O’Connor, Kyle P.

Abstract Background: Resilience, quantified by the brief resilience scale (BRS), has been recognized for its role in pain and symptomatology in musculoskeletal conditions. The role of psychological factors in the clinical presentation and outcomes of FAI surgery continues to be poorly understood. Methods: This is a prospective multicenter study of FAI patients undergoing primary hip arthroscopy. PROMs were administered at baseline, 3-, and 6-months post-op and included the Patient Reported Outcomes Measurement Information System (PROMIS) domains of anxiety and depression, as well as Hip Disability and Osteoarthritis and Outcome Score (HOOS), modified Harris Hip Score (mHHS), and International Hip Outcome Tool (iHOT-12). Resilience was characterized by BRS score and divided into low (“L”, score<3), normal (“N”, score 3-4.3), and high resilience (“H”, score>4.3). Results: 675 patients were included with a mean age of 24.9±7.8 years and female predominance (56%). Mean BRS scores were 3.7±0.7 (1.5-5.0). 13.8% (n=93) had low resilience, 65.9% (n=445) had normal resilience, and 20.3% (n=137) had high resilience. Lower resilience had more severe symptoms in HOOS pain (p<0.001), HOOS sports (p=0.003), HOOS ADL (p<0.001), HOOS QoL (p<0.001), iHOT-12 (p=0.002), and mHHS (p<0.001). Anxiety (L: 50.5%/N: 14.4%/H: 2.2%) and depression (L: 38.7%/N: 8.8%/H: 2.9%) were higher in lower resilience groups (all p<0.001) and this trend stayed consistent in female and male sub-analyses with females having greater anxiety and depression symptoms. The follow-up cohort with 3- and 6-months follow-up was 487 patients and had similar baseline characteristics as the baseline cohort. Lower resilience had lower postoperative PROs (with similar change) (p<0.05). After treatment, rates of anxiety or depression decreased from 22.1% to 15.6% with the low resilience group having the highest change from 62.9% to 45.9%. Conclusion: Low resilience correlates with more severe symptoms and predicts anxiety/depression in FAI. 13.8% had low resilience while 20.3% had high resilience. Lower resilience had worse postoperative PROs. Particularly in patients with low resilience at presentation, rates of anxiety or depression symptoms decreased postoperatively. Further studies are needed to understand the role of resilience in longer-term outcomes of FAI and whether concurrent psychological treatment will help improve patient outcomes after hip arthroscopy for FAI.

Abstract Introduction: Low-dose computed tomography (CT) has been increasingly utilized in FAI due to its improved ability to characterize the complex and variable hip morphologies of FAI patients, compared to plain radiographs. This study defined FAI morphology between females and males as well as across adolescents, young adults, and older adults. Methods: A multi-center, prospective cohort of FAI patients undergoing primary arthroscopy was performed. Patients 14-45 years of age with idiopathic FAI were included. Low-dose CT was used for preoperative planning. Analysis focused on acetabular and femoral morphology and the differences between females/males and adolescents (A,14-18.9)/young adults (Y,19-24.9)/older adults (O,25+). Adolescents were the reference group during analysis. Results: There were 604 patients with CT data. Mean age was 24.9 years with 55.9% female. Males had more anterosuperior coverage (i.e. 64.2% vs 62.5% at 1:00), lower version (14.1° vs 18.0°), smaller femoral neck-shaft angles (130.9° vs 133.4°), and larger alpha angles (i.e. 72.1° vs 58.6° at 1:00) compared to females. Multivariable analysis demonstrated that females had associations with more femoral anteversion (OR: 1.05,CI: 1.03-1.07) and larger femoral neck-shaft angles (OR: 1.11,CI: 1.06-1.16). Males has associations with larger alpha angles at 1:00 (OR: 1.05,CI: 1.02-1.07) and 1:30 (OR: 1.03,CI: 1.00-1.06) as well as radial coverage at 1:00 (OR: 1.18,CI: 1.11-1.26). For females, adolescents had slightly less radial coverage at 2:00 (49.9%) compared to young (51.2%) and older adults (51.4%). Femoral neck-shaft angle decreased across age groups (A: 134.4°,Y: 133.0°,O: 132.7°). Alpha angles increased at 2:00 with age (A:54.6°,Y:55.3°,O:58.7°). Multivariable analysis had femoral neck-shaft angle decreasing for young (OR: 0.932,CI: 0.87) and older adults (OR:0.92,CI: 0.86-0.98) and it also had alpha angle at 1:15 increasing for young adults (OR: 1.03,CI: 1.00-1.06) and older adults (OR: 1.03,CI: 1.01-1.06). Males did not have any appreciable differences alpha angles, femoral version, or acetabular coverage across age groups. Conclusion: Differences in morphology identified on CT exist between females and males as well as across age groups for females. These differences may offer insight into disease pathomechanics between these patient populations. Further studies should confirm these findings and look at how they affect patient outcomes after treatment.

Abstract Introduction: Femoroacetabular impingement commonly causes labral and cartilage damage. Understanding what clinical and CT-morphological factors are associated with increased labral and acetabular cartilage damage may give insight into the FAI pathophysiology. The present study aims to identify factors associated with labral and cartilage damage. Method: This is a prospective, multicenter cohort of patients undergoing primary arthroscopy for treatment of symptomatic FAI. Enrollment was between 2020 and 2022. The current study investigated predictive factors of advanced labral damage (detachment or full-thickness tear length >4cm) and advanced acetabular cartilage damage (delamination or full-thickness defect ≥200mm2). Finally, we performed external validation for the previously reported RAPID score that predicts high-grade cartilage injury. Results: There were 647 patients in the cohort. For labral injuries, there were 384/647 (59.4%) detachments and 154/647 (23.8%) full-thickness defects, with labral tears ≥4cm was present in 100/558 (17.9%) hips. Older age (OR:1.04, p=0.002), males (OR:1.83,p=0.005), and larger alpha angles at 2:00 (OR:1.02,p=0.04) were associated with full-thickness labral injuries. Older age (OR:1.06,p<0.001) and larger alpha angles at 2:00 (OR:1.03,p=0.01) were associated with tears ≥4cm. 258/679 (38.0%) patients had delamination or full-thickness cartilage defects. Older age (OR:1.09,p<0.001), males (OR:1.91 p=0.003), decreased IRF (OR:0.95,p<0.001), higher femoral version (OR:1.02,p=0.04), and larger alpha angles at 1:30 (OR:1.06,p<0.001) were associated with delamination or defect cartilage injuries. Advanced acetabular cartilage damage ≥200mm2 was present in 109/679 (16.8%) hips and was associated with larger alpha angles at 2:00 (OR:1.07,p<0.001), decreased IRF (OR:0.95,p<0.001), and males (OR:2.52,p=0.002), and age (OR:1.05,p=0.002). For RAPID score external validation, we used our data for their model (sex, Tonnis OA Grade, radiographic alpha angle) and found an AUC of 0.685. With an adjusted model using CT alpha angles, AUC improved to 0.703. Our final model improved the AUC to 0.809 and included age, sex, IRF, femoral version, and CT alpha angles. Conclusion: FAI commonly has associated labral and cartilage injuries. The current study found multiple predictive factors for advanced labral and cartilage injuries as well as for larger lesions. A model including age, sex, IRF, femoral version, and CT alpha angles appears to best predict acetabular cartilage damage. Further research should investigate how these affect outcomes.

Objectives: The role of psychological factors in the clinical presentation and outcomes of treated is increasingly recognized in orthopaedic surgery. Particularly, in prearthritic hip disorders, young adult hip patients often have significant psychological undertones. Patient resiliency, as quantified by the brief resiliency scale (BRS), is a static patient characteristic and has been increasingly recognized for its potential role in pain and symptomatology. The purpose of the current study was to investigate the correlation between BRS and traditional hip patient-reported outcome measures (PROMs). Methods: A prospective multicenter cohort study of 696 patients undergoing femoroacetabular impingement (FAI) primary hip arthroscopy surgery was performed and utilized for the current study. Inclusion criteria are patients aged 14 to 45 years old with idiopathic FAI not caused by childhood disease. Exclusion criteria are previous ipsilateral hip procedures or disease processes such as neuromuscular disease or high-grade osteoarthritis. PROMs included the Patient-Reported Outcomes Measurement Information System (PROMIS) domains of pain interference, physical function, mobility, anxiety, and depression, as well as hip disability and osteoarthritis and outcome score (HOOS), modified Harris hip score (mHHS), international hip outcome tool (iHOT-12), and short form-12 (SF-12). Resiliency was divided into low resiliency (score < 3), normal resiliency (score 3 to 4.3), and high resiliency (score > 4.3) as described by Smith et al 1 to use as categorical variables to compare to the other patient-reported scores. The Pearson correlation coefficient (r) was calculated and the Kruskall Willis test was used to measure association between BRS and the other PROMs for continuous and categorical values, respectively. R values ≥0.7, ≥0.4, and ≥0.1 signify a strong, moderate, and weak correlation, respectively. For categorical analysis, P values < 0.05 were considered significant. Results: The cohort of 696 patients had mean age was 24.9 ± 7.9 years and a female predominance at 56%. Average BRS scores were 3.7 ± 0.7. Overall, 13.7% of patients had low resiliency, while 65.8% had normal resiliency and 20.5% had high resiliency. Linear correlation, using Pearson coefficients, found associations between BRS and all other scores. There were only weak associations between BRS scores and PROs (all r < 0.25) except a moderate correlation with PROMIS depression (r = -0.476, p < 0.001) and PROMIS anxiety (r = -0.481, p < 0.001). Patients in higher resiliency groups reported less severe symptoms in HOOS – quality of life (p < 0.001), HOOS – sports and recreation (p = 0.004), HOOS – activities of daily living (p = 0.004), HOOS – pain (p = 0.026), iHOT-12 (p = 0.01), mHHS (p = 0.004), SF-12 mental (p < 0.001), PROMIS physical function (p = 0.003), PROMIS pain (p < 0.001), PROMIS mobility (p < 0.001), PROMIS depression (p < 0.001), and PROMIS anxiety (p < 0.001). Patients with higher activity levels (UCLA ≥9) demonstrated higher resiliency (p = 0.04). Conclusions: In FAI patients, patient resiliency appears to influence baseline PROs. Overall, 14% of patients had low resiliency while 21% had high resiliency. Further studies are needed to investigate this relationship and whether concurrent psychological treatment will help improve patient outcomes after hip arthroscopy for FAI. [Figure: see text]

Objectives: Femoroacetabular impingement (FAI) is classically described as restricted internal rotation in flexion resulting in labral and cartilage pathology. Despite 20 years of FAI research, there is still limited understanding of the drivers of symptomatology in the subset of patients with underlying FAI morphology. While the prevalence of FAI morphologies is substantially higher in men, numerous studies have shown more women being treated for FAI compared to men. Soft-tissue laxity and hip instability are increasingly recognized as a potential contributor to symptoms in addition to FAI. The Beighton score is a well-accepted means to quantify soft-tissue laxity and has been validated for self-scoring. The purpose of the current study was to (1) investigate the prevalence of soft-tissue laxity in male and female patients presenting with symptomatic FAI in a multicenter prospective cohort study, and (2) correlate soft-tissue laxity with patient primary complaints of either mobility, stability, or pain. Methods: A prospective multicenter cohort study of 696 FAI patients undergoing primary hip arthroscopy surgery was performed and utilized for the current study. Inclusion criteria are patients aged 14 to 45 years old with idiopathic FAI not caused by childhood disease. Exclusion criteria are previous ipsilateral hip procedures or disease processes such as neuromuscular disease or Tonnis 2 or greater osteoarthritis. The Beighton score was assessed by electronic patient self-scoring. Beighton scores >4 were considered a marker of soft-tissue laxity. The MSP index was utilized to have patients rank from most to least the biggest problems with their hip: Mobility (M), Stability (S), or Pain (P). The chi-square or Fisher exact test were utilized to compare groups. Results: The prevalence of Beighton scores >4 was 57.2% in female patients, compared to 29.3% in male patients (p < 0.001). In female patients, 44.4%, 22.6%, and 7.7% had Beighton scores of 5+, 7+, and 9 respectively, compared to 16.7%, 5.8%, and 1.8% in male patients (all p < 0.005). In the overall FAI cohort, pain was the primary complaint in 72.1% of patients, compared to 24.2% complaining primarily of mobility and 3.7% complaining primarily of stability. Among female patients, the presence of soft-tissue laxity (relative to thresholds of Beighton 4, 5, 7, and 9) did not significantly influence the patient primary complaints (with pain being the predominant complaint). Overall, 85 female patients had a Beighton score of 7 or greater and only 2.4% reported stability of the hip as a primary complaint, compared to 2.4% of female patients with a Beighton <7. Stability was more commonly indicated as a second most important factor in the setting of soft-tissue laxity, compared to mobility. Among female patients with a Beighton >7, 29.5% reported stability as a primary or secondary complaint, compared to 15.2% of female patients with a Beighton score <7. Conclusions: Over half of female patients undergoing FAI surgery have underlying soft-tissue laxity as measured by the Beighton score. In the setting of soft-tissue laxity, patient primary symptomatic complaint remains pain, but a secondary complaint is significant more likely to be stability rather than mobility (compared to FAI patients without soft tissue laxity complain of mobility secondarily over stability). Further research is needed to better understand the role of soft-tissue laxity in the pathophysiology of FAI and the outcomes of surgical treatment.

Abstract BACKGROUND Laser interstitial thermal therapy (LITT) is being used for the treatment of recurrent glioblastoma multiforme (GBM). Lesions can be treated using 1 or multiple LITT fibers depending on the preference of surgeons. Usually, more fibers are needed for coverage of larger tumors. OBJECTIVE To investigate and analyze how tumor size affected the number of LITT fibers used. METHODS This is a retrospective review of patients undergoing treatment of recurrent GBM. Patients were treated with up to 4 LITT fibers for adequate tumor coverage. Patient demographics, tumor characteristics, length of stay, complications, and biopsy results were recorded. RESULTS A total of 43 cases were treated using LITT, and of these cases, 31 consisted of contiguous lesions. We used more fibers to treat larger tumor volumes. On average, for each 5 cc of tumor volume, a fiber was added for proper coverage ( P = .554). Complications and length of stay were similar across the groups ( P = .378, P = .941). CONCLUSION LITT can be used for the treatment of recurrent GBM. For each 5 cc of tumor volume, a LITT fiber can be added to the treatment plan.

OBJECTIVEGlioblastoma (GBM) during infancy is rare, and the clinical outcomes of congenital GBM are not well understood. Correspondingly, the aim of this study was to present a long-term survivor case from the authors’ institution, and establish an integrated cohort of cases across the published literature to better understand the clinical course of this disease in this setting.METHODSThe authors report the outcomes of an institutional case of congenital GBM diagnosed within the first 3 months of life, and performed a comprehensive literature search for published cases from 2000 onward for an integrated survival analysis. All cases were integrated into 1 cohort, and Kaplan-Meier estimations, Fisher’s exact test, and logistic regression were used to interrogate the data.RESULTSThe integrated cohort of 40 congenital GBM cases consisted of 23 (58%) females and 17 (42%) males born at a median gestational age of 38 weeks (range 22–40 weeks). Estimates of overall survival (OS) at 1 month was 67%, at 1 year it was 59%, and at 10 years it was 45%, with statistically superior outcomes for subgroups in which patients survived to be treated by resection and chemotherapy. In the overall cohort, multivariable analysis confirmed resection (p < 0.01) and chemotherapy (p < 0.01) as independent predictors of superior OS. Gestational age > 38 weeks (p < 0.01), Apgar scores ≥ 7 at 5 minutes (p < 0.01), absence of prenatal hydrocephalus (p < 0.01), and vaginal delivery (p < 0.01) were associated with greater odds of surgical diagnosis versus autopsy diagnosis.CONCLUSIONSCongenital GBM can deviate from the expected poor prognosis of adult GBM in terms of OS. Both resection and chemotherapy confer statistically superior prognostic advantages in those patients who survive within the immediate postnatal period, and should be first-line considerations in the initial management of this rare disease.

OBJECTIVE Traditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device. METHODS This study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. RESULTS A total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A 1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2. CONCLUSIONS PulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.