Depression Scores Decrease After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Purpose: To evaluate clinical depression scores and functional outcomes following arthroscopic treatment of femoroacetabular impingement syndrome in patients with elevated preoperative depressive symptoms as defined by Patient-Reported Outcomes Measurement Information System for Depression (PROMIS-D). Methods: Patients with femoroacetabular impingement syndrome completed the PROMIS-D Computer Adaptive Test and additional patient-reported outcome (PRO) measures preoperatively and at the time of postoperative visits. Patients were categorized into preoperative clinically depressed (CD) and nonclinically depressed (NCD) groups based on preoperative PROMIS-D scores. Scores ≥55 correlate to mild clinical depression, and this cutoff was used to determine preoperative depression status. PROMIS-D scores and functional outcome scores were assessed at 6 months and a minimum of 1-year postoperatively. Results: In total, 100 patients were included with complete PROs at a minimum of 1-year follow-up. Of those included, 21 (21%) were categorized with preoperative CD. There were no differences in demographic or radiographic variables between the preoperative CD and NCD groups. At 6 months and 12 months postoperatively, the percentage of patients in the preoperative CD group with continued depression was 33.3% and 23.8%, respectively. Overall, 1-year change in PROMIS-D score for the CD group was -9.1 versus -0.8 in the NCD group (P = .001). There was no significant difference in rates of patients achieving patient acceptable symptom state between the preoperative CD and NCD groups. Conclusions: Patients with symptoms of preoperative CD, as defined by the PROMIS-D score, demonstrated significant improvement in depressive symptoms following hip arthroscopy. In addition, patients with CD preoperatively did not show decreased rates of achieving minimum clinically important difference or patient acceptable symptom state on postoperative PROs compared with patients with NCD. Level of Evidence: Level IV, therapeutic case series.

Shoulder Anteroinferior Glenoid Labrum Reconstruction With the Long Head of the Biceps Tendon Restores Glenohumeral Stability: A Cadaveric Biomechanical Study.

PURPOSE: The purpose of this cadaveric study was to determine feasibility and assess biomechanical stability of glenoid labral reconstruction utilizing the long head of the biceps tendon (LHBT) as a local autograft for labral deficient shoulders. METHODS: Ten cadaveric shoulders underwent resection of all soft tissue structures except the labrum and LHBT. The scapula and humerus were separately attached to a custom shoulder testing apparatus allowing for 22.5 N of compressive isotonic force across the joint. An Instron (Electroplus 1000) measured the peak force (N) as the humeral head was translated over the anteroinferior glenoid rim through 10 cycles. Shoulders were tested in 3 separate scenarios: intact labrum, resected labrum from 3- to 6-o'clock (for a right shoulder), and labral reconstruction with the LHBT. Reconstruction was performed by performing LHBT tenotomy at the level of the pectoralis major insertion. The proximal LHBT tendon, left attached to the supraglenoid tubercle, was then attached to the anteroinferior glenoid rim with suture anchors. RESULTS: Mean (SD) length of the LHBT was 76.1 (12.9 mm) and the diameter was 5.9 (1.6) mm. Peak force for intact labrum was significantly greater than the deficient labrum state (14.06 vs 11.78 N; P = .012). Peak force for labral reconstruction (16.67 N) was significantly greater than both intact and deficient labral states (P < .001 and P = .011, respectively). In all specimens, the length for the LHBT to the pectoralis major insertion was sufficient for reconstruction of the labrum to the 6-o'clock position. CONCLUSIONS: Glenoid labrum reconstruction with the LHBT is a feasible option to restore glenohumeral stability, with peak force to displacement significantly greater than the labral-intact and labral-deficient states. CLINICAL RELEVANCE: This reconstruction may be an option for augmentation in the labral-deficient shoulder.

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction.

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Patient-reported outcome scores following patellar instability surgery-high prevalence does not equal high responsiveness: a systematic review.

PURPOSE: The purpose of this study was to determine the utilization and responsiveness of common patient-reported outcomes (PROs) in patients undergoing surgery for patellar instability. METHODS: Using PRISMA guidelines, a systematic review of studies reporting outcomes following surgical intervention for patellar instability was conducted using Pubmed, Cochrane, OVID Medline, and Google Scholar. Subgroup analysis of articles reporting at least two PROs with baseline and follow-up data were used to evaluate responsiveness of instruments using relative efficiency and effect size. RESULTS: From the search, 2,848 unique articles were found, of which 178 were included in final analysis (7,122 patients, mean age 22.6, 63.6% female). The most commonly used PRO was the Kujala score (79.2%), followed by the Lysholm (34.8%), and Tegner (30.9%). Seventy-nine articles were eligible for subgroup analysis. The Kujala had a higher relative efficiency than ten of the 14 instruments to which it was compared but had lower relative efficiency compared to the IKDC and Lysholm scores. The Banff Patella Instability Instrument (BPII) and the Norwich score, condition-specific tools, were unable to be fully assessed due to rarity of use and lack of comparisons. CONCLUSION: The hypothesis that the Kujala score is the most commonly used PRO for patellar instability, although other instruments offer greater efficiency was supported by our results. The IKDC and Lysholm scores had similar effect sizes but higher relative efficiencies than the Kujala, thus suggesting better responsiveness. This analysis adds useful information for surgeons on the effectiveness of the most common PRO's for evaluating patellofemoral instability outcomes. LEVEL OF EVIDENCE: Level III.

Psychological Healthcare Burden Lessens After Hip Arthroscopy for Those With Comorbid Depression or Anxiety.

PURPOSE: In this study, we investigated whether patients undergoing arthroscopic treatment of femoral acetabular impingement syndrome (FAIS) seek health care for treatment of comorbid depression and anxiety in the year following hip arthroscopy. METHODS: Using the Truven Health Marketscan database, FAIS patients who underwent hip arthroscopy between January 2009 and December 2016 were identified. Claims related to depression or anxiety filed during the year before surgery were required for inclusion. Using claims for pharmaceutical and psychological therapy treatments for mental health disorders, four groups of patients were analyzed on the basis of preoperative anxiety/depression treatment: medication only, therapy only, medication + therapy, and no treatment. Number of opioid pain prescriptions within 180 days prior to surgery and >90 days after hip arthroscopy were also compared. RESULTS: Depression and anxiety claims were identified in 5,208/14,830 (35.1%) patients. Preoperative treatment for depression and anxiety included medication only (n = 648, 12.4%), therapy only (n = 899, 17.3%), medication + therapy (n = 252, 4.8%), and no treatment (n = 3,409, 65.5%). Of the 900 patients who filled an anxiety/depression-related prescription prior to surgery, 422 (46.9%) patients did not fill a similar prescription in the postoperative year. Of the 1,151 patients receiving anxiety/depression-related therapy prior to surgery, 549 (47.7%) did not receive therapy in the postoperative year. Preoperative opioid prescriptions were filled for 393 patients (60.6%) in medication-only group, 275 (30.6%) in therapy-only group, 156 (61.9%) in medication + therapy group, and 1,059 (31.1%) in the group receiving no treatment. Opioid prescriptions >90 days postoperatively were filled for 330 (50.9%), 225 (25.0%), 120 (47.6%), and 861 (25.3%) patients, respectively. CONCLUSION: Hip arthroscopy for FAIS is associated with a decreased postoperative use of health care resources for the treatment of depression and anxiety. Clinicians should also be aware of the potential interplay between preoperative psychotropic medication use and prolonged opioid use when counseling patients. LEVEL OF EVIDENCE: IV, therapeutic case series.

Age at the Time of Surgery Is Not Predictive of Early Patient-Reported Outcomes After Periacetabular Osteotomy.

BACKGROUND: The clinical success of periacetabular osteotomy (PAO) for the treatment of symptomatic acetabular dysplasia is well-documented. Conflicting evidence exists regarding the correlation of age with clinical outcomes. Hip disability and Osteoarthritis Outcome Score - global (HOOSglobal) is a recently validated patient-reported outcome measure following PAO. The purpose of this study is to asses HOOSglobal and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at early follow-up based on age at the time of PAO. METHODS: A prospective multicenter cohort of 391 patients undergoing PAO with minimum 2-year follow-up (average 4.71 years) were identified. Patients were categorized into 4 age groups: <20 years (N = 131), 20-29 (N = 102), 30-39 (N = 65), and ≥40 (N = 34). A 4 × 2 repeated measures analysis of variance (Age Group × Time) was used to compare preoperative and postoperative HOOSglobal and WOMAC scores between age groups. A multiple linear regression was used to identify predictors of postoperative HOOSglobal scores. RESULTS: HOOSglobal and WOMAC scores increased across all age groups; however, a statistically greater increase in preoperative to postoperative HOOSglobal and WOMAC scores was found in those ≥40 years compared to those <20 (P< .002), 20-29 (P = .01), and 30-39 years (P = .02). Higher preoperative HOOSglobal scores were predictive of greater postoperative HOOSglobal scores (P < .001) but age (P = .65), gender (P = .80), body mass index (P = .50), and Tönnis Classification (P = .07) were not independent predictors of 1-year outcomes. CONCLUSION: The absence of differences in early postoperative patient-reported outcomes across multiple age ranges emphasizes that PAO in the setting of symptomatic acetabular dysplasia can be successful regardless of patient age alone. Therefore, age alone might not be an appropriate selection criterion when evaluating surgical candidates for PAO. LEVEL OF EVIDENCE: II.

Pitch break and performance metrics remain unchanged in pitchers who returned to the same level of play after ulnar collateral ligament reconstruction in Major League Baseball pitchers.

BACKGROUND: The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR. MATERIALS AND METHODS: This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown. RESULTS: In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics. CONCLUSION: Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

Injury Rates in Major League Baseball During the 2020 COVID-19 Season.

BACKGROUND: The 2020 Major League Baseball (MLB) season was drastically altered because of the COVID-19 pandemic. The changes included an extended layoff between March and July as well as a shortened preseason. PURPOSE/HYPOTHESIS: To determine the incidence and epidemiology of MLB injuries in the abbreviated 2020 season compared with prior seasons. We hypothesized that there was an increase in the overall injury rate in the 2020 season compared with the 2018-2019 seasons and that it equally affected all body regions. STUDY DESIGN: Descriptive epidemiology study. METHODS: The MLB transactions database was queried to find players who had been placed on the injury list between 2018 and 2020. Injuries were categorized into upper extremity, lower extremity, spine/core, and other injuries. Incidence per 1000 athlete-exposures was calculated for the prior 2 seasons (2018-2019) and for the 2020 season separately. Incidence for each category was also calculated separately for pitchers and fielders. Incidence rate ratios (IRRs) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z test for proportions was used to determine significant differences between injury incidences. RESULTS: In 2020, the overall incidence rate per 1000 athlete-exposures was almost twice the rate compared with the 2 seasons before COVID-19 (8.66 vs 5.13; IRR, 1.69 [95% CI, 1.53-1.87]; P < .001). Injury incidence increased similarly in 2020 for both pitchers (IRR, 1.68 [95% CI, 1.47-1.91]; P < .001) and fielders (IRR, 1.68 [95% CI, 1.45-1.96]; P < .001). Increases in injury incidence were seen in the upper extremity, spine/core, and other injury categories; however, the incidence of the lower extremity did not change significantly. CONCLUSION: There was a significant increase in injury incidence for both pitchers and fielders in 2020. Injury rates increased in anatomic zones of the upper extremity and spine/core but were not significantly changed in the lower extremity. The overall increase in injury rate suggests that irregular or insufficient sport-specific preparation prior to the start of the season placed athletes at a greater risk of injury when play resumed.

Making Sense of Hip Preservation Procedural Coding-Getting Paid for Your Work!

Hip preservation and peri-trochanteric procedures are becoming more commonplace for the arthroplasty surgeon. Understanding the reimbursement for these procedures remains a challenge for those looking to expand this portion of their practice. In order to financially maximize the surgeon's efforts, we present recommendations for hip preservation procedural coding.

Secondary Injuries After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review With Quantitative Analysis.

BACKGROUND: In the skeletally mature anterior cruciate ligament (ACL) reconstruction population, patients aged <25 years are at significantly increased risk of graft failure and injury to the contralateral ACL. Skeletal immaturity often affects graft selection and reconstruction technique. PURPOSE: To examine the incidence of ipsilateral graft failure and contralateral ACL injury in the skeletally immature patient population. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines, we reviewed all literature that involved ACL reconstruction performed on skeletally immature patients between May 1976 and May 2019. Patient demographics, surgical technique, and the prevalence of ipsilateral graft failure or subsequent contralateral ACL injury were recorded. Ipsilateral, contralateral, and secondary ACL injuries were then compared between sexes via chi-square tests. RESULTS: A total of 24 articles (1254 children; 1258 knees) met inclusion criteria for analysis. Ipsilateral graft failures occurred in 105 of 1258 patients (8.3%), and there were no statistically significant sex differences in the prevalence of graft failures (female, 9.7%; male patients, 7.1%; P = .14). The prevalence of contralateral ACL injury was significantly greater in female (29/129; 22.5%) than male (18/206; 8.7%; P = .0004) patients in the 9 studies that reported contralateral injury. Skeletally immature female patients were at significantly increased risk of contralateral ACL injury (odds ratio = 3.0; P = .0006) when compared with their male counterparts. CONCLUSION: In the literature to date, 1 in 3 female skeletally immature patients experienced an ipsilateral graft failure or contralateral ACL injury. Regardless of sex, the 24% prevalence of secondary injury after pediatric ACL reconstruction is almost identical to previously published secondary injury rates in skeletally mature patients <25 years old. As such, skeletal maturity alone does not seem to be a determinant of secondary injury; however, there is a clear need to improve postoperative rehabilitation, activity progression, and return-to-play testing to allow a safe return to sports that protects the long-term health of the reconstructed and contralateral limbs, especially for female patients.

Comparative Effectiveness of Hepatic Artery Based Therapies for Unresectable Colorectal Liver Metastases: A Meta-Analysis.

BACKGROUND: Patients with unresectable Colorectal Liver Metastases (CRLM) are increasingly being managed using Hepatic Artery Based Therapies (HAT), including Hepatic Arterial Infusion (HAI), Radioembolization (RE), and Transcatheter Arterial Chemoembolization (TACE). Limited data is available on the comparative effectiveness of these options. We hypothesized that outcomes in terms of survival and toxicity were equivalent across the three strategies. METHODS: A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013003861) that utilized studies from PubMed (2003-2013). Primary outcome was median overall survival (OS). Secondary outcomes were treatment toxicity, tumor response, and conversion of the tumor to resectable. Additional covariates included prior or concurrent systemic therapy. RESULTS: Of 491 studies screened, 90 were selected for analyses-52 (n = 3,000 patients) HAI, 24 (n = 1,268) RE, 14 (n = 1,038) TACE. The median OS (95% CI) for patients receiving HAT in the first-line were RE 29.4 vs. HAI 21.4 vs. TACE 15.2 months (p = 0.97, 0.69 respectively). For patients failing at least one line of prior systemic therapy, the survival outcomes were TACE 21.3 (20.6-22.4) months vs. HAI 13.2 (12.2-14.2) months vs. RE 10.7 (9.5-12.0). Grade 3-4 toxicity for HAT alone was 40% in the HAI group, 19% in the RE group, and 18% in the TACE groups, which was increased with the addition of systemic chemotherapy. Level 1 evidence was available in 5 studies for HAI, 2 studies for RE and 1 for TACE. CONCLUSION: HAI, RE, and TACE are equally effective in patients with unresectable CRLM with marginal differences in survival.

Comparative effectiveness of hepatic artery based therapies for unresectable intrahepatic cholangiocarcinoma.

BACKGROUND: Hepatic artery based therapies (HAT) are offered for patients with unresectable intrahepatic cholangiocarcinoma (ICC). We aimed to evaluate the comparative effectiveness of HAT -hepatic arterial infusion (HAI), transcatheter arterial chemoembolization (TACE), drug-eluting bead TACE (DEB-TACE), and Yttrium(90) radioembolization (Y-90) for unresectable ICC. METHODS: A meta-analysis was performed using a prospectively registered search strategy at PROSPERO (CRD42013004830) that utilized PubMed (2003-2013). Primary outcome was median overall survival (OS), and secondary outcomes were tumor response to therapy and toxicity. RESULTS: A total of 20 articles (of 793, n=657 patients) were selected for data extraction. Highest Median OS was observed for HAI (22.8, 95% CI 9.8-35.8) months versus Y90 (13.9, 9.5-18.3) months versus TACE (12.4, 10.9-13.9) months versus DEB-TACE (12.3, 11-13.5) months. Response to therapy (complete and partial) was highest for HAI (56.9%, 95%CI 41.0-72.8) versus Y90 (27.4%, 17.4-37.5) versus TACE (17.3%, 6.8-27.8). The grade III/IV toxicity (Events per patient) was highest for HAI (0.35, 95% CI 0.22-0.48) versus TACE (0.26, 0.21-0.32) versus DEB-TACE (0.32, 0.17-0.48). CONCLUSION: For patients with unresectable ICC treated with HAT, HAI offered the best outcomes in terms of tumor response and survival but may be limited by toxicity.

Effect of the experience of surgical chairpersons on departmental National Institutes of Health funding.

BACKGROUND: Experience and application of recruitment packages can be critical in leadership efforts of surgical chairpersons in promoting research, although attrition of these efforts can happen over time due to lack of new resources. We aimed to examine the impact of experience of surgical chairpersons on departmental National Institutes of Health (NIH) funding. METHODS: Experience as a chairperson defined as the number of years spent as an interim or permanent chair was abstracted from the department Web site (US medical schools only). The NIH funding (US dollars) of the departments were obtained from the Blue Ridge Medical Institute (www.brimr.org). The change in NIH funding from the immediate previous financial year (2010-2009 and 2011-2010) was used to classify chairpersons into four groups: group 1 (-/-), group 2 (-/+), group 3 (+/+), and group 4 (+/-) for analysis. RESULTS: Median NIH funding were $1.9 (0.7-6) million, $1.8 (0.6-5) million, and $1.7 (0.7-5) million for 2009, 2010, and 2011, respectively, and the median experience as a surgical chairperson was 6 y (3-10). Recent chairpersons (<1 y) inherited departments that usually lost NIH funding (62%) and were frequently unable to develop a positive trend for growth over the next fiscal year ([-/-] n = 4 and [+/-] n = 2, 75%). Chairpersons who held their positions for 4-6 y were most likely to be associated with trends of positive funding growth, whereas chairpersons >10 y were most likely to have lost funding (66%, P = 0.07). CONCLUSIONS: Provision of new development dollars later in their tenure and retention of chairpersons might lead to more positive trends in increase in NIH funding.

Role of laparoscopy in patients with peritoneal metastases considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: We hypothesized that diagnostic laparoscopy (DL) was feasible for the evaluation of patients with peritoneal carcinomatosis (PC) undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). METHODS: A retrospective review of PC patients treated from January 2010 to April 2013 was conducted. Data on tumor characteristics, treatment details and survival outcomes were extracted and analyzed. RESULTS: Of the 101 PC patients (mean age 52.9 ± 14.1 years), 73 diagnostic laparoscopies DL (61 concurrent with CRS + HIPEC) were performed in 70 patients whereas 31 patients underwent direct exploratory laparotomy (EL). Complete laparoscopic assessment was possible in 63 cases (86.3%), resulting in 18 exclusions (27.7%) while 10 cases were converted to open due to inadequate laparoscopic visualization. Subsequently, CRS + HIPEC was performed in 85.4% (of 55 selected for HIPEC, DL) versus 74.2% (EL, P value = 0.20). Among those excluded from HIPEC at the initial operation, delayed HIPEC after conversion chemotherapy was achieved in 6 (of 11 with extensive disease, DL). The incidence of grade 3 to 5 complications was 0% DL versus 10% EL (P value = 0.2). There were no port site recurrences at mean follow up of 9.1 ± 8 months. CONCLUSIONS: Laparoscopy is a feasible technique for selecting patients with PC for CRS + HIPEC, and can help select patients for conversion chemotherapy in the setting of high peritoneal carcinomatosis index (PCI) score.