Marigi, Erick

Background: Particulated juvenile articular cartilage (PJAC) implantation has demonstrated promising early results in the treatment of symptomatic articular cartilage defects of the patella. However, some uncertainty exists regarding the stability of this cell-based technique in lesions that are not well contained or shouldered. Purpose: To compare clinical and magnetic resonance imaging (MRI) outcomes of PJAC treatment in shouldered versus unshouldered full-thickness cartilage defects of the patella. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of prospectively collected data from an institutional knee registry was conducted to identify patients treated with PJAC for full-thickness symptomatic patellar cartilage lesion between January 2009 and August 2017. Cartilage defects were graded arthroscopically according to the Outerbridge classification and characterized as shouldered or unshouldered. For the primary outcome, postoperative MRI studies were read by a musculoskeletal fellowship-trained radiologist who characterized the percentage of fill based on both coronal and sagittal images. Patient-reported outcome measures (PROMs) were obtained at baseline and 2-year follow-up. MRI and PROM results were compared between the shouldered and unshouldered cohorts. Results: A total of 64 knees in 60 patients (mean age, 26.3 ± 7.6 years) were identified, of which 62 (97%) knees underwent a concomitant patellar stabilization or offloading procedure. There were 32 (50%) shouldered and 32 (50%) unshouldered defects. On postoperative MRI, 68.8% of shouldered lesions demonstrated 67% to 100% fill, compared with 59.4% of unshouldered lesions; 12.5% of shouldered lesions and 15.6% of unshouldered lesions demonstrated 34% to 66% fill; and 18.8% of shouldered lesions and 25.0% of unshouldered lesions demonstrated 0% to 33% fill ( P = .604). At 2 years, significant improvements were observed in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QOL) (23.1 to 65.3; P < .001), International Knee Documentation Committee (IKDC) (41.2 to 76.0; P < .001), KOOS Physical Function Shortform (PS) (34.8 to 13.9; P < .001), Kujala (52.0 to 87.5; P < .001), 12-Item Short Form Survey (SF-12) Physical Health (39.5 to 51.5; P < .001), Veterans Rand 12 Item Health Survey (VR-12) Physical Health (40.7 to 52.8; P < .001), Veterans Rand 6D (0.66 to 0.79; P < .001), SF-12 Mental Health (48.9 to 53.4; P = .015), and VR-12 Mental Health (49.4 to 54.0; P = .019) values. No significant change was observed in Pediatric Functional Activity Brief Scale score (9.1 to 10.3; P = .384). All PROMs were equivalent between shouldered and unshouldered defects at the 2-year follow-up ( P = .318-.980). There was a greater improvement in both KOOS PS (27.2 vs 10.7; P = .015) and Kujala (44.3 vs 26.9; P = .039) values from baseline to the 2-year follow-up in the shouldered group. Conclusion: PJAC implantation with concomitant patellar stabilization led to significantly improved PROMs for both shouldered and unshouldered patellar cartilage lesions over time. Additionally, minimal differences were observed between shouldered and unshouldered defects treated with PJAC at the 2-year follow-up.

Abstract » A thorough understanding of glenoid deformity is essential to anticipate intraoperative needs and manage bony deficiencies. Management strategies include eccentric reaming, alternate scapular line baseplate orientation, bone grafting, or metallic augmentation as either “off-the-shelf” or custom baseplates. Accurate implantation of the glenoid component in the presence of glenoid bone loss (GBL) may also benefit from shoulderspecific guides, navigation, or robotic assistance. » GBL can negatively affect outcomes due to compromised bony fixation, altered soft tissue tensioning, and component malposition, which can contribute to impingement, dislocation, aseptic loosening, polyethylene wear, and component failure. » In this article, we provide a comprehensive review of published literature regarding the management of GBL in primary RSA and provide additional insight on the effectiveness of current approaches to manage bony deficiency.

Purpose To evaluate the clinical outcomes of lower trapezius tendon (LTT) transfer using an Achilles tendon allograft in patients with failed superior capsular reconstruction (SCR). Methods A retrospective therapeutic review was conducted on patients who underwent LTT transfer using an Achilles tendon allograft after SCR failure between January 2018 and May 2020. The inclusion criteria encompassed both structural and functional failures of SCR in patients with minimal glenohumeral arthritis and a minimum follow‐up of 2 years. Exclusion criteria were insufficient clinical data or loss to follow‐up. Clinical outcomes were assessed preoperatively and at final follow‐up using the visual analog scale (VAS), subjective shoulder value (SSV), Constant score, American Shoulder and Elbow Surgeons (ASES) score, and range of motion (ROM). Results Eighteen patients were included, with a mean follow‐up of 42.5 months (range: 24‐62 months). All outcome measures demonstrated statistically significant improvement: VAS scores improved from 5.9 ± 1.3 to 1.8 ± 1.4; SSV scores improved from 18.0 ± 9.1 to 61.4 ± 18.5; Constant score improved from 33.3 ± 5.3 to 65.5 ± 17.4; and ASES score improved from 38.5 ± 5.2 to 67.1 ± 17.7 (all P < .001). On the basis of the minimal clinically important difference (MCID) using a 0.5 SD distribution‐based method, clinically meaningful improvements were observed in 88.9% of patients for VAS and ASES scores, and 94.4% for Constant and SSV scores. ROM gains included forward elevation (73° to 120°), abduction (57° to 93°), and external rotation (−22° to 40°). At final follow‐up, 77.8% of patients had resumed occupational activities, and 61.1% returned to sports. Four patients (22.2%) required conversion to reverse shoulder arthroplasty. Conclusions LTT transfer using an Achilles tendon allograft following failed SCR yields significant improvements in pain relief, functional outcomes, and ROM. LTT transfer using an Achilles tendon allograft following failed SCR may offer a potential treatment option, particularly in younger, active patients who seek to preserve native shoulder anatomy and function. Level of Evidence Level IV retrospective case series.

Background: Hip arthroscopy has seen a significant surge in utilization, but complications remain, and optimal functional outcomes are not guaranteed. Artificial intelligence (AI) has emerged as an effective supportive decision-making tool for surgeons. The purpose of this systematic review was to characterize the outcomes, performance, and validity (generalizability) of AI-based prediction models for hip arthroscopy in current literature. Methods: Two reviewers independently completed structured searches using PubMed/MEDLINE and Embase databases on August 10, 2022. The search query used the terms as follows: (artificial intelligence OR machine learning OR deep learning) AND (hip arthroscopy). Studies that investigated AI-based risk prediction models in hip arthroscopy were included. The primary outcomes of interest were the variable(s) predicted by the models, best model performance achieved (primarily based on area under the curve, but also accuracy, etc), and whether the model(s) had been externally validated (generalizable). Results: Seventy-seven studies were identified from the primary search. Thirteen studies were included in the final analysis. Six studies (n = 6,568) applied AI for predicting the achievement of minimal clinically important difference for various patient-reported outcome measures such as the visual analog scale and the International Hip Outcome Tool 12-Item Questionnaire, with area under a receiver-operating characteristic curve (AUC) values ranging from 0.572 to 0.94. Three studies used AI for predicting repeat hip surgery with AUC values between 0.67 and 0.848. Four studies focused on predicting other risks, such as prolonged postoperative opioid use, with AUC values ranging from 0.71 to 0.76. None of the 13 studies assessed the generalizability of their models through external validation. Conclusion: AI is being investigated for predicting clinical outcomes after hip arthroscopy. However, the performance of AI models varies widely, with AUC values ranging from 0.572 to 0.94. Critically, none of the models have undergone external validation, limiting their clinical applicability. Further research is needed to improve model performance and ensure generalizability before these tools can be reliably integrated into patient care. Level of Evidence: Level IV . See Instructions for Authors for a complete description of levels of evidence.

» Gluteal tendinopathy/greater trochanteric pain syndrome (GTPS) is the most prevalent of all lower limb tendinopathies, affecting 1 in 4 women older than 50 years and commonly individuals within their fifth and sixth decades of life regardless of activity level. » The condition is believed to originate from age-related degenerative changes about the hip abductor tendon insertions and the surrounding bursae, and is exacerbated by congenital and acquired abnormal hip biomechanics. » Treatment of gluteal tendinopathy/GTPS often begins with noninvasive nonoperative modalities such as activity modifications, nonsteroidal anti-inflammatory drugs, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies have been used; however, there remains a lack of comparative efficacy between these adjunct treatments. » In this article, we examine the available literature regarding the nonoperative management of gluteal tendinopathy/GTPS and provide insight into the effectiveness of current treatment modalities.

Background: In smaller studies, allograft-prosthetic composite (APC) has been used for proximal humerus bone loss with some success, although with notable complication risk. This systematic review and meta-analysis sought to describe outcomes and complications after proximal humerus APC and how major APC complications are defined in the literature. Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for articles on APC for proximal humeral bone loss secondary to tumor, fracture, or failed arthroplasty. Primary outcomes included postoperative range of motion, outcome scores (Musculoskeletal Tumor Society [MSTS], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, visual analog scale [VAS], and subjective shoulder value [SSV]), and complication incidence. We also described individual study definitions of APC malunion/nonunion, methods of postoperative evaluation, malunion/nonunion rates, allograft fracture/fragmentation rates, and mean union time, when available. Secondarily, we compared hemiarthroplasty and reverse total shoulder arthroplasty. Results: Sixteen articles including 375 shoulders were evaluated (average age: 49 years, follow-up: 54 months). Fifty-seven percent of procedures were performed for tumors, 1% for proximal humerus trauma sequelae, and 42% for revision arthroplasty. Average postoperative forward elevation was 82° (69-94°), abduction 60° (30-90°), and external rotation 23° (17-28°). Average MSTS score was 82% (77%-87%), SST score 5.3 (4.5-6.1), ASES score 64 (54-74), Constant score 44 (38-50), VAS score 2.2 (1.7-2.7), and SSV 51 (45-58). There was a 51% complication rate with an 18% nonallograft surgical complication rate, 26% APC nonunion/malunion/resorption rate, and 10% APC fracture/fragmentation rate. Fifteen percent of nonunited APCs underwent secondary bone grafting; 3% required a new allograft; and overall revision rate was 12%. APC nonunion/malunion was defined in 2 of 16, malunion/nonunion rates in 14 of 16, fracture/fragmentation rates in 6 of 16, and mean union time (7 months) in 4 of 16 studies. Conclusion: APC reconstruction of the proximal humerus remains a treatment option, albeit with substantial complication rates. In addition, there is a need for APC literature to report institutional definitions of nonunion/malunion, postoperative evaluation, and time to union for a more standardized evaluation. Level of Evidence: Level IV ; systematic review. See Instructions for Authors for a complete description of levels of evidence.

Abstract Despite the development of various therapeutic options, surgical management of irreparable rotator cuff tears (IRCTs) remains controversial. Recently, implantation of a biodegradable subacromial balloon spacer (InSpace, Stryker Corporation; Kalamazoo, MI) has gained considerable interest for the treatment of certain IRCTs. The reported outcome of balloon implantation has not been consistent, likely due to differing indications and technical approaches. The purpose of this article is to present a reproducible arthroscopic technique for implantation of a subacromial balloon and to review the literature published to date, regarding the efficacy and outcomes of this procedure. Technique Video video See video under supplementary data.

Purpose To evaluate the outcomes of arthroscopic superior capsular reconstruction (SCR) and arthroscopy‐assisted lower trapezius tendon transfer (LTT) for posterosuperior irreparable rotator cuff tears (IRCTs). Methods Over an almost 6‐year period (October 2015 to March 2021), all patients who underwent IRCT surgery with a minimum 12‐month follow‐up period were identified. For patients with a substantial active external rotation (ER) deficit or lag sign, LTT was preferentially selected. Patient‐reported outcome scores included the visual analog scale (VAS) pain score, strength score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Results We included 32 SCR patients and 72 LTT patients. Preoperatively, LTT patients had more advanced teres minor fatty infiltration (0.3 vs 1.1, P = .009), a higher global fatty infiltration index (1.5 vs 1.9, P = .035), and a higher presence of the ER lag sign (15.6% vs 48.6%, P < .001). At a mean follow‐up of 2.9 ± 1.3 years (range, 1.0‐6.3 years), no differences in patient‐reported outcome scores were observed. Postoperatively, SCR patients had a lower VAS score (0.3 vs 1.1, P = .017), higher forward elevation (FE) (156° vs 143°, P = .004), and higher FE strength (4.8 vs 4.5, P = .005) and showed greater improvements in the VAS score (6.8 vs 5.1, P = .009), FE (56° vs 31°, P = .004), and FE strength (1.0 vs 0.4, P < .001). LTT patients showed greater improvement in ER (17° vs 29°, P = .026). There was no statistically significant between‐cohort difference in complication rate (9.4% vs 12.5%, P = .645) or reoperation rate (3.1% vs 10%, P = .231). Conclusions With adequate selection criteria, both SCR and LTT provided improved clinical outcomes for posterosuperior IRCTs. Additionally, SCR led to better pain relief and restoration of FE whereas LTT provided more reliable improvement in ER. Level of Evidence Level III, treatment study with retrospective cohort comparison.

Introduction: To date, there has been a paucity of research evaluating the demographics, characteristics, and surgical training of orthopaedic residency program directors (PDs). Purpose: To determine the objective characteristics of orthopaedic residency PDs by analyzing their demographic characteristics, academic backgrounds, institutional histories, research productivity, and professional leadership affiliations. Methods: Data for each PD were collected by searching publicly available curriculum vitae , LinkedIn, Healthgrades, Doximity, and/or institutional biographies and consolidated into a database. Research productivities were collected by searching PubMed and Scopus. Results: Of the 210 PDs, 188 (89.5%) were male and 22 (10.5%) were female. One hundred seventy-four (82.9%) were non-Hispanic White, 14 (6.7%) Asian American and Pacific Islander, 12 (5.7%) Black or African American, 4 (1.9%) Hispanic or Latino, and 6 (2.9%) other/unknown. Twenty-four (11.4%) PDs had a military affiliation. Moreover, the most common subspecialties among orthopaedic PDs were orthopaedic traumatology (19.5%, n = 41), sports medicine (15.7%, n = 33), and hand surgery (11.9%, n = 25). The mean Scopus h -index, total number of publications at the time of data collection (June 2022), and total number of citations for all orthopaedic residency PDs were 10.5 ± 9.5, 33.9 ± 51.0, and 801.9 ± 1,536.4, respectively. Among all PDs, the mean tenure in the position was 8.9 ± 6.2 years to date, and the mean time from completion of residency to appointment as PD was 10.0 ± 6.2 years. Conclusions: Among orthopaedic surgery residency PDs, there is sparse female and minority representation. Overarchingly, orthopaedic PDs are White men in their early 50s. Moreover, 59.1% of PDs were appointed at an institution where they completed medical school, residency, or fellowship. orthopaedic traumatology (19.5%), sports medicine (15.7%), and hand surgery (11.9%) were the subspecialties most represented in current orthopaedic surgery PDs. Clinical Relevance: This study outlines important demographic characteristics among orthopaedic surgery residency PDs. Level of Evidence: III

Purpose To evaluate the cost‐effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet‐rich plasma (PRP)–augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation. Methods A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality‐adjusted life‐years (QALYs), and the incremental cost‐effectiveness ratio (ICER). Results Total costs of IMR with an MVP were $8,250; PRP‐augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP‐augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non‐augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP‐augmented IMR versus MVP‐augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness‐to‐pay threshold. Conclusions IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non‐augmented IMR, suggesting that biological augmentation is cost‐effective. Total costs of IMR with an MVP were significantly lower than those of PRP‐augmented IMR, whereas the number of additional QALYs produced by PRP‐augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP‐augmented IMR fell well above the $50,000 willingness‐to‐pay threshold, IMR with an MVP was determined to be the overall cost‐effective treatment strategy in the setting of young adult patients with isolated meniscal tears. Level of Evidence Level III, economic and decision analysis.