Uvodich, Mason E.

Background: Adequate cam resection during hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is necessary to restore femoral head-neck offset while avoiding under- or over-resection. The relationship between the extent of femoroplasty and postoperative patient-reported outcomes remains unclear. Purpose: We sought to answer the following questions: What is the association between the extent of cam femoroplasty resection and postoperative improvements? and is a 5% resection threshold associated with improved outcomes? Methods: We conducted a retrospective review of patients with adequate acetabular coverage who underwent primary hip arthroscopy with femoroplasty between January 2015 and December 2022 at our institution and had preoperative and 1- and/or 2-year postoperative modified Harris hip score (mHHS) and/or International Hip Outcome Tool (iHOT) scores. We included 400 patients (409 hips; ages 14–50 years). Outcomes included score changes and achievement of minimum clinically important difference (MCID) and substantial clinical benefit (SCB). Postoperative Dunn lateral radiographs quantified femoroplasty by resection depth percentage (resection depth/femoral head diameter), proximal resection angle, and postoperative α angle. Hips were classified as under-resection, neutral (0%–5%), or over-resection (>5%), and differences in outcomes were compared between resection groups. Multivariable regression analyses controlled for demographic, radiographic, and surgical variables. Results: Mean resection depth was 4.8%; mean proximal resection angle was 72.6°. No differences were observed in score improvements or MCID/SCB rates between groups with under-resection versus over-resection at 1 or 2 years. Greater resection depth was associated with larger 1-year mHHS and iHOT improvements and independently predicted 1-year iHOT MCID and SCB. Higher proximal resection angle predicted 2-year iHOT MCID. Conclusion: In this retrospective, single-institution cohort study, we found that in patients with FAIS, greater femoroplasty depth was associated with improved 1-year clinical outcomes. Level of Evidence: Level III, retrospective cohort study.

AimsThe prevalence of obesity is increasing substantially around the world. Elevated BMI increases the risk of complications following total hip arthroplasty (THA). We sought to evaluate trends in BMI and complication rates of obese patients undergoing primary THA over the last 30 years.MethodsThrough our institutional total joint registry, we identified 15,455 primary THAs performed for osteoarthritis from 1990 to 2019. Patients were categorized according to the World Health Organization (WHO) obesity classification and groups were trended over time. Cox proportional hazards regression analysis controlling for confounders was used to investigate the association between year of surgery and two-year risk of any reoperation, any revision, dislocation, periprosthetic joint infection (PJI), venous thromboembolism (VTE), and periprosthetic fracture. Regression was stratified by three separate groups: non-obese; WHO Class I and Class II (BMI 30 to 39 kg/m2); and WHO Class III patients (BMI ≥ 40 kg/m2).ResultsThere was a significant increase in the proportion of all obesity classes from 1990 to 2019, and the BMI values within each WHO class significantly increased over time. Risk of any reoperation did not change over time among non-obese or WHO Class I/II patients, but increased for WHO Class III patients (hazard ratio (HR) 1.04; p = 0.044). Risk of dislocation decreased over time for non-obese (HR 0.96; p < 0.001) and WHO Class I/II (HR 0.96; p = 0.002) patients, but did not change over time for WHO Class III (HR 0.94; p = 0.073) patients. Risks of any revision and PJI did not change over time for any group.ConclusionThe proportion of patients undergoing THA who are obese has increased dramatically at our institution between 1990 and 2019. Despite BMI values increasing within all WHO classes over time, two-year complication risks have remained stable or decreased in WHO Class I/II patients. However, continued efforts will be required to mitigate risks in the heaviest WHO Class III patients.Cite this article: Bone Joint J 2024;106-B(11):1223–1230.

Background: The rates of obesity among patients undergoing total knee arthroplasty (TKA) have substantially increased. In addition, obesity is a well-established risk factor for complications after TKA. The purpose of this study was to analyze trends in body mass index (BMI) and complication risk among obese patients undergoing primary TKA treated at a single institution over 3 decades. Methods: Utilizing an institutional total joint registry, 13,919 primary TKAs performed to treat osteoarthritis between 1990 and 2019 were identified. Patients were stratified by BMI according to the World Health Organization (WHO) classification into 3 groups: non-obese (BMI, <30 kg/m 2 ), WHO Class-I and II obese (BMI, 30 to 39.9 kg/m 2 ), and WHO Class-III obese (BMI, ≥40 kg/m 2 ). Trends in BMI and survivorship free from reoperation, revision, and periprosthetic joint infection (PJI) were analyzed over time while controlling for age, sex, and the Charlson Comorbidity Index. Results: Over the study period, there was a 90% increase in the prevalence of Class-II obesity (13% to 25%) and a 300% increase in Class-III obesity (3% to 12%). Analysis of the entire cohort demonstrated a decrease in the 2-year risk of any reoperation, any revision, and PJI (p < 0.05 for all) with time. The risk decreased significantly over time for non-obese patients for any reoperation (p = 0.029) and any revision (p = 0.004) and for Class-III obese patients for any reoperation (p = 0.038) and any revision (p = 0.012), but it remained stable for Class-I and II obese patients. The risk of PJI decreased from 1990 to 2019 for non-obese patients (p = 0.005), but there were no significant changes in PJI risk for any obesity group. Conclusions: Despite increasing rates of obesity among our patients who underwent TKA, we observed decreasing risks of reoperation, revision, and PJI over time. The risks of reoperation and revision declined among non-obese patients, remained stable for Class-I and II obese patients, and declined for Class-III obese patients. The PJI risk declined for non-obese patients over the study period, but no such decline occurred for any category of obesity. Despite the decreasing risks of reoperation and revision, further work is needed to improve PJI risk in obese patients. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Purpose To determine the relationship between cam morphology of the hip and ipsilateral sacroiliac motion compared to the native hip in a cadaveric model. Methods A simulated cam state was created using a 3‐dimensional printed cam secured to the head‐neck junction of 5 cadaveric hips. Hips were studied using a computed tomography–based optic metrology system and a 6 degree‐of‐freedom robot to exert an internal rotation torque at 3 different torque levels (6 N‐m, 12 N‐m, 18 N‐m). Outcomes included translational and rotational movement about 3 axes and composite (total) translational motion at the ipsilateral sacroiliac (SI) joint. Statistical analysis included a linear mixed model regression with repeated measures. Results The presence of a simulated cam was associated with medial motion in the coronal plane ( P = .03) and posterior motion in the sagittal plane ( P < .01) but not composite motion ( P = .37). Motion in the axial plane was in an inferior direction ( P = .08). Cam morphology significantly changed rotation in the sagittal plane ( P < .01) but not in the coronal ( P = .63) or axial plane ( P = .18). Composite motion was related to the amount of torque applied to the hip ( P < .01). The amount of torque applied to the hip was related to rotation in the coronal plane ( P < .01), axial plane ( P < .01), and sagittal plane ( P < .01) with increased effects as torque increased. Torque was not associated with translation movement in any of the anatomic planes. Conclusions The presence of simulated cam morphology is associated with motion in a more medial, inferior, and posterior direction at the ipsilateral SI joint relative to a native state. Increasing torque affects the magnitude of translation, but not its direction, which in this study is primarily influenced by cam morphology. Clinical Relevance This biomechanical connection between cam‐type femoroacetabular impingement syndrome and the ipsilateral SI joint provides insight into SI joint dysfunction in patients with femoroacetabular impingement syndrome.

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p<0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

Purpose To (1) report the long‐term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. Methods All patients who received a diagnosis of capitellar OCD from 1995‐2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Results Fifty elbows with a mean follow‐up period of 10.5 years (median, 10.3 years; range, 1‐25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long‐term follow‐up. Older patients trended toward increased failure of nonoperative management ( P = .06). The presence of an intra‐articular loose body predicted failure of nonoperative management ( P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Conclusions Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level of Evidence Level III, retrospective cohort study.

Objectives: To evaluate the association between preoperative international normalized ratio (INR) and postoperative mortality and other outcomes after hemiarthroplasty for geriatric femoral neck fractures. Design: Retrospective cohort study. Setting: A single Level-I trauma center. Patients/Participants: Patients ≥55 years of age with OTA/AO 31B proximal femur fractures [1556 patients (1616 hips)] Intervention: Hip hemiarthroplasty. Main Outcome Measurements: Ninety-day mortality, postoperative transfusion within 72 hours, and 90-day postoperative outcomes. Results: Adjusting for confounders, the association of preoperative INR and 90-day mortality was not statistically significant [hazard ratio (HR): 1.3; 95% confidence interval (CI): 0.97, 1.8; P = 0.08]. Dementia (HR: 1.9; 95% CI: 1.4–2.6; P < 0.001), Charlson Comorbidity Index (HR: 1.1; 95% CI: 1.1–1.2; P < 0.001), and age by decade (HR: 1.4; 95% CI: 1.1–1.8; P = 0.002) were associated with 90-day mortality. Increasing INR was significantly associated with blood transfusion [odds ratio (OR) 1.4; 95% CI 1.03–1.6; P = 0.031]. Preoperative hemoglobin <10 g/dL (OR 13.7; 95% CI 8.4–23.3; P < 0.001) was also associated with a postoperative transfusion, whereas intraoperative tranexamic acid use (OR 0.3; 95% CI 0.2–0.5; P < 0.001) was inversely associated with postoperative transfusion rate. INR was associated with superficial wound infection (HR: 2.0; 95% CI: 1.1–3.7; P = 0.02) and noninfected wound complications (HR: 1.6; 95% CI: 1.1–2.4; P = 0.007). Risk of superficial infection increased when INR was >1.8. Conclusion: When controlling for confounders, preoperative INR was not significantly associated with 90-day mortality. Underlying medical conditions contribute to postoperative mortality more than an elevated INR. However, INR is associated with superficial wound complications. This risk becomes statistically significant as INR rises above 1.8. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: There are limited data on the incidence of capitellar osteochondritis dissecans (OCD) in the United States (US) population. Purpose: To determine the incidence of symptomatic capitellar OCD in a representative US subpopulation and identify changes in its incidence over time and to investigate the relationship between the incidence of capitellar OCD and patient sex and age. Study Design: Descriptive epidemiology study. Methods: A retrospective review was performed of patients aged ≤24 years from Olmsted County, Minnesota, with symptomatic capitellar OCD over a 25-year period (1995-2019). Patients with acute osteochondral injuries, Panner disease, and hereditary arthropathy were excluded. Poisson regression was utilized to identify the predictors of a capitellar OCD diagnosis. Incidence rates (per 100,000) were assessed for changes over time. Age groups of younger (10-15 years) versus older (16-24 years) patients were compared. Results: A total of 45 patients (78% male) were identified. The mean age was 14.5 years (range, 10-24 years); 31 patients were in the younger group, and 14 patients were in the older group. Sport participation was seen in 89%of patients; 90% were overhead athletes, and 58% were throwing athletes. The incidence of capitellar OCD was 6.0 per 100,000 overall, 9.5 per 100,000 for male patients, and 2.6 per 100,000 for female patients. The incidence was highest for male patients in the younger group (15.3/100,000) and lowest for female patients in the older group (0.8/100,000). The estimated incidence rate ratio for younger versus older patients was 3.3 ( P < .001), and the incidence rate ratio for male versus female patients was 3.5 ( P < .001). There were no changes in the incidence of capitellar OCD over time as a continuous or 5-year categorical variable ( P = .290 and P = .460, respectively). Overall, 82% of patients were treated surgically. There were no significant changes in surgical rates over time. Conclusion: In this US subpopulation, the overall incidence of symptomatic capitellar OCD between the ages of 10 and 24 years was 6.0 per 100,000 over the 25-year period studied, which is higher than previously reported US estimates. Incidence rates and treatment strategies did not change significantly over time.

AimsIt remains difficult to diagnose early postoperative periprosthetic joint infection (PJI) following total knee arthroplasty (TKA). We aimed to validate the optimal cutoff values of ESR, CRP, and synovial fluid analysis for detecting early postoperative PJI in a large series of primary TKAs.MethodsWe retrospectively identified 27,066 primary TKAs performed between 2000 and 2019. Within 12 weeks, 169 patients (170 TKAs) had an aspiration. The patients were divided into two groups: those evaluated ≤ six weeks, or between six and 12 weeks postoperatively. The 2011 Musculoskeletal Infection Society (MSIS) criteria for PJI diagnosis in 22 TKAs. The mean follow-up was five years (two months to 17 years). The results were compared using medians and Mann-Whitney U tests and thresholds were analyzed using receiver operator characteristic curves.ResultsWithin six weeks, the median CRP (101 mg/l vs 35 mg/l; p = 0.011), synovial WBCs (58,295 cells/μl vs 2,121 cells/μl; p ≤ 0.001), percentage of synovial neutrophils (91% vs 71% (p < 0.001), and absolute synovial neutrophil count (ANC) (50,748 cells/μl vs 1,386 cells/μl (p < 0.001) were significantly higher in infected TKAs. Between six and 12 weeks, the median CRP (85 mg/l vs 5 mg/l (p < 0.001)), ESR (33 mm/hr vs 14 mm/hr (p = 0.015)), synovial WBCs (62,247 cells/μl vs 620 cells/μl (p < 0.001)), percentage of synovial neutrophils (93% vs 54% (p < 0.001)), and ANC (55,911 cells/μl vs 326 cells/μl (p < 0.001)) were also significantly higher in infected TKAs. Optimal thresholds at ≤ six weeks were: CRP ≥ 82 mg/l (sensitivity 70%, specificity 77%), synovial WBCs ≥ 8,676 cells/μl (83%, 90%), percentage of synovial neutrophils ≥ 88% (67%, 78%), and ANC ≥ 8,346 cells/μl (83%, 91%). Between six and 12 weeks, thresholds were: CRP ≥ 34 mg/l (90%, 93%), synovial WBCs ≥ 1,983 cells/μl (80%, 85%), percentage of synovial neutrophils ≥ 76% (80%, 81%), and ANC ≥ 1,684 cells/μl (80%, 87%).ConclusionEarly PJI after TKA should be suspected within six weeks if the CRP is ≥ 82 mg/l, synovial WBCs are ≥ 8,676 cells/μl, the percentage of synovial neutrophils is ≥ 88%, and/or the ANC is ≥ 8,346 cells/μl. Between six and 12 weeks, thresholds include a CRP of ≥ 34 mg/l, synovial WBC of ≥ 1,983 cells/μl, a percentage of synovial neutrophils of ≥ 76%, and/or an ANC of ≥ 1,684 cells/μl. Cite this article: Bone Joint J 2021;103-B(6 Supple A):177–184.

Abstract Introduction: The inconsistent use of standardized approaches for classifying postamputation pain (PAP) has been a barrier to establishing its prevalence. Objectives: The primary objective of this systematic review and meta-analysis is to determine the prevalence of nontraumatic lower-extremity PAP using an established taxonomy. The secondary objective is to determine the prevalence of PAP subtypes, including phantom limb pain and residual limb pain (RLP). Methods: An a priori protocol was registered, and a database search was conducted by a reference librarian. Randomized trials and uncontrolled studies were eligible for inclusion. The risk of bias was assessed using a tool developed for uncontrolled studies. A total of 2679 studies were screened, and 13 studies met inclusion criteria (n = 1063). Results: The sources of risk of bias included selection bias and, to a lesser extent, whether the outcome was adequately ascertained. Two studies reported the prevalence of PAP and the pooled prevalence was 61% (95% confidence interval [CI], 33%–86%) with high heterogeneity (I2 = 93%). Thirteen studies reported the prevalence of phantom limb pain and the pooled prevalence was 53% (95% CI, 40%–66%) with high heterogeneity (I2 = 93%). Eight studies reported the prevalence of RLP and the pooled prevalence was 32% (95% CI 24%–41%) with high heterogeneity (I2 = 76%). Clinical subtypes of RLP were not reported. Conclusions: The prevalence of PAP is high in patients with nontraumatic lower-extremity amputations. Ongoing research that uses a taxonomy for PAP is needed to fully delineate the prevalence of PAP subtypes.