Endoscopic spine surgery (ESS) has emerged as a transformative approach in the treatment of spine pathology, offering advantages over traditional open surgical techniques. This review examines the historical development of ESS, highlighting key figures and milestones that have shaped its evolution. It explores different endoscopic techniques, including transforaminal, interlaminar, lumbar fusion, cervical, and thoracic approaches. The review also provides an overview of the ongoing debate between uniportal and biportal ESS, discussing the relative invasiveness, capabilities, costs, and learning curves. In addition, it examines the complication profiles of ESS compared with open surgery as well as the economic implications of these techniques. Finally, the review outlines future directions for ESS and the impact of enabling technology.

ABSTRACTIntroduction:Prosthetic joint infection is a serious complication after primary shoulder arthroplasty, yet no standardized infection prevention protocol exists. This study evaluated current trends in infection prevention among members of the American Shoulder and Elbow Surgeons.Methods:A 25-item cross-sectional survey was developed to capture commonly used preoperative, intraoperative, and postoperative infection prevention strategies in primary shoulder arthroplasty. The finalized instrument was administered electronically through REDCap to all active American Shoulder and Elbow Surgeons members in November 2024, with 1 reminder sent 2 weeks later. Anonymized responses were categorized by years in practice (<5, 5–10, 10–20, and >20 years). Statistical analyses assessed variability across experience groups.Results:Of 229 responses, 224 were complete and included for analysis. Most surgeons reported using hemoglobin A1c cutoffs (77%), avoiding corticosteroid injections within 3 months of surgery (86%), performing preoperative skin cleansing (78%), using chlorhexidine for preparation (94%), switching scalpel blades (80%) or using electrocautery (79%) after skin incision, and administering perioperative IV antibiotics (76%). Surgeons with <5 years of experience were more likely to use hydrogen peroxide or alcohol-based skin preparation, vancomycin powder, topical skin glue, silver-impregnated dressings, and apply stricter hemoglobin A1c cutoffs, reaching statistical significance in all cases (P < .05). A body mass index cutoff was used by 25% of respondents, with a mean threshold of 42 kg/m2.Conclusion:Substantial variation exists in infection prevention strategies for primary shoulder arthroplasty (SA) across experience levels, highlighting the need for standardized protocols.Level of Evidence:IV, epidemiological study.

ABSTRACTPurpose:The purpose of this in vivo study was to determine whether localized external compression of muscle combined with physiologic muscle contraction leads to muscle deoxygenation. The hypothesis was that a cyclic hypoxic environment was created when localized external compression was combined with muscle contraction.Methods:Near infrared spectroscopy was used to measure soft tissue oxygenation in 9 patients while applying 40 mm Hg (mercury) of external pressure simultaneously with muscle contraction.Results:A statistically significant decrease in oxygenated hemoglobin was demonstrated in muscle with utilization of a specialized brace to apply a localized pressure, simultaneous with muscle contraction. The decrease in oxygenation was more than 3 times greater than the decrease seen with muscle contraction alone without external pressure (−22.58 vs. −5.82 µM).Conclusion:Application of external pressure combined with muscle contraction can be used to produce decreased soft tissue oxygenation.

ABSTRACTThis case is a 37-year-old man with diffuse primary synovial chondromatosis of the elbow, with associated ulnar nerve compression and flexion contracture at the elbow. An open synovectomy with removal of loose bodies and an ulnar nerve decompression with anterior subcutaneous transposition were performed. Postoperatively, the patient’s elbow mobility and nerve compression symptoms improved steadily, which significantly improved his function. Primary synovial chondromatosis of the elbow is a rare disease that can result in pain, swelling, decreased range of motion, and mechanical symptoms. Treatment usually involves synovectomy and removal of loose bodies to address patients’ pain and joint motion.

Purpose:The purpose of this study was to evaluate changes in perioperative tranexamic acid (TXA) utilization among patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), based on patient demographics and comorbidities, including those at higher and lower risk of venous thromboembolism (VTE).Methods:Patients who underwent THA or TKA between 2012 and 2021 were identified using the TriNetX electronic health record database. Perioperative TXA use was evaluated among patients stratified according to risk of VTE. Utilization rates were analyzed using compound annual growth rates (CAGRs) and linear regression analysis.Results:From 2012 to 2021, TXA use increased by 406% (CAGR: +17.66%; P < 0.001) for THA and 459% for TKA (CAGR: +18.86%; P < 0.001). Among patients with at least 1 factor placing them at high risk of VTE, TXA use increased by 1277% for THA (CAGR: +30.0%; P < 0.001) and by 966% for TKA (CAGR: +26.7%; P < 0.001). During the final study year (2021), surgeons overall used TXA in 67.8% of THA cases and 62.5% of TKA cases. In the high-risk group, TXA use was lowest among patients with a history of myocardial infarction (THA, 48.7%; TKA, 51.4%), cerebrovascular accident (THA, 51.0% and TKA, 50.6%), bleeding or clotting disorder (THA, 57.4% and TKA, 57.1%), or previous VTE (THA, 57.3%; TKA, 53.6%).Conclusion:Despite the rapid growth in TXA utilization over the past decade in THA and TKA, patients at high risk of VTE and ischemia are still less likely to receive perioperative TXA.

Background:The COVID-19 pandemic led to increased sedentary behavior and body mass index during 2020, which may decondition musculotendinous units and lead to increased risk for injury. As patients return to pre-COVID levels of activity, we hypothesize that there will be a resultant rebound increase in tendon ruptures.Level of Evidence:III, descriptive epidemiology study.Methods:The electronic medical record was queried for current procedural terminology codes for tendon ruptures (Achilles, patella, quadriceps, hamstring, distal biceps, triceps, and pectoralis major) from January 2017 to December 2021 at a single academic urban center. Data were reviewed to ensure only acute tendon rupture repairs were included. The years 2017–2019 were used as a proxy for pre-COVID rates, 2020 as a proxy for the COVID quarantine, and 2021 as a proxy for “post-COVID” activity. Univariate analysis was performed for comparative data.Results:A total of 1,879 patients (82.8% male, mean age 47.8 years) who sustained tendon injuries and underwent surgical repair were identified. There were 589 (31.3%) Achilles tendon repairs, 181 (9.6%) patella tendon repairs, 414 (22.0%) quadriceps tendon repairs, 100 (5.3%) hamstring tendon repairs, 397 (21.1%) distal biceps repairs, 105 (5.6%) triceps repairs, and 93 (4.9%) pectoralis tendon repairs. The total number of tendon injuries per year was 2017—357 (19.0%), 2018—380 (20.2%), 2019—380 (20.2%), 2020—308 (16.4%), and 2021—454 (24.2%). The rates in 2017, 2018, and 2019 were within 1% of each other, but there were a 3.8% decrease in rate of tendon injuries from 2019 to 2020 and a 7.8% increase in rate of tendon injuries from 2020 to 2021. When analyzed by quarter, a linear regression model demonstrated a statistically significant increase in case counts over the period from Q2 2020 to Q2 2021 (β = 21.20; 95% confidence interval = 13.62–28.78, P-value < .01).Conclusions:A “COVID rebound” of tendon rupture repairs in 2021 from a prolonged period of inactivity during 2020 occurred at a single academic center. As patients return to pre-COVID levels of activity that may be unsuitable to their deconditioned state, healthcare providers should counsel patients appropriately on return to activity or sport following long periods of induced inactivity.

Background:The purpose of our study was to compare patient-reported outcomes at 6-month follow-up between primary hip arthroscopy patients who were partial weight bearing on crutches for 4 weeks vs. 1 week postoperatively.Methods:We conducted a pseudorandomized clinical trial involving patients who underwent arthroscopic treatment of femoroacetabular imipingement at a single center from September 2020 to April 2021. Subjects aged 18–65 years old were alternately assigned to one of the 2 rehabilitation regimens involving either 4-week or 1-week partial weight bearing on crutches. Subjects completed the modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) surveys before surgery and at 6-month follow-up. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) was assessed using published mHHS cutoff values. Outcomes were compared between groups with the Mann-Whitney U test and analysis of covariance, while MCID, SCB, and PASS rates were compared with the Fisher exact test. P-values < .05 were considered significant.Results:Fifty patients were included in the study of whom 28 (56.0%) were assigned to 4-week crutch use and 22 (44.0%) to 1-week crutch use. The 4-week crutch use group was significantly older on average (38.4 vs. 32.1 years, P = .03) and had significantly higher mean body mass index (27.6 vs. 24.5, P = .01), but there were no significant baseline differences between the 2 groups (P > .05). After adjusting for age and body mass index, there was no significant difference in preoperative to postoperative improvement in mHHS (P = .43) or NAHS (P = .46) between the 2 groups at 6-month follow-up. Furthermore, there were no significant differences in achievement rates for MCID (P = .50), SCB (P = .51), or PASS (P = .77) between the 2 groups.Conclusion:We identified no significant differences in improvement of mHHS and NAHS or achievement of the MCID, SCB, or PASS at 6-month follow-up between patients on crutches for 4 weeks vs. 1 week postoperatively.Level of Evidence:II, Pseudorandomized clinical trial.

Background:Acute blood loss anemia is a common complication of hip fractures. Due to this complication, the rate of allogenic blood transfusions remains high in this patient population. More recently, surgeons have utilized intraoperative tranexamic acid as a strategy to minimize blood loss.Purpose:The purpose of this study was to identify risk factors and associated outcomes of blood transfusions in hip fracture patients.Study Design:Retrospective cohort study.Methods:A trauma database from one academic medical center was queried for hip fracture patients (OTA/AO 31A or 31B). Demographic, clinical, quality, and cost data were obtained for each patient. A Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), a validated risk predictive and matching tool, was calculated for each patient. Patients receiving blood transfusions during their hospitalization were identified. Multivariate logistic regression analysis identified independent risk factors for transfusion during admission. Patients receiving transfusions were matched to patients not receiving a transfusion based on STTGMA. Comparative analyses of matched cohorts were performed.Results:In total, 1,344 hip fracture patients (29.8% male and 70.2% female) with mean age 81.04 ± 10.18 were identified. Four hundred ninety-nine (37.1%) patients received a transfusion during their admission. Risk factors for transfusion included higher STTGMA scores (P = .006), lower hemoglobin levels on admission (P < .001), anticoagulation or antiplatelet use on admission (P = .019), and fracture repair with a long cephalomedullary nail (P = .005). Trauma risk score–matched cohort outcomes show transfusions correlated with increased mortality, complications, readmission, and longer, more costly hospital stays.Conclusion:Surgeons should be cognizant of transfusion risk factors such as repair with long cephalomedullary nail and poorer matched outcomes correlated with patients receiving transfusions.Level of Evidence:Level 3.

Purpose:To determine the clinical outcomes of hip arthroscopy for anterior inferior iliac spine subspine impingement (SSI).Level of Evidence:Case Series; level IV.Methods:Patients who underwent unilateral, primary hip arthroscopy for SSI from February 2015 to December 2017 with minimum 3-year follow-up data were identified (SSI). Analysis of variance, Kaplan-Meier analysis, and regression modeling were used to analyze outcomes.Results:Of 23 eligible, 19 (83% inclusion) patients (mean [standard error of the mean]: age: 45.9 [3.1]; body mass index, 26.3 [0.9]; 79% female, 53% right side) had a minimum of 3-year follow-up (48.3 [2.2] months). The estimated mean survival time of index procedure across the whole cohort was 64.9 ± 3.1 months. One patient underwent total hip arthroplasty. Patients improved from baseline modified Harris Hip Score (62.7 [5.1]) to follow-up (75.1 [4.3]; P = .014). Twelve patients (63%) met minimal clinically importance difference criteria while 7 (37%) met patient acceptable symptomatic state criteria. Linear regression modeling demonstrated lower postoperative lateral center edge angle (beta = −2.1, 95% confidence interval: −0.5 to −2.9, P = .035) and presence of labral repairs (beta = 46.1, 95% confidence interval: 24.8–67.4, P = .003) were associated with higher follow-up modified Harris Hip Score.Conclusion:In conclusion, patients undergoing anterior inferior iliac spine decompression during hip arthroscopy for SSI in the setting of femoroacetabular impingement syndrome have acceptable, improved clinical outcomes at minimum 3-year follow-up. Labral repair and decreasing postoperative lateral center edge angle were predictive of improved patient-reported outcomes. Hip arthroscopy remains a viable successful treatment options in the treatment of concomitant SSI during femoroacetabular impingement syndrome surgery.