Ishaan Swarup

Embryology, diagnosis, and evaluation of congenital hand anomalies

Although congenital hand anomalies are rare, musculoskeletal clinicians should have a basic understanding of their clinical manifestations and the possibility of concurrent anomalies and syndromes. In this review, we provide a brief overview of the embryology of limb development and the molecular pathways involved. We also summarize the clinical manifestations, diagnostic evaluation, and principles of surgical treatment for radial longitudinal deficiency, thumb hypoplasia, ulnar longitudinal deficiency, central deficiency, syndactyly, polydactyly, and amniotic constriction band. Although one of the main goals of treatment is to provide a functional upper extremity, musculoskeletal clinicians should be aware of the clinical findings that should trigger referral to evaluate for life-threatening syndromes.

Implant Survival and Patient-Reported Outcomes After Total Hip Arthroplasty in Young Patients With Juvenile Idiopathic Arthritis

Juvenile Idiopathic Arthritis (JIA) is a common rheumatologic disease that frequently involves the hip joint and requires treatment with total hip arthroplasty (THA). A retrospective study with prospective follow-up was conducted to determine implant survival and patient-reported outcomes in JIA patients aged 35 or younger treated with THA. This study included 56 patients, and the mean time to follow-up was 12 years. The 10-year implant survival was 85%, and implant survival was significantly longer in older patients (P value=0.04). Hip disability and osteoarthritis outcome (HOOS) scores were favorable at follow-up, but significantly worse in women and patients with custom implants or history of revision THA. Overall, patient factors and implant characteristics predict implant survival and outcomes after THA in young patients with JIA.

Implant survival and patient-reported outcomes after total hip arthroplasty in young patients with developmental dysplasia of the hip

Background Developmental dysplasia of the hip (DDH) is a common cause of hip pain in young patients, and may require treatment with total hip arthroplasty (THA). This study evaluates implant survival and describes patient-reported outcomes after primary THA in DDH patients aged 35 or younger. Methods A retrospective study with prospective follow-up was conducted at a major academic medical centre. Patient charts were reviewed to identify young THA patients with DDH, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes. Results This study included 61 patients (75 THAs, 75% follow-up), and the mean time to follow-up was 13 years (range 3-25 years). The 10-year and 20-year implant survival was 87% (95% CI, 78%-94%) and 55% (95% CI, 37%-72%), respectively, and implant survival was significantly better in patients over the age of 25 at the time of surgery (p value <0.01). The mean HOOS patient scores were 83 for pain (SD 20.29), 78 for symptoms (SD 19.72), 83 for ADLs (SD 20.89), and 74 for sports (SD 25.92). Patients that were younger at the time of surgery or required custom implants reported worse HOOS-Symptom scores at follow-up (p value = 0.02). Discussions Young patients with DDH have good outcomes after surgery. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with DDH.

Patellar instability treated with distal femoral osteotomy

BACKGROUND Patellar instability can cause significant disability in both pediatric and adult patients, and it is associated with several factors including genu valgum. In this study, we describe the role of a lateral opening wedge distal femoral osteotomy (DFO) combined with lateral retinacular release in addressing genu valgum with associated patellar instability. The rationale for this approach is to medialize the patellar tendon insertion and decrease the Q angle with DFO. METHODS A consecutive series of patients were studied, and our outcomes of interest included improvements in radiographic measures and patient outcomes. Radiographic improvement was assessed using patella congruency angle (PCA), mechanical axis deviation (MAD), and lateral distal femoral angle (LDFA). Patient outcomes were assessed using Oxford Knee scores, KOOS-PS scores, VAS pain scores, and Kujala scores. RESULTS We studied eight patients (10 knees) that underwent a lateral opening wedge DFO for genu valgum and patellar instability. Mean follow-up duration was 27 months. PCA improved from 30.4° lateral preoperatively to 5.7° lateral postoperatively (p=0.016). Similarly, MAD improved from 33.1mm lateral to 6.5mm medial, and LDFA improved from 82.4° to 92.7° after surgery (p=0.002). There were significant improvements in VAS pain and Kujala scores after surgery (p<0.05), and a trend towards improvement in KOOS-PS scores (p=0.14). The mean Oxford Knee score at follow-up was 36.25. CONCLUSION There is an important relationship between mechanical alignment and patellar instability. Lateral opening wedge DFO is an effective treatment for patellar instability in patients with genu valgum.

Outcomes after total hip arthroplasty in young patients with osteonecrosis of the hip

Background Osteonecrosis of the hip is a clinical, radiographic, and pathologic entity that commonly affects young patients. This study evaluates long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients with osteonecrosis aged 35 or younger. Methods A retrospective study with prospective follow-up was conducted at a major academic medical center. Chart review was performed to identify young THA patients with osteonecrosis, and follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Kaplan-Meier survival analysis was performed to evaluate implant survival, and the hip disability and osteoarthritis outcome score (HOOS) was used to describe patient-reported outcomes. Results The study included 135 patients (204 THAs) with a mean time to follow-up of 14 years. In this group, 10-year implant survival was 86% and 20-year implant survival was 66%. Implant survival was longer in male patients (p = 0.02) and patients that were over the age of 25 at the time of surgery (p = 0.03). The mean HOOS scores at follow-up were 87 for pain, symptoms, and ADLs, and 77 for sports. All HOOS measures were lower in patients that underwent a revision THA, and HOOS-Pain and HOOS-Sport scores were lower in patients that were over the age of 25 at the time of surgery (p<0.05). Conclusions Young patients with osteonecrosis have good implant survival and long-term outcomes after THA. Patient factors and implant characteristics should be considered when predicting implant survival and outcomes after THA in young patients with osteonecrosis.

Common factors associated with osteonecrosis of the femoral head in young patients requiring total hip arthroplasty

Osteonecrosis of the femoral head is a pathologic condition that commonly affects young patients and requires treatment with total hip arthroplasty (THA). The most common factors associated with osteonecrosis in young patients have not been previously described in the literature. A retrospective study was conducted to describe the most common factors associated with osteonecrosis in patients aged 35 or younger requiring a primary THA. This study included 235 patients and found that the most common factor associated with osteonecrosis was corticosteroid use (61%), followed by idiopathic causes (11%), trauma (9%), other causes (8%), haemoglobinopathies (7%), and alcoholism (3%). There was no significant difference in age between risk groups (p-value = 0.35), however there were significant differences in sex (p-value = 0.02) and unilateral versus bilateral surgery (p-value<0.01). Several factors are associated with the development of osteonecrosis of the femoral head in young patients, and these factors should be given consideration in determining disease aetiology and counselling patients.

Preoperative body mass index and physical function are associated with length of stay and facility discharge after total knee arthroplasty

BACKGROUND Hospital length of stay (LOS) and facility discharge are primary drivers of the cost of total knee arthroplasty (TKA). We sought to identify modifiable patient factors that were associated with increased LOS and facility discharge after TKA. METHODS Prospective data were reviewed from 716 consecutive, primary TKA procedures performed by two arthroplasty surgeons between 2006 and 2012 at a single institution. Preoperative body mass index (BMI), Veterans RAND-12 (VR-12) physical component score (PCS), and hemoglobin level were collected in addition to other adjusters. Multivariate linear and logistic models were constructed to predict LOS and facility discharge, respectively. RESULTS After adjustment, higher BMI was associated with increased LOS in a dose-response effect: Compared to normal weight (BMI <25) overweight (25-29.9) was associated with longer LOS by 0.32days (P=0.038), class-I obesity (30-34.9) by 0.33days (P=0.024), class-II obesity (35-39.9) by 0.67days (P=0.012) and class-III obesity (>40) by 1.15days (P<0.001). Class-III obesity was associated with facility discharge (odds ratio=2.08, P=0.008). Poor PCS was associated with increasing LOS: compared to PCS≥50, PCS 20-29 was associated with a LOS increase of 0.40days (P=0.014) and PCS<20 with a LOS increase of 0.64days (P=0.031). CONCLUSION Patient BMI has a dose-response effect in increasing LOS. Poor PCS was associated similarly with increased LOS. These associations for of BMI and PCS suggest that improvement preoperatively, by any amount, may potentially translate to decreased LOS and perhaps lower the cost associated with TKA.

Total Hip Arthroplasty in Young Patients with Post-Traumatic Arthritis of the Hip:

Background Post-traumatic arthritis of the hip is a degenerative condition that commonly affects young patients. In this study, we evaluate long-term implant survival and patient-reported outcomes after primary total hip arthroplasty (THA) in patients aged 35 or younger with post-traumatic arthritis of the hip. Methods We conducted a retrospective study with follow-up. A chart review was performed to identify young patients with post-traumatic arthritis of the hip treated with primary THA. Follow-up surveys were conducted to determine implant survival and patient-reported outcomes. Implant survival was assessed using Kaplan-Meier survival analysis, and patient outcomes were determined using the hip disability and osteoarthritis outcome score (HOOS). Results We studied 42 patients (44 THAs) with a mean time to follow-up of 14 years. The 10-year implant survival rate was 87% and 20-year implant survival rate was 41%. Implant survival did not differ based on patient age, gender, implant type, bearing surface, or use of cement for implant fixation (p>0.05). The mean HOOS scores at follow-up were 87 for pain, 85 for symptoms, 89 for ADLs, and 76 for sports. HOOS scores were significantly worse in patients that had undergone revision THA (p<0.05). Conclusions Young patients with post-traumatic arthritis of the hip have good long-term outcomes after THA. However, revision THA is predictive of worse long-term outcomes.

Hypertrophic Osteoarthropathy: an Unusual Cause of Knee Pain and Recurrent Effusion

Knee pain and effusion are a common cause for referral to an orthopedic surgeon. Even though the AAOS recognizes that arthritis is the most common cause for knee pain and disability, other diagnoses should be considered when evaluating patients [14]. Hypertrophic osteoarthropathy is a syndrome characterized by clubbing of the digits, periosteal new bone formation, and synovial effusions [3]. While clubbing of the digits was described by Hippocrates, the clinical triad of digital clubbing, ossifying periostitis, and arthralgias was recognized in the 1800s [6]. Hypertrophic osteoarthropathy is classically described as either primary or secondary. Primary or familial form of hypertrophic osteoarthropathy, also known as pachydermoperiostosis, typically begins in childhood and represents 3% of all cases of hypertrophic osteoarthropathy [3, 4]. Secondary hypertrophic osteoarthropathy is associated with an underlying pulmonary, cardiac, hepatic, or intestinal disease, and it is more common in adults [3]. As a whole, hypertrophic osteoarthropathy is a rare condition. There is a paucity of systematic prevalence studies on hypertrophic osteoarthropathy, but the coincidence of this condition in association with other underlying medical conditions has been described [4]. For example, hypertrophic osteoarthropathy occurs in 5–10% of patients with intrathoracic malignancies, but its prevalence has been reported to be as high as 32% in patients with primary lung cancer [9]. While primary hypertrophic osteoarthropathy occurs in young patients, secondary osteoarthropathy commonly affects patients between the ages of 55–75 [9]. The morbidity and mortality associated with hypertrophic osteoarthropathy is dependent upon its associated medical condition [4]. Patients with hypertrophic osteoarthropathy are most commonly evaluated by primary care physicians, rheumatologists, and other medical specialists. These patients are not typically evaluated primarily by orthopedic surgeons, and as a result, there is limited awareness of the clinical manifestations and medical implications of this condition. Given the association between hypertrophic osteoarthropathy and serious medical conditions, it is important to raise awareness of this condition among orthopedic surgeons. This case report provides an interesting example of a patient who presented for evaluation of his knee osteoarthritis and was found to have hypertrophic osteoarthropathy. In this case report of the incidental and unexpected finding of hypertrophic osteoarthropathy, we present the patient’s history, physical exam, synovial analysis, radiographs, and work-up. Our goal is to educate orthopedic surgeons and other professionals about the classic characteristics and clinical relevance of hypertrophic osteoarthropathy. Ultimately, increased awareness of this condition may result in timely referral and management of serious medical conditions.

Effect of preoperative patient expectations on outcomes after reverse total shoulder arthroplasty

BACKGROUND The purpose of this study was to determine the effect of preoperative expectations on outcomes after reverse shoulder arthroplasty (RSA). We hypothesized that patients with greater expectations would have better outcomes. METHODS Patients undergoing primary RSA completed the Hospital for Special Surgerys Shoulder Expectations Survey preoperatively. Preoperative and 2-year postoperative clinical outcomes were measured with the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, Shoulder Activity Scale (SAS), 36-Item Short Form Health Survey (SF-36), and visual analog scales (VASs). Pearson correlations were used to assess the relationship between the number of expectations and outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation question were assessed by independent samples t test. Multivariable linear regression analysis was used to control for potential confounding factors. RESULTS We evaluated 135 patients at 2 years postoperatively. Patients had higher expectations for relieving pain, improving self-care, improving ability to perform daily activities, and improving ability to drive or put on a seatbelt. Patients with a greater number of high expectations preoperatively did not have better ASES, SAS, or VAS pain scores postoperatively. However, higher expectations for relieving nighttime pain was associated with ASES (β = 7.0, P = .048) and VAS pain scores (β = -5.9, P = .047) as well as 2-year improvement of VAS pain (β = -6.1, P = .039). Higher expectations for improving the ability to participate in nonoverhead sports was associated with improvements in SAS (β = 2.8, P = .020). CONCLUSION A higher level of expectations for relief of nighttime pain and improving ability to participate in nonoverhead sports is associated with improved outcomes after RSA.