Computed Tomography Scans in Patients With Young Adult Hip Pain Carry a Lifetime Risk of Malignancy.

PURPOSE: To calculate the lifetime risk of malignancy in young adult patients with hip pain using 5 different imaging and radiation dose protocols with or without pre- and postoperative computed tomography (CT). METHODS: Radiographic and CT patient radiation doses were retrospectively reviewed. Imaging protocols for hip pain composed of radiographs with or without pre- and postoperative CT scans were modeled and radiation doses were estimated using the PCXMC computer code. Based on these radiation doses, lifetime attributable risks of cancer and mortality for a 10- through 60-year-old male and female were calculated as published by the committee on the Biological Effects of Ionizing Radiation (BEIR) in the BEIR VII report. Relative risks and number needed to harm (NNH) were calculated for each protocol. RESULTS: Based on a review of our institutional database, 2 CT scan doses were used for this study: a high 5.06 mSv and a low 2.86 mSv. Effective doses of radiation ranged from 0.59 to 0.66 mSv for radiographs alone to 10.71 to 10.78 mSv for radiographs and CT both pre- and postoperatively at the higher dose. Lifetime attributable risk of cancer for radiographs alone was 0.006% and 0.011% for a 20-year-old male and female, respectively. Lifetime attributable risk of cancer for radiographs along with pre- and postoperative CT scans at higher dose was 0.105% and 0.177% for a 20-year-old male and female, respectively. Radiographs alone lead to an NNH of 16,667 for males and 9,090 for females, whereas the protocol with pre- and postoperative CT scans at the higher dose led to an NNH of 952 for males and 564 for females. The relative risk of this protocol compared to radiographs alone was 17.5 for males and 16.1 for females. CONCLUSION: Protocols with CT scans of the hip/pelvis pose a small lifetime attributable risk (0.034%-0.177% for a 20-year-old) but a large relative risk (5-17 times) of cancer compared with radiographs alone in the imaging evaluation for hip pain that decreases with increasing age. CLINICAL RELEVANCE: This study illustrates the need for clinicians to understand the imaging protocols used at their institution to understand the risks and benefits of using those protocols in their practice.

Evaluation of the Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test.

PURPOSE: The Patient-Reported Outcomes Measurement Information System Upper Extremity Computer Adaptive Test (UE CAT) has recently been made available by the National Institutes of Health to measure physical function outcomes in the upper extremity. We hypothesized that the UE CAT would psychometrically outperform the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Patient-Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (PF CAT) in a hand patient population. METHODS: The UE CAT, PF CAT, and DASH were each electronically administered to all adult patients who presented to a tertiary hand and upper extremity (nonshoulder) orthopedic clinic. Patient responses were retrospectively studied to determine the validity, reliability, and floor/ceiling effects of all 3 instruments using the Rasch Partial Credit Model. Responder burden and Pearson correlations were calculated for each instrument. RESULTS: A total of 379 patients completed the UE CAT, PF CAT, and the DASH. On average, 6 UE CAT, 9 PF CAT, and 30 DASH questions were administered to each patient. All 3 instruments were each highly correlated with each other. Floor effects were low and similar between all instruments; however, ceiling effects were higher in the UE CAT (10.82%) than in the PF CAT (1.32%) or DASH (5.28%). High person reliability (PR) and item reliability (IR) were found for all 3 metrics: UE CAT (α = 0.99; PR = 0.91; IR = 0.94); PF CAT (α = 0.95; PR = 0.89; IR = 0.96); and DASH (α = 0.97; PR = 0.95; IR = 0.99). The UE CAT questions had the best item-fit: only 1 of 15 UE CAT items had poor fit in contrast to 4 of 30 DASH items and 7 of 33 PF CAT items. CONCLUSIONS: The psychometric properties of the UE CAT compare favorably with the PF CAT and the DASH in nonshoulder upper extremity patients. The relatively large ceiling effect found in the UE CAT could be improved with item bank expansion to include items at the upper end of function. CLINICAL RELEVANCE: The UE CAT is a useful patient-reported outcome measure that merits further investigation.

Arthroscopic treatment of mild to moderate deformity after slipped capital femoral epiphysis: intra-operative findings and functional outcomes.

PURPOSE: To identify intra-articular pathology during arthroscopic osteochondroplasty for slipped capital femoral epiphysis (SCFE)-related femoroacetabular impingement and determine functional outcomes after treatment. METHODS: Nine hips in 9 patients (6 male and 3 female patients; mean age, 17.5 years; age range, 13.5 to 26.9 years) underwent hip arthroscopy for femoroacetabular impingement after in situ pinning of the SCFE. Medical records, radiographs, and intraoperative images were reviewed to determine the severity of disease and damage to the hip joints. For all patients, we obtained the modified Harris Hip Score and Hip Outcome Score (HOS) preoperatively and at a minimum of 12 months postoperatively, as well as a Likert scale of perceived change in physical activity. RESULTS: All 9 treated patients had some degree of labral or acetabular cartilage injury at the time of arthroscopy, which was a mean of 58.6 months (range, 18 to 169 months) after in situ pinning. The alpha angle improved from 75° preoperatively to 46° postoperatively (P < .001). The mean follow-up period was 28.6 months (range, 12.6 to 55.6 months). The mean modified Harris Hip Score improved from 63.6 preoperatively to 91.4 postoperatively (P = .005). Similarly, the mean HOS activities-of-daily living scale improved from 70.2 to 93.3 (P = .010), and the HOS sports scale improved from 53.4 to 88.9 (P = .004). Most patients reported significant improvement on a physical-activity Likert scale, with 4 reporting much improved, 3 reporting improved, and 1 reporting slightly improved physical activity. One patient reported an unchanged activity level. No patients reported a worse activity level after surgery. CONCLUSIONS: Post-SCFE cartilage and/or labral damage develops in patients with symptomatic mild to moderate SCFE deformity, and arthroscopic treatment improved functional outcomes in a small cohort of patients at short-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Psychometric evaluation of the PROMIS Physical Function Computerized Adaptive Test in comparison to the American Shoulder and Elbow Surgeons score and Simple Shoulder Test in patients with rotator cuff disease.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Test (PF CAT) is a newly developed patient-reported outcome instrument designed by the National Institutes of Health to measure generalized physical function. However, the measurement properties of the PF CAT have not been compared with established shoulder-specific patient-reported outcomes. METHODS: Patients with clinical diagnosis of rotator cuff disease completed the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and PF CAT. Responses to each of the 3 instruments were statistically analyzed with a Rasch partial credit model. Associations between instruments, convergent validity, item and person reliability, ceiling and floor effects, dimensionality, and survey length were determined. RESULTS: Responses from 187 patients were analyzed. The PF CAT required fewer questions than the ASES or SST (PF CAT, 4.3; ASES, 11; SST, 12). Correlation between all instruments was moderately high. Item reliability was excellent for all instruments, but person reliability of the PF CAT was superior (0.93, excellent) to the SST (0.71, moderate) and ASES (0.48, fair). Ceiling effects were similar among all instruments (PF CAT, 0.53%; SST, 6.1%; ASES, 2.3%). Floor effects were found in 21% of respondents to the SST but in only 3.2% of PF CAT and 2.3% of ASES respondents. CONCLUSION: The measurement properties of the PROMIS PF CAT compared favorably with the ASES and SST despite requiring fewer questions to complete. The PROMIS PF CAT had improved person reliability compared with the ASES score and fewer floor effects compared with the SST.

Psychologic distress reduces preoperative self-assessment scores in femoroacetabular impingement patients.

BACKGROUND: In several areas of orthopaedics, including spine and upper extremity surgery, patients with greater levels of psychologic distress report worse self-assessments of pain and function than patients who are not distressed. This effect can lead to lower than expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychologic component. QUESTIONS/PURPOSES: The purposes of this study were to determine (1) the association of psychologic distress and baseline modified Harris hip scores and Hip Outcome Scores in patients undergoing hip arthroscopy; and (2) whether psychologic distress would remain a significant negative predictor of baseline hip scores when other clinical variables such as age, sex, BMI, smoking status, and American Society of Anesthesiologists (ASA) classification were controlled. METHODS: One hundred forty-seven patients at one center were prospectively enrolled when they scheduled hip arthroscopy to treat painful femoroacetabular impingement. Before surgery, psychologic distress was quantified using the Distress Risk Assessment Method questionnaire. Patients also completed baseline self-assessments of hip pain and function including the modified Harris hip score and the Hip Outcome Score. Age, sex, BMI, smoking status, and ASA classification were recorded for each patient. Bivariate correlations and multivariate regression models were used to assess the effect of psychologic distress on patient self-assessment of hip pain and function. RESULTS: Patients with distress reported significantly lower baseline modified Harris hip scores (58 versus 67, p = 0.001), Hip Outcome Score-Activities of Daily Living scores (62 versus 72, p = 0.002), and Hip Outcome Score-Sports scores (36 versus 47, p = 0.02). Distress remained significantly associated with lower baseline modified Harris hip (p = 0.006), Hip Outcome Score-Activities of Daily Living (p = 0.005), and Hip Outcome Score-Sports scores (p = 0.017) when age, sex, BMI, smoking status, and ASA classification were controlled for in the multivariate model. CONCLUSIONS: Practitioners should recognize that psychologic distress has a negative correlation with baseline patient self-assessment using the modified Harris hip score and the Hip Outcome Scores, scales not previously described to correlate with psychologic distress. Longitudinal followup is warranted to clarify the relationship between distress and self-perceived disability and the effect of distress on postoperative outcomes in patients having hip arthroscopy. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Psychological distress in hip arthroscopy patients affects postoperative pain control.

PURPOSE: To determine whether patients with higher levels of preoperative psychological distress more frequently use a postoperative fascia iliaca nerve block for pain control after hip arthroscopy, and to determine whether a fascia iliaca nerve block is an effective adjunct to multimodal oral and intravenous analgesia after hip arthroscopy. METHODS: One hundred seven patients undergoing hip arthroscopy were prospectively enrolled. Before surgery, patients were administered the Distress Risk Assessment Method questionnaire to quantify their level of preoperative psychological distress. Postoperatively, patients with pain inadequately controlled by multimodal oral and intravenous analgesics could request and receive a fascia iliaca nerve block. Pain scores, opioid consumption, time in the post-anesthesia care unit (PACU), and postoperative complications were recorded for all patients. RESULTS: Patients with normal Distress Risk Assessment Method scores requested fascia iliaca nerve blocks approximately half as frequently (18 of 50 [36%]) as patients in the at-risk category (28 of 47 [60%]) or distressed category (7 of 10 [70%]) (P = .02). Patients with high levels of distress also received 40% more intraoperative opioid than patients with normal scores (P = .04). In the study population as a whole, patients who received a fascia iliaca nerve block (n = 53) had a higher initial visual analog scale (VAS) pain score in the PACU (7.2 ± 0.3 v 5.5 ± 0.4, P = .001) and showed greater improvement in the VAS pain score by PACU discharge (-4.3 ± 0.2 v -2.1 ± 0.3, P ≤ .0001) compared with patients who did not receive a block (n = 54). CONCLUSIONS: Patients with higher levels of preoperative psychological distress more frequently requested a postoperative nerve block to achieve adequate pain control after hip arthroscopy. Patients receiving a block had greater improvement in VAS pain scores compared with patients managed with oral and intravenous analgesics alone. LEVEL OF EVIDENCE: Level IV, case series.

Arthroscopic Femoral Osteochondroplasty for Cam-Type Femoroacetabular Impingement: The Trough Technique.

Arthroscopic osteochondroplasty has become the most common treatment for cam-type femoroacetabular impingement. However, gauging the appropriate depth and location of the femoral osteochondroplasty remains challenging, given the parallax observed from using a 70° arthroscope across multiple viewing perspectives. Consequently, reliable techniques must use a combination of arthroscopic and fluoroscopic checks and balances to assess the femoral head-neck junction to help guide bony resection. We have developed a technique for osteochondroplasty that has made the process more efficient and reliable in our hands. It involves creating a trough at the apex of the osteochondroplasty and then contouring the proximal and distal regions to re-create normal proximal femoral geometry. This article details our technique for femoral osteochondroplasty, which can be performed alone for isolated cam impingement or in concert with other intra- and extra-articular procedures to address associated hip pathology.

Arthroscopic Capsular Repair for Symptomatic Hip Instability After Previous Hip Arthroscopic Surgery.

BACKGROUND: Management of the hip capsule has been a topic of recent debate in hip arthroscopic surgery. Postoperative instability after hip arthroscopic surgery has been reported and can lead to poor outcomes. PURPOSE: To determine the outcome of patients diagnosed with symptomatic instability after hip arthroscopic surgery at a minimum of 12 months and 24 months after revision surgery for capsular repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a cohort of approximately 1100 patients who underwent hip arthroscopic surgery, 33 patients (33 hips) developed symptomatic instability requiring a revision surgery. Two patients suffered anterior dislocations following their initial surgery. Radiographs were reviewed to evaluate for acetabular dysplasia. Three patients were lost to follow-up and 10 patients were excluded as they were <1 year out from the revision surgery. A total of 20 patients (18 female, 2 male) completed a preoperative and postoperative modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS) at a minimum of 12 months. Eleven of these patients had a minimum follow-up of 24 months. All patients filled out a Likert scale of perceived improvement in physical ability at final follow-up. RESULTS: The mean age of the patients was 29.7 years (range, 15.2-55.5 years). The mean lateral center-edge angle was 25°, and the mean acetabular index was 7° before revision. All patients underwent interportal capsulotomy during the index arthroscopic procedure. After their index arthroscopic procedures, patients had minimal improvement at a mean of 19.1 months postoperatively on the mHHS (from 57.1 to 57.6; P = .423), HOS-Activities of Daily Living (ADL) (from 62.7 to 66.4; P = .260), and HOS-Sports (from 42.0 to 39.1; P = .800). For the patients with a minimum 1-year follow-up after revision surgery (n = 20; mean follow-up, 21.3 months), the mean mHHS (from 57.6 preoperatively to 85.8 at final follow-up; P < .001), HOS-ADL (from 66.4 to 85.7; P < .001), and HOS-Sports (from 39.1 to 79.8; P < .001) all improved significantly. The results were similar when looking at only the patients with a minimum 2-year follow-up after revision surgery (n = 11; mean follow-up, 26.1 months); the mean mHHS (from 56.0 preoperatively to 91.5 at final follow-up; P = .001), HOS-ADL (from 68.3 to 89.9; P = .009), and HOS-Sports (from 35.7 to 87.9; P = .001) all improved significantly. When comparing patients with isolated capsular repair to those with additional procedures performed, there were no differences between the groups (all P > .05). At final follow-up, all but 1 patient had improved overall physical ability levels. CONCLUSION: Revision hip arthroscopic surgery for capsular repair in patients with symptomatic instability after hip arthroscopic surgery provides good functional outcomes at a minimum of 1 and 2 years postoperatively.

Dislocation After Hip Arthroscopy for Cam-Type Femoroacetabular Impingement Leading to Progressive Arthritis: A Case Report.

CASE: We present the case of a fifty-two-year-old man who underwent hip arthroscopy for cam-type femoroacetabular impingement and had an anterior hip dislocation three weeks postoperatively. The patient did not have any of the previously identified risk factors for instability after hip arthroscopy. He underwent revision involving capsular repair and removal of loose bodies but progressed to needing total hip arthroplasty within two years. CONCLUSION: This case illustrates that even patients without the previously reported risk factors for hip instability are at risk of dislocation after hip arthroscopy and this can lead to rapid joint degeneration necessitating arthroplasty.

Arthroscopic and imaging findings after traumatic hip dislocation in patients younger than 25 years of age.

The aim of this study is to identify intra-articular pathology and loose bodies during arthroscopic examination of young patients after hip dislocation and to correlate arthroscopic findings with preoperative imaging. Twelve hips in 12 patients (eight males, four females; mean age 16.3 years, range 11-25 years) underwent hip arthroscopy after traumatic hip dislocation. Medical records, imaging studies and intra-operative images were reviewed to determine the damage to the hip joint, acetabular morphology, including labral and/or cartilage injury and presence of loose bodies. Imaging findings were compared with arthroscopic findings and treatment. All 12 patients underwent arthroscopy, which was performed an average of 59 (range 1-359, median 17.5) days after dislocation. Ten patients had posterior hip dislocations and two patients had obturator dislocations. All patients underwent closed reduction as initial management, with one incongruent reduction. Eleven patients had computed tomography scans and four patients had magnetic resonance imaging (MRI) with three patients having both modalities. Loose bodies were identified in 6/12 (50%) patients on pre-operative imaging and in 8/12 (67%) patients at arthroscopy. The two patients with unidentified loose bodies on imaging did not have a preoperative MRI. Five patients had acetabular cartilage injuries and three patients had femoral-sided cartilage injuries. Eight patients had labral injuries at arthroscopy. Intra-articular injuries and loose bodies are common in adolescent and young adult patients undergoing arthroscopy following traumatic hip dislocation. Further studies are needed to determine whether arthroscopy after traumatic dislocation may play a role in hip preservation following these injuries.

Detection of a traumatic arthrotomy in the pediatric knee using the saline solution load test.

BACKGROUND: The objective of this study was to quantify the load volume needed for a positive diagnosis of a traumatic arthrotomy in the pediatric knee with use of the saline solution load test (SLT). METHODS: From February 2013 to June 2014, eighty-seven pediatric patients who were undergoing elective knee arthroscopy were prospectively enrolled in this study. An SLT was performed in each patient using a 5-mm superolateral portal as the arthrotomy site, with injection of the saline solution into the lateral aspect of the knee. The 50th, 75th, 90th, and 95th percentiles of saline solution load volume required for a positive result were identified. Univariate linear regression was used to identify possible relationships between demographics (age, height, weight, and body mass index [BMI]) and load volume. RESULTS: Forty-one female and forty-six male patients with a mean age (and standard deviation) of 13.4 ± 3.0 years (range, five to eighteen years) and a mean BMI of 21.9 ± 5.0 kg/m(2) (range, 12.9 to 36.2 kg/m(2)) were enrolled. The mean saline solution load volume was 28.9 ± 14.2 mL (range, 7.0 to 78 mL). The 50th, 75th, 90th, and 95th percentiles of saline solution load volume were 27, 37, 47, and 58 mL, respectively. The mean load volume did not differ significantly between male and female patients (28.8 ± 13.9 versus 29.0 ± 14.7 mL, respectively; p = 0.92). Load volume was significantly correlated with age, height, weight, and BMI. CONCLUSIONS: On the basis of our findings, a saline solution load volume of 47 mL is required to detect 90% of superolateral traumatic arthrotomies of 5 mm in the pediatric knee with use of the SLT.

Effect of Naproxen Prophylaxis on Heterotopic Ossification Following Hip Arthroscopy: A Double-Blind Randomized Placebo-Controlled Trial.

BACKGROUND: Heterotopic ossification (HO) is a known complication of hip arthroscopy. Our objective was to determine the effect of postoperative naproxen therapy on the development of HO following arthroscopic surgery for femoroacetabular impingement. METHODS: Between August 2011 and April 2013, 108 eligible patients were enrolled and randomized to take naproxen or a placebo for three weeks postoperatively. Radiographs were made at routine follow-up visits for one year following surgery. The primary outcome measure was the development of HO, as classified with the Brooker criteria and two-dimensional measurements on radiographs made at least seventy-five days postoperatively (average, 322 days). The primary analysis, performed with a Fisher exact test, compared the proportion of subjects with HO between the treatment and control groups. A single a priori interim analysis was planned at the midpoint of the study. RESULTS: Our data safety and monitoring board stopped this study when the interim analysis showed that the stopping criterion had been met for demonstration of efficacy of the naproxen intervention. The prevalence of HO was 46% (twenty-two of the forty-eight in the final analysis) in the placebo group versus 4% (two of forty-eight) in the naproxen group (p < 0.001). Medication compliance was 69% overall, but it did not differ between the naproxen and placebo groups. Minor adverse reactions to the study medications were reported in 42% of the patients taking naproxen versus 35% of those taking the placebo (p = 0.45). CONCLUSIONS: In this trial, prophylaxis with naproxen was effective in reducing the prevalence of HO without medication-related morbidity.

The prevalence of radiographic findings of structural hip deformities in female collegiate athletes.

BACKGROUND: Structural deformities of the hip, including femoroacetabular impingement (FAI) and acetabular dysplasia, often limit athletic activity. Previous studies have reported an increased prevalence of radiographic cam FAI in male athletes, but data on the prevalence of structural hip deformities in female athletes are lacking. PURPOSE: (1) To quantify the prevalence of radiographic FAI deformities and acetabular dysplasia in female collegiate athletes from 3 sports: volleyball, soccer, and track and field. (2) To identify possible relationships between radiographic measures of hip morphologic characteristics and physical examination findings. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Anteroposterior (AP) pelvis and frog-leg lateral radiographs were obtained from 63 female athletes participating in Division I collegiate volleyball, soccer, and track and field. Lateral center edge angle (LCEA) and acetabular index were measured on AP films. Alpha angle and head-neck offset were measured on frog-leg lateral films. Pain during the supine impingement examination and hip rotation at 90° of flexion were recorded. Random-effects linear regression was used for group comparisons and correlation analyses to account for the lack of independence of observations made on left and right hips. RESULTS: Radiographic cam deformity (alpha angle >50° and/or head-neck offset <8 mm) was found in 48% (61/126) of hips. Radiographic pincer deformity (LCEA >40°) was noted in only 1% (1/126) of hips. No hips had radiographic mixed FAI (at least 1 of the 2 cam criteria and LCEA >40°). Twenty-one percent (26/126) of hips had an LCEA <20°, indicative of acetabular dysplasia, and an additional 46% (58/126) of hips had borderline dysplasia (LCEA ≥20° and ≤25°). Track and field athletes had significantly increased alpha angles (48.2° ± 7.1°) compared with the soccer players (40.0° ± 6.8°; P < .001) and volleyball players (39.1° ± 5.9°; P < .001). There was no significant difference in the LCEA (all P > .914) or the prevalence of dysplasia (LCEA <20°) between teams (all P > .551). There were no significant correlations between the radiographic measures and internal rotation (all P > .077). There were no significant differences (all P > .089) in radiographic measures between hips that were painful (n = 26) during the impingement examination and those that were not. CONCLUSION: These female athletes had a lower prevalence of radiographic FAI deformities compared with previously reported values for male athletes and a higher prevalence of acetabular dysplasia than reported for women in previous studies.

Functional outcomes assessment in shoulder surgery.

The effective evaluation and management of orthopaedic conditions including shoulder disorders relies upon understanding the level of disability created by the disease process. Validated outcome measures are critical to the evaluation process. Traditionally, outcome measures have been physician derived objective evaluations including range of motion and radiologic evaluations. However, these measures can marginalize a patient's perception of their disability or outcome. As a result of these limitations, patient self-reported outcomes measures have become popular over the last quarter century and are currently primary tools to evaluate outcomes of treatment. Patient reported outcomes measures can be general health related quality of life measures, health utility measures, region specific health related quality of life measures or condition specific measures. Several patients self-reported outcomes measures have been developed and validated for evaluating patients with shoulder disorders. Computer adaptive testing will likely play an important role in the arsenal of measures used to evaluate shoulder patients in the future. The purpose of this article is to review the general health related quality-of-life measures as well as the joint-specific and condition specific measures utilized in evaluating patients with shoulder conditions. Advances in computer adaptive testing as it relates to assessing dysfunction in shoulder conditions will also be reviewed.

The Effect of NSAID Prophylaxis and Operative Variables on Heterotopic Ossification After Hip Arthroscopy.

BACKGROUND: Heterotopic ossification (HO) is a known complication of hip arthroscopy. Little is known about the factors that lead to HO after hip arthroscopy. PURPOSE: The aim of this study was to evaluate the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) and other operative variables on the development of HO. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 357 consecutive cases of hip arthroscopy were retrospectively reviewed over a 3-year period. Routine NSAID prophylaxis was not performed for the first 117 cases. Prophylaxis with naproxen for 3 weeks was then routinely prescribed for the remaining 240 cases. Complete follow-up was available for 288 of the original 357 cases. The presence of HO and its characteristics were recorded for each patient, along with baseline demographic and surgical variables. Odds ratios and logistic regression were used to identify causal factors for HO. RESULTS: The incidence of HO in cases in which the patient did not receive NSAID prophylaxis was 25.0% (23/92) versus 5.6% (11/196) of cases in which the patient received NSAIDs. Patients who received no NSAID prophylaxis were 13.6 times more likely to develop HO postoperatively (95% confidence interval, 2.44-75.5; P = .003). Comparing just mixed-type femoroacetabular impingement resections, patients who received no NSAID prophylaxis were 16.6 times more likely to develop HO postoperatively (95% confidence interval, 2.2-126.0; P = .006). Multivariate logistic regression identified the performance of a mixed-type femoroacetabular impingement resection (P = .011) and the absence of NSAID prophylaxis (P = .003) as predictors of HO development. The majority of HO cases (29/34) occurred in patients with mixed-type femoroacetabular impingement who had both osteochondroplasty and acetabuloplasty. Complications of NSAID therapy in this study population included acute renal failure, hematochezia from acute colitis, and gastritis. CONCLUSION: Routine NSAID prophylaxis reduces but does not eliminate the incidence of HO in patients undergoing hip arthroscopy. Heterotopic ossification was more likely to develop in patients undergoing acetabuloplasty along with osteochondroplasty and in those who did not receive prophylactic postoperative NSAIDs. Side effects from the investigated NSAID regimen can be serious and should be weighed against the potential benefits in preventing the formation of HO.

Operative agreement on lateral compression-1 pelvis fractures. a survey of 111 OTA members.

OBJECTIVES: To better characterize operative agreement and disagreement among orthopaedic surgeons treating lateral compression type 1 (LC-1) pelvic fractures in an effort to improve communication between care providers and improve patient care. DESIGN: Decision analysis. SETTING: Level 1 trauma center. METHODS: Twenty-seven LC-1 cases were selected to represent a wide array of LC-1 injuries. Each case was presented with 3 plain pelvic radiographs (anteroposterior, inlet, and outlet) and a scrollable computed tomography at the OTA national meeting. Attendees were queried whether they would perform operative stabilization "yes/no." Years of surgical practice (0-5, 6-10, and >10), annual pelvic fracture case volume (0-20, 21-50, and >50), and completion of a trauma fellowship (yes/no) were also collected. Fleiss' kappa (K) was used to measure operative agreement among survey respondents, where K = 0.21-0.40 was fair and K = 0.41-0.60 was moderate agreement. RESULTS: One hundred eleven surgeons completed the survey where the average tendency to operate across surveys was 40%. Of the 27 cases presented, only 9 cases (33%) showed substantial agreement. There were 4 cases where nearly everyone chose operative stabilization (93.1%-94.4%) and 5 cases where nearly no one chose operative stabilization (0%-8.7%). The overall agreement was fair with K = 0.39 [95% confidence interval (CI), 0.34-0.44]. Although there was a trend for surgeons with more years of surgical practice to have a lower tendency to operate, it did not achieve statistical significance (odds ratio for >10 years vs. 0-5 years = 0.73; 95% CI, 0.48-1.11). Annual case volume and completion of a trauma fellowship were not statistically significant predictors of operative tendency. CONCLUSIONS: Our results show only fair operative agreement (K = 0.39; 95% CI, 0.34-0.44) in a radiographic survey representing a broad range of LC-1 fracture morphologies among OTA surgeons. Only 9 of the 27 cases (33%) had substantial agreement. There was no difference in the decision to operate based on surgical volume, completion of a trauma fellowship, or time in practice. These results highlight the differing practice decisions among surgeons currently treating LC-1 injuries, and there is need for further studies to more fully understand stability after this injury pattern.

Angiogenic pretreatment to enhance myocardial function after cellular cardiomyoplasty with skeletal myoblasts.

OBJECTIVE: Improvements in ventricular function after cellular cardiomyoplasty appear to be limited by the poor survival of the cellular implants. Angiogenic pretreatment of infarcted myocardium may improve implanted cell survival and consequently myocardial function. METHODS: Fischer 344 rats underwent coronary artery ligation and injection of an adenovirus encoding vascular endothelial growth factor 121 or of saline solution at increasing intervals after ligation. Myocardial perfusion and mass preservation were assessed. On the basis of these data, four groups of animals underwent coronary ligation and adenovirus with or without syngeneic skeletal myoblast administration: (1) adenovirus at ligation and myoblasts 3 weeks later (n = 7), (2) saline solution at ligation and myoblasts 3 weeks later (n = 8), (3) saline solution at ligation and 3 weeks later (n = 8), and (4) saline solution at ligation and adenovirus with myoblasts 3 weeks later (n = 5). Left ventricular ejection fraction was analyzed by echocardiography before coronary ligation and 3 and 5 weeks later, after which cell survival was assessed in harvested tissues. RESULTS: Myocardial infarct perfusion was at least 50% greater in animals treated with adenoviral vector than with saline solution immediately after ligation (P < .02). In comparison, delayed adenovirus administration did not significantly diminish infarct perfusion but resulted in decreased myocardial preservation (P < .05). Accordingly, adenovirus administration nearly tripled implanted myoblast survival relative to saline solution-treated animals (P = .004). Left ventricular ejection fraction was improved, however, only after cell implantation with adenovirus pretreatment (P = .027). CONCLUSION: Angiogenic strategies can help to preserve myocardium jeopardized by acute coronary occlusions. Angiogenic pretreatment enhances the efficacy of cellular cardiomyoplasty.

An Egr-1 master switch for arteriogenesis: studies in Egr-1 homozygous negative and wild-type animals.

BACKGROUND: Arteriogenesis has been implicated as an important biologic response to acute vascular occlusion. The early growth response 1 (Egr-1) gene encodes an immediate-early response transcription factor that is upregulated by changes in vascular strain and that in turn upregulates a number of putative angiogenic and arteriogenic growth factors. We therefore hypothesized that early growth response 1 might be a critical arteriogenic messenger that induces revascularization in the setting of acute vascular occlusions. METHODS: Wild-type or Egr-1-/- (null) C57 BL mice, or Sprague-Dawley rats, underwent unilateral iliofemoral artery excision and subsequent analyses for angiogenesis and arteriogenesis through cell-specific immunohistochemistry. Rats were also administered an adenoviral vector encoding for Egr-1 (AdEgr group), noncoding vectors (AdNull group), or saline, after which these animals were assessed by means of serial laser Doppler perfusion imaging and morphologic examination of rat foot-pad ischemic lesions. RESULTS: Egr-1 wild-type mice demonstrated an equivalent number of capillaries but a greater number of arterioles following excision versus Egr-1 null mice. AdEgr group rats demonstrated greater distal perfusion from 7 to 21 days after excision compared with control animals (P < .02), which approximated normal perfusion at 21 days after excision. AdEgr group rats also demonstrated greater arteriolar density and less severe ischemic foot-pad lesions than control animals. CONCLUSION: These data suggest the importance of Egr-1 as a critical and potentially therapeutic mediator of revascularization after vascular occlusion and implicate arteriogenesis (collateral vessel formation) as a critical component of this process.