It’s not arthritis! Resolution of the illusion of joint space narrowing with acetabuloplasty and labral reconstruction for the calcified labrum

ABSTRACT

Labral calcification may be part of the natural history of untreated femoroacetabular impingement syndrome (FAIS) in certain patients, making it a potential target for intervention with the goal of preserving the hip joint. The purpose of this study was to investigate if calcified labra create the appearance of lateral joint space narrowing and report minimum 2-year patient-reported outcome measures (PROMs) after treating patients with arthroscopic acetabuloplasty and labral reconstruction. Prospectively collected data on patients who underwent primary hip arthroscopy for FAIS and labral tearing from February 2015 to April 2021 were reviewed. Patients treated with primary labral reconstruction for an intraoperatively confirmed diagnosis of labral calcification were included. A sub-analysis was performed for patients with a minimum of 2-year follow-up. Preoperative and postoperative PROMs for the modified Harris hip score, nonarthritic hip score, the International Hip Outcome Tool-12 and visual analog scale for pain were recorded. Forty-six hips (46 patients) were included, with 19 hips in the sub-analysis. There was a significant increase in apparent lateral joint space width (JSW) measured on supine anteroposterior (AP) pelvis radiographs with no significant changes in medial and central JSW and significant decreases in the lateral and anterior center-edge angles and alpha angle. Patients experienced significant increases in PROMs and high rates of achieving psychometric thresholds. Patients presenting with FAIS and calcified labra may have apparent lateral joint space narrowing on pre-operative supine AP pelvis radiographs. These patients have low rates of full-thickness femoral head and acetabular cartilage pathology, this apparent narrowing can be corrected and excellent outcomes and survivorship can be achieved, with primary labral reconstruction.

INTRODUCTION

Femoroacetabular impingement syndrome (FAIS) is a well-described condition in which the abnormal contact between the femoral neck and acetabular rim is thought to contribute to the development of early hip joint degeneration [1]. If left untreated, FAIS can cause labral tearing, acetabular chondrolabral junction injury and, eventually, osteoarthritis [2–4]. Calcification of the labrum may represent an intermediate finding in this chronic, pathologic process. Corten et al. [5] proposed a pathomechanism, supported by imaging and histologic findings, by which repetitive abutment of the femoral neck against the labrum initiates bone apposition at the acetabular rim, either encasing or displacing the native labrum. Subsequently, other studies have supported an association between calcification of the labrum and early hip osteoarthritis, reporting that calcification can occur independent of age and may precede joint degeneration [6].

Restoring the native function of the acetabular labrum has been one of the central guiding principles of arthroscopic hip preservation surgery and is the key to achieving long-term success [7–9]. In the past, labral repair was the standard method of accomplishing this, with debridement reserved for select cases in which the labrum was deemed irreparable [10, 11]. Today, the advent of labral reconstruction has given hip arthroscopists a valuable arrow in the quiver when managing irreparable labral tears [12, 13], and labral reconstruction has proven itself to be superior to debridement in these cases [14]. The efficacy of labral reconstruction is supported by a growing body of mid- and long-term evidence that supports successful clinical outcomes in both the primary and revision settings [15–20]. Performing this procedure arthroscopically previously required exceptional technical skills and a steep learning curve [21]. However, advancements in implant and instrument technology and the development of novel surgical techniques have made the performance of this procedure more accessible and reproducible [21, 22].

There are established indications for labral reconstruction in the setting of primary hip arthroscopy. When encountered intraoperatively, poor labral tissue quality, calcified labrum and hypoplastic labrum are reasons to perform a labral reconstruction [23]. In fact, in a 2018 survey of high-volume hip arthroscopists, 91.6% responded that they would perform a reconstruction in the primary setting when conditions warrant it, with the highest proportion (83.3%) agreeing that reconstruction was indicated to manage calcified labra [23].

The idea that labral calcification may be part of the natural history of untreated FAIS in certain patients makes it a potential target for intervention with the goal of preserving the hip joint. The purpose of this study was to (i) demonstrate that a calcified labrum results in the appearance of lateral joint space narrowing and (ii) report minimum 2-year patient-reported outcome measures (PROMs) after treating these patients with arthroscopic acetabuloplasty and labral reconstruction. The hypothesis was that these patients would have low rates of full-thickness acetabular and femoral head chondral injury, demonstrate significant increases in their lateral hip joint space width (JSW) following labral reconstruction and would experience significant improvements in PROMs.

METHODS

Patient selection

Data were prospectively collected and retrospectively reviewed for all patients who underwent arthroscopic hip surgery between February 2015 and April 2021. Patients were included if they were identified as having a calcified labrum on pre-operative radiographs, confirmed to have one during arthroscopy and treated with labral reconstruction. Patients with a minimum of 2-year follow-up were also included in a sub-analysis evaluating PROMs. Patients were excluded from the study if they underwent a previous ipsilateral hip surgery; had an ipsilateral hip condition (e.g. avascular necrosis, slipped capital femoral epiphysis or Legg–Calvé–Perthes disease); had radiographic evidence of osteoarthritis (Tönnis grade >1) [24], JSW < 2 mm, acetabular dysplasia defined by a lateral center-edge angle (LCEA) <18° [25] or had a worker’s compensation claim.

Participation in the A.H.I. Hip Preservation Registry

All patients participated in the A.H.I. Hip Preservation Registry. While the present study represents a unique analysis, data on some patients in this study might have been reported in other studies. All data collection and reporting received institutional review board approval.

Radiographic imaging

Radiographs included standing and supine anteroposterior (AP) pelvis, modified 45° Dunn lateral and false-profile views. All radiographs obtained were evaluated using the General Electric Healthcare’s Picture Archiving and Communication System. The supine AP projection was used to assess the level of osteoarthritis using the Tönnis grade [24] and measure JSW [26] and LCEA [27]. The JSW was measured at the lateral, medial and central points of the sourcil using a previously published protocol [26]. JSW has been extensively used to assess the degree of osteoarthritis in the hip joint [26, 28, 29]. Additionally, relative regional differences in JSWs have been consistently described, with increased lateral widths compared to medial widths [28, 30]. Apparent lateral joint space narrowing was defined as lateral joint space narrowing when compared to medial and central JSWs. Alpha angle was measured using the 45° Dunn lateral view. Anterior center-edge angle (ACEA) was measured on the false-profile projection. Radiographic measurements were made by two sports medicine fellowship-trained orthopedic surgeons (B.G.D and A.C.L.). Magnetic resonance arthrography was used to assess for the presence of labral tears and other extra- and intra-articular pathology.

Surgical indications and technique

All patients were diagnosed with FAIS, and acetabular labral tears based on history, physical examination, plain radiography and magnetic resonance imaging. Surgical intervention was recommended if patients had persistent hip pain for at least 3 months that interfered with activities of daily living and attempted and failed conservative management, which included measures such as activity modification, physical therapy, nonsteroidal anti-inflammatory drugs and intra-articular injections.

All hip arthroscopies were performed by the two senior authors (B.G.D and A.C.L.) with the patient under general anesthesia. Patients were placed in the supine position on a hip distractor table, and after applying traction, the hip joint was accessed using anterolateral, mid-anterior and distal lateral accessory portals. An interportal capsulotomy was performed between the mid-anterior and anterolateral portals. A routine diagnostic arthroscopy was then performed. Labral calcification was identified and associated tear-type graded using the Seldes classification system [31]. Acetabular and femoral head chondral damage was graded using the Outerbridge classification system [32]. Chondrolabral junction damage was classified according to acetabular labrum articular disruption grade [33]. Microfracture was performed when full-thickness chondral defects were identified. Ligamentum teres tears were graded according to the classification system by Domb et al. [34] and debrided when encountered. Acetabuloplasty was performed in preparation for reconstruction, to address labral calcification and to treat associated pincer lesions [35]. A posterolateral portal was established, and labral reconstruction using allograft was performed in all cases using a previously published technique [22]. Traction was then removed, and the peripheral compartment was accessed to perform femoral osteoplasty using a round bur under fluoroscopic guidance to correct cam-type morphology [36]. The decision of whether or not to repair or plicate the capsule was dictated by patient-specific factors such as the range of motion, bony coverage or the presence of generalized ligamentous laxity [37, 38]. Over the study period, capsular management practices evolved, with repair/plication becoming the standard of care for nearly all patients, except in cases of excessive stiffness or insufficient capsular tissue.

Surgical outcome tools

PROMs including modified Harris hip score (mHHS) [39], nonarthritic hip score (NAHS) [40], the International Hip Outcome Tool-12 (iHOT-12) [41] and visual analog scale (VAS) for pain were recorded preoperatively and postoperatively. In addition to these PROMs, VAS for patient satisfaction was recorded postoperatively. VAS for pain and satisfaction were graded from 0 to 10 with a score of 0 representing the lowest possible pain and satisfaction scores. The minimal clinically important difference (MCID) was calculated using the distribution-based method described by Norman et al. [42]. This calculation involves dividing the standard deviation of the baseline scores by two. The percentage of patients achieving MCID at a minimum of 2-year follow-up was calculated for the mHHS, NAHS and iHOT-12. Rates of patients who reached the maximum outcome improvement satisfaction threshold (MOIST) were calculated for the mHHS, NAHS, iHOT-12 and VAS for pain [43].

Statistical analyses

Statistical analysis was performed in Microsoft Excel with the Real Statistics Add-in package (Microsoft Corporation; Redmond, WA). Normality and equality of variance were measured with the Shapiro–Wilk test and F-test, respectively. The two-tailed paired t-test was used to determine statistical significance, with a threshold P value of 0.05. Surprise indices (S values) were also calculated. S values are defined as -log₂ (P value) and demonstrate the likelihood of a given result occurring by random chance by comparing it to the number of successive identical coin flips from a fair coin. The purpose is to express differences in an intuitive manner, less susceptible to dichotomizing results as significant or not significant [44]. For example, an S value of 5.9 roughly correlates with the chances of six consecutive coin flips of the same side occurring. The interobserver and intraobserver reproducibility of radiographic measurements was calculated using intraclass correlation coefficients (ICC), absolute agreement and a two-way random effects model. For interpretation of ICCs, values below 0.40 indicate poor agreement; values between 0.40 and 0.59 indicate fair agreement; values between 0.60 and 0.74 indicate good agreement and values >0.75 indicate excellent agreement [45].

RESULTS

Patient demographics

During the study period, 46 subjects met the overall inclusion criteria for analysis of pre- and postoperative radiographic measurements. Of these, 23 hips were eligible for a minimum 2-year follow-up, and 19 hips (82.6%) had adequate follow-up and were included in the sub-analysis of PROMs. The 46 patients (46 hips) included in this study had a mean age of 41.39 ± 10.13 years and a mean body mass index of 27.15 ± 5.75. There were 28 female (60.9%) and 18 male patients (39.1%). Full demographic data of the study group are presented in Table I.

Table I.

Patient characteristics^a

No. of hips	46
Age at time of surgery, years	41.39 ± 10.13
Body mass index, kg/m2	27.15 ± 5.75
Sex
Male, n (%)	18 (39.1%)
Female, n (%)	28 (60.9%)
Laterality
Right, n	25
Left, n	21
Follow-up time, months	36.47 ± 12.47

^aValues presented as mean ± standard deviation unless otherwise specified.

Intraoperative findings and surgical procedures

All patients underwent allograft labral reconstruction and required both acetabuloplasty and femoroplasty. The summaries of intraoperative findings and associated surgical procedures performed are outlined in Tables II and III. Figure 1 demonstrates the arthroscopic images of a patient who was found to have extensive calcification of the acetabular labrum. This patient was treated with allograft labral reconstruction.

Table II.

Intraoperative findings^a

Labral tear grade (Seldes type)
Undefined	1 (2.2%)
1	2 (4.3%)
2	11 (23.9%)
1 & 2	32 (69.6%)
ALAD grade
0	3 (6.5%)
1	9 (19.6%)
2	13 (28.3%)
3	15 (32.6%)
4	6 (13.0%)
Acetabular Outerbridge grade
0	3 (6.5%)
1	9 (19.6%)
2	14 (30.4%)
3	14 (30.4%)
4	6 (13.0%)
Femoral head Outerbridge grade
0	42 (91.3%)
1	1 (2.2%)
2	0 (0.0%)
3	3 (6.5%)
4	0 (0.0%)
LT percentile class
0: 0	32 (69.6%)
1: 0 to <50	8 (17.4%)
2: 50 to <100	5 (10.9%)
3: 100	1 (2.2%)

^aValues are presented as n (%). ALAD, acetabular labrum articular disruption.

Table III.

Arthroscopic procedures^a

Labral reconstruction	46 (100.0%)
Anchors used, mean ± SD	7.5 ± 1.7
Capsular management
Repair/plication	31 (67.4%)
Unrepaired capsulotomy	15 (32.6%)
Acetabuloplasty	46 (100.0%)
Femoroplasty	46 (100.0%)
Acetabular microfracture	4 (8.7%)

^aValues are presented as n (%) unless otherwise specified. SD, standard deviation; LT, ligamentum teres.

Fig. 1.

Intraoperative images of a patient who underwent labral reconstruction for extensive labral calcification. All images were taken using a 70° arthroscope from the anterolateral portal on the patient’s left side. (A) Complex labral tearing with extensive labral calcification found during diagnostic arthroscopy. (B) Completed allograft labral reconstruction with the joint distracted. (C) Restoration of the hip joint suction seal following the release of traction. FH, femoral head; C, hip capsule; A, acetabulum; CL, calcified labrum; RL, reconstructed labrum.

Radiographic findings

A summary of preoperative and postoperative radiographic measurements is detailed in Table IV. ICCs for the intra- and interobserver reliability analysis of radiographic measurements were calculated to be 0.91 and 0.89, respectively. This indicates excellent agreement for both. There was a significant increase in lateral JSW following surgery (P < 0.001). There were also significant decreases in mean LCEA (P < 0.001), ACEAs (P < 0.001) and alpha angle (P < 0.001) following surgery. Figure 2 demonstrates the preoperative and 2-week postoperative radiographs of a patient who underwent labral reconstruction for labral calcification.

Table IV.

Radiographic findings

	n (%) or mean ± SD
Tönnis grade at presentation
0	44 (95.7%)
1	2 (4.3%)
LCEA, °
Presentation	36.9 ± 8.6
Postoperative	29.4 ± 6.1
P value	<0.001*
S value	>9.97*
Δ	−7.5 ± 5.4
ACEA, °
Presentation	38.0 ± 9.0
Postoperative	32.9 ± 7.1
P value	<0.001*
S value	>9.97*
Δ	−5.0 ± 5.5
AA, °
Presentation	58.3 ± 10.1
Postoperative	41.0 ± 3.4
P value	<0.001*
S value	>9.97*
Δ	−17.3 ± 10.3
JSW M, mm
Presentation	4.3 ± 0.7
Postoperative	4.4 ± 0.7
P value	0.715
S value	0.483
Δ	0.1 ± 0.2
JSW C, mm
Presentation	4.6 ± 0.7
Postoperative	4.7 ± 0.7
P value	0.475
S value	1.07
Δ	0.1 ± 0.4
JSW L, mm
Presentation	4.2 ± 1.1
Postoperative	4.8 ± 0.8
P value	<0.001*
S value	>9.97*
Δ	0.6 ± 0.9

Values are presented as n (%) or mean ± SD unless otherwise specified.

^*Statistically significant (P < 0.05, S > 4.32). AA, alpha angle; C, central; L, lateral; M, medial; SD, standard deviation.

Fig. 2.

(A) Preoperative and (B) 2-week postoperative supine AP pelvis radiographs of a patient with labral calcification who underwent arthroscopic labral reconstruction. Magnified images of those same pre- and post-radiographs (C and D, respectively) demonstrating the increases in apparent lateral JSW.

Surgical outcomes

There were significant improvements in preoperative to postoperative mHHS (P < 0.001), NAHS (P < 0.001) and iHOT-12 (P < 0.001) scores at a minimum 2-year follow-up. There was also a significant decrease in reported VAS for pain following surgery (P < 0.001). Patients reported high rates of satisfaction at a minimum of 2 years, with a mean score of 8.8 ± 2.0. There were no revision arthroscopies performed. One patient (5.3%) converted to total hip arthroplasty (THA), with a time-to-conversion of 17.0 months after index hip arthroscopy. Outcomes are presented in Table V.

Table V.

Preoperative and latest follow-up patient-reported outcome scores

mHHS
Presentation	67.3 ± 15.8
Latest follow-up	88.6 ± 14.8
P value	<0.001*
S value	>9.97*
Δ	21.3 ± 16.9
NAHS
Presentation	64.6 ± 17.5
Latest follow-up	87.4 ± 15.8
P value	<0.001*
S value	>9.97*
Δ	22.8 ± 15.3
iHOT-12
Presentation	37.7 ± 20.7
Latest follow-up	78.3 ± 27.0
P value	<0.001*
S value	>9.97*
Δ	42.6 ± 26.9
VAS pain
Presentation	4.9 ± 2.0
Latest follow-up	1.9 ± 2.2
P value	<0.001*
S value	>9.97*
Δ	−3.1 ± 2.7
Latest satisfaction	8.8 ± 2.0

Values are presented as mean ± standard deviation unless otherwise specified.

^*Statistically significant (P < 0.05, S > 4.32).

MCID and MOIST

Patients achieved the MCID at high rates for the mHHS, NAHS and iHOT-12 (89.5%, 89.5% and 78.9%, respectively). Patients achieved MOIST at rates of 73.7%, 78.9%, 73.7% and 63.2% for the mHHS, NAHS, iHOT-12 and VAS for pain, respectively.

DISCUSSION

The central finding of this investigation was that patients with calcified acetabular labra had the appearance of lateral joint space narrowing on pre-operative supine AP pelvis radiographs and were found to have increases in lateral JSW following arthroscopic labral reconstruction. Additionally, there were overall low rates of full-thickness acetabular and femoral head chondral injury found during arthroscopy. Overall, these patients achieved excellent clinical outcomes and survivorship following arthroscopy, with high rates of clinically meaningful improvement recorded.

JSW has been extensively used to assess the degree of osteoarthritis in the hip joint [26, 28, 29]. Additionally, relative regional differences in JSWs have been consistently described, with increased lateral widths compared to medial widths [28, 30]. This may be due to thicker articular cartilage in the lateral joint [46]. When stratified by acetabular bony coverage measured using LCEA, increasing coverage was associated with decreasing JSW [28]. However, the relationship between the medial and lateral JSW persisted, with the lateral JSW consistently larger than the medial along the whole spectrum of acetabular coverage. The opposite relationship has been demonstrated in this patient population. The mean pre-operative lateral JSW in this group of patients with calcified labra was 4.2 mm, compared to means of 4.6 mm and 4.3 mm for the central and medial joint spaces, respectively. These values certainly fall within the normal range of JSWs that have been previously reported [28, 47–50]. None of the patients in the cohort had JSW < 2 mm, a known risk factor for poor outcomes after hip arthroscopy [51], and only two patients (4.3%) had radiographic changes graded as Tönnis 1. Overall, these patients had well-preserved hips but clearly demonstrated relative lateral joint space narrowing when compared to both central and medial. Post-operatively, the mean lateral JSWs were the largest of the three, consistent with previously described controls and perhaps indicative of the patient’s true JSW in the absence of calcified labra.

Etiologies of radiopaque ossific densities adjacent to the acetabular rim include os acetabuli, calcific labritis, acetabular rim fractures and labral ossification [52, 53]. The pathologic process by which labral tissue is progressively enveloped in or replaced by bone due to repetitive impingement is the focus of this study, and there is a paucity of literature describing the management of this challenging condition [5, 54, 55]. Ninomiya et al. [55] published a case report describing a phenomenon, in which the acetabular labrum had been completely ossified in a 40-year-old male patient, in the absence of any significant osteoarthritic changes within the joint. The patient was treated with open resection of the ossified labrum and had resolution of his symptoms for at least 2 years post-operatively. Corten et al. [5] elegantly reported the clinical, radiographic and histologic characteristics associated with this phenomenon. To account for their observations, they suggested that repetitive abutment of the femoral neck against the labrum was the pathomechanism by which bony apposition occurred along the acetabular rim. This bony apposition either displaced or encased the native labrum. They additionally made it a point to distinguish this process from acetabular osteophytes, which occur in the setting of osteoarthritis. Hawellek et al. [6] analyzed 170 cadaveric hips and noted a correlation between the degree of labral calcification and the extent of cartilage degeneration. The authors speculated that progressive calcification of the labrum may contribute to the eventual degeneration of the joint. They likened these findings to meniscal calcification in degenerative knees. Taken together, one can presume that perhaps labral calcification plays a role in the progression of hip degeneration caused by untreated FAIS.

Arthroscopic management of patients with extensive labral calcification can be quite challenging. Difficult access due to acetabular overcoverage, limited distractibility and poor-quality labral tissue can make these cases formidable. There are limited data available evaluating how these patients undergo the following arthroscopic surgery. Byrd et al. [54] reported on the 2-year outcomes of patients with labral ossification treated with hip arthroscopy. When compared to a chronologically matched cohort of patients with pincer lesions but no labral ossification, the patients with ossification were older, were more likely to be female and had more severe symptoms on presentation. Both groups had similarly favorable outcomes, with only one patient from the labral ossification cohort converting to total hip arthroplasty during the study period. The authors also distinguished this pathologic process from acetabular osteophytosis and noted that the majority had no or low-grade cartilage damage found during arthroscopy, reiterating the notion that these patients are frequently not arthritic. The findings of this investigation support this as well, with only 13% of patients exhibiting full-thickness acetabular cartilage injury and none demonstrating full-thickness femoral head cartilage injury. While the previous study certainly gave some insight into how patients with calcified labra do following hip arthroscopy, 88% of the patients with ossification underwent labral debridement by virtue of excising the ossified portion of the labrum. The management in the current study differed since all subjects included underwent labral reconstruction instead of debridement.

LIMITATIONS

There are several limitations that warrant discussion. This study was retrospective in nature, resulting in a lack of randomization, which might have introduced selection bias into the results. Additionally, no comparison or control groups were included. The sample size was modest; this was due to the limited number of patients who were found to have calcified labra intra-operatively extensive enough to require labral reconstruction. The decision to perform reconstruction was based on the senior author’s opinion and expertise, which might have also introduced bias into the study. Furthermore, only short-term outcomes were reported. The mid- to long-term outcomes and survivorship of this cohort are yet to be determined. The outcomes reported here were for surgeries, which were all performed at a single center with extensive experience performing hip arthroscopy, including labral reconstruction, a technically demanding procedure with a steep learning curve. This decreased the overall generalizability of the study results.

CONCLUSION

Patients presenting with FAIS and calcified labra may have apparent lateral joint space narrowing on pre-operative supine AP pelvis radiographs. However, these patients have low rates of full-thickness femoral head and acetabular cartilage pathology, this apparent narrowing can be corrected and excellent outcomes and survivorship can be achieved, with primary labral reconstruction.

DATA AVAILABILTY

The data analyzed during the current study will be shared by the corresponding author upon reasonable request.

FUNDING

No funding was received for this work.

CONFLICT OF INTEREST STATEMENT

Dr. Lall reports educational support from Arthrex, Medwest, and Smith & Nephew; research support from Arthrex, Stryker, and Medacta; food and beverage from Smith & Nephew, Stryker, Zimmer Biomet, Arthrex; travel and lodging from Stryker, Arthrex, and Smith & Nephew; and consulting fees from Arthrex and Graymont Medical. Dr. Lall is the Co-Medical Director of Hip Preservation at St. Alexius Medical Center, the Clinical Instructor at the University of Illinois College of Medicine, and member of the AANA Learning Center Committee.

Dr. Domb has had ownership interests in Hinsdale Orthopaedics, the American Hip Institute SCD#3, North Shore Surgical Suites, and Munster Specialty Surgery Center; has received research support from Arthrex, ATI, the Kauffman Foundation, Stryker, and Pacira Pharmaceuticals; has received consulting fees from Adventist Hinsdale Hospital, Arthrex, MAKO Surgical, Medacta, Pacira Pharmaceuticals, and Stryker; has received educational support from Arthrex, Breg, and Medwest; has received speaking fees from Arthrex, Stryker, and Pacira Pharmaceuticals; has received honoraria from Medacta; and receives royalties from Amplitude, Arthrex, DJO Global, MAKO Surgical, Medacta, Stryker, and Orthomerica. Dr. Domb is the Medical Director of Hip Preservation at St. Alexius Medical Center, the Clinical Instructor at the University of Illinois College of Medicine, a board member for the American Hip Institute Research Foundation, AANA Learning Center Committee, the Journal of Hip Preservation Surgery, and the Journal of Arthroscopy. The American Hip Institute Research Foundation fund research and is where our study was performed.

Dr. Maldonado reports non-financial support from Arthrex, non-financial support from Stryker, non-financial support from Smith & Nephew, non-financial support from Ossur, outside the submitted work; and Dr. Maldonado is an editorial board member of the Journal of Arthroscopy.

Dr. Saks reports grants from Arthrex, personal fees from DJO Global, outside the submitted work.