Darby A. Houck

A Cost-Effectiveness Analysis of Surgical Treatment Modalities for Chondral Lesions of the Knee: Microfracture, Osteochondral Autograft Transplantation, and Autologous Chondrocyte Implantation

Background: Numerous surgical options exist to treat chondral lesions in the knee, including microfracture (MFx), osteochondral autograft transplantation (OAT), first-generation autologous chondrocyte implantation (ACI-1), and next-generation ACI (ACI-2). Purpose: To compare the cost-effectiveness of MFx, OAT, and ACI-1. The secondary purpose of this study was to compare the functional outcomes of MFx, OAT, ACI-1, and ACI-2. Study Design: Systematic review; Level of evidence, 2. Methods: Two independent reviewers conducted an online literature search of 2 databases for level 1 and 2 studies using the Lysholm, International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), and/or Hospital for Special Surgery (HSS) Knee Score. A weighted mean difference in pre- to postoperative functional outcome score was calculated for each treatment. The mean per-patient costs associated with MFx, OAT, and ACI-1 were determined from a recent publication based on review of a national private insurance database. The cost for each procedure was then divided by the weighted mean difference in functional outcome score to give the cost-per-point change in outcome score. Results: A total of 12 studies (6 level 1, 6 level 2) met the inclusion criteria for the functional outcome analysis, including 730 knees (MFx, n = 300; OAT, n = 90; ACI-1, n = 68; ACI-2, n = 272). The mean follow-up was not significantly different between groups (MFx, 29.4 months; OAT, 38.3 months; ACI-1, 19.0 months; ACI-2, 26.7 months). The mean increase in functional outcome score was 23 for MFx, 19 for OAT, 20 for ACI-1, and 35 for ACI-2. The change in functional outcome score was significantly greater for ACI-2 when compared with all other treatments (P < .0001). The cost-per-point change in functional outcome score was

Early Versus Delayed Motion After Rotator Cuff Repair: A Systematic Review of Overlapping Meta-analyses:

200.59 for MFx,

Similar clinical outcomes following collagen or polyurethane meniscal scaffold implantation: a systematic review

313.84 for OAT, and

Clinical Outcomes Following Primary Anterior Cruciate Ligament Reconstruction with Hamstring Autograft versus Planned Hybrid Graft

536.59 for ACI-1. Conclusion: MFx, OAT, ACI-1, and ACI-2 are effective surgical procedures for the treatment of cartilage defects in the knee. All 4 treatments led to an increase in functional outcome scores postoperatively with a short-term follow-up. ACI-2 had a statistically greater improvement in functional outcome scores as compared with the other 3 procedures. MFx was found to be the most cost-effective treatment option and ACI-1 the least cost-effective.

Bone–Patellar Tendon–Bone Versus Hamstring Tendon Autografts for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Overlapping Meta-analyses:

Background: Previous meta-analyses have been conducted to compare outcomes of early versus delayed motion after rotator cuff repair. Purpose: To conduct a systematic review of overlapping meta-analyses comparing early versus delayed motion rehabilitation protocols after rotator cuff repair to determine which meta-analyses provide the best available evidence. Study Design: Systematic review. Methods: A systematic review was performed by searching PubMed and Cochrane Library databases. Search terms included “rotator cuff repair,” “early passive motion,” “immobilization,” “rehabilitation protocol,” and “meta-analysis.” Results were reviewed to determine study eligibility. Patient outcomes and structural healing were extracted from these meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad decision algorithm was then used to determine which meta-analyses provided the best level of evidence. Results: Seven meta-analyses containing a total of 5896 patients met the eligibility criteria (1 Level I evidence, 4 Level II evidence, 2 Level III evidence). None of these meta-analyses found immobilization to be superior to early motion; however, most studies suggested that early motion would increase range of motion (ROM), thereby reducing time of recovery. Three of these studies suggested that tear size contributed to the choice of rehabilitation to ensure proper healing of the shoulder. A study by Chan et al in 2014 received the highest QUOROM and Oxman-Guyatt scores, and therefore this meta-analysis appeared to have the highest level of evidence. Additionally, a study by Riboh and Garrigues in 2014 was selected as the highest quality study in this systematic review according to the Jadad decision algorithm. Conclusion: The current, best available evidence suggests that early motion improves ROM after rotator cuff repair but increases the risk of rotator cuff retear. Lower quality meta-analyses indicate that tear size may provide a better strategy in determining the correct rehabilitation protocol.

Do Focal Chondral Defects of the Knee Increase the Risk for Progression to Osteoarthritis? A Review of the Literature

PurposeThe purpose of this systematic review is to evaluate the current literature in an effort to assess specific clinical outcomes following meniscal scaffold implantation using the two available scaffolds: Collagen Meniscal Implant (CMI) and the Actifit polyurethane meniscal scaffold.MethodsA systematic review was performed by searching PubMed, Embase, and Cochrane Library to find studies evaluating clinical outcomes of patients undergoing meniscal scaffold implantation. Search terms used were “meniscus”, “meniscal”, “scaffold”, and “implant”. Studies were evaluated based on scaffold type, treatment failure rates, patient-reported outcome scores, concomitant procedures, and radiological findings. Radiological findings were recorded using the Genovese scale to assess morphology and signal intensity and the Yulish score to assess articular cartilage.ResultsNineteen studies (1 level I, 1 level II, 17 level IV evidence) were identified that met inclusion criteria, including a total of 658 patients (347 Actifit, 311 CMI). The overall average follow-up was 45 months. Treatment failure occurred in 9.9% of patients receiving the Actifit scaffold at a mean follow-up of 40 months and 6.7% of patients receiving CMI at a mean follow-up of 44 months (n.s.). However, the rate of failure ranged from 0 to 31.8% amongst the included studies with a variable definition of failure. Additionally, overlapping patients and presence of concomitant surgeries such as anterior cruciate ligament reconstruction (ACLR) and high tibial osteotomy (HTO) may have a significant influence on these results. Outcomes for the Visual Analog Scale (VAS) for pain, Lysholm knee score, and Tegner activity score improved from preoperatively to latest follow-up in both groups, while the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee scores improved from preoperatively to latest follow-up for Actifit scaffold patients. Overall, patients receiving CMI scaffolds had higher grades for Genovese morphology and signal intensity when compared to Actifit scaffold patients.ConclusionPatients undergoing meniscal scaffold implantation with either CMI or Actifit scaffold can both be expected to experience improvement in clinical outcomes when used in association with concomitant procedures such as ACLR and HTO.Level of evidenceIV, systematic review.

Fixed- Versus Adjustable-Loop Femoral Cortical Suspension Devices for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Biomechanical Studies

Abstract Few studies have compared outcomes between autografts versus hybrid grafts (combination of autograft and allograft) for anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare revision rate and patient‐reported outcomes following primary ACLR with a hamstring autograft versus a preoperatively planned hybrid autograft‐allograft. At a minimum 2‐year follow‐up, patients who had undergone primary ACLR with a double‐stranded semitendinosus and gracilis hamstring autograft (A) or a planned hybrid (H) graft (single‐strand semitendinosus with nonirradiated peroneus longus or tibialis posterior allograft) were contacted to fill out a survey containing the Knee Injury and Osteoarthritis Outcome Score (KOOS), Subjective International Knee Documentation Committee (IKDC) score, Single Assessment Numeric Evaluation (SANE), 12‐Item Short‐Form Health Survey (SF‐12), and visual analog scale (VAS) for activity level prior to injury and at follow‐up. From this collection of patients, a matched‐pair comparison was made between groups, with patients matched by gender, age at the time of surgery, and follow‐up time. Revision rate at follow‐up was 8.4 and 2.4% in the A and H groups, respectively (p = 0.073). A total of 148 surveys were completed (83 A, 65 H), from which 36 matched pairs were formed. Within the matched pairs, average age at surgery did not differ significantly between groups (A: 35.7 years, H: 36.0 years, p = 0.23). Time to follow‐up was 4.3 and 3.7 years in the A and H groups, respectively. Patients with a hybrid graft had significantly higher KOOS Quality of Life subscores (A 69.6, H 79.2, p = 0.028), subjective IKDC scores (A 72.6, H 79.7, p = 0.031), and SANE scores (A 83.2, H 91.4, p = 0.015) at follow‐up. Otherwise, no significant differences were found in patient‐reported outcome scores between groups. A preoperatively planned hybrid graft, with use of a fresh‐frozen, nonirradiated allograft, should be considered as a viable alternative for primary ACLR in older patients.

Evaluation of information available on the internet regarding reverse total shoulder arthroplasty

Background: Previous meta-analyses have compared bone–patellar tendon–bone (BPTB) with hamstring tendon (HT) autografts for primary anterior cruciate ligament reconstruction (ACLR). Purpose: To conduct a systematic review of overlapping meta-analyses comparing BPTB with HT autografts for ACLR to determine which meta-analyses provide the best available evidence. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed by searching the PubMed and Cochrane Library databases. Search words included “anterior cruciate ligament” AND “patellar tendon” AND “hamstring tendon” AND “meta-analysis.” Results were reviewed to determine study eligibility. Patient outcomes and postoperative complications were extracted from the included meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) scores. The Jadad decision algorithm was then utilized to determine which meta-analyses provided the best level of evidence. Results: Sixteen meta-analyses containing an average of 1396 patients met the eligibility criteria. Most studies found BPTB autografts to provide superior stability but more postoperative complications, such as anterior knee pain and kneeling pain. Studies by Gabler et al (2016), Mohtadi et al (2011), and Xie et al (2015) received the highest Oxman-Guyatt and QUOROM scores, and therefore, these meta-analyses proved to provide the highest level of evidence. Additionally, Xie et al was selected as the highest-quality study in this systematic review based on the Jadad decision algorithm. Conclusion: The current best evidence suggests that ACLR with BPTB autografts provides superior static knee stability and that there are fewer postoperative complications in ACLR with HT autografts.

Variance in Anterior Cruciate Ligament Reconstruction Graft Selection based on Patient Demographics and Location within the Multicenter Orthopaedic Outcomes Network Cohort

Background: Focal chondral defects (FCDs) of the knee are believed to contribute to the development of osteoarthritis (OA), resulting in pain and dysfunction. Purpose: To investigate whether untreated FCDs of the knee progress to radiographically evident OA over time. Study Design: Systematic review; Level of evidence, 3. Methods: A literature review was performed by searching the PubMed, Embase, and Cochrane Library databases to locate studies evaluating clinical and/or radiological outcomes of patients with FCDs that were diagnosed by arthroscopic surgery or magnetic resonance imaging (MRI) and were left untreated with a minimum 2-year follow-up. Additionally, studies were included if there was a radiographic assessment of OA. Search terms used were “knee,” “focal,” “isolated,” “chondral,” “cartilage,” and “osteoarthritis.” Studies were evaluated based on clinical/radiological outcomes and OA risk factors. The study methodology was assessed using the modified Coleman Methodology Score. Results: Eight studies comprising 1425 knees met the inclusion criteria. All studies were of level 3 evidence. The risk of incident cartilage damage (enlargement of original FCDs or incidence of additional FCDs) at latest follow-up was assessed in 3 studies, while 1 study only reported the incidence of cartilage damage at follow-up. All 4 studies noted an increased progression of cartilage damage at follow-up. The progression of cartilage damage was most commonly seen in the patellofemoral joint and medial femoral condyle but was not associated with the development of knee OA based on the Kellgren-Lawrence grade. MRI of the FCDs revealed increased water content, cartilage deterioration, and proteoglycan loss within the medial and lateral compartments. Conclusion: Patients with untreated FCDs of the knee joint are more likely to experience a progression of cartilage damage, although the studies included in this review did not demonstrate the development of radiographically evident OA within 2 years of follow-up.

Lesser tuberosity osteotomy and subscapularis tenotomy repair techniques during total shoulder arthroplasty: A meta-analysis of cadaveric studies

Background: Fixed- and adjustable-loop femoral cortical suspension devices are commonly used for femoral graft fixation during anterior cruciate ligament reconstruction (ACLR). Purpose: To compare the biomechanical results of fixed- versus adjustable-loop femoral cortical suspension devices in studies simulating ACLR with an isolated device and/or specimen setup using porcine femora and bovine flexor tendons. Study Design: Systematic review. Methods: Two independent reviewers searched PubMed, Embase, and the Cochrane Library databases to find studies comparing the biomechanical strength of fixed- and adjustable-loop cortical suspension devices for ACLR with isolated device and/or specimen setups using porcine femora and bovine flexor tendons. Studies that compared both devices with similar biomechanical methods were included. Data extracted included displacement during cyclic loading, ultimate load to failure, and mode of failure of the different cortical suspension devices for ACLR. Results: Six studies were identified that met the inclusion criteria, including a total of 76 fixed-loop devices and 120 adjustable-loop devices. Load to failure was significantly different (P < .0001), with the strongest fixation device being the ToggleLoc with ZipLoop adjustable-loop device (1443.9 ± 512.3 N), compared with the Endobutton CL fixed-loop device (1312.9 ± 258.1 N; P = .04) and the TightRope RT adjustable-loop device (863.8 ± 64.7 N; P = .01). Cyclic displacement was significantly different, with Endobutton CL (3.7 ± 3.9 mm) showing the least displacement, followed by ToggleLoc with ZipLoop (4.9 ± 2.3 mm) and TightRope RT (7.7 ± 11.1 mm) (P < .0001). Mode of failure was statistically different between the 3 groups (P = .01), with suture failure accounting for 83.8% of TightRope RT devices, 69.4% of ToggleLoc with ZipLoop devices, and 60.3% of Endobutton CL devices. Conclusion: Current biomechanical data suggest that the ToggleLoc with ZipLoop device is the strongest fixation device at “time zero” in terms of ultimate load to mechanical failure. However, the Endobutton CL device demonstrated the least cyclic displacement, which may be a more clinically applicable measure of device superiority.