Geoffrey D. Abrams

Complications and Reoperations During and After Hip Arthroscopy: A Systematic Review of 92 Studies and More Than 6,000 Patients

PURPOSE To determine the prevalence of complications and reoperations during and after hip arthroscopy. METHODS A systematic review of multiple medical databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All clinical outcome studies that reported the presence or absence of complications and/or reoperations were eligible for inclusion. Length of follow-up was not an exclusion criterion. Complication and reoperation rates were extracted from each study. Duplicate patient populations within separate distinct publications were analyzed and reported only once. RESULTS Ninety-two studies (6,134 participants) were included. Most were Level IV evidence studies (88%) with short-term follow-up (mean 2.0 years). Labral tears and femoroacetabular impingement (FAI) were the 2 most common diagnoses treated, and labral treatment and acetabuloplasty/femoral osteochondroplasty were the 2 most common surgical techniques reported. Overall, major and minor complication rates were 0.58% and 7.5%, respectively. Iatrogenic chondrolabral injury and temporary neuropraxia were the 2 most common minor complications. The overall reoperation rate was 6.3%, occurring at a mean of 16 months. Total hip arthroplasty (THA) was the most common reoperation. The conversion rate to THA was 2.9%. CONCLUSIONS The rate of major complications was 0.58% after hip arthroscopy. The reoperation rate was 6.3%, and the most common reason for reoperation was conversion to THA. Minor complications and the reoperation rate are directly related to the learning curve of hip arthroscopy. As surgical indications evolve, patient selection should limit the number of cases that would have been converted to THA. Similarly, the number of minor complications is directly related to technical aspects of the procedure and therefore will decrease with surgeon experience and improvement in instrumentation. LEVEL OF EVIDENCE Level IV, a systematic review of Level I to IV studies.

Trends in Meniscus Repair and Meniscectomy in the United States, 2005-2011

Background: Meniscus deficiency may lead to degenerative arthritis in the knee. There is a significant emphasis on meniscus preservation, particularly in the young patient, to reduce the risk of arthritis. Purpose: To report on the incidence of meniscus repair and meniscectomy, with and without concomitant anterior cruciate ligament (ACL) reconstruction, in the United States (US) over the past 7 years. Study Design: Descriptive epidemiology study. Methods: Patients who underwent arthroscopic meniscectomy (Current Procedural Terminology [CPT] codes 29880 and 29881), meniscus repair (CPT codes 29882 and 29883), and ACL reconstruction (CPT code 29888) for the years 2005 through 2011 were identified using the PearlDiver Patient Record Database. Age group and sex were collected for each patient. Patient groups included meniscectomy alone, meniscus repair alone, meniscus repair followed by meniscectomy, ACL reconstruction with concomitant meniscus repair, and ACL reconstruction with concomitant meniscus repair followed by meniscectomy. Linear regression and Student t tests were utilized for comparisons, with an α value of .05 set as significant. Results: The database represented approximately 9% of the US population under 65 years of age. There was no significant change in the number of patients in the covered population during the study time frame (P = .138). From 2005 to 2011, there were a total of 387,833 meniscectomies, 23,640 meniscus repairs, and 84,927 ACL reconstructions. There was a significant increase in the total number of isolated meniscus repairs performed (P = .001) and a doubling of the incidence of repairs from 2005 to 2011. There was no significant increase in the total number of meniscectomies performed (P = .712), while the incidence of meniscectomies increased only 14% from 2005 to 2011. There was no significant change in the number of meniscus repairs performed at the same time as ACL reconstruction during the study time frame. The total number and incidence of meniscectomies after repair with and without ACL reconstruction significantly decreased. Conclusion: There has been an increased number of isolated meniscus repairs being performed in the US over the past 7 years without a concomitant increase in meniscectomies over the same time frame. These data suggest that meniscus repairs are preferentially being performed over meniscectomies.

Rate of Return to Pitching and Performance After Tommy John Surgery in Major League Baseball Pitchers

Background: Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers in the United States. Purpose: To determine (1) the rate of return to pitching (RTP) in the MLB after UCL reconstruction, (2) the RTP rate in either the MLB and minor league combined, (3) performance after RTP, and (4) the difference in the RTP rate and performance between pitchers who underwent UCL reconstruction and matched controls without UCL injuries. Study Design: Cohort study; Level of evidence, 3. Methods: Major League Baseball pitchers with symptomatic medial UCL deficiency who underwent UCL reconstruction were evaluated. All player, elbow, and surgical demographic data were analyzed. Controls matched by age, body mass index, position, handedness, and MLB experience and performance were selected from the MLB during the same years as those undergoing UCL reconstruction. An “index year” was designated for controls, analogous to the UCL reconstruction year in cases. Return to pitching and performance measures in the MLB were compared between cases and controls. Student t tests were performed for analysis of within-group and between-group variables, respectively. Results: A total of 179 pitchers with UCL tears who underwent reconstruction met the inclusion criteria and were analyzed. Of these, 148 pitchers (83%) were able to RTP in the MLB, and 174 pitchers were able to RTP in the MLB and minor league combined (97.2%), while only 5 pitchers (2.8%) were never able to RTP in either the MLB or minor league. Pitchers returned to the MLB at a mean 20.5 ± 9.72 months after UCL reconstruction. The length of career in the MLB after UCL reconstruction was 3.9 ± 2.84 years, although 56 of these patients were still currently actively pitching in the MLB at the start of the 2013 season. The revision rate was 3.9%. In the year before UCL reconstruction, pitching performance declined significantly in the cases versus controls in the number of innings pitched, games played, and wins and the winning percentage (P < .05). After surgery, pitchers showed significantly improved performance versus before surgery (fewer losses, a lower losing percentage, lower earned run average [ERA], threw fewer walks, and allowed fewer hits, runs, and home runs) (P < .05). Comparisons between cases and controls for the time frame after UCL reconstruction (cases) or the index year (controls) demonstrated that cases had significantly (P < .05) fewer losses per season and a lower losing percentage. In addition, cases had a significantly lower ERA and allowed fewer walks and hits per inning pitched. Conclusion: There is a high rate of RTP in professional baseball after UCL reconstruction. Performance declined before surgery and improved after surgery. When compared with demographic-matched controls, patients who underwent UCL reconstruction had better results in multiple performance measures. Reconstruction of the UCL allows for a predictable and successful return to the MLB.

Trends in the Surgical Treatment of Articular Cartilage Lesions in the United States: An Analysis of a Large Private-Payer Database Over a Period of 8 Years

PURPOSE The purpose of this study was to quantify the current trends in knee cartilage surgical techniques performed in the United States from 2004 through 2011 using a large private-payer database. A secondary objective was to identify salient demographic factors associated with these procedures. METHODS We performed a retrospective database review using a large private-payer medical record database within the PearlDiver database. The PearlDiver database is a publicly available, Health Insurance Portability and Accountability Act-compliant national database compiled from a collection of private insurer records. A search was performed for surgical techniques in cartilage palliation (chondroplasty), repair (microfracture/drilling), and restoration (arthroscopic osteochondral autograft, arthroscopic osteochondral allograft, autologous chondrocyte implantation, open osteochondral allograft, and open osteochondral autograft). The incidence, growth, and demographic factors associated with the surgical procedures were assessed. RESULTS From 2004 through 2011, 198,876,000 patients were analyzed. A surgical procedure addressing a cartilage defect was performed in 1,959,007 patients, for a mean annual incidence of 90 surgeries per 10,000 patients. Across all cartilage procedures, there was a 5.0% annual incidence growth (palliative, 3.7%; repair, 0%; and restorative, 3.1%) (P = .027). Palliative techniques (chondroplasty) were more common (>2:1 ratio for repair [marrow-stimulation techniques] and 50:1 ratio for restoration [autologous chondrocyte implantation and osteochondral autograft and allograft]). Palliative surgical approaches were the most common technique, regardless of age, sex, or region. CONCLUSIONS Articular cartilage surgical procedures in the knee are common in the United States, with an annual incidence growth of 5%. Surgical techniques aimed at palliation are more common than cartilage repair and restoration techniques regardless of age, sex, or region. LEVEL OF EVIDENCE Level IV, retrospective database analysis.

Survival and Reoperation Rates After Meniscal Allograft Transplantation: Analysis of Failures for 172 Consecutive Transplants at a Minimum 2-Year Follow-up

Background: Meniscal allograft transplantation (MAT) is a treatment option for knee pain in young patients with meniscal deficiency in the setting of intact articular surfaces, ligamentous stability, and normal alignment. It is being performed with increasing frequency, and the need for reoperations is not uncommon. A mean survival rate of allografts and indications for reoperations would be helpful information when counseling patients regarding the procedure. Purpose/Hypothesis: The purpose of this study was to quantify survival for MAT and report findings at reoperation. The hypothesis was that the reoperation rate would be frequent and that the most common secondary surgery would be arthroscopic debridement. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of a prospectively collected database of patients who underwent MAT from 2003 to 2011 was conducted; all surgeries were performed by a single surgeon. The reoperation rate, timing of reoperation, procedure performed at reoperation, and findings at surgery, including the status of the meniscal and articular cartilage, were reviewed. Survival was defined as a lack of revision MAT or knee arthroplasty. Descriptive statistics, log-rank testing, cross-tabulation, and χ2 testing were analyzed, with an α value of .05 set as significant. Results: Of 200 patients who underwent MAT during the study period, 172 patients (86%; mean age, 34.3 ± 10.3 years) were evaluated at a mean of 59 months (range, 24-118 months) with a minimum 2-year follow-up. Forty-one percent of MATs were isolated, while 60% were performed with concomitant procedures. Sixty-four patients (32%) returned to the operating room after their index procedure. Arthroscopic debridement was performed in 59% (38/64) of these patients. The mean time to subsequent surgery was 21 months (range, 2-107 months), with 73% occurring within 2 years. Eight of 172 patients (4.7%) went on to require revision MAT or total knee replacement. Patients requiring secondary surgery within 2 years had an odds ratio of 8.4 (95% CI, 1.6-43.4) for future arthroplasty or MAT revision (P = .007). Conclusion: In this series, there was a 32% reoperation rate for MAT, with simple arthroscopic debridement being the most common surgical treatment (59%), and a 95% allograft survival rate at a mean of 5 years. Those requiring additional surgery still benefited, having an 88% allograft survival rate, but were at an increased risk of failure. Patients requiring secondary surgery within 2 years had an odds ratio of 8.4 for future arthroplasty or MAT revision.

Return to sport after ACL reconstruction

Objective guidelines permitting safe return to sport following anterior cruciate ligament (ACL) reconstruction are infrequently used. The purpose of this study was to determine the published return to sport guidelines following ACL reconstruction in Level I randomized controlled trials. A systematic review was performed using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Level I randomized controlled trials were included if they reported a minimum 2-year follow-up after ACL reconstruction and return to sport criteria. Outcomes analyzed were the timing of initiation of return to sport, follow-up duration, and use of quantitative/qualitative criteria to determine return to sport. Forty-nine studies were included (N=4178; 68% male; mean patient age, 27.5±3.2 years; mean follow-up, 3.0±1.9 years; mean time from injury to reconstruction, 379±321 days). Ninety-six percent of reconstructions used autograft and 87% were single-bundle reconstructions. Lysholm score, single-leg hop, isokinetic strength, and KT-1000 or KT-2000 arthrometer (MEDmetric, San Diego, California) testing were performed in 67%, 31%, 31%, and 82% of studies, respectively. Only 5 studies reported whether patients were able to successfully return to sport. Ninety percent and 65% of studies failed to use objective criteria or any criteria, respectively, to permit return to sport. Description of permission/allowance to return to sport was highly variable and poor. Twenty-four percent of studies failed to report when patients were allowed return to sport without restrictions. Overall, 39%, 45%, and 51% of studies permitted running at 3 months, return to cutting/pivoting sports at 6 months, and return to sport without restrictions at 6 months, respectively. Further research into validated return to sport guidelines is necessary to fill the existing void in contemporary literature and to guide clinical practice.

Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players.

Background: Anterior cruciate ligament (ACL) rupture is a significant injury in National Basketball Association (NBA) players. Hypotheses: NBA players undergoing ACL reconstruction (ACLR) have high rates of return to sport (RTS), with RTS the season following surgery, no difference in performance between pre- and postsurgery, and no difference in RTS rate or performance between cases (ACLR) and controls (no ACL tear). Study Design: Case-control. Methods: NBA players undergoing ACLR were evaluated. Matched controls for age, body mass index (BMI), position, and NBA experience were selected during the same years as those undergoing ACLR. RTS and performance were compared between cases and controls. Paired-sample Student t tests, chi-square, and linear regression analyses were performed for comparison of within- and between-group variables. Results: Fifty-eight NBA players underwent ACLR while in the NBA. Mean player age was 25.7 ± 3.5 years. Forty percent of ACL tears occurred in the fourth quarter. Fifty players (86%) RTS in the NBA, and 7 players (12%) RTS in the International Basketball Federation (FIBA) or D-league. Ninety-eight percent of players RTS in the NBA the season following ACLR (11.6 ± 4.1 months from injury). Two players (3.1%) required revision ACLR. Career length following ACLR was 4.3 ± 3.4 years. Performance upon RTS following surgery declined significantly (P < 0.05) regarding games per season; minutes, points, and rebounds per game; and field goal percentage. However, following the index year, controls’ performances declined significantly in games per season; points, rebounds, assists, blocks, and steals per game; and field goal and free throw percentage. Other than games per season, there was no significant difference between cases and controls. Conclusion: There is a high RTS rate in the NBA following ACLR. Nearly all players RTS the season following surgery. Performance significantly declined from preinjury level; however, this was not significantly different from controls. ACL re-tear rate was low. Clinical Relevance: There is a high RTS rate in the NBA after ACLR, with no difference in performance upon RTS compared with controls.

Reverse total shoulder arthroplasty in patients of varying body mass index

BACKGROUND Body mass index (BMI) is an independent predictor of complications after hip and knee arthroplasty. Whether similar trends apply to patients undergoing reverse total shoulder arthroplasty (RTSA) is unknown. METHODS A retrospective review of primary RTSAs with a minimum 90-day follow-up were included. Complications were classified as major or minor and medical or surgical. Patients were classified into 3 groups: normal BMI (BMI <25 kg/m(2)), overweight or mildly obese (BMI 25-35 kg/m(2)), and moderately or severely obese (BMI >35 kg/m(2)). RESULTS Of the 119 patients met our inclusion criteria, 30 (25%) had a BMI of less than 25 kg/m(2); 65 (55%) had a BMI of 25 to 35 kg/m(2), and 24 (20%) had BMI exceeding 35 kg/m(2). Complications occurred in 30 patients (25%), comprising major in 11 (9%), minor in 19 (16%), surgical in 21 (18%), and medical in 14 (12%). The most common surgical complications were acute blood loss anemia requiring transfusion (8.4%) and dislocation (4.2%). The most common medical complications were atelectasis (2.5%) and acute renal insufficiency (2.5%). Patients with a BMI exceeding 35 kg/m(2) had a significantly higher overall complication rate (P < .05) and intraoperative blood loss (P = .05) than the other groups. Patients with BMI of less than 25 kg/m(2) had a greater overall complication rate than those with a BMI of 25 to 35 kg/m(2) (P < .05). Multivariate regression analysis demonstrated BMI was the only significant determinant of overall complication rates and medical complication rates (P < .05). CONCLUSION Patients with a BMI exceeding 35 kg/m(2) (severely obese) or a BMI of less than 25 kg/m(2) have higher rates of complication after RTSA.

Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4500 patients.

Objectives: To compare the outcomes of open reduction and internal fixation (ORIF), closed reduction and percutaneous pinning, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA) for proximal humerus fractures. Data Sources: The search was performed on September 9, 2012 using an explicit search algorithm in the following databases: Medline, SportDiscus, CINAHL, and Cochrane Central Register of Controlled Trials. Inclusion criteria were English language studies reporting clinical outcomes after surgical treatment of 3- or 4-part proximal humerus fractures with a minimum of 1-year follow-up. Study Selection: English language studies reporting clinical outcomes after surgical treatment of 3- or 4-part proximal humerus fractures with a minimum of 1-year follow-up. Levels 1–4 studies were eligible for inclusion. Data Extraction: Study methodological quality and bias was evaluated using the Modified Coleman Methodology Score. Data Synthesis: Two-proportion Z test and multivariate linear regression analyses were used for group comparisons. Conclusions: Significantly better clinical outcomes were observed for ORIF over HA and RSA (American Shoulder and Elbow Score, Disabilities of Arm, Shoulder, and Hand, Constant) (P < 0.05). However, ORIF had a significantly higher reoperation rate versus HA and RSA (P < 0.001 for both). Comparing HA with RSA, there was no difference in any outcome measure. The rate of tuberosity nonunion was 15.4% in the HA group. There were more complications following closed reduction and percutaneous pinning versus ORIF, HA, and RSA (P < 0.05). ORIF for proximal humerus fractures demonstrates better clinical outcome scores but with a significantly higher reoperation rate. HA and RSA are effective as well, but tuberosity nonunion remains a concern with HA.

Functional Performance Testing After Anterior Cruciate Ligament Reconstruction A Systematic Review

Background: When to allow an athlete to return to unrestricted sporting activity after anterior cruciate ligament (ACL) reconstruction remains controversial. Purpose: To report the results of functional performance testing reported in the literature for individuals at differing time points following ACL reconstruction and to examine differences between graft types. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of Medline, Scopus, and Cochrane Central Register of Controlled Trials was performed using PRISMA guidelines. Inclusion criteria were English-language studies that examined any functional rehabilitation test from 6 months to 2 years following ACL reconstruction. All patient-, limb-, and knee-specific demographics were extracted from included investigations. All functional rehabilitation tests were analyzed and compared when applicable. Results: The search term returned a total of 890 potential studies, with 88 meeting inclusion and exclusion criteria. A total of 4927 patients were included, of which 66% were male. The mean patient age was 26.5 ± 3.4 years. The predominant graft choices for reconstruction were bone–patellar tendon–bone (BPTB) autograft (59.8%) and hamstring autograft (37.9%). The most commonly reported functional tests were the hop tests. The results of these functional tests, as reported in the Limb Symmetry Index (LSI), improved with increasing time, with nearly all results greater than 90% at 1 year following primary ACL reconstruction. At 6 months postoperatively, a number of isokinetic strength measurements failed to reach 80% LSI, most commonly isokinetic knee extension testing in both BPTB and hamstring autograft groups. The knee flexion strength deficit was significantly less in the BPTB autograft group as compared with those having hamstring autograft at 1 year postoperatively, while no significant differences were found in isokinetic extension strength between the 2 groups. Conclusion: Hop testing was the most commonly reported functional test following ACL reconstruction. Increases in performance on functional tests were predictably seen as time increased following surgery. Those with hamstring autografts may experience increased strength deficits with knee flexion versus those having BPTB autograft. These data provide information that may assist providers in determining timing of return to unrestricted sporting activity.