Citations

ABSTRACTThe purpose of this study was to determine the sex differences in the overall prevalence of radiographic femoroacetabular impingement (FAI) deformity patients presenting with hip pain and to identify the most common radiographic findings in male and female patients. A geographic database was used to identify patients between the age of 14 and 50 years with hip pain from 2000 to 2016. A chart and radiographic review was performed to identify patients with cam, pincer and mixed-type FAI. A total of 374 (449 hips) out of 612 (695 hips) male patients and 771 (922 hips) out of 1281 (1447 hips) female patients had radiographic features consistent with FAI. Ninety-four male hips (20.9%) and 45 female hips (4.9%) had cam type, 20 male hips (4.5%) and 225 female hips (24.4%) had pincer type and 335 male hips (74.6%) and 652 female hips (70.7%) had mixed type. The overall prevalence of radiographic findings consistent with FAI in male and female patients with hip pain was 61.1% and 60.2%, respectively. Mixed type was the most prevalent. The most common radiographic finding for cam-type FAI was an alpha angle >55°, and the most common radiographic finding for pincer-type FAI was a crossover sign. Male patients were found to have a higher prevalence of cam-type deformities, whereas female patients were found to have a higher prevalence of pincer-type deformities.

Background: Charge and reimbursement trends for arthroscopic partial meniscectomies among orthopaedic surgeons, anesthesiologists, and hospital/surgery centers have not been formally analyzed, even though meniscectomies are the most commonly performed orthopaedic surgery. Purpose: To analyze Medicare charge and reimbursement trends for surgeons, anesthesiologists, and hospital/surgery centers for outpatient arthroscopic partial meniscectomies performed in the United States. Study Design: Economic and decision analysis; Level of evidence, 4. Methods: We analyzed trends in surgeon, anesthesiologist, and hospital charges and reimbursements for outpatient isolated arthroscopic partial meniscectomies from 2005 to 2014. Current Procedural Terminology codes were used to capture charge and reimbursement information using the nationally representative 5% Medicare sample. National and regional trends for charge, reimbursement, and Charlson Comorbidity Index (CCI) were evaluated using linear regression analysis. Results: A total of 31,717 patients were analyzed in this study. Charges across all groups increased significantly ( P < .001) during the 10-year study period, with an increase of 18.4% ($2754-$3262) for surgeons, 85.5% ($802-$1480) for anesthesiologists, and 116.8% ($2743-$5947) for hospitals. Surgeon reimbursements declined by 15.5% ($504-$426; P = .072) during this period. Anesthesiologist and hospital reimbursements increased significantly during by 36.5% ($133-$182; P < .001) and 28.9% ($1540-$1984; P < .001) during the 10-year study period, respectively. The annual incidence of partial meniscectomies per 10,000 database patients decreased significantly from 18.3 to 15.6 over the course of the study (14.8% decrease; P = .009), while the CCI did not change significantly ( P = .798). Conclusion: Hospital and anesthesiologist Medicare reimbursements for outpatient arthroscopic partial meniscectomies increased significantly, while surgeon reimbursements decreased. In 2005, hospitals were reimbursed 205% more ($1540 vs $504) than surgeons, and by 2014, they were reimbursed 365% more ($1984 vs $426), indicating that the gap between hospital and surgeon reimbursement is rising. Improved understanding of charge and reimbursement trends represents an opportunity for key stakeholders to improve financial alignment across the field of orthopaedics.

Purpose The purpose of this review is to perform a meta‐analysis of studies reporting meniscus repair outcomes. Pooled analyses of such studies will provide an accurate estimate of the outcomes that can be expected following meniscal repair at various postoperative time points. Methods A meta‐analysis of meniscal repair failure (defined as persistent symptoms, lack of healing on magnetic resonance imaging or revision surgery) and other clinical outcomes was performed following meniscal repair. Patients included had traumatic, nondegenerative meniscal tears, were skeletally mature, and had specific time‐points after surgery. Repairs included were performed either in isolation, or with concomitant ACL reconstruction. Because of the inherent heterogeneity of single‐arm meta‐analyses, pooled analyses were performed using a random‐effects model. Results Rates of all‐cause meniscal repair failure was pooled to be 12% at 0‐1 years (95% CI: .09‐.16), 15% at 2‐3 years (95% CI: .11‐.20), and 19% at 4‐6 years (95% CI: .13‐.24). Sensitivity analysis for studies performing meniscal repair entirely on patients with concomitant ACL reconstruction (ACLR) showed comparable rates of failure at similar time intervals. Development of osteoarthritis, in patients with knees previously free from articular pathologies, was 4% at 2‐3 years (95% CI: .02‐.07), and 10% at 4‐6 years (95% CI: .03‐.25). Conclusion Meniscus repair for traumatic injuries have an all‐cause failure rate that increases from 12% to 19% through a time period ranging from 1‐6 years following surgery. The failure rates were comparable for patients with meniscal repairs performed with concomitant ACLRs. Level of Evidence IV; Systematic Review of Level II‐IV Studies.

Purpose To describe double radial tears of the lateral meniscus (LM), report early clinical treatment outcomes, and determine reoperation and failure rates. Methods Twenty‐one (N = 21) consecutive cases of arthroscopic‐treated lateral meniscus double radial tears treated between 2012 and 2018 were reviewed, including 15 males (71.4%) and 6 females (28.6%). Meniscus repairs were all performed at the time of anterior cruciate ligament (ACL) reconstruction. Patients with associated fractures or prior surgeries were excluded. Concomitant injuries were reported, as were preinjury and postoperative Tegner scores, preoperative and postoperative visual analogue pain scale (VAS) scores, and postoperative International Knee Documentation Committee (IKDC) subjective scores. Reoperation and failure rates were documented. Results Twenty‐one (N = 21) tears were located in the posterior horn of the meniscus near the root attachment; 15 (71.4%) underwent all‐inside repair, 4 (19.0%) underwent transtibial pull‐through repair, 1 (4.8%) was partially debrided, and 1 (4.8%) was left untreated. Twenty‐one tears (N = 21) were in the body of the meniscus; 7 (33.3%) were repaired, 7 (33.3%) were partially debrided, and 7 (33.3%) were left untreated. Thirteen patients (62%) had associated medial collateral ligament (MCL) injuries. Mean follow‐up was 2.6 years. VAS at rest and with activity improved by 2.1 points ( P < .001) and 3.1 points ( P = .017) after surgery. The mean postoperative Tegner activity score was 6.4, and the mean IKDC score was 83.2 at final follow‐up. Reoperation was required in 5 patients (23.8%), and the surgical treatment failed in 1 patient (4.7%). Conclusions Double radial tears of the LM are uncommon injuries that occur in the setting of ACL tears, usually combined with MCL injury. The variety of surgical treatment techniques have a low failure rate at short‐term follow‐up. Patients tend to have good clinical outcomes with improvement in pain and overall function after surgically treating these injuries with simultaneous ACL reconstruction. Level of Evidence Level IV, therapeutic study, case series

Purpose To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US‐geographic population‐based cohort of patients with anterior shoulder instability. Methods An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient‐specific risk factors were individually incorporated into the 10‐point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. Results The study population consisted of 405 patients with a mean follow‐up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high‐risk group were more likely to fail nonoperative management than those in the low‐risk group (60.3% vs 48.9%; P = .028). Conclusions The NISIS has been proposed as a potentially useful tool in clinical decision‐making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US‐geographic population‐based cohort consisting of competitive and recreational athletes under the age of 40 with longer‐term follow‐up, the NISIS high‐risk cutoff was able to predict overall failure with 60.3% accuracy. Level of Evidence III, retrospective observation trial

Abstract The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients &gt;40 years of age and by &gt;84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by &gt;80% of respondents for patients ≤40 years of age and &gt; 80% of respondents if the labral size was &gt;3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was &lt;3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.

AbstractMeniscus allograft transplantations (MATs) represent established surgical procedures with proven outcomes. Yet, storage as frozen specimens and limited cellular repopulation may impair graft viability. This proof‐of‐concept study tests the feasibility of injecting allogeneic mesenchymal stromal/stem cells (MSCs) in meniscus allograft tissue. We investigated the injectable cell quantity, survival rate, migration, and proliferation ability of MSCs up to 28 days of incubation. In this controlled laboratory study, seven fresh‐frozen human allografts were injected with human allogeneic MSCs. Cells were labeled and histological characteristics were microscopically imaged up to 28 days. Mock‐injected menisci were included as negative controls in each experiment. Toluidine blue staining demonstrated that a 100‐µl volume can be injected while retracting and rotating the inserted needle. Immediately after injection, labeled MSCs were distributed throughout the injection channel and eventually migrated into the surrounding tissues. Histological assessment revealed that MSCs cluster in disc‐like shapes, parallel to the intrinsic lamination of the meniscus and around the vascular network. Quantification showed that more than 60% of cells were present in horizontally injected grafts and more than 30% were observed in vertically injected samples. On Day 14, cells adopted a spindle‐shaped morphology and exhibited proliferative and migratory behaviors. On Day 28, live/dead ratio assessment revealed an approximately 80% cell survival. The study demonstrated the feasibility of injecting doses of MSCs (>0.1 million) in meniscus allograft tissue with active cell proliferation, migration, and robust cell survival.

Objective: To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). Design: A retrospective review of 143 patients with PSI using a large geographic database. Setting: Single county between January 1994 and July 2012. Patients: A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. Interventions: Patients with PSI were managed nonoperatively or operatively. Main Outcome Measures: Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. Results: One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management ( P = 0.234). Pain at follow-up was more common in nonoperative than operative patients ( P = 0.017). Conclusions: Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

Purpose To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long‐term outcomes of nonoperative treatment after the index traumatic anterior instability event. Methods The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long‐term outcomes (recurrence rate, pain at last follow‐up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan‐Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. Results A total of 379 patients met the study criteria, with an average follow‐up period of 10.2 years (range, 0.53‐25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow‐up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow‐up (HR, 4.21; P < .001). Conclusions Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level of Evidence Level III, retrospective database review.