading system was used to quantify synovitis under light microscopy whereas digital image analysis was used to quantify immunofluorescence staining area. Comparison were made with Student t test, Mann-Whitney U, χ(2), and regression analysis.There were 12 patients in the FAI group and 5 in the instability group. Mean age was not significantly different (P > .05), but there was a significantly greater proportion of females in the instability group versus the FAI group (P < .001). There was a significant correlation (r = 0.653; P = .005) between number of turns needed for 10 mm of distraction and increased synovitis. Synovitis scores also were increased significantly in patients with cam morphology and articular cartilage damage (P = .024) versus those without. Immunohistochemistry did not reveal differences (P > .082) between the instability and FAI groups, but CD68 staining was significantly greater in those with cam morphology and cartilage damage (P < .045). CD45+/CD68- cells were noted in the perivascular area while CD45+/CD68+ cells were noted within the synovial lining in both groups.Increased synovial inflammation was associated with an increased number of turns to achieve joint distraction. Both instability and FAI groups demonstrated baseline levels of synovial inflammation. Synovitis scores also were increased in patients with cartilage damage.An understanding of the molecular and cellular mechanisms behind both hip instability and FAI may lead to novel therapeutic anti-inflammatory therapy, which may serve as an adjunct to treatment of mechanical abnormalities in this conditions.

    View details for DOI 10.1016/j.arthro.2016.09.007

    View details for PubMedID 27939067

  • AOSSM 2017 Specialty Day Abstracts ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Shibata, K., Safran, M. R. 2017; 5 (3)
  • Editorial: is the hip really a stable joint? KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Ayeni, O. R., Larson, C. M., Bonin, N., Safran, M. R. 2017; 25 (1): 1–2

    View details for PubMedID 27544272

  • Diagnostic Accuracy of 3 Physical Examination Tests in the Assessment of Hip Microinstability. Orthopaedic journal of sports medicine Hoppe, D. J., Truntzer, J. N., Shapiro, L. M., Abrams, G. D., Safran, M. R. 2017; 5 (11): 2325967117740121


    Hip microinstability is a diagnosis gaining increasing interest. Physical examination tests to identify microinstability have not been objectively investigated using intraoperative confirmation of instability as a reference standard.To determine the test characteristics and diagnostic accuracy of 3 physical examination maneuvers in the detection of hip microinstability.Cohort study (diagnosis); Level of evidence, 2.A review was conducted of 194 consecutive hip arthroscopic procedures performed by a sports medicine surgeon at a tertiary-care academic center. Physical examination findings of interest, including the abduction-hyperextension-external rotation (AB-HEER) test, the prone instability test, and the hyperextension-external rotation (HEER) test, were obtained from prospectively collected data. The reference standard was intraoperative identification of instability based on previously published objective criteria. Test characteristics, including sensitivity, specificity, positive and negative predictive values, and accuracy, were calculated for each test as well as for combinations of tests.A total of 109 patients were included in the analysis. The AB-HEER test was most accurate, with a sensitivity of 80.6% (95% CI, 70.8%-90.5%) and a specificity of 89.4% (95% CI, 80.5%-98.2%). The prone instability test had a low sensitivity (33.9%) but a very high specificity (97.9%). The HEER test performed second in both sensitivity (71.0%) and specificity (85.1%). The combination of multiple tests with positive findings did not yield significantly greater accuracy. All tests had high positive predictive values (range, 86.3%-95.5%) and moderate negative predictive values (range, 52.9%-77.8%). When all 3 tests had positive findings, there was a 95.0% (95% CI, 90.1%-99.9%) chance that the patient had microinstability.The AB-HEER test most accurately predicted hip instability, followed by the HEER test and the prone instability test. However, the high specificity of the prone instability test makes it a useful test to "rule in" abnormalities. A positive result from any test predicted hip instability in 86.3% to 90.9% of patients, but a negative test result did not conclusively rule out hip instability, and other measures should be considered in making the diagnosis. The use of these tests may aid the clinician in diagnosing hip instability, which has been considered a difficult diagnosis to make because of its dynamic nature.

    View details for PubMedID 29226163

  • Cytokines as a predictor of clinical response following hip arthroscopy: minimum 2-year follow-up. Journal of hip preservation surgery Shapiro, L. M., Safran, M. R., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J., Abrams, G. D. 2016; 3 (3): 229-235


    Hip arthroscopy in patients with osteoarthritis has been shown to have suboptimal outcomes. Elevated cytokine concentrations in hip synovial fluid have previously been shown to be associated with cartilage pathology. The purpose of this study was to determine whether a relationship exists between hip synovial fluid cytokine concentration and clinical outcomes at a minimum of 2 years following hip arthroscopy. Seventeen patients without radiographic evidence of osteoarthritis had synovial fluid aspirated at time of portal establishment during hip arthroscopy. Analytes included fibronectin-aggrecan complex as well as a multiplex cytokine array. Patients completed the modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index and the International Hip Outcomes Tool pre-operatively and at a minimum of 2 years following surgery. Pre and post-operative scores were compared with a paired t-test, and the association between cytokine values and clinical outcome scores was performed with Pearson's correlation coefficient with an alpha value of 0.05 set as significant. Sixteen of seventeen patients completed 2-year follow-up questionnaires (94%). There was a significant increase in pre-operative to post-operative score for each clinical outcome measure. No statistically significant correlation was seen between any of the intra-operative cytokine values and either the 2-year follow-up scores or the change from pre-operative to final follow-up outcome values. No statistically significant associations were seen between hip synovial fluid cytokine concentrations and 2-year follow-up clinical outcome assessment scores for those undergoing hip arthroscopy.

    View details for DOI 10.1093/jhps/hnw013

    View details for PubMedID 27583163

  • Hip Arthroscopy A Brief History CLINICS IN SPORTS MEDICINE Kandil, A., Safran, M. R. 2016; 35 (3): 321-?


    Hip arthroscopy is a fast-growing and evolving field. Like knee and shoulder arthroscopy, hip arthroscopy began as a diagnostic procedure and then progressed to biopsy and resection of abnormalities. Subsequently, it has evolved to repair of various tissues and treatment of underlying causes. As the understanding of the hip joint and its associated pathophysiology grows, indications will continue to expand for this diagnostic and therapeutic modality. This article outlines the historic developments of hip arthroscopy, including advancements in instrumentation and techniques from the days of the first hip arthroscopies to the present day.

    View details for DOI 10.1016/j.csm.2016.02.001

    View details for Web of Science ID 000380291700003

    View details for PubMedID 27343387

  • Pathological findings in patients with low anterior inferior iliac spine impingement SURGICAL AND RADIOLOGIC ANATOMY Amar, E., Warschawski, Y., Sharfman, Z. T., Martin, H., Safran, M. R., Rath, E. 2016; 38 (5): 569–75


    Femoroacetabular impingement (FAI) has been well described in recent years as one of the major causes of hip pain potentially leading to acetabular labral tears and cartilage damage, which may in turn lead to the development of early degenerative changes. More recently, extra-articular patterns of impingement such as the anterior inferior iliac spine (AIIS)/subspine hip impingement have gained focus as a cause of hip pain and limitation in terminal hip flexion and internal rotation. The purpose of this study was to evaluate the prevalence of low AIIS in patients undergoing hip arthroscopy and to characterize the concomitant intra-articular lesions.Between November 2011 and April 2013, 100 consecutive patients underwent hip arthroscopy for various diagnoses by a single surgeon. After intra-operative diagnosis of low AIIS was made, a comprehensive review of the patients' records, preoperative radiographs, and intra-operative findings was conducted to document the existence and location of labral and chondral lesions.Twenty-one (21 %) patients had low AIIS. There were 13 males (mean age 38.4 years) and eight females (mean age 35.5 years). Eight patients had pre-operative radiographic evidence of low AIIS. All patients had a labral tear anteriorly, at the level of the AIIS; 17 had chondrolabral disruption and 17 had chondral lesions in zone two (antero-superior); and four patients had lesion in zones two and three.Low AIIS is a common intra-operative finding in hip arthroscopy patients. Characteristic labral and chondral lesions are routinely found in a predictable location that effaces the low AIIS. Level of Evidence-Level IV, Case Series.

    View details for PubMedID 26620219

  • ISAKOS celebrates 20 years of education, fellowship and outreach! KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Neyret, P. N., Safran, M. R., van der Merwe, W., Kurosaka, M. 2016; 24 (1): 4–5

    View details for PubMedID 26387123

  • Portal Placement in Hip Arthroscopy Anatomic Considerations and Access to the Central, Peripheral, and Peritrochanteric Spaces HIP: AANA ADVANCED ARTHROSCOPIC SURGICAL TECHNIQURES Abrams, G. D., Harris, J. D., Safran, M. R., Byrd, J. W., Bedi, A., Stubbs, A. J. 2016: 103–12
  • Level of clinical evidence presented at the International Society for Hip Arthroscopy Annual Scientific Meeting over 5 years (2010-2014) JOURNAL OF HIP PRESERVATION SURGERY Kay, J., de Sa, D., Shallow, S., Simunovic, N., Safran, M. R., Philippon, M. J., Ayeni, O. R. 2015; 2 (4): 332–38
  • MRI of the Hip for the Evaluation of Femoroacetabular Impingement; Past, Present, and Future JOURNAL OF MAGNETIC RESONANCE IMAGING Riley, G. M., McWalter, E. J., Stevens, K. J., Safran, M. R., Lattanzi, R., Gold, G. E. 2015; 41 (3): 558–72

    View details for DOI 10.1002/jmri.24725

    View details for Web of Science ID 000450816400001

  • Anchor-induced chondral damage in the hip JOURNAL OF HIP PRESERVATION SURGERY Matsuda, D. K., Bharam, S., White, B. J., Matsuda, N. A., Safran, M. 2015; 2 (1): 56–64


    The purpose of this study is to investigate the outcomes from anchor-induced chondral damage of the hip, both with and without frank chondral penetration. A multicenter retrospective case series was performed of patients with chondral deformation or penetration during initial hip arthroscopic surgery. Intra-operative findings, post-surgical clinical courses, hip outcome scores and descriptions of arthroscopic treatment in cases requiring revision surgery and anchor removal are reported. Five patients (three females) of mean age 32 years (range, 16-41 years) had documented anchor-induced chondral damage with mean 3.5 years (range, 1.5-6.0 years) follow-up. The 1 o'clock position (four cases) and anterior and mid-anterior portals (two cases each) were most commonly implicated. Two cases of anchor-induced acetabular chondral deformation without frank penetration had successful clinical and radiographic outcomes, while one case progressed from deformation to chondral penetration with clinical worsening. Of the cases that underwent revision hip arthroscopy, all three had confirmed exposed hard anchors which were removed. Two patients have had clinical improvement and one patient underwent early total hip arthroplasty. Anchor-induced chondral deformation without frank chondral penetration may be treated with close clinical and radiographic monitoring with a low threshold for revision surgery and anchor removal. Chondral penetration should be treated with immediate removal of offending hard anchor implants. Preventative measures include distal-based portals, small diameter and short anchors, removable hard anchors, soft suture-based anchors, curved drill and anchor insertion instrumentation and attention to safe trajectories while visualizing the acetabular articular surface.

    View details for DOI 10.1093/jhps/hnv001

    View details for Web of Science ID 000218645400007

    View details for PubMedID 27011815

    View details for PubMedCentralID PMC4718472

  • Level of clinical evidence presented at the International Society for Hip Arthroscopy Annual Scientific Meeting over 5 years (2010-2014). Journal of hip preservation surgery Kay, J. n., de Sa, D. n., Shallow, S. n., Simunovic, N. n., Safran, M. R., Philippon, M. J., Ayeni, O. R. 2015; 2 (4): 332–38


    The International Society for Hip Arthroscopy (ISHA) Annual Scientific Meeting is at the forefront of informing today's orthopaedic surgeons and society of the rapid advances in the exponentially growing field of hip arthroscopy. The purpose of this study was to evaluate and observe any trends in the level of clinical evidence in the papers and posters presented at the ISHA Annual Scientific Meeting from 2010 to 2014. The online abstracts of the paper and poster presentations presented at the ISHA Annual Scientific Meetings were independently evaluated by two reviewers (582 total resulting presentations). Two reviewers screened these results for clinical studies and graded the quality of evidence from level I (i.e. randomized trials) to IV (i.e. case series) based on the American Academy of Orthopaedic Surgeons classification system. Four hundred and twenty-eight presentations met the inclusion criteria and were evaluated. Overall, 10.1% of the presentations were level I, 12.8% were level II, 30.1% were level III and 47.0% were level IV evidence. Over time, from 2010 to 2014, we observed an increase in the percentage of level II paper presentations, an increase in the proportion of level III poster presentations, and a decrease in the proportion of both level IV paper and poster presentations. Significant non-random improvement in the level of evidence presented was noted for the poster presentations (P = 0.012) but not for the paper presentations (P = 0.61) over the study period. Statistical trends demonstrate ISHA's increased awareness and commitment to presenting higher quality evidence as the availability of this evidence increases.

    View details for PubMedID 27011857

    View details for PubMedCentralID PMC4732371

  • Global Discrepancies in the Diagnosis, Surgical Management, and Investigation of Femoroacetabular Impingement ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Yeung, M., Khan, M., Schreiber, V. M., Adamich, J., Letkemann, S., Simunovic, N., Bhandari, M., Musahl, V., Philippon, M. J., Safran, M. R., Ayeni, O. R. 2014; 30 (12): 1625–33


    The purpose of this study was to review the global pattern of surgical management of femoroacetabular impingement (FAI), particularly in diagnosis, outcome measurement, and management.We performed a systematic search in duplicate for surgical studies addressing FAI published up to June 2013. Study parameters, including sample size, study location, surgical intervention technique, diagnostic imaging, outcome measures used, sex distribution, and level of evidence, were obtained. The number of trials and cumulative sample size were analyzed. The surgical interventions, sex distribution, outcome measures, and diagnostic imaging used were compared between geographic regions.We identified 105 studies reporting surgical interventions for FAI. Most studies were completed in North America (52 studies, 3,629 patients) and in Europe (44 studies, 3,745 patients). Asia (3 studies, 49 patients) and Oceania (6 studies, 394 patients) had smaller contributions. There were no studies from South America or Africa. Most research performed in North America, Europe, and Oceania investigated arthroscopic FAI surgery (55% of studies) followed by surgical dislocation (33%), and miniopen (15%) and combined approaches (8%). Methods of diagnosis were consistent worldwide, with radiography being the mainstay of diagnosis (84% of studies). Case series were the most common type of study globally (75% of studies). Outcome measures varied by region; Harris hip scores were most common in North America, Oceania, and Asia, whereas Non-Arthritic Hip Scores and Western Ontario McMaster scores predominated in Europe.Global surgical trends for FAI show a predominance of North American and European studies, studies of lower level evidence, and inconsistent use of outcome measures. However, patterns of diagnostic imaging, sex proportions, and predominance of arthroscopic techniques are consistent worldwide. Future research should focus on development of reliable validated outcome measures and international collaboration to conduct high-quality research and improve our understanding of FAI diagnosis and management.Level IV, systematic review of Level I-IV studies.

    View details for PubMedID 25150405

  • Fibronectin-aggrecan complex as a marker for cartilage degradation in non-arthritic hips. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Abrams, G. D., Safran, M. R., Shapiro, L. M., Maloney, W. J., Goodman, S. B., Huddleston, J. I., Bellino, M. J., Scuderi, G. J. 2014; 22 (4): 768-773


    To report hip synovial fluid cytokine concentrations in hips with and without radiographic arthritis.Patients with no arthritis (Tonnis grade 0) and patients with Tonnis grade 2 or greater hip osteoarthritis (OA) were identified from patients undergoing either hip arthroscopy or arthroplasty. Synovial fluid was collected at the time of portal establishment for those undergoing hip arthroscopy and prior to arthrotomy for the arthroplasty group. Analytes included fibronectin-aggrecan complex (FAC) as well as a standard 12 cytokine array. Variables recorded were Tonnis grade, centre-edge angle of Wiberg, as well as labrum and cartilage pathology for the hip arthroscopy cohort. A priori power analysis was conducted, and a Mann-Whitney U test and regression analyses were used with an alpha value of 0.05 set as significant.Thirty-four patients were included (17 arthroplasty, 17 arthroscopy). FAC was the only analyte to show a significant difference between those with and without OA (p < 0.001). FAC had significantly higher concentration in those without radiographic evidence of OA undergoing microfracture versus those not receiving microfracture (p < 0.05).There was a significantly higher FAC concentration in patients without radiographic OA. Additionally, those undergoing microfracture had increased levels of FAC. As FAC is a cartilage breakdown product, no significant amounts may be present in those with OA. In contrast, those undergoing microfracture have focal area(s) of cartilage breakdown. These data suggest that FAC may be useful in predicting cartilage pathology in those patients with hip pain but without radiographic evidence of arthritis.Diagnostic, Level III.

    View details for DOI 10.1007/s00167-014-2863-2

    View details for PubMedID 24477496

  • Current state-of-the-art of hip arthroscopy KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Ayeni, O. R., Levy, B. A., Musahl, V., Safran, M. R. 2014; 22 (4): 711–13

    View details for DOI 10.1007/s00167-014-2866-z

    View details for Web of Science ID 000333157000001

    View details for PubMedID 24509832

  • Hip arthroscopy: from the beginning to the future-an innovator's perspective KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Glick, J. M., Valone, F., Safran, M. R. 2014; 22 (4): 714-721


    Hip arthroscopy is one of the fastest-growing areas of orthopaedic surgery. There are many reasons for this, including a better understanding of the pathophysiology of damage to the hip joint, improvements in imaging and technology advancements in arthroscopic instrumentation. This manuscript documents the historical development of hip arthroscopy, in general, as well as advances and ideas that have led to common techniques with regard to portal placement, traction and instrumentation. These advances have led to expanding indications for hip arthroscopy. This manuscript ends with some thoughts about the future of hip arthroscopy from the perspective of one of the leaders who helped shape hip arthroscopy, as it is performed today.

    View details for DOI 10.1007/s00167-014-2859-y

    View details for Web of Science ID 000333157000002

    View details for PubMedID 24482213

  • The Learning Curve for Hip Arthroscopy: A Systematic Review ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Hoppe, D. J., de Sa, D., Simunovic, N., Bhandari, M., Safran, M. R., Larson, C. M., Ayeni, O. R. 2014; 30 (3): 389–97


    The learning curve for hip arthroscopy is consistently characterized as "steep." The purpose of this systematic review was to (1) identify the various learning curves reported in the literature, (2) examine the evidence supporting these curves, and (3) determine whether this evidence supports an accepted number of cases needed to achieve proficiency.The electronic databases Embase and Medline were screened for any clinical studies reporting learning curves in hip arthroscopy. Two reviewers conducted a full-text review of eligible studies and a hand search of conference proceedings and reference sections of the included articles. Inclusion/exclusion criteria were applied, and a quality assessment was completed for each included article. Descriptive statistics were compiled.We identified 6 studies with a total of 1,063 patients. Studies grouped surgical cases into "early" versus "late" in a surgeon's experience, with 30 cases being the most common cutoff used. Most of these studies used descriptive statistics and operative time and complication rates as measures of competence. Five of 6 studies showed improvement in these measures between early and late experience, but only one study proposed a bona fide curve.This review shows that when 30 cases was used as the cutoff point to differentiate between early and late cases in a surgeon's experience, there were significant reductions in operative time and complication rates. However, there was insufficient evidence to quantify the learning curve and validate 30, or any number of cases, as the point at which the learning curve plateaus. As a result, this number should be interpreted with caution.Level IV, systematic review of Level IV studies.

    View details for PubMedID 24461140

  • Functional testing provides unique insights into the pathomechanics of femoroacetabular impingement and an objective basis for evaluating treatment outcome JOURNAL OF ORTHOPAEDIC RESEARCH Rylander, J., Shu, B., Favre, J., Safran, M., Andriacchi, T. 2013; 31 (9): 1461-1468


    Femoroacetabular impingement (FAI) has been recognized as a significant clinical problem. While hip reshaping surgery for treating FAI has had positive clinical outcomes, there remains a need for objective functional outcomes of FAI treatment. We tested the hypothesis that during walking and stair climbing significant changes in hip kinematics would occur following hip reshaping surgery that indicate restoration of normal function post-operatively. Hip and pelvic kinematics were collected for 17 FAI patients pre- and 1 year post-operatively and compared to 17 healthy matched controls. Prior to surgery, FAI patients had significantly reduced hip internal rotation and hip sagittal plane range of motion during walking (p = 0.01, p < 0.001, respectively) and stair climbing (p = 0.01, p < 0.001, respectively) as compared with controls. Post-operatively, these motions were restored to normal during walking (p = 0.70, p = 0.46, respectively), but remained significantly reduced in the FAI patients during stair climbing (p = 0.03, p < 0.001, respectively). These results have important implications for understanding the functional pathomechanics of FAI and providing an objective basis for evaluating treatment outcome. The stair climbing results indicate that problems still exist in the hip joint for activities requiring higher ranges of hip motion and suggest a basis for exploring future improvements for the treatment of FAI.

    View details for DOI 10.1002/jor.22375

    View details for Web of Science ID 000322005300017

    View details for PubMedID 23625839

  • Spontaneous Hip Labrum Regrowth After Initial Surgical D,bridement CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Abrams, G. D., Safran, M. R., Sadri, H. 2013; 471 (8): 2504-2508


    BACKGROUND: Anecdotal evidence from second-look hip arthroscopies and animal studies has suggested spontaneous labral regrowth may occur after débridement. However, these observations have not been systematically confirmed. QUESTIONS/PURPOSES: We (1) determined whether labral regrowth occurs after débridement in human hips; (2) if so, described the characteristics of the reconstituted labrum; and (3) determined the association, if any, of age with the presence and quality of labral regrowth. METHODS: We retrospectively reviewed all 24 patients who previously had open hip surgical dislocation with labral débridement for treatment of femoroacetabular impingement (FAI) and concomitant hip arthroscopy 2 years after index procedure in association with planned removal of trochanteric hardware between January and December 1999. Data recorded included amount of labral resection at the index procedure using the clockface method, presence and quality of any labral regrowth, presence of any labral scarring or inflammation, and WOMAC(®) scores. Minimum clinical followup was 11 years (average, 12 years; range, 11-12 years). RESULTS: All patients demonstrated labral regrowth at arthroscopy at 2 years. Homogeneous regrowth of labral height was seen in 21 of 24 patients, with labral scarring noted in four of 24. Average WOMAC(®) score was 98 points (range, 90-100 points) at the time of hardware removal. Increasing patient age was independently associated with decreased WOMAC(®) score and inhomogeneous regrowth of the labrum. CONCLUSIONS: Labral regrowth after resection was seen in all patients at 2 years from index operation. Increasing age, however, was associated with poorer quality of the reconstituted labrum. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1007/s11999-013-2914-x

    View details for Web of Science ID 000321549600017

    View details for PubMedID 23483380

  • Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft. Journal of shoulder and elbow surgery Abrams, G. D., McGarry, M. H., Jain, N. S., Freehill, M. T., Shin, S., Cheung, E. V., Lee, T. Q., Safran, M. R. 2013; 22 (7): 979-985


    Reconstruction of only the coracoclavicular (CC) ligaments may restore superior-inferior (S-I) but not anterior-posterior (A-P) stability of the acromioclavicular (AC) joint. Concomitant reconstruction of both the AC and CC ligaments may more reliably restore intact biomechanical characteristics of the AC joint.Ten matched pairs of shoulders were utilized. Five specimens underwent CC ligament reconstruction while an equal number underwent combined AC and CC ligament reconstruction utilizing an intramedullary tendon graft. Each of the reconstructions was compared with the intact contralateral control. Translational and load to failure characteristics were compared between groups.No difference was found in S-I translation between intact specimens and CC-only reconstructions (P = .20) nor between intact specimens and AC/CC reconstructions (P = .33) at 10 Newton (N) loads. Significant differences were noted in A-P translation between intact specimens and CC-only reconstructions (P < .001) but no difference in A-P translation between intact specimens and AC/CC reconstructions (P = .34).The A-P and S-I translational biomechanical characteristics of the AC joint were restored using the new technique described. Reconstruction of the CC ligaments only (versus AC/CC combined) led to significantly increased translational motion in the A-P plane as compared to intact control specimens.

    View details for DOI 10.1016/j.jse.2012.09.013

    View details for PubMedID 23313367

  • Hip-femoral acetabular impingement. Clinics in sports medicine Anderson, C. N., Riley, G. M., Gold, G. E., Safran, M. R. 2013; 32 (3): 409-425

    View details for DOI 10.1016/j.csm.2013.03.010

    View details for PubMedID 23773875

  • In vitro analysis of peri-articular soft tissues passive constraining effect on hip kinematics and joint stability. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA Safran, M. R., Lopomo, N., Zaffagnini, S., Signorelli, C., Vaughn, Z. D., Lindsey, D. P., Gold, G., Giordano, G., Marcacci, M. 2013; 21 (7): 1655-1663


    PURPOSE: Aim of the study is to assess the contribution of peri-articular soft tissues to hip joint kinematics and their influence on hip stability. METHODS: Four hemi-corpse specimens (3 males, average age 72 years) were studied using a custom navigation system. Hip kinematics (femoral head motion relative to the acetabulum and joint range of motion) were evaluated with the hip manually positioned in 36 different positions with (I) soft tissues intact, (II) after removal of the skin and muscles and (III) after partial capsulectomy. Each position was repeated 3 times in each state. RESULTS: Excellent interclass correlation for each test was determined (ICC range, 0.84-0.96). Femoral head anatomical centre displacement relative to the acetabulum occurred in all 3 planes, even with all the soft tissue intact (average, 3.3 ± 2.8 mm lateral translation; 1.4 ± 1.8 mm posterior translation and 0.3 ± 1.5 mm distally). These translations increased as more soft tissue was removed, except medial-lateral displacement, with an average 4.6 ± 2.9 mm lateral translation, 0.7 ± 1.3 mm posterior translation and 1.5 ± 1.9 mm distal translation when partial capsulectomy was performed. Range of motion increased in all 3 planes with increasing removal of the soft tissues. CONCLUSIONS: This study showed that femoral head anatomical centre displacement within the acetabulum occurs and increases with increasing removal of peri-articular soft tissues, confirming their influence on hip stability. Hip kinematics was also influenced by peri-articular soft tissues; specifically range of motion increases with increasing removal of those tissues. From clinicians' point of view, they have therefore to consider the influence of their surgeries on peri-articular soft tissues, since excessive translations may promote hip arthritis.

    View details for DOI 10.1007/s00167-012-2091-6

    View details for PubMedID 22752414

  • Hip-femoral acetabular impingement. Clinics in sports medicine Anderson, C. N., Riley, G. M., Gold, G. E., Safran, M. R. 2013; 32 (3): 409-425


    Magnetic resonance imaging (MRI) has become a valuable technology for the diagnosis and treatment of femoroacetabular impingement (FAI). This article reviews the basic pathophysiology of FAI, as well as the techniques and indications for MRI and magnetic resonance arthrography. Normal MRI anatomy of the hip and pathologic MRI anatomy associated with FAI are also discussed. Several case examples are presented demonstrating the diagnosis and treatment of FAI.

    View details for DOI 10.1016/j.csm.2013.03.010

    View details for PubMedID 23773875

  • Arthroscopic Internal Fixation of Osteochondritis Dissecans of the Femoral Head ORTHOPEDICS Matsuda, D. K., Safran, M. R. 2013; 36 (5): E683–E686


    Osteochondritis dessicans of the femoral head is an uncommon problem. Limited literature reports the incidence of osteochondritis dessicans and its treatment. The surgical technique used and outcomes for a 40-year-old man with symptomatic femoral head osteochonditis dissecans who was treated 11 years previously with retrograde drilling and hip arthroscopy are discussed.Despite temporary symptomatic improvement without subchondral collapse after his index procedure, increasing pain a decade later was thought to be caused by a large apical osteochondritic fragment and chondrolabral dysfunction from femoroacetabular impingement. Acetabuloplasty of acetabular overcoverage permitted arthroscopic internal fixation of the bone fragment by improving screw trajectory. Labral refixation and femoroplasty were subsequently performed. At 18-month follow-up, his nonarthritic hip score improved from 53 to 76 and his osteochondritic lesion had healed radiographically.Although clinical improvement with radiographic union has been reported following open screw fixation of femoral head osteochondritis dissecans, to the authors' knowledge this is the first published case with a similar outcome using arthroscopic techniques. Clinical improvement and union of even long-standing osteochondritis dissecans of the femoral head may occur with arthroscopic fragment fixation. Hip arthroscopy may play significant therapeutic and diagnostic roles in the treatment of this condition while offering a less invasive alternative to open osteosynthesis.

    View details for DOI 10.3928/01477447-20130426-37

    View details for Web of Science ID 000319811900024

    View details for PubMedID 23672924

  • The Anterior Inferior Iliac Spine: Size, Position, and Location. An Anthropometric and Sex Survey ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Amar, E., Druckmann, I., Flusser, G., Safran, M. R., Salai, M., Rath, E. 2013; 29 (5): 874–81


    The purpose of this study was to investigate and describe the size, location, and position of the anterior inferior iliac spine (AIIS) in normal individuals.We reviewed 50 computed tomography (CT) scans of 50 patients without hip pain or pathologic features. Mean patient height was 169.8 cm (women, 163 cm; men, 176.8 cm) and mean weight was 69.6 kg (women, 63.8 kg; men, 75.4 kg). We used all scans to measure both the left and right AIIS for the anatomic description of 100 AIISs. We measured AIIS dimensions, specifically length, width, and height. We also measured vertical, horizontal, and straight distances between the most anteroinferior prominence of the AIIS and the acetabular rim. We normalized AIIS size and distances from the acetabular rim according to the patient's height and body mass index (BMI). We also assessed the version of the AIIS using 2 angles. The first angle was the angle between the AIIS midaxis line and a plumb line, and the second angle was calculated as the angle subtended by the AIIS midaxis line and the ilium midaxis line.There were no significant differences between the AIIS in men and women in all measurements (except the width of the AIIS) when normalized to the patient's height and BMI. There were no significant differences in AIIS dimensions when comparing side-to-side differences in the entire study population.In quantifying AIIS dimensional size, distance from the anterior acetabular rim, and version, this study found no significant difference in all measurements normalized to patient size (height and BMI) between the left and right sides, and no significant sex difference was found in AIIS measurements, except the width of the AIIS.Morphologic variations that deviate from these normal values may help the clinician identify cases of subspinal impingement.

    View details for DOI 10.1016/j.arthro.2013.01.023

    View details for Web of Science ID 000319038900012

    View details for PubMedID 23523127

  • MR Imaging of the Hip Pathologies and Morphologies of the Hip Joint, What the Surgeon Wants to Know MAGNETIC RESONANCE IMAGING CLINICS OF NORTH AMERICA Botser, I., Safran, M. R. 2013; 21 (1): 169-?


    MR imaging of the hip is frequently used in symptomatic patients before hip preservation surgery; it is used as a decision-making tool and as a planning tool. The MRI can confirm the preliminary working diagnosis, identify other possible sources of pain, and highlight anatomic areas that are not routinely viewed during surgery. In addition, MR imaging is capable of illustrating normal and abnormal bony morphology of the femur and pelvis; and in the case that arthrography is used, diagnostic injection can be administrated concurrently. This article highlights a surgeon's perspective on the use of MR imaging in the patient with nonarthritic hip pain.

    View details for DOI 10.1016/j.mric.2012.08.008

    View details for Web of Science ID 000312619200014

    View details for PubMedID 23168190

  • Relationship between femoroacetabular contact areas and hip position in the normal joint: an in vitro evaluation KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Signorelli, C., Lopomo, N., Bonanzinga, T., Muccioli, G. M., Safran, M. R., Marcacci, M., Zaffagnini, S. 2013; 21 (2): 408-414


    Different approaches have been proposed to diagnose femoroacetabular impingement (FAI) condition and hip instability. It is still debatable which test is the most effective to make a correct diagnosis. The true mechanics of the hip during particular physical examination manoeuvres is unknown.Eight fresh frozen hips were passively taken through 3 different commonly used positions for FAI diagnosis and hip instability: 90° Flexion-Adduction-Internal Rotation, Hyperextension-Adduction-External Rotation and Hyperextension-Neutral-External Rotation. Kinematics and anatomical data were acquired by an optoelectronic system. The contact areas between acetabulum and femoral head were analysed to determine whether these tests are able to localize regions of the hip that may give patients pain.In the hip positions where the femur was in Hyperextension-External Rotation, the contact area was mainly concentrated in the posterosuperior area of the acetabulum, while during 90° Flexion-Adduction-Internal Rotation position, there was a wider distribution of contact, not specific to the anterolateral acetabulum.The results confirm the ability of the Hyperextension-External Rotation tests to particularly analyse the posterior region of the acetabulum. Placing the hip in 90° of Flexion-Adduction-Internal Rotation allows for testing a wider zone of the acetabulum and is not specific to abutment of the femoral head-neck region against the anterolateral acetabulum.

    View details for DOI 10.1007/s00167-012-2151-y

    View details for Web of Science ID 000313809600020

  • Intra-Abdominal Fluid Extravasation During Hip Arthroscopy: A Survey of the MAHORN Group ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Kocher, M. S., Frank, J. S., Nasreddine, A. Y., Safran, M. R., Philippon, M. J., Sekiya, J. K., Kelly, B. T., Byrd, J., Guanche, C. A., Martin, H. D., Clohisy, J. C., Mohtadi, N. G., Griffin, D. R., Sampson, T. G., Leunig, M., Larson, C. M., Ilizaliturri, V. M., McCarthy, J. C., Gambacorta, P. G. 2012; 28 (11): 1654-+


    The purpose of this study was to survey experts in the field of hip arthroscopy from the Multicenter Arthroscopy of the Hip Outcomes Research Network (MAHORN) group to determine the frequency of symptomatic intra-abdominal fluid extravasation (IAFE) after arthroscopic hip procedures, identify potential risk factors, and develop preventative measures and treatment strategies in the event of symptomatic IAFE.A survey was sent to all members of the MAHORN group. Surveys collected data on general hip arthroscopy settings, including pump pressure and frequency of different hip arthroscopies performed, as well as details on cases of symptomatic IAFE. Responses to the survey were documented and analyzed.Fifteen hip arthroscopists from the MAHORN group were surveyed. A total of 25,648 hip arthroscopies between 1984 and 2010 were reviewed. Arthroscopic procedures included capsulotomies, labral reattachment after acetabuloplasty, peripheral compartment arthroscopy, and osteoplasty of the femoral head-neck junction. Of the arthroscopists, 7 (47%) had 1 or more cases of IAFE (40 cases reported). The prevalence of IAFE in this study was 0.16% (40 of 25,650). Significant risk factors associated with IAFE were higher arthroscopic fluid pump pressure (P = .004) and concomitant iliopsoas tenotomy (P < .001). In all 40 cases, the condition was successfully treated without long-term sequelae. Treatment options included observation, intravenous furosemide, and Foley catheter placement, as well as 1 case of laparotomy.Symptomatic IAFE after hip arthroscopy is a rare occurrence, with an approximate prevalence of 0.16%. Prevention of IAFE should include close intraoperative and postoperative monitoring of abdominal distention, core body temperature, and hemodynamic stability. Concomitant iliopsoas tenotomy and high pump pressures may be risk factors leading to symptomatic IAFE.Level IV, therapeutic case series.

    View details for DOI 10.1016/j.arthro.2012.04.151

    View details for Web of Science ID 000310503500015

    View details for PubMedID 22989716

  • Arthroscopy of the Hip, The Snapping Hip: Surgical Management Pearls TECHNIQUES IN ORTHOPAEDICS Shu, B., Safran, M. R. 2012; 27 (3): 193–204
  • Epidemiology of musculoskeletal injury in the tennis player BRITISH JOURNAL OF SPORTS MEDICINE Abrams, G. D., Renstrom, P. A., Safran, M. R. 2012; 46 (7): 492-498


    Tennis is a popular sport with tens of millions of players participating worldwide. This popularity was one factor leading to the reappearance of tennis as a medal sport at the 1988 Summer Olympics in Seoul, South Korea. The volume of play, combined with the physical demands of the sports, can lead to injuries of the musculoskeletal system. Overall, injury incidence and prevalence in tennis has been reported in a number of investigations. The sport creates specific demands on the musculoskeletal system, with acute injuries, such as ankle sprains, being more frequent in the lower extremity while chronic overuse injuries, such as lateral epicondylitis, are more common in the upper extremity in the recreational player and shoulder pain more common in the high-level player. This review discusses the epidemiology of injuries frequently experienced in tennis players and examines some of these injuries' correlation with the development of osteoarthritis. In addition, player-specific factors, such as age, sex, volume of play, skill level, racquet properties and grip positions as well as the effect of playing surface on the incidence and prevalence of injury is reported. Finally, recommendations on standardisation of future epidemiological studies on tennis injuries are made in order to be able to more easily compare results of future investigations.

    View details for DOI 10.1136/bjsports-2012-091164

    View details for Web of Science ID 000305280500010

    View details for PubMedID 22554841

  • A Short Version of the International Hip Outcome Tool (iHOT-12) for Use in Routine Clinical Practice ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Griffin, D. R., Parsons, N., Mohtadi, N. H., Safran, M. R., MAHORN 2012; 28 (5): 611–18


    The purpose of this study was to develop and validate a shorter version of the 33-item International Hip Outcome Tool (iHOT-33) that could be easily used in routine clinical practice to measure both health-related quality of life and changes after treatment in young, active patients with hip disorders.A development dataset (104 patients) was explored with forward-selection linear regression analysis to choose a reduced item set for the new scale. This was tested in a validation dataset (1,833 patients) and responsiveness subset (80 patients) to measure agreement between the shorter and longer versions and to test the sensitivity of the shorter instrument to change after treatment.Twelve items were chosen for a short version of the International Hip Outcome Tool (iHOT-12). The iHOT-12 showed excellent agreement with the long version (iHOT-33). It captured 95.9% (95% confidence interval, 95.0% to 96.8%) of the variation of the iHOT-33 and showed equivalent sensitivity to change with a standardized effect size of 0.98 (95% confidence interval, 0.67 to 1.28).A short version of the International Hip Outcome Tool (iHOT-12) has been developed. It has very similar characteristics to the original rigorously validated 33-item questionnaire, losing very little information despite being only one-third the length. It is valid, reliable, and responsive to change. We suggest that it be used for initial assessment and postoperative follow-up in routine clinical practice.

    View details for DOI 10.1016/j.arthro.2012.02.027

    View details for Web of Science ID 000303456000005

    View details for PubMedID 22542434

  • Reconstruction of Lateral and Medial Elbow Ligaments for Chronic Instability Using a Single Graft With Hybrid Fixation: A New Technique of Reconstruction TECHNIQUES IN SHOULDER AND ELBOW SURGERY Pun, S. Y., Safran, M. R. 2012; 13 (1): 6–10
  • Articular cartilage friction increases in hip joints after the removal of acetabular labrum JOURNAL OF BIOMECHANICS Song, Y., Ito, H., Kourtis, L., Safran, M. R., Carter, D. R., Giori, N. J. 2012; 45 (3): 524-530


    The acetabular labrum is believed to have a sealing function. However, a torn labrum may not effectively prevent joint fluid from escaping a compressed joint, resulting in impaired lubrication. We aimed to understand the role of the acetabular labrum in maintaining a low friction environment in the hip joint. We did this by measuring the resistance to rotation (RTR) of the hip, which reflects the friction of the articular cartilage surface, following focal and complete labrectomy. Five cadaveric hips without evidence of osteoarthritis and impingement were tested. We measured resistance to rotation of the hip joint during 0.5, 1, 2, and 3 times body weight (BW) cyclic loading in the intact hip, and after focal and complete labrectomy. Resistance to rotation, which reflects articular cartilage friction in an intact hip was significantly increased following focal labrectomy at 1-3 BW loading, and following complete labrectomy at all load levels. The acetabular labrum appears to maintain a low friction environment, possibly by sealing the joint from fluid exudation. Even focal labrectomy may result in increased joint friction, a condition that may be detrimental to articular cartilage and lead to osteoarthritis.

    View details for DOI 10.1016/j.jbiomech.2011.11.044

    View details for Web of Science ID 000300863600017

    View details for PubMedID 22176711

  • MRI and arthroscopy correlations of the elbow: a case-based approach. Instructional course lectures Abrams, G. D., Stoller, D. W., Safran, M. R. 2012; 61: 235-249


    The number of elbow arthroscopies and indications for the procedure have increased significantly since the advent of modern elbow arthroscopy in the 1980s. In addition to the patient history, physical examination, and plain radiography, MRI is an important tool for the clinician in diagnosing several pathologies within and around the elbow. Understanding the pathophysiology and clinical presentation and being familiar with the MRI characteristics of a variety of elbow conditions will assist the physician in making an accurate diagnosis and help guide appropriate treatment.

    View details for PubMedID 22301236

  • MRI and arthroscopy correlations of the hip: a case-based approach. Instructional course lectures McCall, D. A., Safran, M. R. 2012; 61: 327-344


    Disorders of the hip joint can be physically disabling for the patient and a diagnostic challenge for the physician. Advances in imaging the hip with MRI can help the physician determine a more specific diagnosis for patients with acute or chronic hip pain. MRI and particularly magnetic resonance arthrography have helped raised awareness of nonarthritic hip problems and have made the diagnosis of hip problems much easier. Intra-articular and extra-articular processes can be evaluated with MRI; multiple sequences are available to increase the sensitivity and specificity for detecting specific pathology around the hip. Because the hip is a deep joint within a large soft-tissue envelope, MRI more precisely delineates the sources of hip pain by evaluating the soft tissues and ligamentous structures around the hip. It is helpful to understand the role of MRI in evaluating common pathologic conditions within the hip joint, including labral tears, chondral lesions, loose bodies, tears of the ligamentum teres, femoral acetabular impingement, developmental dysplasia of the hip, and pigmented villonodular synovitis. Hip arthroscopy, a less invasive technique for treating hip problems, has also contributed to the rapid growth of interest in this area of orthopaedic surgery. Hip arthroscopy can be used to evaluate disorders in the intra-articular region (central and peripheral compartments) and periarticular region (iliopsoas bursa and tendon disorders) as well as those in the peritrochanteric region.

    View details for PubMedID 22301244

  • Preoperative and Postoperative Sagittal Plane Hip Kinematics in Patients With Femoroacetabular Impingement During Level Walking AMERICAN JOURNAL OF SPORTS MEDICINE Rylander, J. H., Shu, B., Andriacchi, T. P., Safran, M. R. 2011; 39: 36S-42S


    Femoroacetabular impingement (FAI) has been linked to osteoarthritis. Treatment options range from nonoperative to operative, and current outcome measures are generally subjective or not conducted under actual activities of daily living. Thus, there is a need for the use of motion capture techniques to quantitatively assess the outcome of surgical intervention for those treated for FAI.The gait of FAI patients 1 year after operative treatment (arthroscopic hip reshaping) will be significantly closer to the normal range and pattern of hip flexion motion, relative to pretreatment.Case series; Level of evidence, 4.Eleven patients between 18 and 44 years of age with diagnosed FAI were enrolled in this study. Kinematics and kinetics for this group of patients were collected using motion capture techniques before arthroscopic bone-reshaping surgery and again 1 year after surgery. Pain and perceived activity level (Tegner scale) were also collected. All collected data were compared using a paired t test.Overall hip sagittal plane range of motion increased on the affected side from 27.6° ± 5.0° to 30.7° ± 4.3° (P = .02). The presence of abnormal reversals (second-order change in the slope in the hip flexion/extension curve) that was present in 5 patients preoperatively disappeared or was reduced in prevalence and magnitude in 4 of the patients postoperatively. Additionally, pain decreased and activity level increased postoperatively.The results supported the hypothesis that surgical intervention for FAI restores more normal patterns of gait and provides objective support that the surgical procedure is useful. The results help establish motion capture as a potential method for quantitatively assessing the outcome in FAI surgical interventions. The presence of abnormal reversals in hip flexion has been reported in end-stage hip osteoarthritis, and the presence of these reversals in FAI patients reinforces the idea of FAI being a precursor to hip osteoarthritis.

    View details for DOI 10.1177/0363546511413993

    View details for Web of Science ID 000292167400006

    View details for PubMedID 21709030

  • Strains Across the Acetabular Labrum During Hip Motion A Cadaveric Model AMERICAN JOURNAL OF SPORTS MEDICINE Safran, M. R., Giordano, G., Lindsey, D. P., Gold, G. E., Rosenberg, J., Zaffagnini, S., Giori, N. J. 2011; 39: 92S-102S


    Labral tears commonly cause disabling intra-articular hip pain and are commonly treated with hip arthroscopy. However, the function and role of the labrum are still unclear.(1) Flexion, adduction, and internal rotation (a position clinically defined as the position for physical examination known as the impingement test) places greatest circumferential strain on the anterolateral labrum and posterior labrum; (2) extension with external rotation (a position clinically utilized during physical examination to assess for posterior impingement and for anterior instability) places significant circumferential strains on the anterior labrum; (3) abduction with external rotation during neutral flexion-extension (the position the extremity rests in when a patient lies supine) places the greatest load on the lateral labrum.Descriptive laboratory study. Methods: Twelve cadaveric hips (age, 79 years) without labral tears or arthritis were studied. Hips were dissected free of soft tissues, except the capsuloligamentous structures. Differential variable reluctance transducers were placed in the labrum anteriorly, anterolaterally, laterally, and posteriorly to record circumferential strains in all 4 regions as the hip was placed in 36 different positions.The posterior labrum had the greatest circumferential strains identified; the peak was in the flexed position, in adduction or neutral abduction-adduction. The greatest strains anteriorly were in flexion with adduction. The greatest strains anterolaterally were in full extension. External rotation had greater strains than neutral rotation and internal rotation. The greatest strains laterally were at 90° of flexion with abduction, and external or neutral rotation. In the impingement position, the anterolateral strain increased the most, while the posterior labrum showed decreased strain (greatest magnitude of strain change). When the hip is externally rotated and in neutral flexion-extension or fully extended, the posterior labrum has significantly increased strain, while the anterolateral labrum strain is decreased.These are the first comprehensive strain data (of circumferential strain) analyzing the whole hip labrum. For the intact labrum, the greatest strain change was at the posterior acetabulum, whereas clinically, acetabular labral tears occur most frequently anterolaterally or anteriorly. The results are consistent with the impingement test as an assessment of anterolateral acetabular labral stress. The hyperextension-rotation test, often used clinically to assess anterior hip instability and posterior impingement, did not show a change in strain anteriorly, but did reveal an increase in strain posteriorly.Although this study does not include muscular forces across the hip joint, it does provide a clue as to the stresses about the labrum through the complete range of motions of the hip, which may help in providing a better understanding of the cause of labral tears and in the protection of labral repairs.

    View details for DOI 10.1177/0363546511414017

    View details for Web of Science ID 000292167400014

    View details for PubMedID 21709038

  • An Anatomic Arthroscopic Description of the Hip Capsular Ligaments for the Hip Arthroscopist ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Telleria, J. J., Lindsey, D. P., Giori, N. J., Safran, M. R. 2011; 27 (5): 628-636


    To examine and describe the normal anatomic intra-articular locations of the hip capsular ligaments in the central and peripheral compartments of the hip joint.Eight paired fresh-frozen human cadaveric hips (mean age, 73.3 years) were carefully dissected free of soft tissue to expose the hip capsule. Needles were placed through the capsule along the macroscopic borders of the hip capsular ligaments. Arthroscopy was performed on each hip, and the relations of the needles, and thus the ligaments, to the arthroscopic portals and other soft-tissue and osseous landmarks in the hip were recorded by use of a clock-face reference system.The iliofemoral ligament (ILFL) ran from 12:45 to 3 o'clock. The ILFL was pierced by the anterolateral and anterior portals just within its lateral and medial borders, respectively. The pubofemoral ligament was located from the 3:30 to the 5:30 clock position; the lateral border was at the psoas-U perimeter, and the medial border was at the junction of the anteroinferior acetabulum and the cotyloid fossa. The ischiofemoral ligament (ISFL) ran from the 7:45 to the 10:30 clock position. The posterolateral portal pierced the ISFL just inside its superior/lateral border, and the inferior/lateral border was located at the posteroinferior acetabulum. In the peripheral compartment the lateral ILFL and superior/lateral ISFL borders were in proximity to the lateral synovial fold. The medial ILFL and lateral pubofemoral ligament borders were closely approximated to the medial synovial fold.The hip capsular ligaments have distinct and consistent arthroscopic locations within the hip joint and are associated with clearly identifiable landmarks in the central and peripheral compartments. The standard hip arthroscopy portals are closely related to the borders of the hip capsular ligaments.These findings will help orthopaedic surgeons know which structures are being addressed during arthroscopic surgery and may help in the development of future hip procedures.

    View details for DOI 10.1016/j.arthro.2011.01.007

    View details for Web of Science ID 000289557700006

    View details for PubMedID 21663720

  • The Labrum of the Hip: Diagnosis and Rationale for Surgical Correction CLINICS IN SPORTS MEDICINE Freehill, M. T., Safran, M. R. 2011; 30 (2): 293-?


    The treatment of labral pathologic condition of the hip has become a topic of increasing interest. In patients undergoing hip arthroscopy, tears of the acetabular labrum are the most commonly found pathologic condition and most common cause of mechanical symptoms. Although a labral tear may occur with a single traumatic event, often another underlying cause may be already present, predisposing the individual to injury. This article discusses the structure and function of the acetabular labrum, the diagnosis of labral injury through physical examination and imaging modalities, and the current treatment options, including labrectomy, labral repair, and reconstruction.

    View details for DOI 10.1016/j.csm.2010.12.002

    View details for Web of Science ID 000289811500007

    View details for PubMedID 21419957

  • Hip Instability: Anatomic and Clinical Considerations of Traumatic and Atraumatic Instability CLINICS IN SPORTS MEDICINE Shu, B., Safran, M. R. 2011; 30 (2): 349-?


    Hip instability is uncommon because of the substantial conformity of the osseous femoral head and acetabulum. It can be defined as extraphysiologic hip motion that causes pain with or without the symptom of hip joint unsteadiness. The cause can be traumatic or atraumatic, and is related to both bony and soft tissue abnormality. Gross instability caused by trauma or iatrogenic injury has been shown to improve with surgical correction of the underlying deficiency. Subtle microinstability, particularly from microtraumatic or atraumatic causes, is an evolving concept with early surgical treatment results that are promising.

    View details for DOI 10.1016/j.csm.2010.12.008

    View details for Web of Science ID 000289811500010

    View details for PubMedID 21419960

  • Review of tennis serve motion analysis and the biomechanics of three serve types with implications for injury SPORTS BIOMECHANICS Abrams, G. D., Sheets, A. L., Andriacchi, T. P., Safran, M. R. 2011; 10 (4): 378-390


    The tennis serve has the potential for musculoskeletal injury as it is an overhead motion and is performed repetitively during play. Early studies evaluating the biomechanics and injury potential of the tennis serve utilized skin-based marker technologies; however, markerless motion measurement systems have recently become available and have obviated some of the problems associated with the marker-based technology. The late cocking and early acceleration phases of the kinetic chain of the service motion produce the highest internal forces and pose the greatest risk of injury during the service motion. Previous biomechanical data on the tennis serve have primarily focused on the flat serve, with some data on the kick serve, and very little published data elucidating the biomechanics of the slice serve. This review discusses the injury potential of the tennis serve with respect to the four phases of the service motion, the history, and early findings of service motion evaluation, as well as biomechanical data detailing the differences between the three types of serves and how this may relate to injury prevention, rehabilitation, and return to play.

    View details for DOI 10.1080/14763141.2011.629302

    View details for Web of Science ID 000299832400010

    View details for PubMedID 22303788

  • Case Report Bifid Iliopsoas Tendon Causing Refractory Internal Snapping Hip CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Shu, B., Safran, M. R. 2011; 469 (1): 289-293


    Treatment of painful internal snapping hip (coxa saltans) via arthroscopic lengthening or release of the iliopsoas tendon is becoming preferred over open techniques because of the benefits of minimal dissection, the ability to address concomitant intraarticular disorders, and a low complication rate. Persistent snapping after release is uncommon, especially when performed arthroscopically. Reported causes include incomplete release, intraarticular disorders, and incorrect diagnosis. Anatomic variants are not discussed in the orthopaedic literature.We report a case of an 18-year-old softball player with internal snapping hip treated with arthroscopic iliopsoas release in the peripheral compartment. Postoperatively, the athlete continued to have painful snapping. Repeat arthroscopy with a larger capsulotomy revealed a bifid iliopsoas tendon causing refractory internal snapping hip, which resolved after revision arthroscopic release.Bifid iliopsoas tendon as a cause of persistent snapping of the hip has not been reported in the orthopaedic literature. Prior sonographic and anatomic studies suggest the bifid iliopsoas tendon exists but is uncommon. PURPOSE AND CLINICAL RELEVANCE: Recognition that a bifid iliopsoas tendon may be the source of painful internal snapping hip is important to prevent clinical failure of surgical management of the internal snapping hip. The differential diagnosis of failed iliopsoas lengthening surgery should include the consideration of an incompletely lengthened tendon attributable to bifid iliopsoas tendon anatomy. Prevention of this complication includes making a large enough capsulotomy to identify the tendon and to ensure it is not bifid.

    View details for DOI 10.1007/s11999-010-1452-z

    View details for Web of Science ID 000286938400040

    View details for PubMedID 20593254

    View details for PubMedCentralID PMC3008906

  • Hip Arthroscopy Assessment Tools and Outcomes OPERATIVE TECHNIQUES IN ORTHOPAEDICS Safran, M. R., Hariri, S. 2010; 20 (4): 264–77
  • Sport Injury Prevention: Time for an Intervention? CLINICAL JOURNAL OF SPORT MEDICINE Matheson, G. O., Mohtadi, N. G., Safran, M., Meeuwisse, W. H. 2010; 20 (6): 399-401

    View details for DOI 10.1097/JSM.0b013e318203114c

    View details for Web of Science ID 000284379100001

    View details for PubMedID 21079431

  • The Athlete's Elbow Preface CLINICS IN SPORTS MEDICINE Safran, M. R. 2010; 29 (4): XIII-XV

    View details for DOI 10.1016/j.csm.2010.06.002

    View details for Web of Science ID 000283562000002

    View details for PubMedID 20883895

  • Ulnar Collateral Ligament Injury in the Overhead Athlete CLINICS IN SPORTS MEDICINE Hariri, S., Safran, M. R. 2010; 29 (4): 619-?


    The ulnar collateral ligament (UCL), particularly the anterior portion of the anterior oblique ligament, is the primary static contributor to elbow valgus stability. UCL injuries are most common in athletes participating in overhead sports. Acute and chronic injuries to the UCL result in valgus instability, which may predispose the athlete to the development of disabling secondary elbow conditions. Provocative physical examination maneuvers include the valgus abduction test, the modified milking maneuver, and the moving valgus stress test. Plain radiographs and magnetic resonance imaging are the most common imaging modalities, although ultrasonography and computed tomography arthrograms can alternatively be used. UCL injuries can be treated initially with rest, anti-inflammatory medications, bracing, and/or physical therapy. Acute avulsion injuries can be repaired, especially in those under 20 years of age, but most UCL tears are now treated with reconstruction. Modifications of the Jobe figure-of-8 technique, and now the Altchek docking technique, are the most common reconstruction techniques. Many new and hybrid techniques have been described with limited clinical experience in the literature. Current techniques offer the athlete a greater than 90% chance of return to play at their preinjury level.

    View details for DOI 10.1016/j.csm.2010.06.007

    View details for Web of Science ID 000283562000008

    View details for PubMedID 20883901

  • The Acetabular Labrum: Anatomic and Functional Characteristics and Rationale for Surgical Intervention JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Safran, M. R. 2010; 18 (6): 338-345


    The past decade has seen unprecedented growth in the number of hip arthroscopies. Acetabular labral tears are the leading indication for arthroscopy of this joint. However, labral anatomy and function, as well as the effects of labral tears and surgical outcomes, have only recently been studied. Labral tears may cause pain and microinstability of the hip joint. They also may increase friction within the joint, cartilage consolidation, and strain within the articular cartilage, thereby possibly resulting in accelerated degeneration of the joint. Partial labrectomy and labral repair are the current surgical options, and basic science data suggest that labral repairs can heal and subsequently restore function. However, a good, validated outcomes measure to adequately assess active patients with a painful nonarthritic hip is needed to determine the efficacy of such repair and aid in managing patient expectations.

    View details for Web of Science ID 000278238500006

    View details for PubMedID 20511439

  • Arthroscopic Femoral Osteoplasty/Chielectomy for Cam-type Femoroacetabular Impingement in the Athlete SPORTS MEDICINE AND ARTHROSCOPY REVIEW Vaughn, Z. D., Safran, M. R. 2010; 18 (2): 90-99


    Femoroacetabular impingement (FAI) represents an underlying bony abnormality of either the femoral head-neck junction or acetabulum, or most commonly, both. This often is associated with damage to intra-articular structures, primarily the labrum and chondral surfaces. Like pincer impingement, cam impingement has been associated with pain, limited hip range of motion, pain affecting athletic performance, and has been linked to the development of osteoarthritis. Cam impingement is the loss of offset of the femoral head-neck junction associated with loss of sphericity of the femoral head. Isolated cam impingement, although more common than isolated pincer impingement, it is much less common than both cam and pincer coexisting in people with FAI. Classically, the patient with isolated cam impingement is a young athletic male near 20 years of age. The classic pathology associated with the cam lesion is an acetabular articular cartilage injury in the anterosuperior acetabulum that is fairly well defined and may be deep, 1 to 1.5 cm from the acetabular rim, initially sparing the labrum, but eventually leading to labral detachment from the underlying bone. Treatment generally focuses on restoring the femoral head-neck offset by removing the excess bone. This article will review the underlying pathology of cam-type FAI, the evaluation and diagnosis, arthroscopic treatment, and reported outcomes.

    View details for DOI 10.1097/JSA.0b013e3181dfce63

    View details for Web of Science ID 000278105700006

    View details for PubMedID 20473127

  • The Evidence for Surgical Repair of Articular Cartilage in the Knee JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Safran, M. R., Seiber, K. 2010; 18 (5): 259-266


    The complex structure and biomechanical function of articular cartilage make chondral injuries a management challenge. Articular cartilage has limited, if any, capacity to heal and/or regenerate. Although the natural history of articular cartilage lesions has not been clearly studied, significant injuries are believed to progress, resulting in degenerative arthritis of the joint. Changes have been made in surgical techniques in an attempt to better manage these lesions, and a large industry has been built around arthroscopic and open surgical procedures for managing cartilage repair. However, there is limited evidence that any intervention significantly alters the natural history of these lesions. Randomized trials have been done to examine the outcomes of common restoration procedures performed in the United States today, such as microfracture, osteochondral autograft transfer, and autologous chondrocyte implantation. Because the natural history of articular cartilage lesions has not been defined, we can assess the utility of surgical interventions only by comparing methods.

    View details for Web of Science ID 000277310300002

    View details for PubMedID 20435876

  • Reliability of clinical diagnosis in intraarticular hip diseases KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY Martin, R. L., Kelly, B. T., Leunig, M., Martin, H. D., Mohtadi, N. G., Philippon, M. J., Sekiya, J. K., Safran, M. R. 2010; 18 (5): 685–90


    This study investigated the ability of experienced orthopedic surgeons to agree on a diagnosis of labral tear, femoroacetabular impingement (FAI), and capsular laxity using clinical examination. Eight patients under the care of an experienced hip arthroscopist underwent independent clinical evaluations by six orthopedic surgeons who specialized in management hip pain. No attempt was made to regulate the evaluation process as surgeons performed their examination as they would in their own practice. Average subject age was 27 years (19-47 years) with five females and three males. Subjects subsequently underwent arthroscopic surgery by the treating surgeon. Surgical findings were recorded with respect to the presence or absence of a labral tear, FAI, and/or capsular laxity. The percent agreement between the surgical findings and clinical examinations were determined. Surgical findings noted four subjects had a labral tear, five FAI, and three laxity. Based on clinical examination, surgeons agreed 63, 65 and 58% of the time with the surgical diagnosis of labral tear, FAI, and capsular laxity, respectively. The level of agreement did not seem to be dependent on the size or type of labral tear. Also, the ability to detect FAI did not seem to depend on whether the lesion was a cam, pincer, combined cam/pincer or size of the cam lesion. This study offers support that clinical examination techniques used for making a diagnosis needs to be improved and standardized if they are to be useful in diagnosing specific pathologies found with arthroscopic hip surgery.

    View details for DOI 10.1007/s00167-009-1024-5

    View details for Web of Science ID 000276722900021

    View details for PubMedID 20057996

  • Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes BRITISH JOURNAL OF SPORTS MEDICINE Abrams, G. D., Safran, M. R. 2010; 44 (5): 311-318


    Shoulder pain is a common complaint in overhead athletes, and superior labrum anterior posterior (SLAP) lesions are a common cause of this pain. The pathological cascade which results in the SLAP lesion consists of a combination of posterior inferior capsular tightness and scapular dyskinesis, resulting in a 'peel back' phenomenon at the biceps anchor and leading to the SLAP tear. Physical exam tests vary in their sensitivity and specificity in detecting SLAP lesions, so MRI is helpful in demonstrating the anatomical alteration. Treatment can be conservative, with posterior inferior capsular stretching and scapular open and closed chain exercises. Many SLAP lesions in overhead athletes require surgical treatment that involves repair of the labrum back to the glenoid. Treatment of concomitant injuries such as rotator cuff tears and Bankart lesions in conjunction with the SLAP repair may be necessary.

    View details for DOI 10.1136/bjsm.2009.070458

    View details for Web of Science ID 000276368100005

    View details for PubMedID 20371556

  • Medical Advances in Treating the Masters Athlete BIOMEDICAL ENGINEERING PRINCIPLES OF THE BIONIC MAN Luke, A., Safran, M. R., Hung, G. 2010; 5: 455–90
  • Injuries about the shoulder in skiing and snowboarding BRITISH JOURNAL OF SPORTS MEDICINE McCall, D., Safran, M. R. 2009; 43 (13): 987-992


    There has been a decrease in the overall injury rate, particularly the rate of lower-extremity injuries, for alpine skiing, with a resultant increase in the ratio of upper-extremity to lower-extremity injuries. The upper extremity is injured nearly twice as often during snowboarding than alpine skiing, with approximately half of all snowboarding injuries involving the upper extremity. Shoulder injuries are likely under-reported, as many patients seek evaluation for minor shoulder injuries with their local physicians, and not at the ski medical clinic, where most epidemiology studies obtain their data. Shoulder injuries account for 4 to 11% of all alpine skiing injuries and 22 to 41% of upper-extremity injuries. During snowboarding, shoulder injuries account for 8 to 16% of all injuries and 20 to 34% of upper-extremity injuries. Falls are the most common mechanism of shoulder injury, in addition to pole planting during skiing and aerial manoeuvres during snowboarding. Common shoulder injuries during skiing and snowboarding are rotator cuff strains, glenohumeral dislocations, acromioclavicular separations and clavicle fractures. It is still unclear, when comparing snowboarding and skiing injury data, which sport has the higher incidence of shoulder injuries. Stratifying shoulder injuries by type allows better delineation as to which sport has an increased incidence of certain injury patterns. The differing mechanisms of injury combined with distinct equipment for each sport plays a role in the type and frequency of shoulder injuries seen in these two subgroups. With the increased ratio of upper- to lower-extremity injuries during alpine skiing and the boom in popularity of snowboarding, shoulder injuries are seen with increasing frequency by those who care for alpine sport injuries. According to recent epidemiological data, only clavicle and humerus fractures have shown increased rates of incidence among alpine skiers. Over the past 30 years, there has been a general decrease in both upper- and lower-extremity injuries which can be attributed to improved designs of protective equipment, increased awareness of injury patterns and emphasis on prevention. In the future, physicians and therapists who treat this population must be comfortable and confident in their treatment algorithms to help keep skiers and snowboarders conditioned and ready for the slopes and develop strategies for the prevention of upper-extremity injuries associated with these activities.

    View details for DOI 10.1136/bjsm.2009.068767

    View details for Web of Science ID 000272170300007

    View details for PubMedID 19945981

  • Graft Orientation Influences the Knee Flexion Moment During Walking in Patients With Anterior Cruciate Ligament Reconstruction AMERICAN JOURNAL OF SPORTS MEDICINE Scanlan, S. F., Blazek, K., Chaudhari, A. M., Safran, M. R., Andriacchi, T. P. 2009; 37 (11): 2173-2178


    Anterior cruciate ligament graft orientation has been proposed as a potential mechanism for failure of single-bundle anterior cruciate ligament reconstruction and has been considered important in the restoration of normal ambulatory knee mechanics.To evaluate the possibility that patients adapt their mechanics of walking to the orientation of the anterior cruciate ligament graft. This was determined by testing the hypothesis that peak external knee flexion moment (net quadriceps moment) during walking in patients with anterior cruciate ligament reconstruction is correlated with coronal and sagittal anterior cruciate ligament graft orientations.Cross-sectional study; Level of evidence, 3.Gait analysis was performed to assess dynamic knee function during walking in 17 subjects with unilateral anterior cruciate ligament reconstructions. Magnetic resonance imaging was used to measure coronal and sagittal anterior cruciate ligament graft orientations.A negative correlation was observed between peak external knee flexion moment during walking and coronal angle of the anterior cruciate ligament graft (1.0 m/s walking speed, r = -0.87, P < .001; 1.3 m/s, r = -0.66, P = .004; 1.6 m/s, r = -0.24, P > .05); no correlation was found with the sagittal graft angle (1.0 m/s walking speed, r = 0.21, P > .05; 1.3 m/s, r = 0.20, P > .05; 1.6 m/s, r = 0.13, P > .05).The negative correlation between peak external knee flexion moment during walking and the coronal angle of the anterior cruciate ligament graft indicates that as the anterior cruciate ligament graft is placed in a more vertical coronal orientation, patients reduce their net quadriceps usage during walking.This finding supports the hypothesis that graft placement plays a critical role in the restoration of normal ambulatory mechanics after anterior cruciate ligament reconstruction and thus could provide a partial explanation for the increased incidence of premature osteoarthritis at long-term follow-up in patients with anterior cruciate ligament reconstruction.

    View details for DOI 10.1177/0363546509339574

    View details for Web of Science ID 000271216600012

    View details for PubMedID 19729363

  • Differences in Physician and Patient Ratings of Items Used to Assess Hip Disorders AMERICAN JOURNAL OF SPORTS MEDICINE Martin, R. L., Mohtadi, N. G., Safran, M. R., Leunig, M., Martin, H. D., McCarthy, J., Guanche, C. A., Kelly, B. T., Byrd, J., Clohisy, J. C., Philippon, M. J., Sekiya, J. K. 2009; 37 (8): 1508–12


    The purpose of this study was to determine what issues are important to active individuals with hip lesions and to assess whether these issues are different from those that surgeons think are important.A discrepancy will be noted between what patients and surgeons believe to be important.Cross-sectional study; Level of evidence, 3.This study comprised 150 consecutive patients (73 men, 77 women) from the international practices of 9 orthopaedic surgeons specializing in the management of hip disorders. All participants were seeking treatment for musculoskeletal hip disease. Average patient age was 42 +/- 11 years (range, 18-60). Patients and surgeons rated the importance of 146 potential hip outcome assessment items on a 6-point Likert-type scale.Of the 23 items identified as being important to patients, 16 were in the sports and recreation category. The top 11 items that the clinicians thought were most important were rated significantly lower by patients (P < .0005). Specifically, surgeons rated several items as being important that fell into the symptoms, functional limitations, and occupational issues categories, whereas patients did not. That is, a difference was found between patients and clinicians in how they rated items related to symptoms, functional limitations, and occupation (P < .01). A difference was not found between patients and surgeons in how they rated items related to sports and recreation and social-emotional lifestyle (P > .01).The hypothesis of this study was affirmed: a discrepancy was found between what issues patients believe are important and what surgeons perceive as being important to patients. This information may be particularly important when assessing treatment outcomes from a patient's perspective. Clinicians must be careful in presuming that the issues that they are attempting to improve with treatment are issues that are important to patients. These findings also emphasize the importance of discussing appropriate postoperative expectations for those considering surgery.

    View details for DOI 10.1177/0363546509333851

    View details for Web of Science ID 000268289400006

    View details for PubMedID 19417122

  • Stress fracture of the acetabular rim: arthroscopic reduction and internal fixation. A case report. journal of bone and joint surgery. American volume Epstein, N. J., Safran, M. R. 2009; 91 (6): 1480-1486

    View details for DOI 10.2106/JBJS.H.01499

    View details for PubMedID 19487528

  • Stress Fracture of the Acetabular Rim: Arthroscopic Reduction and Internal Fixation A Case Report JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Epstein, N. J., Safran, M. R. 2009; 91A (6): 1480-1486
  • Hip Disease in the Young Adult: Current Concepts of Etiology and Surgical Treatment Clohisy, J. C., Beaule, P. E., O'Malley, A., Safran, M. R., Schoenecker, P. JOURNAL BONE JOINT SURGERY. 2008: 2267–81

    View details for DOI 10.2106/JBJS.G.01267

    View details for Web of Science ID 000259873300026

    View details for PubMedID 18829926

  • The use of scaffolds in the management of art articular cartilage injury JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Safran, M. R., Kim, H., Zaffagnini, S. 2008; 16 (6): 306-311


    Managing articular cartilage injury continues to be a difficult challenge for the clinician. Although the short- and intermediate-term results of autologous chondrocyte implantation appear to be favorable, resources are being directed toward research to improve the technology. One promising area of investigation is the combination of cultured chondrocytes with scaffolds. Clinicians desire techniques that may be implanted easily, reduce surgical morbidity, do not require harvesting of other tissues, exhibit enhanced cell proliferation and maturation, have easier phenotype maintenance, and allow for efficient and complete integration with surrounding articular cartilage. The characteristics that make scaffolds optimal for clinical use are that they be biocompatible, biodegradable, permeable, reproducible, mechanically stable, noncytotoxic, and capable of serving as a temporary support for the cells while allowing for eventual replacement by matrix components synthesized by the implanted cells. Clinical experience is growing with three scaffold-based cartilage repair techniques, each using a different type of scaffold material: matrix-induced autologous chondrocyte implantation, a hyaluronic acid-based scaffold, and a composite polylactic/polyglycolic acid polymer fleece. Clinical results are encouraging. Future directions in scaffold-based cartilage repair include bioactive and spatially oriented scaffolds.

    View details for Web of Science ID 000256280600002

    View details for PubMedID 18524981

  • Injury of the distal biceps at the musculotendinous junction JOURNAL OF SHOULDER AND ELBOW SURGERY Schamblin, M. L., Safran, M. R. 2007; 16 (2): 208-212


    Although complete rupture of the distal biceps tendon at the osseous insertion has been well documented in the literature, musculotendinous ruptures of the distal biceps remain exceedingly uncommon. In this report, we present a series of 6 distal biceps musculotendinous ruptures in 6 different patients, verified either with magnetic resonance imaging or by direct visualization at surgical exploration. In 5 of 6 patients, a single traumatic injury was reported, whereas the sixth reported 2 episodes of injury and pain occurring approximately 1 week apart. A common mechanism of injury seems to prevail in this type of injury: glenohumeral elevation with the elbow extended and the forearm in supination. Although surgical outcomes of distal biceps osseous avulsions frequently lead to excellent results, the surgical options for musculotendinous junction injuries are limited, with outcome studies lacking. These 6 patients, who did not undergo repair, obtained a mean score of 97.5 on the Mayo Clinic Performance Index for the Elbow. Symptoms of musculotendinous injury to the distal biceps are similar to tendinitis or complete or partial avulsion of this muscle-tendon unit. The examination reveals an intact distal biceps tendon. In patients with a mechanism of injury consistent with a musculotendinous injury of the distal biceps, radiographic modalities, particularly magnetic resonance imaging, are recommended to confirm the diagnosis to differentiate it from the more common distal biceps tendon avulsion, or partial rupture, to limit the morbidity associated with potentially unnecessary operative procedures.

    View details for DOI 10.1016/j.jse.2006.06.009

    View details for Web of Science ID 000245426200013

    View details for PubMedID 17169581

  • Interobserver agreement in the classification of rotator cuff tears AMERICAN JOURNAL OF SPORTS MEDICINE Kuhn, J. E., Dunn, W. R., Ma, B., Wright, R. W., Jones, G., Spencer, E. E., Wolf, B., Safran, M., Spindler, K. P., McCarty, E., Kelly, B., Holloway, B. 2007; 35 (3): 437-441


    Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions.To assess the interobserver variation for these classification systems and identify the method with the best interobserver agreement.Cohort study (diagnosis); Level of evidence, 2.Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis.Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, kappa = 0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, kappa = 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, kappa = 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, kappa = 0.54).With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane.

    View details for DOI 10.1177/0363546506298108

    View details for Web of Science ID 000244686100011

    View details for PubMedID 17267769

  • A peek into the possible future of management of articular cartilage injuries: Gene therapy and scaffolds for cartilage repair JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY Kim, H. T., Zaffagnini, S., Mizuno, S., Abelow, S., Safran, M. R. 2006; 36 (10): 765-773


    Two rapidly progressing areas of research will likely contribute to cartilage repair procedures in the foreseeable future: gene therapy and synthetic scaffolds. Gene therapy refers to the transfer of new genetic information to cells that contribute to the cartilage repair process. This approach allows for manipulation of cartilage repair at the cellular and molecular level. Scaffolds are the core technology for the next generation of autologous cartilage implantation procedures in which synthetic matrices are used in conjunction with chondrocytes. This approach can be improved further using bioreactor technologies to enhance the production of extracellular matrix proteins by chondrocytes seeded onto a scaffold. The resulting "neo-cartilage implant" matures within the bioreactor, and can then be used to fill cartilage defects.

    View details for DOI 10.2519/jospt.2006.2284

    View details for Web of Science ID 000241065800006

    View details for PubMedID 17063838

  • Short-term effectiveness of hyperthermia for supraspinatus tendinopathy in athletes - A short-term randomized controlled study AMERICAN JOURNAL OF SPORTS MEDICINE Giombini, A., Di Cesare, A., Safran, M. R., Ciatti, R., Maffulli, N. 2006; 34 (8): 1247-1253


    Hyperthermia has been introduced as a physical therapy modality for soft tissue injuries.The authors tested the null hypothesis that there are no short-term differences after the use of hyperthermia, ultrasound, and exercises for tendinopathy of the supraspinatus tendon.Randomized controlled trial; Level of evidence, 1.The authors studied 37 athletes (29 men, 8 women; mean age, 26.7 +/- 5.8 years; range, 19-43 years) with supraspinatus tendinopathy who had had symptoms between 3 and 6 months. Subjects were randomly assigned to 3 groups. Group A (n = 14) received hyperthermia at 434 MHz. Group B (n = 12) received continuous ultrasound at 1 MHz at an intensity of 2.0 w/cm(2) 3 times a week. Group C (n = 11) undertook exercises, consisting of pendular swinging and stretching exercises 5 minutes twice a day every day. All interventions were undertaken for 4 weeks. Subjects were evaluated at baseline, immediately on completion of treatment, and at 6 weeks after the end of the intervention using mean pain score for pain at night, during movement, and at rest on a visual analog scale; pain on resisted movement and painful arc on active abduction between 40 degrees and 120 degrees on a 4-point scale; and Constant score.Patients who received hyperthermia experienced significantly better pain relief than did patients receiving ultrasound or exercises: group A, 5.96 to 1.2 (P = .03); group B, 6.3 to 5.15 (P = .10); group C, 6.1 to 4.9 (P = .09).Hyperthermia at 434 MHz appears safe and effective in the short term for the management of supraspinatus tendinopathy.

    View details for DOI 10.1177/0363546506287827

    View details for Web of Science ID 000239168600005

    View details for PubMedID 16636345

  • MRI analysis of in vivo meniscal and tibiofemoral kinematics in ACL-deficient and normal knees JOURNAL OF ORTHOPAEDIC RESEARCH Shefelbine, S. J., Ma, C. B., Lee, K., Schrumpf, M. A., Patel, P., Safran, M. R., Slavinsky, J. P., Majumdar, S. 2006; 24 (6): 1208-1217


    The objectives of this study were to analyze simultaneously meniscal and tibiofemoral kinematics in healthy volunteers and anterior cruciate ligament (ACL)-deficient patients under axial load-bearing conditions using magnetic resonance imaging (MRI). Ten healthy volunteers and eight ACL-deficient patients were examined with a high-field, closed MRI system. For each group, both knees were imaged at full extension and partial flexion ( approximately 45 degrees ) with a 125N compressive load applied to the foot. Anteroposterior and medial/lateral femoral and meniscal translations were analyzed following three-dimensional, landmark-matching registration. Interobserver and intraobserver reproducibilities were less than 0.8 mm for femoral translation for image processing and data analysis. The position of the femur relative to the tibia in the ACL-deficient knee was 2.6 mm posterior to that of the contralateral, normal knee at extension. During flexion from 0 degrees to 45 degrees , the femur in ACL-deficient knees translated 4.3 mm anteriorly, whereas no significant translation occurred in uninjured knees. The contact area centroid on the tibia in ACL-deficient knees at extension was posterior to that of uninjured knees. Consequently, significantly less posterior translation of the contact centroid occurred in the medial tibial condyle in ACL-deficient knees during flexion. Meniscal translation, however, was nearly the same in both groups. Axial load-bearing MRI is a noninvasive and reproducible method for evaluating tibiofemoral and meniscal kinematics. The results demonstrated that ACL deficiency led to significant changes in bone kinematics, but negligible changes in the movement of the menisci. These results help explain the increased risk of meniscal tears and osteoarthritis in chronic ACL deficient knees.

    View details for DOI 10.1002/jor.20139

    View details for Web of Science ID 000237825600011

    View details for PubMedID 16652339

  • Postero-medial elbow problems in the adult athlete BRITISH JOURNAL OF SPORTS MEDICINE Eygendaal, D., Safran, M. R. 2006; 40 (5): 430-434


    The ligamentous, osseous, musculotendinous, and neural structures at the postero-medial side of the elbow are at risk for various injuries in overhead athletes. The combination of valgus and extension overload during overhead activities results in tensile forces along the medial stabilising structures, with compression on the lateral compartment and shear stress posteriorly. The combination of tensile forces medially and shear forces posteriorly can result in ulnar collateral ligament (UCL) tears, flexor-pronator mass injuries, neuritis of the ulnar nerve, posterior impingement, and olecranon stress fractures. Most symptomatic conditions of the overhead athlete can be treated conservatively initially. In cases where conservative treatment is unsuccessful surgical intervention is indicated. Recent advances in arthroscopic surgical techniques and ligamentous reconstruction ensure that the prognosis for return to pre-injury level is good.

    View details for DOI 10.1136/bjsm.2005.025437

    View details for Web of Science ID 000236994800013

    View details for PubMedID 16632574

  • Osteochondritis dissecans of the knee JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS Crawford, D. C., Safran, M. R. 2006; 14 (2): 90-100


    Osteochondritis dissecans is a condition of the joints that appears to affect subchondral bone primarily, with secondary effects on articular cartilage. With progression, this pathology may present clinically with symptoms related to the integrity of the articular cartilage. Early signs, associated with intact cartilage, may be related to a softening phenomenon and alteration in the mechanical properties of cartilage. Later stages, because of the lack of underlying support of the cartilage, can present with signs of articular cartilage separation, cartilage flaps, loose bodies, inflammatory synovitis, persistent or intermittent joint effusion, and, in severe cases, secondary joint degeneration. Selecting and recommending a surgical intervention require balancing application of nonsurgical interventions with assessment of the degree of articular cartilage stability and the potential for spontaneous recovery.

    View details for PubMedID 16467184

  • Avoidance and management of intra-articular complications of anterior cruciate ligament reconstruction. Instructional course lectures Safran, M. R., Greene, H. S. 2006; 55: 475-488


    An estimated 70,000 to 100,000 anterior cruciate ligament reconstructions are performed each year in the United States. With the increasing number of anterior cruciate ligament surgeries being performed, a concomitant increase in intraoperative complications can be expected. Complications include those associated with tunnel placement, notchplasty, graft fixation and advancement, suture laceration, graft laceration, guidewire insertion and removal, intra-articular hardware, posterior cruciate ligament laceration, compartment syndrome, and vascular injury.

    View details for PubMedID 16958482

  • Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction - art. no. E1 ARTHROSCOPY-THE JOURNAL OF ARTHROSCOPIC AND RELATED SURGERY Busfield, B. T., Safran, M. R., Cannon, W. D. 2005; 21 (10): 1268-1268


    The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

    View details for DOI 10.1016/j.arthro.2005.07.010

    View details for Web of Science ID 000232907700019

    View details for PubMedID 16226659

  • Effects of elbow flexion and forearm rotation on valgus laxity of the elbow. journal of bone and joint surgery. American volume Safran, M. R., McGarry, M. H., Shin, S., Han, S., Lee, T. Q. 2005; 87 (9): 2065-2074


    Clinical evaluation of valgus elbow laxity is difficult. The optimum position of elbow flexion and forearm rotation with which to identify valgus laxity in a patient with an injury of the ulnar collateral ligament of the elbow has not been determined. The purpose of the present study was to determine the effect of forearm rotation and elbow flexion on valgus elbow laxity.Twelve intact cadaveric upper extremities were studied with a custom elbow-testing device. Laxity was measured with the forearm in pronation, supination, and neutral rotation at 30 degrees, 50 degrees, and 70 degrees of elbow flexion with use of 2 Nm of valgus torque. Testing was conducted with the ulnar collateral ligament intact, with the joint vented, after cutting of the anterior half (six specimens) or posterior half (six specimens) of the anterior oblique ligament of the ulnar collateral ligament, and after complete sectioning of the anterior oblique ligament. Laxity was measured in degrees of valgus angulation in different positions of elbow flexion and forearm rotation.There were no significant differences in valgus laxity with respect to elbow flexion within each condition. Overall, for both groups of specimens (i.e., specimens in which the anterior or posterior half of the anterior oblique ligament was cut), neutral forearm rotation resulted in greater valgus laxity than pronation or supination did (p < 0.05). Transection of the anterior half of the anterior oblique ligament did not significantly increase valgus laxity; however, transection of the posterior half resulted in increased valgus laxity in some positions. Full transection of the anterior oblique ligament significantly increased valgus laxity in all positions (p < 0.05).The results of this in vitro cadaveric study demonstrated that forearm rotation had a significant effect on varus-valgus laxity. Laxity was always greatest in neutral forearm rotation throughout the ranges of elbow flexion and the various surgical conditions.The information obtained from the present study suggests that forearm rotation affects varus-valgus elbow laxity. Additional investigation is warranted to determine if forearm rotation should be considered in the evaluation and treatment of ulnar collateral ligament injuries of the elbow joint.

    View details for PubMedID 16140822

  • Effects of elbow flexion and forearm rotation on valgus laxity of the elbow JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Safran, M. R., McGarry, M. H., Shin, S., Han, S., Lee, T. Q. 2005; 87A (9): 2065-2074
  • Soft-tissue stabilizers of the elbow Closed Meeting of the American-Shoulder-and-Elbow-Surgeons Safran, M. R., Baillargeon, D. MOSBY-ELSEVIER. 2005: 179S–185S


    Elbow stability is afforded by both static and dynamic structures. Static structures include the complex bony architecture and soft-tissue stabilizers. Knowledge of the anatomy and biomechanics of the stabilizers is important to understand, diagnose, and treat elbow instability. Bony anatomy, detailed elsewhere, contributes to the inherent stability of the elbow. The static soft-tissue stabilizers consist of the anterior and posterior joint capsule and both medial and lateral collateral ligament complexes. Additional stability is conferred by dynamic structures--the muscles crossing the elbow joint.

    View details for DOI 10.1016/j.jse.2004.09.032

    View details for Web of Science ID 000227328400026

    View details for PubMedID 15726079

  • Elbow injuries in athletes CLINICS IN SPORTS MEDICINE Safran, M. R. 2004; 23 (4): XVII-XIX

    View details for DOI 10.1016/j.csm.2004.06.009

    View details for Web of Science ID 000224471500002

    View details for PubMedID 15474217

  • Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment CLINICS IN SPORTS MEDICINE Safran, M. R. 2004; 23 (4): 643-?


    The ulnar collateral ligament (UCL) is more commonly injured than previously suggested. Injury to this ligament can result in secondary symptoms and problems in other parts of the elbow, including the ulnar nerve, the flexor-pronator musculotendinous unit, the radiocapitellar joint, and the posterior compartment of the elbow, in addition to being a cause of loose bodies within the elbow. This article briefly reviews the anatomy, biomechanics, and pathophysiology of injury, in addition to discussing evaluation and treatment of the athlete with an injured UCL.

    View details for DOI 10.1016/j.csm.2004.05.002

    View details for Web of Science ID 000224471500012

    View details for PubMedID 15474227

  • Nerve injury about the shoulder in athletes, Part 2 - Long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome AMERICAN JOURNAL OF SPORTS MEDICINE Safran, M. R. 2004; 32 (4): 1063-1076


    Nerve injuries about the shoulder in athletes are being recognized with increasing frequency. Prompt and correct diagnosis of these injuries is important to treat the patient and to understand the potential complications and natural history, so as to counsel our athletes appropriately. This 2-part article is a review and an overview of the current state of knowledge regarding some of the more common nerve injuries seen about the shoulder in athletes, including long thoracic nerve, spinal accessory nerve, burners and stingers, and thoracic outlet syndrome. Each of these clinical entities will be discussed independently, reviewing the anatomy, mechanism of injury, patient presentation (history and examination), the role of additional diagnostic studies, differential diagnosis, and management.

    View details for DOI 10.1177/0363546504265193

    View details for Web of Science ID 000221706200031

    View details for PubMedID 15150060

  • Nerve injury about the shoulder in athletes, part 1 - Suprascapular nerve and axillary nerve AMERICAN JOURNAL OF SPORTS MEDICINE Safran, M. R. 2004; 32 (3): 803-819


    Nerve injuries about the shoulder in athletes are being recognized with increasing frequency. Prompt and correct diagnosis of these injuries is important to treat the patient and to understand the potential complications and natural history so as to appropriately counsel athletes. This 2-part article is a review and an overview of the current state of knowledge regarding some of the more common nerve injuries seen about the shoulder in athletes.

    View details for DOI 10.1177/0363546504264582

    View details for Web of Science ID 000220915100032

    View details for PubMedID 15090401

  • Distal biceps tendon ruptures - Incidence, demographics, and the effect of smoking Annual Meeting of the Knee-Society/Association of-Hip-and-Knee-Surgeons Safran, M. R., Graham, S. M. SPRINGER. 2002: 275–83


    The purpose of the current study was to determine the incidence of distal biceps tendon ruptures within a defined population, to describe the demographics of affected individuals, and to identify potential risk factors. The healthcare system in this study provides care to a known number of members in an area defined by zip codes and proximity to the medical center. Medical records for all members who presented with injuries about the elbow during a 5-year period were reviewed. Thirteen men and one woman with an average age of 47 years comprised the study population. The dominant extremity was involved in 86% of patients. All patients described a mechanism involving excessive eccentric tension as the arm was forced from a flexed position. The incidence of injury in the membership population averaged 1.2 ruptures per 100,000 patients per year. Forty-three percent reported regular tobacco use, whereas only 9% of all members were smokers. A Poisson regression analysis revealed a 7.5 times greater risk of distal biceps tendon rupture in patients who smoke. The incidence of distal biceps tendon ruptures is 1.2 per 100,000 patients, with the majority in the dominant elbow of men who smoke and who are in their fourth decade of life.

    View details for DOI 10.1097/01.blo.0000026560.55792.02

    View details for Web of Science ID 000179273100042

    View details for PubMedID 12439270

  • Sideline management of common dislocations. Current sports medicine reports Hodge, D. K., Safran, M. R. 2002; 1 (3): 149-155


    This article reviews sideline assessment and treatment of commonly encountered joint dislocations. Although often deferred for formal management in an emergency room, many of these injuries can be safely and appropriately reduced by experienced hands on the field. This text provides a practical approach, outlining mechanism, presentation and physical exam, reduction, aftercare, and return to sport for many common joint dislocations. Emphasis is placed on awareness of possible complications of injury and from treatment, proper documentation of neurovascular status before and after intervention, and formal radiographic confirmation following joint reduction. When appropriate, the immediate sideline management of common joint dislocations may minimize morbidity encountered with later treatment in the hospital setting.

    View details for PubMedID 12831707

  • Shoulder proprioception in baseball pitchers JOURNAL OF SHOULDER AND ELBOW SURGERY Safran, M. R., Borsa, P. A., Lephart, S. M., Fu, F. H., Warner, J. J. 2001; 10 (5): 438-444


    We examined proprioceptive differences between the dominant and nondominant shoulders of 21 collegiate baseball pitchers without a history of shoulder instability or surgery. A proprioceptive testing device was used to measure kinesthesia and joint position sense. Joint position sense was significantly (P =.05) more accurate in the nondominant shoulder than in the dominant shoulder when starting at 75% of maximal external rotation and moving into internal rotation. There were no significant differences for proprioception in the other measured positions or with kinesthesia testing. Six pitchers with recent shoulder pain had a significant (P =.04) kinesthetic deficit in the symptomatic dominant shoulder compared with the asymptomatic shoulder, as measured in neutral rotation moving into internal rotation. The net effect of training, exercise-induced laxity, and increased external rotation in baseball pitchers does not affect proprioception, although shoulder pain, possibly due to rotator cuff inflammation or tendinitis, is associated with reduced kinesthetic sensation.

    View details for DOI 10.1067/mse.2001.118004

    View details for Web of Science ID 000171926100007

    View details for PubMedID 11641701

  • Cells degrade a novel inhibitor of differentiation with E1A-like properties upon exiting the cell cycle MOLECULAR AND CELLULAR BIOLOGY Miyake, S., Sellers, W. R., Safran, M., Li, X. T., Zhao, W. Q., Grossman, S. R., Gan, J. M., DeCaprio, J. A., Adams, P. D., Kaelin, W. G. 2000; 20 (23): 8889-8902


    Control of proliferation and differentiation by the retinoblastoma tumor suppressor protein (pRB) and related family members depends upon their interactions with key cellular substrates. Efforts to identify such cellular targets led to the isolation of a novel protein, EID-1 (for E1A-like inhibitor of differentiation 1). Here, we show that EID-1 is a potent inhibitor of differentiation and link this activity to its ability to inhibit p300 (and the highly related molecule, CREB-binding protein, or CBP) histone acetylation activity. EID-1 is rapidly degraded by the proteasome as cells exit the cell cycle. Ubiquitination of EID-1 requires an intact C-terminal region that is also necessary for stable binding to p300 and pRB, two proteins that bind to the ubiquitin ligase MDM2. A pRB variant that can bind to EID1, but not MDM2, stabilizes EID-1 in cells. Thus, EID-1 may act at a nodal point that couples cell cycle exit to the transcriptional activation of genes required for differentiation.

    View details for Web of Science ID 000168366000025

    View details for PubMedID 11073989

    View details for PubMedCentralID PMC86544

  • Musculoskeletal injuries in the young tennis player CLINICS IN SPORTS MEDICINE Ben Kibler, W., Safran, M. R. 2000; 19 (4): 781-?


    Tennis is becoming increasingly popular, especially with young athletes. Despite recent advances in epidemiologic research of tennis injuries, there still is a need for more injury research in all of the racquet sports. The data that does exist show that the young athlete is susceptible to injury in these different sports. Injury patterns in the skeletally immature racquet sports athlete are becoming apparent. Although most of the sports result in similar injury patterns, such as a predominance of lower extremity injury, there are differences. It appears that the physical demands of the sport are becoming more clearly documented, and the adaptive response to these demands is becoming understood. The adaptive response reveals a common origin for many of the injuries in the different sports. This is related most often to repetitive microtrauma with resultant loss in flexibility and strength. The sports medicine practitioner must understand these differences, know the demands, do serial musculoskeletal evaluations for maladaptations, and adhere to a periodized prehabilitation program of preventative exercises to maximize performance and minimize injury risk.

    View details for Web of Science ID 000089536000012

    View details for PubMedID 11019740

  • Zoster paresis of the shoulder - Case report and review of the literature CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Yaszay, B., Jablecki, C. K., Safran, M. R. 2000: 112-118


    More than 95% of people in the United States are infected with the varicella zoster virus at some time in life, and this infection usually is manifested as chicken pox during childhood. The virus then establishes a latent infection of sensory ganglia, from which it may reactivate many years later to cause herpes zoster (shingles), a cutaneous painful rash along a dermatomal distribution. Less commonly, the varicella zoster virus may result in myotomal motor weakness or paralysis in addition to a painful dermatomal rash. A case of unilateral left C5-C6 segmental paresis attributable to herpes zoster in an otherwise healthy individual and a current review of the literature are presented. A case of zoster paresis of the shoulder muscles is presented to remind the orthopaedic community that this diagnosis may be confused with other diagnoses, including rotator cuff tear, and should be considered in the differential diagnosis of shoulder pain and shoulder girdle muscle weakness.

    View details for Web of Science ID 000088559100017

    View details for PubMedID 10943192

  • Proprioception in the posterior cruciate ligament deficient knee Specialty Day Meeting of the American-Orthopaedic-Society-for-Sports-Medicine / 63rd Annual Meeting of the American-Academy-of-Orthopaedic-Srgeons Safran, M. R., Allen, A. A., Lephart, S. M., Fu, F. H., Harner, C. D. SPRINGER. 1999: 310–17


    This study was undertaken to evaluate knee proprioception in patients with isolated unilateral posterior cruciate ligament (PCL) injuries. Eighteen subjects with isolated PCL tears were studied 1-234 months after injury. The threshold to detect passive motion (TTDPM) was used to evaluate kinesthesia and the ability to passively reproduce passive positioning (RPP) to test joint position sense. Two starting positions were tested in all knees: 45 degrees (middle range) and 110 degrees (end range) to evaluate knee proprioception when the PCL is under different amounts of tension. TTDPM and RPP were tested as the knee moved into flexion and extension from both starting positions. A statistically significant reduction in TTDPM was identified in PCL-injured knees tested from the 45 degrees starting position, moving into flexion and extension. RPP was statistically better in the PCL-deficient knee as tested from 110 degrees moving into flexion and extension. No difference was identified in the TTDPM starting at 110 degrees or in RPP with the presented angle at 45 degrees moving into flexion or extension. These subtle but statistically significant findings suggest that proprioceptive mechanoreceptors may play a clinical role in PCL-intact and PCL-deficient patients. Further, it appears that kinesthesia and joint position sense may function through different mechanisms.

    View details for Web of Science ID 000083126700009

    View details for PubMedID 10525701

  • Peroneal tendon subluxation in athletes: new exam technique, case reports, and review MEDICINE AND SCIENCE IN SPORTS AND EXERCISE Safran, M. R., O'Malley, D., Fu, F. H. 1999; 31 (7): S487-S492


    Traumatic peroneal tendon subluxation is an uncommon cause of ankle pain. As a result, the diagnosis is often delayed. A new technique of examining the patient in the prone position, allowing for easier visualization of the subluxation or dislocation, is described. Three illustrative cases, including a rare case of midsubstance rupture of the peroneal retinaculum are presented along with a review the literature. An acute repair in athletes and in those patients who do not want to risk the chance of a 40-50% failure rate after 4-6 wk of casting is currently recommended. Surgical repair can be facilitated using Mitek suture anchors for acute, symptomatic chronic, and subacute injuries. Deepening of the groove is performed only in those patients that have no sulcus or a convexity of the groove.

    View details for Web of Science ID 000081388800009

    View details for PubMedID 10416549

  • Lateral ankle sprains: a comprehensive review - Part 2: treatment and rehabilitation with an emphasis on the athlete MEDICINE AND SCIENCE IN SPORTS AND EXERCISE Safran, M. R., Zachazewski, J. E., Benedetti, R. S., Bartolozzi, A. R., Mandelbaum, R. 1999; 31 (7): S438-S447


    This is the second part of a two-part comprehensive review of lateral ankle sprains. In the first part of our review, we discussed the etiology, natural history, pathoanatomy, mechanism of injury, histopathogenesis of healing, and diagnostic approach to acute and chronic lateral ligamentous ankle injuries. Conservative intervention and treatment of grade I-III and chronic, recurrent sprains of the lateral ankle ligaments and appropriate rehabilitation guidelines are the topics of this article. We review the use and benefit of different modalities and external supports and outline our five-phase intervention program of rehabilitation based on the histopathogenesis of ligament healing. We discuss the expected timing of recovery of the acute injury as well as the management of chronic, recurrent ankle sprains. Treatment of acute ankle sprains depends on the severity of the injury. Conservative therapy has been found to be uniformly effective in treating grade I and II ankle sprains. Some controversy exists regarding the appropriate treatment of grade III injuries, particularly in high-level athletes. Our belief is that the majority of these patients may also be treated well with conservative management. Other options for the management of grade III sprains will be briefly discussed at the end of this article.

    View details for Web of Science ID 000081388800005

    View details for PubMedID 10416545

  • Lateral ankle sprains: a comprehensive review - Part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis MEDICINE AND SCIENCE IN SPORTS AND EXERCISE Safran, M. R., Benedetti, R. S., Bartolozzi, A. R., Mandelbaum, B. R. 1999; 31 (7): S429-S437


    Ankle sprains are among the most common injuries sustained by athletes and seen by sports medicine physicians. Despite their prevalence in society, ankle sprains still remain a difficult diagnostic and therapeutic challenge in the athlete, as well as in society in general. The purpose of this section of our two-part study is to review scope of the problem, the anatomy and biomechanics of the lateral ankle ligaments, review the pathoanatomical correlates of lateral ankle sprains, the histopathogenesis of ligament healing, and define the mechanisms of injury to understand the basis of our diagnostic approach to the patient with this common acute and chronic injury. We extensively review the diagnostic evaluation including historical information and physical examination, as well as options for supplementary radiographic examination. We further discuss the differential diagnosis of the patient with recurrent instability symptoms. This will also serve as the foundation for part two of our study, which is to understand the rationale for our treatment approach for this common problem.

    View details for Web of Science ID 000081388800004

    View details for PubMedID 10416544

  • The effects of joint position and direction of joint motion on proprioceptive sensibility in anterior cruciate ligament-deficient athletes AMERICAN JOURNAL OF SPORTS MEDICINE Borsa, P. A., Lephart, S. M., Irrgang, J. J., Safran, M. R., Fu, F. H. 1997; 25 (3): 336-340


    We studied a group of anterior cruciate ligament-deficient athletes to identify whether joint position and direction of joint motion have a significant effect on proprioception. Twenty-nine anterior cruciate ligament-deficient athletes were tested for their threshold to detect passive motion at both 15 degrees and 45 degrees moving into the directions of both flexion and extension. The single-legged hop test was used to identify function in the deficient limb. Results demonstrated statistically significant deficits in threshold to detect passive motion for the deficient limb at 15 degrees moving into extension. For the deficient limb, threshold to detect passive motion was significantly more sensitive moving into extension than flexion at a starting angle of 15 degrees; at a starting angle of 15 degrees moving into extension threshold was significantly more sensitive than at a starting angle of 45 degrees moving into extension. We conclude that in deficient limbs proprioception is significantly more sensitive in the end ranges of knee extension (15 degrees) and is significantly more sensitive moving into the direction of extension. To effectively restore reflex stabilization of the lower limb we recommend a rehabilitation program emphasizing performance-based, weightbearing, closed kinetic chain exercise for the muscle groups that act on the knee joint.

    View details for Web of Science ID A1997XA52700011

    View details for PubMedID 9167813

  • Technical considerations of revision anterior cruciate ligament surgery CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Safran, M. R., Harner, C. D. 1996: 50-64


    Revision anterior cruciate ligament surgery will become more common as the number of primary anterior cruciate ligament reconstructions increases. Also contributing to this increase are those patients who had anterior cruciate ligament reconstruction using synthetic ligaments and other nonanatomic techniques that are no longer used. Preoperative planning is imperative to a successful outcome. This begins with determining the primary, and often times secondary, mechanism of failure for each patient. The determination of the etiology of failure is the first step in a carefully constructed preoperative plan, including the type of revision, skin incision, graft removal, hardware removal, tunnel placement, graft selection, graft fixation, and rehabilitation. The precise preoperative plan should have enough flexibility to accommodate unanticipated findings in the operating room. Rehabilitation protocols must be designed specifically for the revision surgery patient and be flexible enough to accommodate changes based on surgical findings and techniques. Finally, the importance of counseling the patient preoperatively regarding the potential results which, in general, are somewhat less satisfactory than with most primary reconstructions, must be emphasized. However, with proper planning, attention to detail, and adherence to basic principles of anterior cruciate ligament reconstruction, revision anterior cruciate ligament surgery can provide a satisfying solution to difficult knee instability cases.

    View details for Web of Science ID A1996UD41500007

    View details for PubMedID 8998899

  • Graft selection in knee surgery. Current concepts. The American journal of knee surgery Safran, M. R. 1995; 8 (4): 168-180


    Recent advances in the understanding of knee mechanics and pathomechanics, in addition to newer techniques and instrumentation, have resulted in broadened indications for knee ligament surgery. Further, revision knee ligament or tendon surgery and delayed primary reconstruction are becoming more common as well. With the poor results of primary suture repair of the cruciate ligaments and the lateral collateral ligament, other graft sources often must be used. As a result, one must be familiar with the advantages and disadvantages of the different graft options available to the knee surgeon. This article discusses the current concepts regarding the advantages and disadvantages of the different graft options available to the knee surgeon.

    View details for PubMedID 8590129



    Athletes expose their elbows to significantly high forces, in addition to multiple repetitive motions. Athletic injuries about the elbow include ligamentous, tendon, articular, and nerve injuries. The proper diagnosis requires a thorough knowledge of the anatomy, pathomechanics, and physical findings associated with these injuries. Treatment entails a methodical progression from nonoperative to operative intervention.

    View details for Web of Science ID A1995RK06000007

    View details for PubMedID 7609961



    There are many causes of knee pain in the athlete. Clearly, common things, such as meniscal tears, ligament sprains, contusions, and patellofemoral dysfunction, are common. The infrequency of other entities, however, should not make the physician complacent. A thorough history and physical examination will, in most cases, elicit inconsistencies in the occasional athlete presenting with one of these uncommon causes of knee pain (Table 1). Diagnosing these uncommon causes, when they do present to the health care provider, allows for early and correct treatment with a more rapid return to sports.

    View details for Web of Science ID A1995RK06000011

    View details for PubMedID 7609965



    Automotive airbag technology has reduced the number of injuries and fatalities resulting from motor vehicle crashes. With the increasingly frequent application of this safety feature in automobiles, recent reports of airbag-associated injuries have emerged, including ocular and non-lethal cardiac trauma. We report three cases of airbag-related upper extremity injuries seen at a level-I trauma center over a 6-month period. A heightened awareness of this type of injury in patients injured in motor vehicle crashes with airbag deployment is recommended. The awareness, identification, and management of these high energy injuries will take on added meaning as the airbag technology becomes universally applied.

    View details for Web of Science ID A1995RD56300018

    View details for PubMedID 7723098



    We performed a retrospective review of a series of knee arthroscopic procedures that were completed using local, general, or regional anesthesia to evaluate the efficacy of these anesthetic techniques. Operative time, complications or failures, procedures successfully performed, recovery room time and postoperative stay, and patient satisfaction were recorded. Local anesthesia with intravenous sedation compared favorably with the other techniques: operative time was not increased, a large variety of operative procedures were successfully completed, recovery time was significantly shortened, and patient satisfaction remained high. This technique offers several advantages over other types of anesthesia for knee arthroscopy, including improved cost effectiveness.

    View details for Web of Science ID A1995QC08700008

    View details for PubMedID 7726350

  • Revision ACL surgery: Technique and results utilizing allografts 1994 Instructional Course Lectures, at the 61st Annual Meeting of the American-Academy-of-Orthopaedic-Surgeons Safran, M. R., Harner, C. D. AMER ACAD ORTHOPAEDIC SURGEONS. 1995: 407–415

    View details for Web of Science ID A1995BH44U00036

    View details for PubMedID 7797879



    Elbow injuries are becoming more common as increasing numbers of people participate in throwing and racquet sports. The understanding and treatment of elbow injuries is becoming more sophisticated in conjunction with better noninvasive and invasive diagnostic techniques. The majority of injuries to the elbow in the athlete are chronic, overuse injuries. These injuries are the result of repetitive intrinsic or extrinsic overload, or both, resulting in microrupture of soft tissue such as ligament or tendon. In children, apophyses, being the weakest link in the immature musculoskeletal system, are susceptible to stress injuries. Elbow injuries are most commonly caused by valgus stress, from throwing or axial compression, resulting in increased force absorbed by the medial elbow. With repetitive valgus stress, patients may develop chondromalacia, loose bodies in the posterior or lateral compartments, injury to the ulnar collateral ligament, myotendinous injury to the flexor-pronator muscle group, osteochondritis dissecans, or ulnar neuritis. The purpose of this paper is to (1) define the significance of elbow injuries in athletics, (2) review the anatomy and biomechanics of the elbow, and (3) discuss the prevention and treatment of elbow injuries.

    View details for Web of Science ID A1995QB44700039

    View details for PubMedID 7641448

  • DORSAL DEFECT OF THE PATELLA JOURNAL OF PEDIATRIC ORTHOPAEDICS Safran, M. R., McDonough, P., Seeger, L., Gold, R., Oppenheim, W. L. 1994; 14 (5): 603-607


    Dorsal defect of the patella is a benign subchondral lesion of unknown etiology, located in the superolateral region of the patella. The lesion presents with a characteristic radiographic appearance consisting of a rounded focus of radiolucency surrounded by a sclerotic margin. Although often an incidental finding on knee radiographs, it occasionally may be symptomatic. It occurs in males and females with equal frequency, is bilateral in up to one third of individuals, and is most frequently found in adolescents. This report describes a series of eight such lesions in five patients.

    View details for Web of Science ID A1994PC79600009

    View details for PubMedID 7962501

  • 151 endoprosthetic reconstructions for patients with primary tumors involving bone. Contemporary orthopaedics Safran, M. R., KODY, M. H., Namba, R. S., Larson, K. R., Kabo, J. M., Dorey, F. J., Eilber, F. R., Eckardt, J. J. 1994; 29 (1): 15-25


    As part of the UCLA limb salvage program, 151 patients received 151 endoprostheses for primary tumors involving bone. Follow-up of all patients was to death (56), revision (21), or a minimum two years for the 74 additional survivors (range: 24-114 months; mean: 52 months). Endoprosthetic replacements were of the distal femur (81), proximal femur (19), proximal humerus (13), proximal tibia (11), scapula (11), total femur (8), total humerus (4), intercalary prostheses (2), and one each of the distal humerus and the pelvis. There were three soft tissue sarcomas, five benign bone lesions, and 143 primary malignant tumors of bone. MSTS function was good-excellent in 78%. There were 64 local complications in 55 patients (36%). Mechanical failure occurred in 24 patients (15.9%), local recurrence occurred in ten (6.6%), minor wound healing problems in nine (5.9%), and infection in eight (5.3%). Few systemic complications were reported. Function appeared to be location dependent. All of the 29 patients with benign or low grade malignant tumors (parosteal, IA, IB) have survived. Of the 116 patients with stage IIA and IIB disease, 59% survived three years, and a Kaplan-Meier analysis projects that 56% are expected to survive at five years. Only 17 (11%) of these 151 endoprostheses have been revised; an additional four (3%) eventually came to amputation. The Kaplan-Meier analysis revealed that 91% of the prostheses survived three years and 83% survived five years. The Cox Proportional Hazards model revealed that for patients with stage IIA and IIB disease, the risk of death is four times the risk of the need for revision at five years. Although endoprosthetic reconstructions have their own unique complications, they have proven durable in this series of patients. Local problems usually can be managed without amputation, and patient satisfaction is high.

    View details for PubMedID 10172089



    The effect of a single injection of unpreserved blood on joint stiffness and on synovial and cartilage histomorphology in the ankle joints of rabbits was determined at ten and 28 days after injection. The same volume of saline was placed in the contralateral ankle for comparison. After ten days, the hemarthrosis ankle was stiffer than the control ankle (p < 0.027), whereas at 28 days there was no statistical difference in stiffness between the hemarthrosis and control ankles, regardless of whether the limbs had been immobilized. Also after ten days, the hemarthrosis ankles had varying amounts of clotted blood, darkened articular cartilage, hypertrophic synovium with reactive blood vessels, and macrophages containing heme. The gross and histologic appearance of the saline ankles was normal. After 28 days, there were no differences in gross or microscopic appearance between the two ankles of the caged or immobilized rabbits. All ankles exhibited retreating inflammatory response in the synovium and mild synovial thickening. Acute hemarthrosis, unassociated with fracture or discernible joint injury, caused only transient changes in joint stiffness and synovial histology. These results indicate that the presence of blood in an otherwise grossly uninjured joint should not lead to ultimate compromise in cartilage integrity or joint function. Therapeutic arthrocentesis for acute posttraumatic hemarthrosis does not appear to be necessary for the prevention of permanent problems.

    View details for Web of Science ID A1994NP39100037

    View details for PubMedID 8194245

  • Precision-fit surface hemiarthroplasty for femoral head osteonecrosis. Long-term results. journal of bone and joint surgery. British volume Amstutz, H. C., Grigoris, P., Safran, M. R., Grecula, M. J., Campbell, P. A., Schmalzried, T. P. 1994; 76 (3): 423-427


    Cemented Ti-6Al-4V components were used to resurface ten femoral heads in nine young adult patients with osteonecrosis of the femoral head (average age 32 years; range 20 to 51). There were eight hips at Ficat stage III and two at stage IV. Five hips have maintained satisfactory function for an average period of 11.2 years (10 to 12.2) with no radiographic evidence of component loosening or osteolysis; five have been revised after an average period of 7.8 years (3.3 to 10.3) for pain caused by deterioration of the acetabular cartilage. No component required revision for loosening and the specimens retrieved at revision showed no evidence of osteolysis despite burnishing of the titanium bearing surface and the presence of particulate titanium debris in the tissues.

    View details for PubMedID 8175846



    Periarticular long bone fractures usually result in soft-tissue swelling because of edema and hemorrhage, as well as progressive, often permanent joint stiffness. The authors evaluated the effects of chlorothiazide, a commonly used diuretic, and acetazolamide, a weaker diuretic with a different mechanism of action, on joint stiffness and swelling using an established rabbit hindlimb model. Bilateral distal tibial fractures were produced in 30 adolescent New Zealand white rabbits. Twelve rabbits served as age-matched controls and received no treatment, 11 were treated with chlorothiazide, and seven were treated with acetazolamide, each for five days at doses adjusted for body weight but equivalent to human dosing. Eleven limbs were excluded from study because of fracture angulation in excess of 10 degrees. The mean stiffness ratios, comparing preoperative stiffness with stiffness at the end of the three-week study period, for diuretic-treated rabbits were significantly less than those in the control rabbits; there was no difference between the two treated groups. The total swelling and time to peak swelling did not differ among the three groups; however, peak swelling was least in the chlorothiazide group, the strong diuretic, when compared with the control and acetazolamide groups. The marked effect of diuretics on joint stiffness and their minimal effect on limb swelling were unexpected results and, taken in conjunction with previous treatment modalities tested in this model, indicate a complex, still poorly understood sequence of events leading to joint stiffness after periarticular injury.

    View details for Web of Science ID A1994NL07400043

    View details for PubMedID 8168315



    Although compartment syndromes of the forearm are infrequently encountered, they are well described in the literature. Forearm compartment syndrome uncommonly occurs after percutaneous arterial blood sampling and is usually associated with anticoagulant therapy. Our review of the English literature revealed no other cases of forearm compartment syndrome after arterial blood sampling in patients with bleeding diathesis due to chronic renal failure. This article discusses a 30-year-old woman with Good-pasture's syndrome who developed a compartment syndrome after a brachial artery blood gas. The cause, diagnosis, and treatment of compartment syndrome and uremic bleeding, as well as a review of the literature, are discussed.

    View details for Web of Science ID A1994NM10900017

    View details for PubMedID 8060080



    The mainstay of local control of primary bone malignancies in the skeletally immature has been amputation or, in selected cases, rotationplasty. The development of expandable endoprostheses has permitted an alternative approach for local control in the growing child. Between January 1985 and December 1987, 12 skeletally immature patients with primary malignant bone tumors were treated with extremity reconstruction with cemented custom-expandable endoprostheses after wide resection of their lesions. All patients were observed until death (four) or revision (two) with a minimum two-year follow-up period for the survivors (average, 3.1 years). Seven patients have undergone a total of 11 expansions and one patient was lengthened with a revision-expandable prosthesis. Four patients have not needed expansion. Eight patients have had a total of ten complications. Seven of the ten complications (70%) were prosthesis related and associated with failure of the expansion mechanism. The Musculoskeletal Tumor Society (MSTS) overall rating was good to excellent in seven patients (58%), fair in three (25%), and poor in two (17%). In five distal femoral arthroplasties and one total femoral arthroplasty where the tibial bearing component was cemented through the physis, tibial and epiphyseal growth was observed to be normal and equal to the nonoperative side. This suggests that partial central epiphyseal and physeal ablation does not cause physeal arrest. Although the high rate of expansion mechanism failure necessitates redesign, preliminary results suggest that expandable endoprostheses do offer an alternative to amputation and rotationplasty as a means of local control and extremity reconstruction in children with primary malignant bone tumors.

    View details for Web of Science ID A1993ML67800032

    View details for PubMedID 8242930

  • Continued growth of the proximal part of the tibia after prosthetic reconstruction of the skeletally immature knee. Estimation of the minimum growth force in vivo in humans. journal of bone and joint surgery. American volume Safran, M. R., Eckardt, J. J., Kabo, J. M., Oppenheim, W. L. 1992; 74 (8): 1172-1179


    We studied five skeletally immature patients who had a cemented endoprosthetic replacement involving the proximal part of the tibia because of a malignant tumor. In each patient, the cement-column fractured, allowing additional physeal growth. With plain radiographs and scanograms, we determined the cross-sectional areas of the physes, the cement-mantle, and the tibial component. Using the known tensile strength of polymethylmethacrylate cement, we then calculated the minimum force that the growth plates must have overcome to fracture the cement. This averaged 584 newtons per square centimeter. This observation of continued tibial growth after partial physeal ablation with a cemented prosthesis in skeletally immature patients presented a unique opportunity to estimate the force generated in the human physis during growth.

    View details for PubMedID 1400545

  • WARM-UP AND MUSCULAR INJURY PREVENTION AN UPDATE SPORTS MEDICINE Safran, M. R., Seaber, A. V., Garrett, W. E. 1989; 8 (4): 239-249


    Musculotendinous injuries are responsible for a significant proportion of injuries incurred by athletes. Many of these injuries are preventable. Importantly, musculotendinous injuries have a high incidence of recurrence. Thus, muscle injury prevention is advocated by coaches and trainers. Yet, most of the recommendations for muscle injury prevention are attempted by athletes and taught by coaches without supporting scientific evidence. This paper reviews the mechanics of muscular injury, associated and predisposing factors, and methods of prevention with a review of the supporting research and rationale for these methods with an emphasis on warm-up, stretching and strengthening. Muscles that are capable of producing a greater force, a faster contraction speed and subjected to a greater stretch are more likely to become injured. Many factors have been associated with muscular injury. From current research, some conclusions and recommendations for muscle injury prevention can be made. Overall and muscular conditioning and nutrition are important. Proper training and balanced strengthening are key factors in prevention of musculotendinous injuries as well. Warm-up and stretching are essential to preventing muscle injuries by increasing the elasticity of muscles and smoothing muscular contractions. Improper or excessive stretching and warming up can, however, predispose to muscle injury. Much research is still needed in this important aspect of sports medicine.

    View details for Web of Science ID A1989AU97100004

    View details for PubMedID 2692118

  • THE ROLE OF WARMUP IN MUSCULAR INJURY PREVENTION AMERICAN JOURNAL OF SPORTS MEDICINE Safran, M. R., Garrett, W. E., Seaber, A. V., Glisson, R. R., RIBBECK, B. M. 1988; 16 (2): 123-129


    This study is an attempt to provide biomechanical support for the athletic practice of warming up prior to an exercise task to reduce the incidence of injury. Tears in isometrically preconditioned (stimulated before stretching) muscle were compared to tears in control (nonstimulated) muscle by examining four parameters: 1) force and 2) change of length required to tear the muscle, 3) site of failure, and 4) length-tension deformation. The tibialis anterior (TA), the extensor digitorum longus (EDL), and flexor digitorum longus (EDL) muscles from both hindlimbs of rabbits comprised our experimental model. Isometrically preconditioned TA (P less than 0.001), EDL (P less than 0.005), and FDL (P less than 0.01) muscles required more force to fail than their contralateral controls. Preconditioned TA (P less than 0.05), EDL (P less than 0.001), and FDL (P less than 0.01) muscles also stretched to a greater length from rest before failing than their nonpreconditioned controls. The site of failure in all of the muscles was the musculotendinous junction; thus, the site of failure was not altered by condition. The length-tension deformation curves for all three muscle types showed that in every case the preconditioned muscles attained a lesser force at each given increase in length before failure, showing a relative increase in elasticity, although only the EDL showed a statistically significant difference. From our data, it may be inferred that physiologic warming (isometric preconditioning) is of benefit in preventing muscular injury by increasing the and length to failure and elasticity of the muscle-tendon unit.

    View details for Web of Science ID A1988T693500006

    View details for PubMedID 3377095



    We compared the biomechanical properties of passive and stimulated muscle rapidly lengthened to failure in an experimental animal model. The mechanical parameters compared were force to tear, change in length to tear, site of failure, and energy absorbed by the muscle-tendon unit before failure. Paired comparisons were made between 1) muscles stimulated at 64 Hz (tetanic stimulation) and passive (no stimulation) muscles, 2) muscles stimulated at 16 Hz (wave-summated stimulation) and passive muscles, and 3) muscles stimulated at 64 Hz and at 16 Hz. Both tetanically stimulated and wave-summation contracted muscles required a greater force to tear (at 64 Hz, 12.86 N more, P less than 0.0004; and at 16 Hz, 17.79 N more, P less than 0.003) than their nonstimulated controls, while there was no statistical difference in failure force between muscles stimulated at 16 Hz and 64 Hz. The energy absorbed was statistically greater for the stimulated muscles than for the passive muscles in Groups 1 and 2 (at 64 Hz, 100% more, P less than 0.0003; and 16 Hz, 88% more, P less than 0.0002). In Group 3, the tetanically contracted muscle-tendon units absorbed 18% more energy than the wave-summated stimulated muscles (P less than 0.01). All muscles tore at the distal musculotendinous junction, and there was no difference in the length increase at tear between muscles in each group. These findings may lead to enhanced understanding of the mechanism and physiology of muscle strain injuries.

    View details for Web of Science ID A1987N199900004

    View details for PubMedID 3674268