Hevesi, Mario

Abstract Clinical recognition and surgical treatment of patellofemoral instability has evolved dramatically over the past 3 decades. However, few patellofemoral patients present with an isolated medial patellofemoral ligament (MPFL) tear. Rather, patients often demonstrate patella alta, increased tibial tubercle to trochlear groove (TT‐TG) distance, dysplasia, coronal malalignment, or combinations thereof. Given this, concomitant procedures such as tibial tubercle osteotomy (TTO) have become increasingly popularized, given their ability to anteriorize, medialize, and even distalize the patella to correct tracking. It is generally recommended that concurrent TTO be considered with primary medial patellofemoral ligament reconstruction (MPFLR) in patients with closed physes whose TT‐TG distance is larger than 17 to 20 mm. MPFLR + TTO is generally safe and may decrease risk of revision surgery when compared with isolated MPFLR in properly indicated patients. However, it important to measure both knee rotation angle and tibial tubercle lateralization on magnetic resonance imaging, as both factors influence TT‐TG. In patients in whom abnormal knee rotation angle is felt to be the primary driver of TT‐TG, surgeons should proceed with caution when considering concomitant TTO. The pen may be mightier than the sword, but the osteotome may be mightier yet than the scalpel.

Purpose To compare the clinical efficacy in the resolution of patellar instability, patient‐reported outcomes (PROs), and complication and reoperation rates between patients who underwent grooveplasty (proximal trochleoplasty) and patients who underwent trochleoplasty as part of a combined patellofemoral stabilization procedure. Methods A retrospective chart review was performed to identify a cohort of patients who underwent grooveplasty and a cohort who underwent trochleoplasty at the time of patellar stabilization. Complications, reoperations, and PRO scores (Tegner, Kujala, and International Knee Documentation Committee scores) were collected at final follow‐up. The Kruskal‐Wallis test and Fisher exact test were performed when appropriate, and P < .05 was considered significant. Results Overall, 17 grooveplasty patients (18 knees) and 15 trochleoplasty patients (15 knees) were included. Seventy‐nine percent of patients were female, and the average follow‐up period was 3.9 years. The mean age at first dislocation was 11.8 years overall; most patients (65%) had more than 10 lifetime instability events and 76% of patients underwent prior knee‐stabilizing procedures. Trochlear dysplasia (Dejour classification) was similar between cohorts. Patients who underwent grooveplasty had a higher activity level ( P = .007) and a higher degree of patellar facet chondromalacia ( P = .008) at baseline. At final follow‐up, no patients had recurrent symptomatic instability after grooveplasty compared with 5 patients in the trochleoplasty cohort ( P = .013). There were no differences in postoperative International Knee Documentation Committee scores ( P = .870), Kujala scores ( P = .059), or Tegner scores ( P = .052). Additionally, there were no differences in complication rates (17% in grooveplasty cohort vs 13% in trochleoplasty cohort, P > .999) or reoperation rates (22% vs 13%, P = .665). Conclusions Proximal trochlear reshaping and removal of the supratrochlear spur (grooveplasty) in patients with severe trochlear dysplasia may offer an alternative strategy to complete trochleoplasty for the treatment of trochlear dysplasia in complex cases of patellofemoral instability. Grooveplasty patients showed less recurrent instability and similar PROs and reoperation rates compared with trochleoplasty patients. Level of Evidence Level III, retrospective comparative study.

Background: Proximal tibial osteotomy (PTO) is a well-established treatment for coronal deformity and focal cartilage defects. However, the utility of joint-preserving interventions must be weighed against potential effects on subsequent total knee arthroplasty (TKA). The purpose of this study was to determine the effect of PTO on subsequent TKA by comparing outcomes in patients with bilateral TKAs following unilateral PTO. Methods: Patients who underwent bilateral TKAs from 2000 to 2015 at a single institution and had previously undergone a unilateral valgus-producing PTO were reviewed. We evaluated 140 TKAs performed in 70 patients (24 female, 46 male) with a mean age at PTO of 50 ± 8 years. The patients underwent conversion to TKA at a mean of 14 ± 7 years following ipsilateral PTO and were followed for a mean of 25 ± 7 years (range, 6 to 40 years) following PTO. The Knee Society Score (KSS), Forgotten Joint Score-12 (FJS-12), subjective knee preference, and revision were compared between the PTO-TKA and contralateral TKA-only sides. Results: The PTO side demonstrated similar KSS Knee subscores (41 ± 16) compared with the contralateral side (39 ± 16, p = 0.67) immediately prior to arthroplasty. Patients had significant improvements in KSS (p < 0.001) after TKA, with clinically similar KSS values at 2 to 15 years of follow-up when knees were compared in a pairwise fashion (p = 0.10 to 0.83). Five PTO-TKA knees (7%) and 4 control TKA-only knees (6%) underwent revision at a mean of 5 years postoperatively (p = 0.76). The number of all-cause reoperations was approximately twice as high in PTO-TKA knees (13% compared with 6% in TKA-only knees, p = 0.24). At the time of final follow-up, PTO-TKA knees demonstrated similar FJS-12 scores (72 ± 26) compared with the contralateral knees (70 ± 28, p = 0.57). Nineteen percent of patients preferred the PTO-TKA knee, 19% preferred the contralateral TKA-only knee, and 62% stated that their knees were equivalent (p > 0.99). The final Tegner activity score was 2.5 ± 1.4. Conclusions: Long-term clinical function of TKA following PTO was excellent, with patients demonstrating comparable subjective outcomes and equivalent knee preference compared with the contralateral TKA-only knees. Further, well-matched studies are needed to evaluate long-term revision and reoperation rates following PTO-TKA. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Dislocation is the most common reason for early revision following total hip arthroplasty (THA). More than 40 years ago, Lewinnek et al. proposed an acetabular “safe zone” to avoid dislocation. While novel at the time, their study was substantially limited according to modern standards. The purpose of this study was to determine optimal acetabular cup positioning during THA as well as the effect of surgical approach on the topography of the acetabular safe zone and the hazard of dislocation. Methods: Primary THAs that had been performed at a single institution from 2000 to 2017 were reviewed. Acetabular inclination and anteversion were measured using an artificial intelligence neural network; they were validated with performance testing and comparison with blinded grading by 2 orthopaedic surgeons. Patient demographics and dislocation were noted during follow-up. Multivariable Cox proportional-hazards regression, including multidimensional analysis, was performed to define the 3D topography of the acetabular safe zone and its association with surgical approach. Results: We followed 9,907 THAs in 8,081 patients (4,166 women and 3,915 men; 64 ± 13 years of age) for a mean of 5 ± 3 years (range: 2 to 16); 316 hips (3%) sustained a dislocation during follow-up. The mean acetabular inclination was 44° ± 7° and the mean anteversion was 32° ± 9°. Patients who did not sustain a dislocation had a mean anteversion of 32° ± 9° (median, 32°), with the historic ideal anteversion of 15° observed to be only in the third percentile among non-dislocating THAs (p < 0.001). Multivariable modeling demonstrated the lowest dislocation hazards at an inclination of 37° and an anteversion of 27°, with an ideal modern safe zone of 27° to 47° of inclination and 18° to 38° of anteversion. Three-dimensional analysis demonstrated a similar safe-zone location but significantly different safe-zone topography among surgical approaches (p = 0.03) and sexes (p = 0.02). Conclusions: Optimal acetabular positioning differs significantly from historic values, with increased anteversion providing decreased dislocation risk. Additionally, surgical approach and patient sex demonstrated clear effects on 3D safe-zone topography. Further study is needed to characterize the 3D interaction between acetabular positioning and spinopelvic as well as femoral-sided parameters. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Abstract Articular cartilage defects are common and can result in substantial pain and disability, prompting operative intervention, which commonly includes chondral debridement. Controlled defect preparation up to but not beyond the calcified cartilage layer is key to clinical success, but this remains technically challenging. We present a technique highlighting the substantial decrease in curette stroke volume and associated shift to a lower pitch when achieving satisfactory open cartilage defect debridement. These audiologic cues correlate well with histologic accuracy of debridement. Therefore, quantifiable pitch and volume changes serve as valuable technical cues for precise defect preparation at the time of joint preservation surgery. Classifications I: knee, II: cartilage. Technique Video video See video under supplementary data.

Background: Periprosthetic joint infections (PJIs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with substantial morbidity. A better understanding of the costs of PJI treatment can inform prevention, treatment, and reimbursement strategies. The purpose of the present study was to describe direct inpatient medical costs associated with the treatment of hip and knee PJI. Methods: At a single tertiary care institution, 176 hips and 266 knees that underwent 2-stage revisions for the treatment of PJI from 2009 to 2015 were compared with 1,611 hips and 1,276 knees that underwent revisions for aseptic indications. In addition, 84 hips and 137 knees that underwent irrigation and debridement (I&D) with partial component exchange were compared with 39 hips and 138 knees that underwent partial component exchange for aseptic indications. Line-item details of services billed during hospitalization were retrieved, and standardized direct medical costs were calculated in 2018 inflation-adjusted dollars. Results: The mean direct medical cost of 2-stage revision THA performed for the treatment of PJI was significantly higher than that of aseptic revision THA ($58,369 compared with $22,846, p < 0.001). Similarly, the cost of 2-stage revision TKA performed for the treatment of PJI was significantly higher than that of aseptic revision TKA ($56,900 compared with $24,630, p < 0.001). Even when the total costs of aseptic revisions were doubled for a representative comparison with 2-stage procedures, the costs of PJI procedures were 15% to 28% higher than those of the doubled costs of aseptic revisions (p < 0.001). The mean direct medical cost of I&D procedures for PJI was about twofold higher than of partial component exchange for aseptic indications. Conclusions: The direct medical costs of operative treatment of PJI following THA and TKA are twofold higher than the costs of similar aseptic revisions. The high economic burden of PJI warrants efforts to reduce the incidence of PJI. Reimbursement schemes should account for the high costs of treating PJI in order to ensure sustainable patient care. Level of Evidence: Economic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: The periacetabular region is a common location for metastatic disease. Although large lytic acetabular defects are commonly treated with a hip arthroplasty with a cemented component according to a Harrington-style reconstruction, the use of highly porous uncemented tantalum acetabular components has been described. Currently, there are no direct comparisons of these reconstructive techniques. The purpose of this study was to compare the outcomes of the Harrington technique and tantalum acetabular component reconstruction for periacetabular metastases. Methods: From 2 tertiary sarcoma centers, we retrospectively reviewed 115 patients (70 female and 45 male) with an acetabular metastatic defect who had been treated between 2002 and 2015 with a total hip arthroplasty using either the cemented Harrington technique (78 patients) or a tantalum acetabular reconstruction (37 patients). The mean patient age was 61 years, and the most common Eastern Cooperative Oncology Group status was 3 (39 patients). The mean follow-up for surviving patients was 4 years. Results: An additional surgical procedure was performed in 24 patients (21%). Harrington-style reconstructions were more likely to require a reoperation compared with tantalum reconstructions (hazard ratio [HR], 4.59; p = 0.003). The acetabular component was revised in 13 patients (11%); 5 patients (4%) underwent revisions that were due to loosening of the acetabular component. The 10-year cumulative incidence of revision of the acetabular component for loosening was 9.6% in the Harrington group and 0% in the tantalum group (p = 0.09). The mean Harris hip score significantly improved following reconstruction (31 to 67 points; p < 0.001), with no significant difference (p = 0.29) between groups. Conclusions: In patients with periacetabular metastatic disease treated with total hip arthroplasty, an acetabular reconstruction strategy utilizing highly porous tantalum acetabular components and augments successfully provided patients with a more durable construct with fewer complications compared with the cemented Harrington-style technique. Levels of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. Methods: This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. Results: In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums. Conclusions: Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Abstract Focal cartilage defects lead to significant pain and disability, prompting the development of various options for biologic restoration of the articular surface. Although each technique and biologic implant provides various advantages and associated limitations, matrix‐induced autologous chondrocyte implantation (MACI) has gained popularity given promising long‐term results. We present a technique for the facile implantation of MACI membranes using cookie cutter instrumentation to aid in defect debridement and graft preparation. The technique described allows for efficient operative workflow while ensuring the creation of vertical, stable defect edges and a form‐fitting MACI membrane in a readily implemented fashion. Technique Video video See video under supplementary data.

Background: Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally. Methods: Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex. Results: Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001). Conclusions: Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients. Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.