Brian Capogna

Infection Rate Following Total Joint Arthroplasty in the HIV Population

The purpose of this study is to review a large series of HIV-infected patients who underwent total joint arthroplasty and identify potential risk-factors for infection. Sixty-nine HIV-infected arthroplasty cases were analyzed with 138 matched controls. Deep infection rate following total hip or knee arthroplasty was 4.4% (3 of 69) among HIV cases compared to 0.72% (1 of 138) among controls, yielding a non-significant 6.22 times increased odds of infection (95% CI 0.64-61.0, P=0.11). Kaplan-Meier survival curves for infection free survival and revision free survival revealed non-significantly decreased survival in HIV cases compared to controls (P=0.06 and P=0.09). Our results suggest that the rate of early joint infection following primary total joint arthroplasty in the HIV-infected population is lower than reported in a number of previously published studies.

Postoperative pain control after arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Clinical Outcomes of Hip Arthroscopy in Patients 60 or Older: A Minimum of 2-Year Follow-up.

PURPOSE To examine clinical outcomes and survivorship in patients aged 60 years or older who underwent hip arthroscopy for management of hip pain. METHODS Prospectively collected data for patients 60 or older undergoing hip arthroscopy were obtained. All patients were indicated for hip arthroscopy based on standard preoperative examination as well as routine and advanced imaging. Demographic data, diagnosis, and details regarding operative procedures were collected. Baseline preoperative modified Harris Hip Scores (mHHS) and Non-arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at the 2-year follow-up. Survivorship was assessed to determine failure rates, with failure defined as any subsequent ipsilateral revision arthroscopic surgery and/or hip arthroplasty. RESULTS Forty-two patients met inclusion criteria. Mean age (standard deviation) and body mass index were 65.8 years (4.5 years) and 26.1 (4.7), respectively. Baseline mean mHHS and NAHS for all patients improved from 47.8 (±12.5) and 47.3 (±13.6) to 75.6 (±17.6) and 78.3 (±18.6), respectively (P < .001 for both). Five patients (11.9%) met failure criteria and underwent additional surgery at an average of 14.8 (8-30) months. Three underwent conversion to total hip arthroplasty (7.1%), whereas 2 had revision arthroscopy with cam/pincer resection and labral repair for recurrent symptoms (4.7%). One- and 2-year survival rates were 95.2% and 88.9%, respectively. CONCLUSIONS Our results suggest that in patients 60 or older with Tonnis grade 0 or 1 osteoarthritic changes on initial radiographs-treatment with hip arthroscopy can lead to reliable improvement in early outcomes. As use of hip arthroscopy for treatment of mechanical hip pain increases, additional studies with long-term follow-up are needed. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Risk factors for recurrent instability or revision surgery following arthroscopic Bankart repair

Aims The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results A total of 5719 patients were analyzed. Their mean age was 24.9 years (SD 9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (SD 23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized. METHODS We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy. RESULTS We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary. CONCLUSION Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Treatment of Nonunions After Malleolar Fractures.

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Independent Risk Factors for Poor Outcome After Hip Arthroscopy

Objectives: Hip arthroscopy has been an increasingly used tool in the treatment of labral tears, chondral defects and ligamentum teres lesions and has demonstrated efficacy in returning patients to function and relieving their pain. Despite this, failures continue to occur. Our understanding of risk factors for failure or poor outcome continues to evolve as larger cohorts of patients are available for study. We sought to identify risk factors for poor outcome in our patient population. Methods: Prospectively collected data for all patients undergoing hip arthroscopy by a single fellowship-trained surgeon was obtained. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline demographic data regarding patient age, gender, BMI was collected. Patients without two year follow-up were excluded. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to mHHS at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure or conversion to THA or mHHS below 70. Multivariate logistic regression was performed to identify independent risk factors for “poor outcome.” Results: 258 patients met inclusion criteria. Mean age (SD) and body mass index (BMI) were 40.4 years (12.7 years) and 25.6 (4.7) respectively. 62.8% (162/258) of the sample was female. Mean preoperative baseline mHHS was 49.6 (12.5) and average mHHS at two year follow-up was 83.6 (15.6), resulting in a mean improvement of 34.1 (p<0.001). Baseline and 2 year differencess in mHHS by demographic be found in Figures 1,2,3,. Overall revision/THA conversion rate was 16.7% (43/258), while another 10.5% (27/258) of patients reported outcome scores <70, resulting in 27.31% (70/258) having poor outcomes. Independent risk factors for poor outcome were female gender (OR 1.79; p=0.03), obesity (OR 2.1; p=0.04), and pre-operative mHHS lower than 40 (OR 3.34, p<0.001). Conclusion: Our findings that female gender, obesity and poorer preoperative functional status increase the risk for failure of hip arthroscopy coincide and add to an increasing volume of literature examining risk factors for poor outcome after hip arthroscopy. These factors should be taken into consideration with operative indications as well as in counseling patients.

Concomitant Lumbar Spine Pathology in Patients Undergoing Hip Arthroscopy: A Matched Cohort Analysis

Objectives: Hip arthroscopy for femoroacetabular impingement (FAI) and related hip pathology is increasing in volume. Variable presentations of hip pain often lead to confusion with lumbar spine pathology however. We sought to define the relationship between the lumbar spine and the hip joint. Our hypothesis is that patients with concurrent lumbar spine pathology will experience inferior outcomes after hip arthroscopy when compared to patients without lumbar spine pathology. Methods: Prospectively-collected data from a single-surgeon database from 2010 to 2014 was used to identify patients who had undergone hip arthroscopy and had documented concurrent lumbar spine pathology. Patients with spine pathology were matched by age, gender, and BMI in a 3:1 fashion to patients without spine pathology. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to scores at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure, conversion to THA, or mHHS below 70. Results: 167 patients met inclusion criteria: 72.5% were “normal” while 27.5% had spine pathology. Baseline demographics were appropriately matched between cohorts (Table I). Preoperative and two-year mHHS scores were significantly different between cohorts (Figure 1). Both cohorts demonstrated significant within-group improvement at two-year follow-up, however normal patients had greater improvements than those with spine pathology (34.0 vs 31.76, p<0.001). Overall revision/THA conversion rate for entire cohort was 14.97%, with nearly twice as many spine co-pathology patients requiring additional surgery than those in the normal cohort (23.91% vs 11.57%, p=0.045). Patients with spine pathology were significantly more likely to have “poor outcomes” than those without spine pathology (36.96% vs 21.49%, p=0.048). Conclusion: Our results demonstrate that patients undergoing hip arthroscopy with concomitant lumbar spine pathology demonstrate significantly lower total improvement, significantly higher revision/THA conversion rates and significantly higher rates of suboptimal outcomes after hip arthroscopy than patients without spine pathology. Table 1: Baseline Demographic Data Between Cohorts Normal (n=121) Spine pathology (n=46) p value Mean (SD) Age 38.78 (11.38) 42.39 (12.03) P=0.14 BMI 24.03 (3.6) 25.32 (4.9) P=0.13 Gender: present female 62.8% (n=76) 63.1% (n=29) P=0.98 Figure 1: Differences in mHHs scores between Cohorts

Distal patellar tendon avulsion in association with high-energy knee trauma: A case series and review of the literature

BACKGROUND Patellar tendon rupture is rare in the general population. Typically, failure occurs proximally or at the mid-substance. Distal avulsion from the tibial tubercle in adults is rare and not well described in the orthopedic literature. METHODS We present the largest series of patients with distal patellar tendon injury with associated multi-ligamentous disruption of the knee. A series of six patients with distal patellar tendon avulsion were identified at a single institution. The cases were reviewed and are presented. RESULTS Each case of distal patellar tendon rupture was associated with high-energy trauma to the knee. There was multi-ligamentous disruption in all cases, associated tibial plateau fracture in one case, and a compartment syndrome diagnosed in another. We propose that distal patellar tendon avulsion is a distinct pathology of the extensor mechanism in healthy adults. When present, it should prompt clinicians to assess patients for occult knee dislocation, monitor their neurovascular status, and obtain an MRI to evaluate for associated multi-ligamentous injury. CONCLUSION We propose a modification to the Schenk classification to include extensor mechanism injury to help guide steps of operative intervention.

Arthroscopic Repair of Hip Labrum With Suture Anchors

The acetabular labrum and the transverse acetabular ligament form a continuous ring of tissue on the periphery of the acetabulum that provides a seal for the hip joint and increases the surface area to spread load distribution during weight-bearing. When a labral tear is suspected, the treatment algorithm always begins with conservative management, including physical therapy and nonsteroidal anti-inflammatory drugs. When conservative management fails, patients become candidates for arthroscopic labral repair. In the last 2 decades, the rate of hip arthroscopy has increased nearly 4-fold. However, as hip arthroscopy is performed more frequently, there is a need for a proper technique to minimize morbidity, because hip arthroscopy has been known to have a steep learning curve. We present a method for arthroscopic hip labral repair using suture anchors without a capsular repair. This Technical Note highlights our technique for labral repair, along with pearls and pitfalls of hip arthroscopy.