Endoscopic Hip Abductor Tendon Repair Results in Successful Outcomes With 5- to 10-Year Follow-up.

PURPOSE: To report the outcomes of endoscopic repair in a consecutive series of patients with follow-up ranging from 5 to 10 years. METHODS: Sixty-five consecutive hips in 63 patients (2 bilateral) undergoing endoscopic abductor tendon repair with minimum 5-year follow-up were assessed with the modified Harris Hip Score. The minimal clinically important difference (MCID) was determined as one-half the standard deviation of the amount of improvement. RESULTS: The mean age was 56.6 years (standard deviation [SD], 11.3 years), with 58 female and 5 male patients. Follow-up was obtained on 64 hips (98.5%) at a mean of 85 months (SD, 15.7 months). There were 33 full-thickness and 32 partial-thickness tears, with 40 gluteus medius tears, 23 medius and minimus tears, and 2 isolated minimus tears. Concomitant arthroscopy of the hip joint was performed in 50 patients (52 hips), including 15 with correction of femoroacetabular impingement. The mean modified Harris Hip Score was 48.4 (SD, 15.7) preoperatively and 83.4 (SD, 15.9) postoperatively, reflecting a mean improvement of 34.9 (95% confidence interval, 34.9 ± 4.3), with 92.2% of patients achieving the MCID of 8.7. There were no complications. Three patients underwent further surgery: One underwent total hip replacement at 11 months after abductor repair, one underwent repeated arthroscopy for joint debridement at 12 months after repair, and one underwent revision abductor repair at 6 years postoperatively. CONCLUSIONS: Collectively, with 5- to 10-year follow-up, patients undergoing endoscopic abductor tendon repair can respond exceptionally well, with 92.2% achieving the MCID, even among a heterogeneous group of partial- and full-thickness tears with single- and 2-tendon involvement undergoing single- and double-row repair. LEVEL OF EVIDENCE: Level IV, case series.

Tissue-, age- and dose-dependent changes in avian ß-defensin and LEAP2 mRNA abundance in the intestines of Salmonella Typhimurium challenged broilers.

Salmonella is a pathogen normally found in the gastrointestinal tract of poultry. The objective of this study was to determine changes in avian ß-defensin (AvBD) and liver-enriched antimicrobial peptide 2 (LEAP2) mRNA following Salmonella challenge. Day of hatch chicks were challenged with 106, 107 or 108 colony-forming units (cfu) of Salmonella typhimurium. There were dose-, tissue- and age-specific changes in AvBD and LEAP2 mRNA. At 1-day post-infection (dpi) there was a transient upregulation of AvBD1, 8, 10 and 12 mRNA in the 108 cfu group. At 5 dpi, all seven AvBD mRNA were downregulated in the ileum, while only AvBD1, 6, 10 and 11 mRNA were downregulated in the jejunum and AvBD6, 8, 10, 12 and 13 were downregulated in the cecum. At 7 dpi, there was downregulation of all seven AvBD mRNA in the duodenum and downregulation of selected AvBD in the jejunum, ileum and cecum. LEAP2 mRNA was downregulated at all doses of Salmonella in the cecum at 1 dpi and in the ileum at 5 dpi. In summary, Salmonella infection caused an initial upregulation followed by a downregulation of AvBD mRNA.

Editorial Commentary: Hip Arthroscopy-A Microcosm in the Evolution of Arthroscopy in Sports Medicine.

Hip arthroscopy represents a microcosm in the evolution of arthroscopy within sports medicine. It has evolved right before our eyes over a condensed time frame with current-day techniques in arthroscopy and concepts in sports medicine. Early on, arthroscopy identified labral tears and other painful problems that had previously gone unrecognized and untreated because open procedures were rarely performed for these poorly defined conditions. The evolution of hip arthroscopy changed when femoroacetabular impingement was described and open surgical procedures were used for treatment. Open procedures for the hip, like the knee and shoulder before it, then evolved to less invasive arthroscopic methods. Techniques, technology, and understanding of hip disorders have all evolved simultaneously, resulting in a quickly changing landscape in the role of arthroscopy. And an improved focus has been gained on disorders other than femoroacetabular impingement that can lead to hip problems. This evolution is not novel because we have seen it in other joints, as well as among other general surgical procedures; most important, this evolution is not complete. Miles to go before we sleep.

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries.

OBJECTIVES: Tracheostomy-related pressure injuries (TRPI) have been demonstrated to occur in approximately 10% of tracheostomy patients. In this study, we present TRPI outcomes after implementation of a standardized tracheostomy care protocol. METHODS: A tracheostomy care protocol was developed by an interdisciplinary quality improvement program and implemented on July 1, 2016. The protocol was designed to minimize factors that contribute to the development of TRPI. Rates of TRPI over the subsequent 20 months were compared to the year before implementation. RESULTS: 9 out of 85 patients (10.6%) developed TRPI in the pre-protocol cohort compared to 0 of 137 (0%) in the post-protocol cohort, which was a statistically significant decrease by Fisher's exact test with a p-value of 0.0001. Pearson's correlation coefficient demonstrated a negative correlation between age and post-operative day of diagnosis (r = -0.641, p = 0.063), indicating that older patients develop TRPI more quickly. CONCLUSIONS: Interdisciplinary peri-operative tracheostomy care protocols can be effective in decreasing rates of TRPI.

Application of a sequential multiple assignment randomized trial (SMART) design in older patients with chronic lymphocytic leukemia.

BACKGROUND: Ibrutinib therapy is safe and effective in patients with chronic lymphocytic leukemia (CLL). Currently, ibrutinib is administered continuously until disease progression. Combination regimens with ibrutinib are being developed to deepen response which could allow for ibrutinib maintenance (IM) discontinuation. Among untreated older patients with CLL, clinical investigators had the following questions: (i) does ibrutinib + venetoclax + obinutuzumab (IVO) with IM have superior progression-free survival (PFS) compared with ibrutinib + obinutuzumab (IO) with IM, and (ii) does the treatment strategy of IVO + IM for patients without minimal residual disease complete response (MRD- CR) or IVO + IM discontinuation for patients with MRD- CR have superior PFS compared with IO + IM. DESIGN: Conventional designs randomize patients to IO with IM or IVO with IM to address the first objective, or randomize patients to each treatment strategy to address the second objective. A sequential multiple assignment randomized trial (SMART) design and analysis is proposed to address both objectives. RESULTS: A SMART design strategy is appropriate when comparing adaptive interventions, which are defined by an individual's sequence of treatment decisions and guided by intermediate outcomes, such as response to therapy. A review of common applications of SMART design strategies is provided. Specific to the SMART design previously considered for Alliance study A041702, the general structure of the SMART is presented, an approach to sample size and power calculations when comparing adaptive interventions embedded in the SMART with a time-to-event end point is fully described, and analyses plans are outlined. CONCLUSION: SMART design strategies can be used in cancer clinical trials with adaptive interventions to identify optimal treatment strategies. Further, standard software exists to provide sample size, power calculations, and data analysis for a SMART design.

Editorial Commentary: Great Expectations or "We'll See," Said the Zen Master-Hip Arthroscopy Patient Selection.

Successful hip arthroscopy is most dependent on patient selection. Chief among the selection criteria are patient expectations. There are few objective contraindications to hip arthroscopy. Subjective contraindications may take precedence and can be less well defined. Paramount among these subjective considerations are unreasonable expectations. Efforts to quantitate patient expectations can be helpful to surgeons to avoid patient selection traps and unsuccessful outcomes.

Arthroscopic Acetabular Labral Repair in Patients Over the Age of 60 Years: A Matched Case-Control Study.

PURPOSE: To report the results of labral repair in a population of patients older than 60 years and compare these with a matched population of younger adults. METHODS: We compared 21 consecutive patients older than 60 years undergoing labral repair with minimum 1-year follow-up with a contemporaneous group of 21 patients aged 18 to 55 years matched for sex, degree of chondral damage, and associated femoroacetabular impingement or dysplasia. RESULTS: Follow-up averaged 18.9 months (range, 12-24 months). The average age in the study group was 63.2 years (range, 61-71 years), and 20 patients had femoroacetabular impingement whereas 1 had dysplasia. Of these patients, 19 had acetabular articular damage (grade IV in 2, grade III in 11, grade II in 5, and grade I in 1) and 6 had femoral changes (grade IV in 1 and grade III in 5). The average age in the control group was 35.8 years (range, 20-54 years). We found average improvements of 28.1 points for the modified Harris Hip Score and 37.5 points for the International Hip Outcome Tool score within the study group and 21.2 points for the modified Harris Hip Score and 37.1 points for the International Hip Outcome Tool score within the control group. No statistically significant difference between the 2 groups was noted in the amount of improvement, with statistically and clinically significant improvements noted in both. Two study group patients underwent total hip arthroplasty (THA) at an average of 10 months, with 1 control group THA at 11 months. All 3 patients with conversion to THA had combined grade IV acetabular and grade III femoral damage. No repeated arthroscopies were performed and no complications occurred in either group. CONCLUSIONS: Patients older than 60 years can benefit from arthroscopic labral repair with improved outcomes, a modest rate of conversion to THA, and a small risk of complications. The results are comparable to those of younger adults. Combined bipolar grade IV and grade III articular damage may be a harbinger of conversion to THA regardless of age. LEVEL OF EVIDENCE: Level III, comparative therapeutic trial.

Labral Ossification and Sacroiliac Joint Disease: Could There Be a Link to an Autoimmune Etiology?

PURPOSE: To determine the prevalence of ipsilateral sacroiliac (SI) joint disease among patients with symptomatic femoroacetabular impingement (FAI) associated with labral ossification (LO) who underwent hip arthroscopy compared with a matched control group of patients with symptomatic FAI and no LO. METHODS: Computed tomography (CT) scans of all patients undergoing arthroscopic correction of FAI were obtained. The inclusion criterion for the study group was a diagnosis of FAI with a secondary diagnosis of LO made by plain radiography, CT, or magnetic resonance imaging or made intraoperatively. The exclusion criterion was the absence of evidence of LO. We reviewed 52 patients (56 hips) with LO to assess the SI joint and compared them with a control group matched by age, sex, and FAI type. The SI joints were graded according to the modified New York criteria. RESULTS: CT scans were available for evaluation of the ipsilateral SI joint in 28 patients (29 hips) with LO: 17 women and 11 men with an average age of 44.6 years (range, 26-56 years). Of the hips, 23 had combined FAI and 6 had pincer-type FAI. The control group consisted of 29 hips, exactly matched for sex and FAI type, with an average age of 44.8 years (range, 21-58 years). Grade 3 SI joint abnormalities were significantly more prevalent in the LO group (28%) than in the control group (7%, P = .037), and grade 0 or 1 changes (relatively normal SI joints) were significantly less common in patients with LO (38%) than in controls (72%, P = .008). Subanalysis showed that 35% of the LO group aged 45 years or younger had ipsilateral grade 3 SI joint abnormalities compared with none of the control patients aged 45 years or younger (P = .041). Grade 3 changes were found in 42% of male patients with LO compared with 8% of male controls (P = .155). Grade 3 changes were noted in 18% of women in the LO group compared with 6% of female controls (P = .601). CONCLUSIONS: Patients with symptomatic FAI and LO are more likely to show associated SI joint pathology than patients with FAI not involving LO. These differences are greatest among men and among patients aged 45 years or younger. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Editorial Commentary: The Warrior Athlete: An Illustrative Microcosm in the War Against Hip Femoroacetabular Impingement.

From an orthopaedic perspective, our military personnel truly are warrior athletes. Distilling the information available in these subjects provides an enlightening microcosm of the management of femoroacetabular impingement (FAI). Symptoms associated with damage caused by FAI represent the culmination of a process present since childhood. Thus, while arthroscopic correction can result in significant improvement, it does not invariably result in full restoration of function. Numerous factors influence an individual's response to injury and recovery from surgery, including subjective parameters such as resiliency. Thus, function is not always based simply on objective parameters. In view of compelling literature to support the efficacy of arthroscopic correction and treatment of FAI, servicemen and women have historically been discriminated against by unilateral lack of coverage. This trend has only partly been reversed as it is now deemed acceptable for active-duty personnel but arbitrarily not for their dependent family members. The war on FAI goes on in terms of better understanding of the FAI enemy, better techniques and technology to use during the war, and better solicitation of the homeland resources for continuing this important battle.

Influence of Tönnis Grade on Outcomes of Arthroscopic Management of Symptomatic Femoroacetabular Impingement.

PURPOSE: To define the outcomes of arthroscopic correction of femoroacetabular impingement (FAI) based on Tönnis findings within a previously reported patient population, including a comparative analysis of Tönnis grade 0 and 1 versus grade 2 changes. METHODS: Outcomes (modified Harris Hip Score [mHHS]) of a previously published study of arthroscopic correction of FAI were correlated with Tönnis grade. The inclusion criteria were the first 100 consecutive patients undergoing arthroscopic FAI correction with minimum 2-year follow-up. These procedures were performed between December 2003 and May 2006. Grades were determined independently by 2 experienced clinicians. Tönnis grades 0 and 1 were compared with Tönnis grade 2. Independent variables of sex and age were also evaluated. RESULTS: The average age of the entire group was 34.7 years (range, 13-76 years), with 66 male and 34 female patients. Of the patients, 17 had Tönnis grade 0, 49 had Tönnis grade 1, 29 had Tönnis grade 2, and 4 had Tönnis grade 3 (1 unknown). The average mHHS improvement for Tönnis grade 0 was 20.6 points; Tönnis grade 1, 22.2 points; Tönnis grade 2, 14.9 points; and Tönnis grade 3, 18.8 points. The improvement was statistically (P < .01) and clinically (>8 points) significant across all Tönnis grades. There was no difference (P = .077) between Tönnis grades 0 and 1 (21.8 points) versus grade 2 (14.9 points). There was no difference based on sex or age. CONCLUSIONS: These data support that statistically and clinically meaningful successful patient-reported outcomes (mHHS) at 2 years can be encountered even in the presence of Tönnis grade 2 radiographic features. Neither age nor sex was an indicator of poorer results within similar Tönnis grades. LEVEL OF EVIDENCE: Level III, case-control study.

Acetabular All-Suture Anchor for Labral Repair: Incidence of Intraoperative Failure due to Pullout.

PURPOSE: To report on the incidence and features of intraoperative anchor pullout in a consecutive series of patients undergoing arthroscopic labral repair of the hip. METHODS: Over an 18-month period, 434 consecutive cases underwent labral repair by a single surgeon with a particular anchor system. The following data were recorded: (1) age and gender of all cases; (2) number of anchors used; (3) number of cases in which intraoperative anchor failure occurred; (4) number of anchors that failed; and (5) age and gender of those cases in which anchor failure occurred. Failures were reported for 3-month intervals. One patient underwent repair with an alternative anchor system during this time period and was excluded. RESULTS: Mean age was 34.2 (14-71) years with 180 males and 254 females. A total of 2,007 anchors were used, averaging 4.6 per case (1-8). Thirty-three anchors pulled out among 30 patients, representing a 1.6% incidence among all anchors. Mean age among pullouts was 37.8 (17-54) years with 11 males and 19 females. There was no difference compared with patient population in which no anchor pulled: mean 33.9 (14-71) years (P = .085) with 169 males and 235 females (P = .578). Pullouts were evenly distributed over the 3-month intervals (4, 4, 6, 6, 5, 8). Pullout was mostly due to failure to securely imbed the anchor in bone. Only 2 were known to pull out in the presence of being securely seated in bone. CONCLUSIONS: These data support that the security of this particular all-suture anchor at implantation is exceptionally reliable for a single experienced surgeon, and there is no demonstrable learning curve. LEVEL OF EVIDENCE: Level IV, retrospective review of a case series.

Incorporating Hip Arthroscopy Into A Practice.

Hip arthroscopy is one of the most rapidly growing areas in orthopaedic surgery because of increased awareness of nonarthritic hip pathologies, advanced imaging modalities, and advanced techniques to reproducibly manage nonarthritic hip pathologies within a deep soft-tissue envelope and a constrained joint. In addition, more academic medical centers are providing residents with education on hip arthroscopy, and many hip preservation fellowships and courses are helping increase awareness of nonarthritic hip pathologies. Nonarthritic hip pathologies currently managed via hip arthroscopy include nonrepairable labral lesions, femoroacetabular impingement, hip instability, and hip fractures. Periarticular hip pathologies currently managed via endoscopy include greater trochanteric pain syndrome, tendinopathy and tears of the gluteus medius and minimus, partial and complete hamstring avulsions, and sciatic nerve entrapment. Ischiofemoral impingement may be addressed endoscopically via the deep gluteal space. Orthopaedic surgeons should understand the role and safety of hip arthroscopy in the pediatric population, specifically in the management of slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and septic arthritis of the hip. The efficacy of hip arthroscopy is limited, and hip arthroscopy is relatively contraindicated in patients with osteoarthritis and hip dysplasia. Complications can occur and likely are underreported in patients who undergo hip arthroscopy. Orthopaedic surgeons should understand practical issues associated with incorporating hip arthroscopy into a practice, including the difficult learning curve associated with hip arthroscopy and the reluctance of some payors to reimburse procedures performed arthroscopically because hip arthroscopy is a relatively new technology.

Editorial Commentary: Hip Femoroacetabular Impingement Correction: Risk Versus Reward, or How Much Is Too Much?

When performing arthroscopic surgical management of symptomatic cases of hip femoroacetabular impingement (FAI), it is important to consider how much cam lesion resection is required, if any. Generally, failure to adequately address a cam lesion could result in progressive damage to the articular cartilage. Thus, while it is important to consider exactly how much arthroscopic intervention is necessary to achieve successful results, the potential consequences of neglecting a cam lesion are at least as worrisome as the risks of indicated cam lesion treatment.

Is There a Role for Robotic Surgery in the Treatment of Head and Neck Cancer?

OPINION STATEMENT: Given the potential for long-term toxicities from concurrent chemoradiation, there is great interest in surgery as a primary treatment modality for head and neck cancers, particularly in the younger HPV-positive oropharyngeal cancer patient. Transoral robotic surgery (TORS) has proven to be an effective technique to safely treat oropharyngeal and select supraglottic tumors surgically. Sound, traditional surgical principles are employed using improved endoscopic visualization and precise instrumentation to perform oncologic surgery without the morbidity of transmandibular or transcervical approaches. Although level 1 evidence prospective clinical trials are currently underway for TORS, the literature supports its safety and efficacy based on numerous studies. Currently, prospective randomized trials are underway to provide better evidence for or against TORS in oropharyngeal cancer. Patient selection based on comorbidities, anatomy, and available pathological data is critical in choosing patients for TORS.

Forensic Entomology in Animal Cruelty Cases.

Forensic entomology can be useful to the veterinary professional in cases of animal cruelty. A main application of forensic entomology is to determine the minimum postmortem interval by estimating the time of insect colonization, based on knowledge of the rate of development of pioneer colonizers and on insect species succession during decomposition of animal remains. Since insect development is temperature dependent, these estimates require documentation of the environmental conditions, including ambient temperature. It can also aid in the detection and recognition of wounds, as well as estimate the timing of periods of neglect. Knowledge of the geographic distribution of insects that colonize animal remains may suggest that there has been movement or concealment of the carcass or can create associations between a suspect, a victim, and a crime scene. In some instances, it can aid in the detection of drugs or toxins within decomposed or skeletonized remains. During animal cruelty investigations, it may become the responsibility of the veterinary professional to document and collect entomological evidence from live animals or during the necropsy. The applications of forensic entomology are discussed. A protocol is described for documenting and collecting entomological evidence at the scene and during the necropsy, with additional emphasis on recording geographic location, meteorological data, and collection and preservation of insect specimens.

Intraoperative Ultrasonography During Transoral Robotic Surgery.

OBJECTIVE: This study describes the potential application of intraoperative ultrasound imaging during transoral robotic surgery (TORS). METHODS: Ultrasound imaging was performed during transoral robotic resection of oropharyngeal tumors in 10 patients at a tertiary academic center. Ultrasound imaging was utilized to identify large-caliber vessels adjacent to the surgical site. Measurements were also taken on the ultrasound of tumor thickness to determine the deep margin. Following resection, the tumor was sectioned, and a gross measurement of the tumor thickness was obtained. RESULTS: Intraoperative ultrasound use led to the identification of larger-caliber blood vessels within the operative field prior to encountering them visually. Ultrasound could also aid in defining deep tumor margins; the tumor thickness measured via ultrasound was found to be accurate within 1 to 2 mm of the grossly measured tumor thickness. This allowed for focused, careful dissection to protect and avoid blood vessels during dissection as well as improved tumor resection. CONCLUSIONS: The use of intraoperative ultrasound provides additional information to the head and neck surgeon during TORS. This may be used to identify blood vessels and assess tumor margins, thereby improving the safety and efficacy of TORS.

Editorial Commentary: Iatrogenic Instability of the Hip: A Perfect Storm.

Iatrogenic instability of the hip is likely a perfect storm with enough factors coming together just wrong to create the problem. Capsular neglect is but one potential component. Instability is also just one of a myriad of problems that can be encountered following hip arthroscopy that ranges on a spectrum from too loose to too stiff with numerous reasons in between for incomplete pain relief and residual dysfunction. Proper capsular management does not always mean capsular repair.

Surgical Outcome of Pincer Femoroacetabular Impingement With and Without Labral Ossification.

PURPOSE: To describe the clinical findings associated with labral ossification (LO), report the outcomes of arthroscopic treatment, and compare this condition to a control group with femoroacetabular impingement (FAI). METHODS: A retrospective review of hip arthroscopy patients from 2004 to 2013 was performed to identify patients with a diagnosis of pincer FAI with LO and at least 2 years of follow-up. Diagnosis was made by plain radiograph, computed tomography, magnetic resonance imaging, or intraoperatively. The LO cohort was compared to a chronologically matched control group of FAI patients with pincer FAI but no LO. Patients were prospectively assessed with modified Harris Hip Score (mHHS) preoperatively and then postoperatively at 3, 12, 24, 60, and 120 months. RESULTS: The LO group included 56 hips in 52 patients whereas the control group included 56 hips in 56 patients. Mean follow-up was 36 months for the LO group and 38 for the control group (P = .28). Patients in the LO group were older than those in the control group, with a mean age of 45 versus 30 years (P < .0001), and had more women: 58% female versus 32% male (P < .0001). The LO group patients were more likely to have pain while sitting (65% v 18%) and restricted activities of daily living (40% v 11%) than the control group (P < .0001), and more likely to have pain during a flexion, abduction, external rotation (FABER) test (67% v 36%) (P = .002). Both groups experienced a similar magnitude of improvement in mHHS, but the LO group had a significantly lower preoperative mHHS (49 v 63, P < .001) and final postoperative mHHS (75 v 87, P < .0001) than the control group. CONCLUSIONS: Patients with LO represent a unique subset of pincer FAI and are more likely to be older, female, and have more severe symptoms. Hip arthroscopy can be used to treat LO with excision of the ossified fragments or rim, with a reasonable expectation of improvement of symptoms. LEVEL OF EVIDENCE: III, retrospective case-control.