Mario Hevesi

Multicenter Analysis of Midterm Clinical Outcomes of Arthroscopic Labral Repair in the Hip: Minimum 5-Year Follow-up

Background: The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown. Purpose: To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years’ follow-up. Factors including age, body mass index (BMI), Tönnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery. Results: A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent periacetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI >30 kg/m2 had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI ≤30 kg/m2 (P < .01). Patients aged >35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged ≤35 years (P = .03). Patients with Tönnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score (P = .02) and a 23.0-point worse HOS-SSS score (P < .01) when compared with patients with Tönnis grade 0. Conclusion: Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with Tönnis grade 2 changes preoperatively, BMI >30 kg/m2, and age >35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.

Arthritis Progression on Serial MRIs Following Diagnosis of Medial Meniscal Posterior Horn Root Tear.

&NA; Medial meniscus posterior root tears (MMPRTs) are a significant source of pain and dysfunction. The purpose of this study was to evaluate changes in the medial compartment of the knee over time following the diagnosis of a MMPRT on MRI. A retrospective review of the institutional database was performed for patients with an initial MRI diagnosis of a MMPRT. Patients were included if they had a subsequent follow‐up MRI on the same knee. Patients with surgical intervention, including debridement or repair, were excluded. MRIs were evaluated by two board‐certified musculoskeletal radiologists. MMPRTs were defined using the LaPrade classification, and the medial compartment articular cartilage was graded using the modified Outerbridge classification. MRIs were reviewed for meniscus extrusion, subchondral bone edema, and insufficiency fractures. Patients were divided into two groups for the analysis to account for differences in MRI time intervals. Group 1 had a follow‐up MRI within 12 months of initial imaging (subacute group) and Group 2 had a follow‐up MRI greater than 12 months after initial imaging (chronic group). Forty‐one knees and 82 MRIs were analyzed, including 20 knees/40 MRIs (13 females, 7 males) in the subacute group and 21 knees/42 MRIs (14 females, 7 males) in the chronic group. Subacute patients had a mean age of 59.5 ± 8.8 years and a mean interval of 4.8 ± 2.6 months between MRIs compared with 53.6 ± 11.0 years and 38.2 ± 20.8 months, respectively, for the chronic group. Meniscal extrusion, femoral modified Outerbridge grade, and tibial modified Outerbridge grade worsened between initial and final MRI in both groups (p < 0.05). In both groups, there were no significant differences between initial and final MRIs with regard to the LaPrade classification, insufficiency fracture, or subchondral cysts of the tibia. Progressive meniscus extrusion and medial compartment articular cartilage degeneration were seen in patients with MMPRTs within a year from diagnosis.

Comparative Outcomes of All-Inside Versus Inside-Out Repair of Bucket-Handle Meniscal Tears: A Propensity-Matched Analysis

Background: There are limited data comparing the outcomes of all-inside versus inside-out meniscal repair techniques. Purpose: To assess failure rates and clinical outcomes after the surgical repair of bucket-handle meniscal tears utilizing either an all-inside or inside-out technique. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with bucket-handle meniscal tears undergoing all-inside or inside-out repair at a single institution between 2003 and 2013 were analyzed. A total of 28 mensici repaired utilizing second-generation all-inside suturing devices and 42 menisci repaired using an inside-out technique were eligible for inclusion. Rigorous propensity matching was performed on the basis of age, sex, tear laterality, rim width, and concomitant anterior cruciate ligament reconstruction (ACLR), resulting in a total of 40 patients equally distributed between the 2 repair techniques for comparison. Retear-free survival as well as preoperative and postoperative International Knee Documentation Committee (IKDC) and Tegner scores and physical examination findings were subsequently analyzed. Results: Twenty patients who underwent all-inside repair (14 male; mean age, 23.7 ± 6.7 years) were successfully propensity matched to 20 patients who underwent inside-out meniscal repair (15 male; mean age, 22.5 ± 7.6 years), with a mean retear-free follow-up of 4.4 years (range, 2.5-7.4 years). Four (20%) all-inside repairs and 4 (20%) inside-out repairs failed over the course of follow-up (P > .999), with a mean time to failure of 2.7 years (range, 1.3-4.4 years) and 5.0 years (range, 0.8-7.5 years), respectively (P = .25). Increasing patient age trended toward a decreased clinical retear rate, independent of the repair technique (hazard ratio, 0.86; P = .056). There were no significant differences in the Tegner scores, IKDC scores, or range of motion between the groups as a whole or when subcategorizing by age, sex, body mass index, tear complexity, rim width, isolated versus concomitant ACLR, or medial- versus lateral-sided repair. There were no complications in the all-inside group, while there was a 10% rate of minor complications in the inside-out group (P = .49). Conclusion: Overall, satisfactory clinical outcomes are achievable at short-term to midterm follow-up with both inside-out and all-inside repair techniques of bucket-handle meniscal tears in rigorously matched patients with similar meniscal tear patterns.

The Rapidly Assessed Predictor of Intraoperative Damage (RAPID) Score: An In-Clinic Predictive Model for High-Grade Acetabular Chondrolabral Disruption

Background: The preoperative assessment of cartilage lesions is critical to surgical planning and decision making. The accurate radiographic determination of acetabular cartilage damage has remained elusive for modern imaging modalities, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). While risk factors have been individually described, no multivariable system exists for predicting high-grade cartilage damage. Purpose: To determine the preoperative predictors of grade 3 to 4 acetabular labrum articular disruption (ALAD) lesions. Study Design: Case-control study; Level of evidence, 3. Cohort study (diagnosis); Level of evidence, 1. Methods: Retrievable radiographs were reviewed from primary hip arthroscopic procedures performed at 2 high-volume institutions between December 2007 and April 2017. The predictive value of demographic and radiographic factors for the intraoperative documentation of ALAD grade 3 to 4 damage was analyzed and entered into a multivariable model, and a statistically guided scoring system for the damage risk was created using the Akaike information criterion. The scoring system was then prospectively validated on 167 patients who underwent primary hip arthroscopy between April 2017 and February 2018. Results: A total of 652 primary hip arthroscopic procedures in 614 patients (390 female, 224 male; mean age, 33.2 ± 12.5 years; mean body mass index, 26.9 ± 5.5 kg/m2) from 2007 to 2017 were analyzed. Male sex (odds ratio [OR], 3.11; P < .01), age ≥35 years (OR, 1.96; P < .01), cam morphology (alpha angle >55°) (OR, 2.96; P < .01), and Tönnis grade 1 to 2 (grade 1: OR, 4.14; P < .01, and grade 2: OR, 9.29; P < .01) were univariate risk factors for intraoperatively documented high-grade damage. A multivariable scoring system, the Rapidly Assessed Predictor of Intraoperative Damage (RAPID) score (0-5 points), was generated based on sex, Tönnis grade, and cam morphology. Patients with increasing RAPID scores had an increasing risk of damage, with a 10.5% risk for those with 0 points and an 88.0% risk for those with 5 points (P < .01). The area under the curve was 0.75 for the study group and 0.76 for the validation group (P = .94). Conclusion: While preoperative MRI has diagnostic value for hip arthroscopic surgery, the RAPID score provides added benefit as a readily employable, in-clinic system for predicting high-grade cartilage damage. The discriminatory value of the RAPID score compares favorably with previous MRI and MRA studies. This information will help the clinician and patient plan for high-grade damage and identify potential targets for cartilage treatment.

Learning From Failure in Cartilage Repair Surgery: An Analysis of the Mode of Failure of Primary Procedures in Consecutive Cases at a Tertiary Referral Center

Background: As the number of cartilage restoration procedures is increasing, so is the number of revision procedures. However, there remains limited information on the reasons for failure of primary cartilage restoration procedures. Purpose: To determine the common modes of failure in primary cartilage restoration procedures to improve surgical decision making and patient outcomes. Study Design: Case series; Level of evidence, 4. Methods: Patients who presented for revision after failed cartilage repair surgery were evaluated for factors contributing to failure of the primary procedure. All revision cases performed by a single surgeon at a tertiary center for failed cartilage restoration over a 6-year time frame were identified. In all cases, the medical records, preoperative radiographs, and magnetic resonance imaging scans were reviewed by 2 experienced cartilage surgeons. The cause for failure was categorized as malalignment, meniscal deficiency, graft or biologic failure, or instability. Univariate and descriptive statistics regarding patient demographics, index procedure, lesion location and size, and mechanism of failure were analyzed. Results: A total of 59 cases in 53 patients (32 male, 21 female) met the inclusion criteria. The mean patient age at the time of revision was 27.6 years, and the mean body mass index was 28.4 kg/m2. Failed index surgical procedures included 35 microfractures (59%), 12 osteochondral allograft transplantations (20%), 10 osteochondral autograft transfers (17%), 2 nonviable osteochondral allografts (3%), and 2 particulated juvenile chondral allografts (3%). The mean lesion size was 4.4 cm2. Reasons for failure included 33 cases with untreated malalignment (56%), 16 with graft failure (27%), 11 with untreated meniscal deficiency (19%), and 3 with untreated instability (5%); 4 cases demonstrated multiple reasons for failure. Conclusion: The most commonly recognized reason for failure was untreated malalignment. While biologic and graft failures will occur, the majority of failures were attributed to untreated background factors such as malalignment, meniscal deficiency, and instability. The stepwise approach of considering and addressing alignment, meniscal volume, and stability remains essential in cartilage restoration surgery.

Incidence and Treatment Trends of Symptomatic Discoid Lateral Menisci: An 18-Year Population-Based Study

Background: A symptomatic discoid lateral meniscus is an uncommon orthopaedic abnormality, and the majority of information in the literature is limited to small case series. Purpose/Hypothesis: The purpose of this study was to determine the incidence of symptomatic discoid menisci in a geographically determined population and to describe treatment trends over time. The hypothesis was that the incidence of symptomatic discoid menisci would be highest among adolescent patients, and thus, the rate of surgical treatment would be high compared with nonoperative treatment. Study Design: Descriptive epidemiology study. Methods: The study population included 79 patients in Olmsted County, Minnesota, identified through a geographic database, who were diagnosed with a symptomatic discoid lateral meniscus between 1998 and 2015. The complete medical records were reviewed to confirm the diagnosis and evaluate the details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 United States population. Results: The overall annual incidence of symptomatic discoid lateral menisci was 3.2 (95% CI, 2.5-3.9) per 100,000 person-years; 12.6% of the patients in the cohort had bilateral symptomatic discoid lateral menisci. The overall annual incidence was similar between male (3.5 per 100,000 person-years) and female patients (2.8 per 100,000 person-years). The highest incidence of symptomatic discoid lateral menisci was noted in adolescent male patients aged 15-18 years (18.8 per 100,000 person-years). A majority (72.2%) of patients presented with a symptomatic tear of the discoid meniscus. The remaining patients presented with mechanical symptoms, including catching/locking or effusion, with no demonstrable meniscus tear on imaging or diagnostic arthroscopic surgery. Additionally, 20.0% of patients were observed to have peripheral instability of the meniscus at the time of diagnostic arthroscopic surgery. The mean age of those with peripheral instability was significantly younger than of those who did not have peripheral instability. Sixty patients (75.9%) received surgical treatment during the study period, including 49 (81.7%) patients who underwent partial lateral meniscectomy and 11 (18.3%) patients who underwent lateral meniscus repair in addition to saucerization. Conclusion: With an overall annual incidence of 3.2 per 100,000 person-years, a symptomatic discoid meniscus is an uncommonly encountered orthopaedic abnormality. However, the incidence of symptomatic discoid lateral menisci is highest in adolescent male patients. Because of the high rate of meniscus tears in patients presenting with symptoms, the majority are treated surgically.

Spinal Fusions in Active Military Personnel: Who Gets a Lumbar Spinal Fusion in the Military and What Impact Does It Have on Service Member Retention?

Introduction Back pain related to spinal degenerative disease is one of the most common causes of missed duty days and medical separation for active service members. While the topic of operative versus non-operative treatment of degenerative spine conditions in active military personnel has received more and much needed attention in the last few years, there remains a paucity of data examining the expanded demographics and clinical findings of those undergoing spinal fusion in which validated outcome measures are used to assess post-operative results. The purpose of this study was to define the characteristics and outcomes of spinal fusion surgery at U.S. military medical treatment facilities. Materials and Methods A cohort of 145 active military personnel undergoing spinal fusion at a single military medical center between 2008 and 2013 were examined in a retrospective fashion using data from primary source documentation recorded prospectively in the military electronic medical records and the image data repository for demographics, clinical/imaging findings and patient reported outcome scores at mean follow-up of 6 mo. Oswestery Disability Index (ODI) scores and the Visual Analog Scale (VAS) were used as patient reported outcome measures. Soldier rank, active duty status, and service-connected disability percentage were also analyzed as military specific outcome measures. Results The typical solider undergoing spinal fusion was a Caucasian male serving in the U.S. Army. At last follow-up, there were statistically significant improvements in pre-operative to post-operative ODI and VAS scores. Younger age at the time of surgery was a negative predictor for post-operative VAS outcomes (p = 0.047). There were six reoperations in the cohort for neurologic symptoms and hardware migration. The majority of soldiers went on to medical retirement but a considerable number saw an increase in their rank prior to doing so. Those who ended their service in regular retirement and medical retirement went on to see 90.7% and 85% service-connected disability respectively. Discussion This investigation reports on the largest cohort of active military personnel undergoing spinal fusion. A variety of demographic information are reviewed to clarify the picture of soldiers at risk for needing a spinal fusion. While younger age was an independent risk factors for worsened VAS scores, no independent variable portended a worse ODI score at last follow-up. Despite improvements in objective measures such as VAS, ODI, and increases in rank, soldiers going on to retirement collected a dramatic service-connected disability percentage. Level of Evidence Level IV, Therapeutic.

Arthroscopy and arthrotomy to address intra-articular pathology during PAO for hip dysplasia demonstrates similar short-term outcomes

ABSTRACT Periacetabular osteotomy (PAO) remains the gold standard procedure for joint preservation in symptomatic developmental dysplasia of the hip (DDH). Hip arthroscopy (HA) and open arthrotomy have been used to correct intra-articular pathology at the time of PAO, but there is limited data regarding differences in outcomes between these techniques when performed at the time of PAO. The aim of this study was to determine if short-term clinical outcomes differed between patients managed with HA versus arthrotomy to evaluate and treat intra-articular pathology at the time of PAO to discern if one technique is associated with better pain and functional results. Data were retrospectively reviewed from two surgeons at one institution managing DDH patients from September 2013 to December 2015. One surgeon treated patients with PAO and arthrotomy (N = 32), while the other performed PAO and HA (N = 39). There were 87% women, median age was 28 years and mean BMI was 25. Seventy-five percent of all patients received an intra-articular intervention. Patients completed 13 PROs at the pre-operative and 1-year post-operative clinical visits. Pre-operatively, there were no differences in any of the 13 PROs between patients treated with HA versus arthrotomy (P ≥ 0.076). Patients treated with PAO and arthrotomy experienced greater mean improvement in two out of the 13 PROs; the other 11 showed no differences. No treatment effect was observed for any of the 13 PROs using multivariable modelling that accounted for severity of dysplasia and degree of arthritis. Few differences were shown in short-term clinical outcomes between HA and arthrotomy at the time of PAO. This work highlights the need for a high quality randomized clinical trial to provide definitive guidance on whether hip preservation surgeons should address intra-articular pathology at the time of PAO for DDH and which technique best serves this purpose.

Thumb carpometacarpal arthritis in patients with Ehlers-Danlos Syndrome: non-operative and operative experiences

Ehlers-Danlos Syndrome is a connective tissue disorder that results in joint and generalized tissue hyperlaxity, predisposing patients to early onset arthritis. An institutional database spanning 1999–2016 was reviewed for all patients with symptomatic carpometacarpal arthritis and coexisting Ehlers-Danlos Syndrome, resulting in 14 thumbs amongst nine patients followed clinically for a median of 5.9 years (range 1–15). Patients managed non-operatively demonstrated stable subjective pain and trended towards decreased range of motion over time, whereas patients managed operatively had significant improvements in pain and trended towards increased grip strength. Our findings suggest that patients with Ehlers-Danlos-associated carpometacarpal arthritis can be successfully managed both operatively and non-operatively and that patients with pain refractory to conservative therapy may benefit from relief and increased hand strength following surgical intervention. Level of evidence: IV

The 2018 Chitranjan S. Ranawat, MD Award: Developing and Implementing a Novel Institutional Guideline Strategy Reduced Postoperative Opioid Prescribing After TKA and THA

Background Opioid prescription management is challenging for orthopaedic surgeons, and we lack evidence-based guidelines for responsible opioid prescribing. Our institution recently developed opioid prescription guidelines for patients undergoing several common orthopaedic procedures including TKA and THA in an effort to reduce and standardize prescribing patterns. Questions/purposes (1) How do opioid prescriptions at discharge and 30-day refill rates change in opioid-naïve patients undergoing primary TKA and THA before and after implementation of a novel prescribing guideline strategy? (2) What patient, surgical, and in-hospital factors influence opioid prescription quantity and refill rate? Methods New institutional guidelines for patients undergoing TKA and THA recommend a maximum postoperative prescription of 400 oral morphine equivalents (OME), comparable to 50 tablets of 5 mg oxycodone or 80 tablets of 50 mg tramadol. All opioid-naïve patients, defined as those who did not take any opioids within 90 days preceding surgery, undergoing primary TKA and THA at a single tertiary care institution were evaluated from program initiation on August 1, 2017, through December 31, 2017, as the postguideline era cohort. This group (n = 751 patients) was compared with all opioid-naïve patients undergoing TKA and THA from 2016 at the same institution (n = 1822 patients). Some providers were early adopters of the guidelines as they were being developed, which is why January to July 2017 was not evaluated. Patients in the preguideline and postguideline eras were not different in terms of age, sex, race, body mass index, education level, employment status, psychiatric illness, marital status, smoking history, outpatient use of benzodiazepines or gabapentinoids, or diagnoses of diabetes mellitus, peripheral neuropathy, or cancer. The primary outcome assessed was adherence to the new guidelines with a secondary outcome of opioid medication refills ordered within 30 days from any provider. Multivariable logistic regression analyses were performed with outcomes of guideline compliance and refills and adjusted for demographic, surgical, and patient care factors. Patients were followed for 30 days after surgery and no patients were lost to followup. Results Median opioid prescription and range of prescriptions decreased in the postguideline era compared with the preguideline era (750 OME, interquartile range [IQR] 575-900 OME versus 388 OME, IQR 350-389; difference of medians = 362 OME; p < 0.001). There was no difference among patients undergoing TKA before and after guideline implementation in terms of the 30-day refill rate (35% [349 of 1011] versus 35% [141 of 399]; p = 0.77); this relationship was similar among patient undergoing THA (16% [129 of 811] versus 17% [61 of 352]; p = 0.55). After controlling for relevant patient-level factors, we found that implementation of an institutional guideline was the strongest factor associated with a prescription of ⩽ 400 OME (adjusted odds ratio, 36; 95% confidence interval, 25-52; p < 0.001); although a number of patient-level factors also were associated with prescription quantity, the effect sizes were much smaller. Conclusions This study provides a proof of concept that institutional guidelines to reduce postoperative opioid prescribing can improve aftercare in patients undergoing arthroplasty in a short period of time. The current report evaluates our experience with the first 5 months of this program; therefore, longer term data will be mandatory to determine longitudinal guideline adherence and whether the cutoffs established by this pilot initiative require further refinement for individual procedures. Level of Evidence Level II, therapeutic study.