Anas Minkara

Systematic Review and Meta-analysis of Outcomes After Hip Arthroscopy in Femoroacetabular Impingement.

Background: Femoroacetabular impingement (FAI) has become a more commonly recognized cause of limited hip range of motion and hip pain among young adults and athletes. Hip arthroscopy is recommended for the surgical treatment of this disorder, unless specific contraindications exist. Despite the increasing rate of published studies in this area, there remains no aggregate data for outcomes after this approach. Purpose: To evaluate risk factors and outcomes after arthroscopic management of FAI, including return to play, revision rate, surgical and nonsurgical complications, change in α-angle, intraoperative bone resection, and patient-reported outcomes. Study Design: Meta-analysis and systematic review. Methods: A review of the current literature was performed with the terms “femoroacetabular impingement,” “hip arthroscopy,” and numerous variations thereof in PubMed, EMBASE, BioMed Central, Cochrane, Science Direct, and Scopus, yielding 1723 abstracts. After screening by eligibility criteria, 31 articles were included. The incidence of bilateral FAI was determined by enrollment data, and pooled estimates were calculated for postoperative patient-reported outcome measures, α-angles, return to sport, postoperative complications, and reoperation risk. Results: A total of 1981 hips among 1911 patients were identified, with a mean ± SD age of 29.9 ± 1.9 years and 29.5 ± 14.0 months of follow-up. The incidence of bilateral FAI in these studies that required operative intervention was 3.6%. The pooled risk of reoperation after hip arthroscopy, including revision surgery or subsequent total hip arthroplasty, was 5.5% (95% CI, 3.6%-7.5%). The risk of clinical complications was 1.7% (95% CI, 0.9%-2.5%). In total, 87.7% of patients demonstrated return to sport after surgery (95% CI, 82.4%-92.9%, P < .001), and all patient-reported outcomes improved postoperatively, with the highest increase observed in the Hip Outcome Score sports scale (41.7 points; 95% CI, 34.1-49.4; P < .001). The α-angle decreased by an average of 23.6° (95% CI, 18.2°-29.0°; P < .001). We identified 11 factors associated with the success of hip arthroscopy in FAI and 16 factors associated with failure or negative outcomes. Conclusion: A high percentage of patients return to sport activities after hip arthroscopy for FAI, with a low rate of complications and reoperation. All patient-reported outcome measures, except for mental health, significantly improved after surgery.

Return to Play After Hip Arthroscopy: A Systematic Review and Meta-analysis:

Background: The use of arthroscopic treatment for intra-articular hip pathology has demonstrated improved patient-reported outcomes (PROs) with a lower rate of complications, reoperation, and patient morbidity as compared with traditional methods. Although the use of this minimally invasive approach has increased in prevalence, no evidence-based return-to-play (RTP) criteria have been developed to ensure an athlete’s preparedness for sporting activities. Purpose: To determine if there exists sufficient evidence in the literature to support an RTP protocol and functional assessment after hip arthroscopy, as well as to assess the mean rate and duration of RTP. Study Design: Systematic review and meta-analysis. Methods: The search terms “hip arthroscopy,” “return to play,” and 10 related terms were searched in PubMed, Cochrane Library, Scopus, and Web of Science, yielding 263 articles. After screening, 22 articles were included. RTP timeline, rehabilitation protocols, and conditional criteria measures were assessed with previously established criteria. Pooled estimates were calculated for RTP rate and duration, and weighted mean scores were determined for PROs. Results: A total of 1296 patients with 1442 total hips were identified. Although 54.5% (12 of 22) of studies did not provide a guideline for RTP duration after hip arthroscopy, 36.4% (8 of 22) recommended a duration of 4 months, while 9.1% (2 of 22) recommended 3 months. The most frequently described postoperative rehabilitation protocols were weightbearing guidelines (15 studies) and passive motion exercises (9 studies). Only 2 studies satisfied the criteria for a sufficient RTP protocol, and 3 provided a specific replicable test for RTP. The mean RTP duration was 7.4 months (95% CI, 6.1-8.8 months), and the return rate was 84.6% (95% CI, 80.4%-88.8%; P = .008) at a mean ± SD follow-up of 25.8 ± 2.4 months. Mean modified Harris Hip Score (mHHS) improved from 63.1 to 84.1 postoperatively (+33.3%), while Non-arthritic Hip Score improved from 61.7 to 86.8 (+40.7%). A lower preoperative mHHS was significantly associated with a higher postoperative improvement (r = −0.95, P = .0003). Conclusion: Significant variability exists in RTP protocols among institutions owing to a lack of standardization. Despite a high overall rate of RTP and improvement in PROs after hip arthroscopy, the majority of rehabilitation protocols are not evidence based and rely on expert opinion. No validated functional test currently exists to assess RTP.

Outcomes of Joint Preservation Procedures for Cartilage Injuries in the Hip: A Systematic Review and Meta-analysis

Background: The detection and management of chondral injuries of the hip, especially in a younger patient population, may preempt joint degeneration. Although the outcomes of preservation techniques have been well described for other weightbearing joints, such as the knee, evidence for hip joint preservation after procedures such as microfracture and autologous chondrocyte implantation remains in its infancy. Purpose: To evaluate outcomes of joint preservation procedures in the hip, including the success rate and patient-reported outcomes (PROs). Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed using the terms “hip arthroscopy,” “microfracture,” “autologous chondrocyte implantation,” “fibrin glue,” “osteochondral transfer,” and variations thereof in 5 electronic databases, yielding 325 abstracts. After the application of eligibility criteria, 19 articles were included. Weighted means were calculated for PROs, and pooled estimates were calculated for age, follow-up, chondral lesion size, and success of hip preservation procedures with a random-effects proportion meta-analysis. Results: A total of 1484 patients (1502 hips) were identified across 19 studies (mean age, 38.0 ± 1.3 years; mean follow-up, 31.8 ± 9.6 months). Hip joint preservation techniques demonstrated a high success rate, ranging from 85.6% to 99.7%. The mean pooled chondral lesion size was 2.5 ± 0.3 cm2 (95% CI, 1.9-3.0 cm2). Microfracture was the most frequent technique, utilized by 11 studies, and demonstrated an 89.6% success rate (95% CI, 82.4%-96.7%). The highest pooled success rate was exhibited by autologous membrane-induced chondrogenesis in 3 studies (99.7% [95% CI, 99.0%-100.0%]). All PROs demonstrated a statistically significant increase postoperatively, including the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score–Activities of Daily Living and Hip Outcome Score–Sports-Specific Subscale (all P < .05). The visual analog scale for pain also demonstrated a statistically significant decrease of 37.2% (P < .05). Conclusion: Hip preservation procedures demonstrate a high success rate, with microfracture representing the most frequently utilized cartilage preservation technique in the peer-reviewed literature. PROs significantly improved after surgery. Further investigation of hip preservation modalities with long-term follow-up is required to create evidence-based clinical recommendations and treatment algorithms.

Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity

STUDY DESIGNnConsensus-building using the Delphi and nominal group technique.nnnOBJECTIVEnTo establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed.nnnMETHODSnThe Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting.nnnRESULTSnParticipants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants.nnnCONCLUSIONnWe developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery.nnnLEVEL OF EVIDENCEnLevel V.STUDY DESIGNnConsensus-building using the Delphi and nominal group technique.nnnOBJECTIVEnTo establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery.nnnSUMMARY OF BACKGROUND DATAnNumerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed.nnnMETHODSnThe Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting.nnnRESULTSnParticipants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants.nnnCONCLUSIONnWe developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery.nnnLEVEL OF EVIDENCEnLevel V.

Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections

OBJECTIVEnTo compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion.nnnSTUDY DESIGNnRetrospective cohort study. Although PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population.nnnMETHODSnPatients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used.nnnRESULTSn115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC.nnnCONCLUSIONnUtilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis.nnnLEVEL OF EVIDENCEnLevel II.OBJECTIVEnTo compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion.nnnSTUDY DESIGNnRetrospective cohort study.nnnSUMMARY OF BACKGROUND DATAnAlthough PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population.nnnMETHODSnPatients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used.nnnRESULTSn115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC.nnnCONCLUSIONnUtilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis.nnnLEVEL OF EVIDENCEnLevel II.

Building the Case for Optimal Prophylaxis for Growth-Friendly Surgery for Non-idiopathic Scoliosis: Using Vancomycin and Aminoglycosides

The pathogens and susceptibility profiles of deep SSIs following growth friendly surgery for children with non-idiopathic scoliosis were assessed to optimize perioperative prophylaxis. Gram positive cocci were detected in 90.1% of SSIs; susceptibility to cefazolin and vancomycin remained unchanged. Gram negative rods (GNR) were detected in 16.5% of SSIs; susceptibility to cefazolin decreased but susceptibility to aminoglycosides increased. Aminoglycosides play a critical role in GNR coverage and should be incorporated into prophylaxis protocols.

Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients

The RSS was developed to quantify the risk of SSI when considering operative intervention in patients with early onset scoliosis undergoing spinal surgery. The tool includes neuromuscular etiology, myelomeningocele, spinal muscular atrophy, endocrine comorbidity, gastrointestinal comorbidity, pulmonary comorbidity, developmental delay, urinary incontinence, and ventriculoperitoneal shunt as predictive variables. The RSS can improve shared decision making with patients and families during preoperative counseling and aid policy makers and administrators in determining reliable and valid risk-adjusted outcome measures.

Acute Kidney Injury Secondary to Cell Saver in Posterior Spinal Fusion

BACKGROUNDnAutologous blood transfusion, commonly referred to as cell saver, is frequently used in spinal fusion to salvage red blood cells because of the risk of significant intraoperative blood loss. This case report describes a case of acute kidney injury (AKI) secondary to cell saver use. Our objective is to increase the knowledge about the process of red blood cell salvage and this exceedingly rare complication.nnnMETHODSnChart and renal biopsy results for a single case were reviewed and reported in this retrospective study.nnnRESULTSnA healthy 18-year-old male patient underwent posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis with utilization of intraoperative autologous blood transfusion. The patient subsequently developed hematuria and AKI with a peak creatinine of 13.9 mg/dL. An extensive clinical workup, including autoimmune serology, excluded any identifying causes. A renal biopsy showed pigment-induced acute tubular necrosis.nnnCONCLUSIONSnThis case, to our knowledge, is the first and only case report of AKI secondary to cell saver demonstrated by renal biopsy. The literature has shown both the benefit of cell saver by decreasing the need for allogeneic transfusion and the risk of transient hematuria. However, this case demonstrates the importance of monitoring patients for potential complications.BACKGROUNDnAutologous blood transfusion, commonly referred to as cell saver, is frequently used in spinal fusion to salvage red blood cells because of the risk of significant intraoperative blood loss. This case report describes a case of acute kidney injury (AKI) secondary to cell saver use. Our objective is to increase the knowledge about the process of red blood cell salvage and this exceedingly rare complication.nnnMETHODSnChart and renal biopsy results for a single case were reviewed and reported in this retrospective study.nnnRESULTSnA healthy 18-year-old male patient underwent posterior spinal instrumentation and fusion for adolescent idiopathic scoliosis with utilization of intraoperative autologous blood transfusion. The patient subsequently developed hematuria and AKI with a peak creatinine of 13.9 mg/dL. An extensive clinical workup, including autoimmune serology, excluded any identifying causes. A renal biopsy showed pigment-induced acute tubular necrosis.nnnCONCLUSIONSnThis case, to our knowledge, is the first and only case report of AKI secondary to cell saver demonstrated by renal biopsy. The literature has shown both the benefit of cell saver by decreasing the need for allogeneic transfusion and the risk of transient hematuria. However, this case demonstrates the importance of monitoring patients for potential complications.

Abstract: Plastic Multilayered Closure in Nonidiopathic Scoliosis Significantly Reduces the Risk of Wound Complications in a Pediatric Population

METHODS: Patients with a diagnosis of nonidiopathic scoliosis undergoing primary or revision growth friendly instrumentation or fusion during 2014 to 2016 were included. Clinical charts and operative reports were reviewed. The SSI and wound complication risk of patients undergoing PMC was compared to standard closure. Additionally, the mean Risk Severity Score (RSS) for SSI, which utilizes patient characteristics to calculate the probability of SSI, was calculated to compare the observed (actual risk) and expected risk (RSS).

Temporary occipital fixation in young children with severe cervical-thoracic spinal deformity

OBJECTIVE The long-term effects of instrumentation and fusion of the occipital-cervical-thoracic spine on spinal growth in young children are poorly understood. To mitigate the effects of this surgery on the growing pediatric spine, the authors report a novel technique used in 4 children with severe cervical-thoracic instability. These patients underwent instrumentation from the occiput to the upper thoracic region for stabilization, but without bone graft at the craniovertebral junction (CVJ). Subsequent surgery was then performed to remove the occipital instrumentation, thereby allowing further growth and increased motion across the CVJ. METHODS Three very young children (15, 30, and 30 months old) underwent occipital to thoracic posterior segmental instrumentation due to cervical or upper thoracic dislocation, progressive kyphosis, and myelopathy. The fourth child (10 years old) underwent similar instrumentation for progressive cervical-thoracic scoliosis. Bone graft was placed at and distal to C-2 only. After follow-up CT scans demonstrated posterior arthrodesis without unintended fusion from the occiput to C-2, 3 patients underwent removal of the occipital instrumentation. RESULTS Follow-up cervical spine flexion/extension radiographs demonstrated partial restoration of motion at the CVJ. One patient has not had the occipital instrumentation removed yet, because only 4 months have elapsed since her operation. CONCLUSIONS Temporary fixation to the occiput provides increased biomechanical stability for spinal stabilization in young children, without permanently eliminating motion and growth at the CVJ. This technique can be considered in children who require longer instrumentation constructs for temporary stabilization, but who only need fusion in more limited areas where spinal instability exists.