Background:
Femoroacetabular impingement (FAI) is a common cause of hip pain, especially in young patients. When left untreated, it has been demonstrated to be a risk factor for the onset or ...progression of osteoarthritis (OA) and has been identified as one of the main contributors leading to the need for total hip arthroplasty (THA) at a young age. While the short-term therapeutic potential of hip arthroscopy is widely recognized, little is known regarding its potential mid- to long-term preventive effect on the progression of hip OA.
Purpose:
To (1) report clinical outcomes of arthroscopically treated FAI syndrome with a minimum 5-year follow-up and compare the results to a cohort with FAI treated nonsurgically and (2) determine the influence of hip arthroscopy on the onset and progression of hip OA in patients diagnosed with FAI.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Patients who had hip pain and were diagnosed with FAI were included. Exclusion criteria were (1) previous or concomitant hip surgery, (2) <5 years of follow-up, and (3) insufficient radiographs. Patients treated with hip arthroscopy were compared with a cohort of patients with FAI who were treated nonsurgically. Kaplan-Meier estimates of failure (defined as conversion to THA) were performed. Bivariate analysis and Cox regression were used to identify factors associated with inferior clinical and radiographic outcomes.
Results:
A total of 957 patients (650 female, 307 male; 1114 hips) (mean age, 28.03 ± 8.9 years range, 6.5-41.0 years) with FAI were included. A total of 132 hips underwent hip arthroscopy and 982 hips were nonoperatively treated. The mean follow-up was 12.5 ± 4.7 years (range, 5.0-23.4 years). At the final follow-up, the rate of OA progression was 26.5% in the operative group and 35.2% in the nonoperative cohort (P < .01). Conversion to THA was performed in 6.8% of the surgical patients and 10.5% of the initially nonsurgical patients (P = .19). Additionally, there was no significant difference in the risk of failure between the operatively and nonoperatively treated patients. Male sex, increased age at initial diagnosis, presence of cam morphology, and increased initial Tönnis grade were risk factors for failure (male sex: hazard ratio HR, 2.3; P < .01; per year of increased age: HR, 1.1; P < .01; presence of cam: HR, 3.5; P < .01; per Tönnis grade: HR, 4.0; P < .01).
Conclusion:
At a mean follow-up of nearly 13 years, 7% of patients of the surgical group experienced progression to THA, compared with 11% of the nonoperative control group. While most of the operative group showed little to no OA at final follow-up, moderate OA (Tönnis grade 2) was present in 12% of the cohort compared with 22% of nonsurgical patients. Increased age at diagnosis, male sex, presence of a cam morphology, and presence of initial arthritic joint changes were found to be risk factors for failure. The results of this study demonstrated evidence for a preventive effect of hip arthroscopy on the development and progression of OA in young patients with FAI at mid- to long-term follow-up.
Background:
Full-thickness radial meniscal tears render the meniscus nonfunctional and have historically been treated with partial meniscectomy. As preservative techniques evolve for radial repair, ...comparisons with other tear patterns are necessary to evaluate repair efficacy and prognosis.
Purpose:
To assess clinical outcomes and reoperation rates of radial meniscal repair and to compare them to bucket-handle meniscal repair.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Radial and bucket-handle meniscal tears without concurrent root injuries undergoing surgical repair at a single institution between 2007 and 2015 were analyzed, including both all-inside and inside-out suturing techniques. Propensity matching was performed on the basis of age at surgery, sex, meniscus laterality, body mass index (BMI), and concomitant anterior cruciate ligament reconstruction (ACLR) using a comparison pool of 70 bucket-handle repairs. Reoperation-free survival rates and Tegner, visual analog scale (VAS) for pain, and International Knee Documentation Committee (IKDC) scores were analyzed.
Results:
Twenty-four patients (18 male, 6 female; mean age, 22.8 ± 11.9 years) who underwent repair of a radial meniscal tear were followed for a mean of 3.5 years (range, 2.0-6.3 years). Significant postoperative improvements in VAS scores at rest and with use and IKDC scores were noted postoperatively (P < .001). Five patients (20.8%) required a reoperation. Subsequently, 18 patients with radial tears (mean age, 19.1 ± 9.1 years; 12 male; mean BMI, 27.0 ± 6.2 kg/m2; 3 medial; 11 ACLR) were propensity matched to 18 patients with bucket-handle tears (mean age, 20.8 ± 5.1 years; 13 male; mean BMI, 25.0 ± 3.5 kg/m2; 3 medial; 11 ACLR). The matched radial and bucket-handle groups demonstrated similar (P = .17) reoperation-free survival rates at 2 years (88.9% and 94.4%, respectively) and 5 years (77.8% and 87.7%, respectively). VAS and IKDC scores improved significantly after surgery (P < .001), with no difference noted between the groups (P ≥ .17). Patients with radial and bucket-handle meniscal repairs achieved mean postoperative Tegner scores (6.6 and 6.6, respectively) not significantly different from their preinjury levels (6.9 and 6.7, respectively) (P ≥ .32).
Conclusion:
Satisfactory clinical outcomes are achievable for radial meniscal tear repair at short-term follow-up. In a robustly matched comparison, radial and bucket-handle meniscal tears demonstrate similar improvements in VAS and IKDC scores, restoration of preoperative Tegner scores, and acceptable reoperation rates. Full-thickness radial meniscal tears should be considered for repair.
Background:
The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the ...durability of the procedure is largely unknown.
Purpose:
To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), Tönnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery.
Results:
A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent periacetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI >30 kg/m2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI ≤30 kg/m2 (P < .01). Patients aged >35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged ≤35 years (P = .03). Patients with Tönnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score (P = .02) and a 23.0-point worse HOS-SSS score (P < .01) when compared with patients with Tönnis grade 0.
Conclusion:
Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with Tönnis grade 2 changes preoperatively, BMI >30 kg/m2, and age >35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.
To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities.
A retrospective review of ...the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features.
A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 95% confidence interval, $3,700-$3,900; logarithmic root-mean-square error, 0.249 95% confidence interval, 0.24-0.26; R2 = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income.
The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities.
Level III, retrospective cohort study.
Background:
Historically, symptomatic hip labral lesions were treated with arthroscopic debridement. Hip labral repair has become the standard treatment for labral pathology; however, to date, there ...are limited long-term studies regarding the outcomes of isolated labral debridement.
Purpose:
To (1) evaluate the long-term patient-reported outcomes of isolated labral debridement, (2) report reoperation and arthroplasty rates, and (3) identify risk factors contributing to reoperation or poor clinical outcomes.
Study Design:
Case series; Level of evidence, 4
Methods:
A retrospective review of a prospectively generated cohort of 59 hips in 57 patients from 1996 to 2010 who underwent hip arthroscopy with labral debridement was performed. Only patients with Tönnis grade <3 were included. Additionally, given the time period analyzed, resection of cam morphology was not performed, and the interportal capsulotomy was not repaired. The pre- and postoperative modified Harris Hip Score; Hip Outcome Score (HOS)-Activities of Daily Living and -Sports scores; and reoperation, conversion to total hip arthroplasty, and risk factors were analyzed.
Results:
In total, 48 hips in 47 patients (14 men, 33 women; mean age, 48.0 ± 12.9 years) met inclusion criteria and were followed for a mean of 17 ± 3 years (range, 13-27 years). The mean preoperative Tönnis grade was 1.3 ± 0.6 (range, 0-2), the mean chondral acetabular International Cartilage Regeneration & Joint Preservation Society (ICRS) grade was 1.7 ± 1.6 (range, 0-4), the mean chondral femoral ICRS grade was 0.9 ± 1.4, and the mean acetabular labral articular cartilage grade was 2.5 ± 1.2 (range, 0-4). At the final follow-up, mean the modified Harris Hip Score, HOS-Activities of Daily Living score, and HOS-Sports score were 82.2 ± 16.6, 81.9 ± 20.5, and 82.2 ± 20.5, respectively. Nineteen hips underwent subsequent reoperation at a mean of 5.5 ± 6.2 years (range, 0.5-21.2 years) postoperatively, including 16 hips (33% overall) being converted to total hip arthroplasty. Higher acetabular ICRS chondral grades at the time of surgery were observed in patients who went on to subsequent surgery compared with those who did not (2.3 ± 1.6 vs 1.1 ± 1.5; P = .02). In reoperation-free hips, Tönnis grade demonstrated a trend of increasing over time (1.4 preoperatively vs 1.7 at radiographic follow-up; P = .08). At the final follow-up, 19 hips (40%) had undergone reoperation, and 5 additional hips (10%) were rated as “abnormal” or “severely abnormal” in function, resulting in an overall clinical failure rate of 50%.
Conclusion:
Isolated labral debridement was found to result in high rates of failure and reoperation, with a third of patients being converted to arthroplasty and half of patients meeting criteria for reoperation or clinical failure. Of note, for patients remaining reoperation-free, satisfactory outcome scores were observed.
Background:
Radiography is the initial imaging modality used to evaluate femoroacetabular impingement (FAI), and diagnostic radiographic findings are well-established. However, the prevalence of ...these radiographic findings in patients with hip pain is unknown.
Purpose:
The purpose was 3-fold: (1) to determine the overall prevalence of radiographic FAI deformities in young patients presenting with hip pain, (2) to identify the most common radiographic findings in patients with cam-type FAI, and (3) to identify the most common radiographic findings in patients with pincer-type FAI.
Study Design:
Cross-sectional study; Level of evidence, 3.
Methods:
A geographic database was used to identify patients aged 14 to 50 years with hip pain between the years 2000 to 2016. The following were evaluated on radiographs: cam type: typical pistol grip deformity, alpha angle >55°; pincer type: crossover sign (COS), coxa profunda or protrusio acetabuli, lateral center edge angle (LCEA) ≥40°, Tönnis angle <0°; and mixed type: both cam- and pincer-type features. Posterior wall sign (PWS) and ischial spine sign (ISS) were also evaluated. The prevalence of each was determined. Descriptive statistics were performed on all radiographic variables.
Results:
There were 1893 patients evaluated, and 1145 patients (60.5%; 1371 hips; 374 male and 771 female; mean age, 28.8 ± 8.4 years) had radiographic findings consistent with FAI. Of these hips, 139 (10.1%) had cam type, 245 (17.9%) had pincer type, and 987 (72.0%) had mixed type. The prevalence of a pistol grip deformity and an alpha angle >55° was 577 (42.1%) and 1069 (78.0%), respectively. The mean alpha angle was 66.9°± 10.5°. The prevalence of pincer-type radiographic findings was the following: COS, 1062 (77.5%); coxa profunda, 844 (61.6%); ISS, 765 (55.8%); PWS, 764 (55.7%); Tönnis angle <0°, 312 (22.8%); LCEA ≥40°, 170 (12.4%); and protrusio acetabuli, 7 (0.5%).
Conclusion:
The overall prevalence of radiographic findings consistent with FAI in young patients with hip pain was 60.5%. Radiographic findings for mixed-type FAI were the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°. The most common radiographic finding for pincer-type FAI was the COS.
Pediatric SARS-CoV-2 data remain limited and seropositivity rates in children were reported as <1% early in the pandemic. Seroepidemiologic evaluation of SARS-CoV-2 in children in a major ...metropolitan region of the US was performed. Children and adolescents less than or equal to19 years were enrolled in a cross-sectional, observational study of SARS-CoV-2 seroprevalence from July-October 2020 in Northern Virginia, US. Demographic, health, and COVID-19 exposure information was collected, and blood analyzed for SARS-CoV-2 spike protein total antibody. Risk factors associated with SARS-CoV-2 seropositivity were analyzed. Orthogonal antibody testing was performed, and samples were evaluated for responses to different antigens. In 1038 children, the anti-SARS-CoV-2 total antibody positivity rate was 8.5%. After multivariate logistic regression, significant risk factors included Hispanic ethnicity, public or absent insurance, a history of COVID-19 symptoms, exposure to person with COVID-19, a household member positive for SARS-CoV-2 and multi-family or apartment dwelling without a private entrance. 66% of seropositive children had no symptoms of COVID-19. Secondary analysis included orthogonal antibody testing with assays for 1) a receptor binding domain specific antigen and 2) a nucleocapsid specific antigen had concordance rates of 80.5% and 79.3% respectively. A much higher burden of SARS-CoV-2 infection, as determined by seropositivity, was found in children than previously reported; this was also higher compared to adults in the same region at a similar time. Contrary to prior reports, we determined children shoulder a significant burden of COVID-19 infection. The role of children's disease transmission must be considered in COVID-19 mitigation strategies including vaccination.
Background:
Tibial tubercle–trochlear groove distance (TT-TG) is a commonly used measurement for surgical decision making in patients with patellofemoral malalignment and instability. This ...measurement has historically been performed utilizing axial computed tomography (CT). More recently, magnetic resonance imaging (MRI) has been proposed as an equivalent method, but this has not yet been fully validated.
Purpose:
To determine the reliability of TT-TG distance measurements on both MRI and CT and to determine whether the measurements are interchangeable with one another.
Study Design:
Cohort study (diagnosis); Level of evidence, 2.
Methods:
All patients with patellar instability who underwent both CT and MRI of the knee from 2003 to 2011 were included (n = 59 knees in 54 patients). Two fellowship-trained musculoskeletal radiologists measured the TT-TG distances for each patient by CT and MRI in a randomized, blinded fashion. Interobserver reliability was calculated between radiologists for both imaging modalities, and intermethod reliability was calculated between the 2 imaging modalities. The results are reported using intraclass correlation coefficients (ICCs) and Bland-Altman analysis.
Results:
The 59 knees had a mean TT-TG distance of 16.9 mm (range, 8.3-25.8 mm) by CT and 14.7 mm (range, 1.5-25.1 mm) by MRI. Interobserver reliability between the radiologists was considered excellent for both CT and MRI (ICC = 0.777 and 0.843, respectively). When comparing CT to MRI, the ICC was considered only fair for each of the raters (0.532 and 0.539). Eleven patients (19%) had a TT-TG distance of ≥20 mm on CT preoperatively and underwent distal realignment by tibial tubercle osteotomy. In this surgical subgroup, the mean TT-TG distance was 22.5 mm (range, 19.8-25.8 mm) by CT and only 18.7 mm (range, 14.4-22.8 mm) by MRI for a mean difference of 3.80 mm (P < .001).
Conclusion:
The TT-TG distance can be measured with excellent interrater reliability on both MRI and CT; however, the values derived from these 2 tests may not be interchangeable. This observation should be taken into consideration when MRI is used for surgical planning because MRI may underestimate the TT-TG distance when compared with CT.
Purpose To compare clinical and functional outcomes of surgically treated medial and lateral knee dislocations. Methods A retrospective review of the medical records of patients who presented with ...knee dislocations was conducted. We identified patients who underwent surgical treatment of KDIII-M (anterior cruciate ligament/posterior cruciate ligament/medial collateral ligament) or KDIII-L (anterior cruciate ligament/posterior cruciate ligament/lateral collateral ligament) knee dislocation as documented by the Schenck classification. Minimum 2-year follow-up with Lysholm and International Knee Documentation Committee (IKDC) outcome scores was required for inclusion. Postoperative range of motion, ligamentous examination, and conversion to total knee arthroplasty were also collected. Data were analyzed using univariate and multivariate statistical models with P < .05 considered significant. Results A total of 56 patients met the inclusion criteria, 24 with the KDIII-M injury pattern (43%) and 32 with the KDIII-L injury pattern (57%), with a mean age of 34 years (range, 16 to 62 years) and a mean follow-up of 6.5 years (range, 2 to 20 years). Patients undergoing medial repairs had worse outcomes for both the Lysholm score ( P = .008) and IKDC score ( P = .003). In addition, female sex was linked to worse outcomes (Lysholm score, 58.8 ± 21.5 v 77.8 ± 21.1, P < .01; IKDC score, 54.9 ± 23.7 v 75.2 ± 20.2, P < .01). No differences in outcome were found between patients with and patients without peroneal nerve injury (Lysholm score, P = .81; IKDC score, P = .77). No difference in laxity testing was found between the 2 groups. Conclusions In patients undergoing multiligament knee reconstruction, our data suggest that those who undergo medial repair for knee dislocations are not as likely to achieve positive results as those who undergo reconstruction or lateral reconstruction/repair, regardless of the status of the peroneal nerve. In addition, medial reconstruction had comparable outcomes to those in patients treated with lateral reconstruction/repair. Lastly, female patients showed less favorable clinical outcomes than male patients. Level of Evidence Level III, retrospective comparative study.
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