Medicaid Insurance Is Associated With More Complications and Emergency Department Visits but Equivalent 5-Year Secondary Surgery Rate After Primary Hip Arthroscopy.

PURPOSE: To compare 90-day complications, 30-day emergency department (ED) visits, and 5-year rate of secondary surgeries for patients with Medicaid vs commercial insurance undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and/or labral tears using a large national database. METHODS: The PearlDiver Mariner151 database was used to identify patients with International Classification of Diseases, Tenth Revision diagnosis codes for FAIS and/or labral tear who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021. Patients with Medicaid were matched 1:4 to a control group of commercially insured patients based on age, sex, body mass index, and Elixhauser Comorbidity Index. Rates of 90-day complications and 30-day ED visits were compared using multivariate regression models. Five-year rates of secondary surgeries-revision arthroscopy or total hip arthroplasty-were compared between cohorts by Kaplan-Meier analysis. RESULTS: A total of 2,033 Medicaid patients were matched with 8,056 commercially insured patients. Rates of adverse events were low; however, Medicaid patients were significantly more likely than commercially insured patients to experience any 90-day complication (2.12% vs 1.43%; odds ratio [OR], 1.2; P = .02). Medicaid patients also experienced more 30-day ED visits than commercially insured patients (8.61% vs 4.28%), and on multivariate logistic regression, insurance status was the strongest determinant of 30-day ED visits (relative to commercial, Medicaid OR, 2.02; P < .001). Despite these differences, 5-year rates of secondary surgeries were comparable between groups (6.1% vs 6.0%; P = .6). CONCLUSIONS: In this large national database study, Medicaid patients undergoing primary hip arthroscopy showed significantly greater odds of experiencing 90-day postoperative complications and 30-day ED visits compared to commercially insured patients. Nevertheless, both groups had similar survivorship rates at 5-year follow-up, similar to prior estimates irrespective of insurance. These results document encouraging secondary surgery rates in Medicaid patients.

Mid- and Long-Term Outcomes Are Favorable for Patients With Borderline Dysplasia Undergoing Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate midterm outcomes, long-term outcomes, and survivorship in the borderline dysplastic population after primary hip arthroscopy. METHODS: A systematic review of current literature was performed with the following key words: "hip, "arthroscopy," "borderline dysplasia," "borderline hip dysplasia," "developmental dysplasia," "ten-year," "survivorship," "10-year," "5-year," "five year," "mid-term," "long-term," "outcomes," "arthroscopic," and "femoroacetabular impingement" in PubMed, Cochrane, and Scopus in March 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The following information was recorded: title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcomes (PROs), characteristics of patients converting to total hip arthroplasty (THA), and rates of secondary surgeries and conversion to THA were recorded. Survivorship was defined as not converting to THA. Kappa values for the title/abstract and full-text screening were calculated. Forest plots were created for PROs that were included in 3 or more studies. RESULTS: Six articles comprising 413 hips were included in the study. Three studies were Level III evidence, and 3 studies were Level IV evidence. Average follow-up ranged from 5.7 to 12.2 years. One study defined borderline hip dysplasia as lateral center-edge angle 18-25° and 5 defined it as lateral center-edge angle 20-25°. All studies included PROs and reported significant improvement after surgery in at least one PRO. Three studies reported clinical benefit and across the studies at least 70% of patients achieved minimum clinically important difference in at least one PRO. Rates of undergoing revision hip arthroscopy and THA ranged from 2.1% to 7% and 0% to 24%, respectively. Tönnis grade 2, Tönnis angle >15, and Outerbridge Grade IV cartilage damage were identified as predictors of conversion to THA. CONCLUSIONS: Patients with borderline hip dysplasia undergoing primary hip arthroscopy demonstrated significant improvement in PROs at midterm and long-term follow-up. Survivorship at midterm follow-up was 98.2% (328/334 hips) and 76.3% (29/38 hips) at long-term follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

Athletes Report Favorable Outcomes at 5-Year Minimum Follow-Up After Primary Hip Arthroscopy: A Systematic Review.

PURPOSE: To evaluate minimum 5-year outcomes and survivorship after primary hip arthroscopy in athletes. METHODS: A systematic review of current literature was performed with the following key words: "hip arthroscopy," "long-term," "outcomes," "ten-year," "survivorship," "10-year," "5-year," "five-year," "midterm," "athlete," "sport," and "femoroacetabular impingement" in PubMed, Cochrane Trials, and Scopus in April 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Study and demographic variables such as title, author, publication date, study design, demographic, number of hips, follow-up time, study period, indications for hip arthroscopy, patient-reported outcome scores, and rates of secondary surgeries and conversion to total hip arthroplasty. Radiographic, intraoperative surgical treatment, and clinical benefit was documented as well. RESULTS: Ten studies that captured data on 691 hips were included in this study. Eight studies reported mean and standard deviation for the modified Harris Hip Score. Significant improvements were reported in all studies with postoperative scores ranging from 83.3 to 94.4 (standardized mean difference [SMD] 1.65; 95% confidence interval [CI] 1.39-1.91, P < .00001). Eight studies reported significant improvement in Hip Outcome Score - Sports Specific Scale with postoperative scores ranging from 59.2 to 94.6 (SMD 1.66; 95% CI 1.33-1.98, P < .00001). Seven studies reported significant improvement in Nonarthritic Hip Score with postoperative scores ranging from 79.6 to 95.3 (SMD 1.41; 95% CI 1.16-1.65, P < .00001). Seven studies also reported significant improvement in VAS with postoperative scores ranging from 0.7 to 3.1 (SMD -1.57; 95% CI -1.88, -1.26, P < .00001). Nine of 10 studies reported achieving at least 1 psychometric threshold at a rate of least 75%. Rates of secondary arthroscopy and conversion to total hip arthroplasty varied from 0% to 15.2% and 0% to 33.3%. CONCLUSIONS: Athletes who underwent primary hip arthroscopy demonstrated favorable outcomes and high rates of clinical benefit at 5-year follow-up. In addition, they demonstrated high rates of survivorship and achieving psychometric thresholds. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review.

PURPOSE: To review outcomes of patients with low-back pathology undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome. METHODS: The PubMed, Cochrane Trials, and Scopus databases were queried in June 2022 to conduct this systematic review using the following terms: ("hip" OR "femoroacetabular impingement") AND ("arthroscopy" OR "arthroscopic") AND ("spine" OR "lumbar" OR "sacral" OR "hip-spine" OR "back") AND ("outcomes"). Articles were included if they reported on patient-reported outcomes (PROs) and/or clinical benefit of patients undergoing hip arthroscopy with concomitant low-back pathology. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Case reports, opinion articles, review articles, and technique articles were excluded from this study. Forest plots were created to analyze preoperative and postoperative outcomes among patients with low-back pathology. RESULTS: Fourteen studies were included in the review. There were 750 hips with low-back pathology and FAI (hip-spine syndrome) and 1,800 hips with only FAI (no hip-spine syndrome). All 14 studies reported PROs. In 4 studies in the group with hip-spine syndrome and 8 studies in the group with FAI without low-back pathology, the respective cohorts were reported to achieve the minimal clinically important difference in at least 1 PRO at a rate of 80%. Eight studies reported that patients with low-back pathology were associated with inferior outcomes or clinical benefit compared with patients without low-back pathology. CONCLUSIONS: Patients undergoing primary hip arthroscopy with concomitant low-back pathology can expect favorable outcomes, but outcomes are superior in patients undergoing hip arthroscopy for FAI alone compared with FAI with concomitant low-back pathology. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to Level IV studies.

Low Rates of 5-Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients.

PURPOSE: To evaluate 90-day complications, 5-year secondary surgery rates, and risk factors for secondary surgery following primary hip arthroscopy performed for femoroacetabular impingement and/or labral tears using a large national dataset. METHODS: A retrospective analysis was conducted using the PearlDiver Mariner151 database. Patients with International Classification of Diseases, Tenth Revision, diagnosis codes for femoroacetabular impingement and/or labral tear undergoing primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021 were identified. Those with concomitant International Classification of Diseases, Tenth Revision, codes for infection, neoplasm, or fracture were excluded, as were patients with a history of previous hip arthroscopy or total hip arthroplasty, or age ≥70 years. Rates of complications within 90 days of surgery were assessed. Five-year rates of secondary surgery-revision hip arthroscopy or conversion to total hip arthroplasty-were determined by Kaplan-Meier analysis, and risk factors for secondary surgery were identified by multivariate logistic regression. RESULTS: A total of 31,623 patients underwent primary hip arthroscopy from October 2015 to April 2021, with annual volumes ranging from 5,340 to 6,343 surgeries per year. Femoroplasty was the most frequent surgical procedure (performed in 81.1% of surgical encounters), followed by labral repair (72.6%) and acetabuloplasty (33.0%). Ninety-day postoperative complication rates were low, with 1.28% of patients experiencing any complication. The 5-year secondary surgery rate was 4.9% (N = 915 patients). Multivariate logistic regression identified age <20 years (odds ratio [OR] 1.50; P < .001), female sex (OR 1.33; P < .001), class I obesity (body mass index 30-34.9: OR 1.30; P = .04), and class II/III obesity (body mass index ≥35.0: OR 1.29; P = .02) as independent predictors of secondary surgery. CONCLUSIONS: In this study of primary hip arthroscopy, 90-day adverse events were low at 1.28%, and the 5-year secondary surgery rate was 4.9%. Age younger than 20 years, female sex, and obesity were risk factors for secondary surgery, suggesting the need for increased surveillance in these patient groups. LEVEL OF EVIDENCE: Level IV, case series.

Successful Management of Impending Skin Necrosis After a Posterolateral Knee Dislocation.

Incarcerated medial soft tissue after posterolateral knee dislocations has been described, but limited information pertaining to the etiology and management of cutaneous injuries from incarceration exists. We present the case of a 64-year-old man, where reduction of a posterolateral knee dislocation resulted in incarceration of medial ligamentous structures and impending skin necrosis. The patient avoided full-thickness skin necrosis, which could have complicated treatment options. Careful consideration of the soft-tissue envelope of the knee for preventing additional skin injury in the perioperative period should be considered to potentially avert additional necrosis in patients with a 'pucker' sign after knee dislocations.

Post-Operative Hyperextension Bracing Has the Potential to Reduce Proximal Junctional Kyphosis: A Propensity Matched Analysis of Braced versus Non-braced Cohorts.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Determine effects of bracing on proximal junctional kyphosis (PJK) after adult deformity correction. METHODS: Patients were identified from a single-surgeon dataset of posterior-only fusions for ASD (pelvis to UIV of T9-12) with a minimum of 1-year follow up. Starting in 2021, all lower thoracic fusions were braced using a hyperextension brace. Patients wore the brace at all times (unless in bed) for the first 6 weeks after surgery. A 1:1 propensity-match was performed based on age, number of levels, 3 column osteotomies, and magnitude of correction to identify a comparative non-braced cohort. RESULTS: 141 patients (113 non-brace, 28 brace) were evaluated. After matching, 56 patients were identified to form similar cohorts. Non-matched and matched groups had no statistically significant differences in demographics, comorbid conditions, surgical characteristics (except shorter operative time and lower EBL in the braced group), and preoperative radiographic parameters. For the overall cohort, the change in proximal junctional angle at 1-year was higher in the non-braced group (7.6° vs 8.1°, P = .047), and non-braced patients had a higher incidence of PJK at 1-year in both the overall cohort (36% vs 14%, P = .045) and matched cohort (43% vs 14%, P = .038). There was no difference in proximal junctional failure between groups. CONCLUSION: This pilot study shows that our protocol for extension bracing may reduce rates of PJK. These findings can form the basis for future multi-center trials examining the effect of extension bracing on junctional complications.

Knotless Implant for Arthroscopic Hip Capsule Closure.

The hip joint capsule plays a significant role in maintaining hip stability, including translation and rotation. Hip capsular closure or plication has been shown to increase stability of the joint following capsulotomy in hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) and/or associated labral tears. This technique article describes a knotless method of closing the hip capsule.

The Association of Lumbar Plexus Lengthening with Neurologic Deficit After Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aimed to evaluate the association between nerve lengthening after adult deformity correction and motor deficits dervied from the upper lumbar plexus or femoral nerve. SUMMARY OF BACKGROUND DATA: Adult spinal deformity (ASD) surgery is associated with high rates of neurological deficits. Certain postoperative deficits may be related to lengthening of the upper lumbar plexus (ULP) and/or femoral nerve (FN) after correction of lumbar deformity. METHODS: Patients with ASD who underwent posterior-only corrective surgery from the sacrum to L3 or above were included. The length of each lumbar nerve root (NR) was calculated geometrically using the distance from the foramen to the midpoint between the anterosuperior iliac crest and pubic symphysis on AP and lateral radiographs. The mean lengths of the L1-3 and L2-4 NRs were used to define the lengths of the ULP and FN, respectively. Pre- to postoperative changes in nerve length were calculated. Neurological examination was performed at discharge. Proximal weakness (PW) was defined as the presence of weakness compared to baseline in either hip flexors or knee extensors. Multiple linear regression analysis was used for estimating the postoperative lengthening according to the magnitude of preoperative curvature and postoperative correction angles. RESULTS: A total of 202 sides were analyzed in 101 patients, and PW was present on 15 (7.4%) sides in 10 patients. Excluding the 10 cases with three-column osteotomies, those with PW had a significantly higher rate of pure sagittal deformity (P<.001) and greater nerve lengthening than those without PW (ULP 24 vs 15 mm, P=0.02; FN 18 vs 11 mm, P=0.05). No patient had advanced imaging showing neural compression, and complete recovery of PW occurred in 8 patients at 1-year follow-up. CONCLUSIONS: After ASD surgery, lengthening of the ULP was associated with PW. In preoperative planning, surgeons must consider how the type of correction may influence the risk for nerve lengthening, which may contribute to postoperative neurologic deficit. LEVEL OF EVIDENCE: 3.

Outcomes After Concomitant Hip Arthroscopy and Periacetabular Osteotomy: A Systematic Review.

Background: Despite several studies' reports on outcomes of concomitant hip arthroscopy and periacetabular osteotomy (PAO), there is a paucity of aggregate data in the literature. Purpose: To evaluate outcomes and survivorship after concomitant hip arthroscopy and PAO. Study Design: Systematic review; Level of evidence, 4. Methods: The PubMed, Cochrane, and Scopus databases were searched in April 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following keywords were used: (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (periacetabular osteotomy or rotational osteotomy) AND (outcomes OR follow-up). Of 270 articles initially identified, 10 studies were ultimately included. The following information was recorded for each study if available: publication information; study design; study period; patient characteristics; follow-up time; indications for hip arthroscopy; patient-reported outcomes (PROs); rates of secondary hip preservation surgeries; and rates of conversion to total hip arthroplasty (THA). Survivorship was defined as nonconversion to THA. Results: The study periods for the 10 included articles ranged from 2001 to 2018. Three studies were level 3 evidence, and 7 studies were level 4 evidence. This review included 553 hips with a mean follow-up of 1 to 12.8 years. All 10 studies listed dysplasia as an indication for surgery. Of 9 studies that reported PRO scores, 7 reported significant improvement after surgery. Studies with a <5-year follow-up reported conversion to THA rates of 0% to 3.4% and overall secondary surgery rates of 0% to 10.3%. Similarly, studies with >5-year follow-up reported conversion to THA rates of 0% to 3% and overall secondary surgery rates of 0% to 10%. Conclusion: Patients who underwent concomitant hip arthroscopy and PAO reported favorable outcomes, with 7 of the 9 studies that provided PRO scores indicating significant preoperative to postoperative improvement.

Postoperative Radiculitis After L5-S1 Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: This study aimed to examine postoperative radiculitis after isolated L5-S1 anterior lumbar interbody fusion (ALIF), determine which factors contribute to its development, and investigate the comparative outcomes of patients with versus without postoperative radiculitis. SUMMARY OF BACKGROUND DATA: Both standalone and traditionalALIF are common and safe lumbar spine fusion techniques. Although optimal safety and effectiveness are achieved through appropriate patient selection, postoperative radiculitis after L5-S1 ALIF is a potential complication that seems to be the least predictable in the absence of iatrogenic injury. PATIENTS AND METHODS: All adult patients (18-80 yr) with preoperative radiculopathies who underwent L5-S1 ALIF by 9 board-certified spine surgeons at a single academic institution from January 2016 to December 2021 with a minimum of 3 months follow-up were included. Patient records were assessed for data on clinical characteristics and patient-reported outcome scores (patient-reported outcome measures). All patient records were evaluated to determine whether postoperative radiculitis developed. Radiographic measurements using x-rays were completed using all available pre and postoperative imaging. Multivariable logistic regressions were performed utilizing radiculitis as the dependent variable and various independent predictor variables. RESULTS: One hundred forty patients were included, 48 (34%) patients developed postoperative radiculitis, with symptom onset and resolution occurring at 14.5 and 83 days, respectively. The two groups had no differences in preoperative or postoperative radiographic parameters. Multivariable regression showed 3 independent predictors of postoperative radiculitis: methylprednisolone use [OR: 6.032; (95% CI: 1.670-25.568)], increased implant height [OR: 1.509; (95% CI: 1.189-1.960)], and no posterior fixation [OR: 2.973; (95% CI: 1.353-0.806)]. CONCLUSIONS: Of the 34% of patients who developed postoperative radiculitis after L5-S1 ALIF, it resolved on average within 3 months of surgery. These findings may help reduce the risk of undue short-term morbidity after isolated L5-S1 ALIF by informing preoperative counseling and intraoperative decision-making.

Hepatoprotective role of Sestrin2 against chronic ER stress.

Upon prolonged endoplasmic reticulum (ER) stress, cells attenuate protein translation to prevent accumulation of unfolded proteins. Here we show that Sestrin2 is critical for this process. Sestrin2 expression is induced by an ER stress-activated transcription factor CCAAT-enhancer-binding protein beta (c/EBPß). Once induced, Sestrin2 halts protein synthesis by inhibiting mammalian target of rapamycin complex 1 (mTORC1). As Sestrin2-deficient cells continue to translate a large amount of proteins during ER stress, they are highly susceptible to ER stress-associated cell death. Accordingly, dietary or genetically induced obesity, which does not lead to any pathological indication other than simple fat accumulation in the liver of wild-type (WT) mice, can provoke Sestrin2-deficient mice to develop severe ER stress-associated liver pathologies such as extensive liver damage, steatohepatitis and fibrosis. These pathologies are suppressed by liver-specific Sestrin2 reconstitution, mTORC1 inhibition or chemical chaperone administration. The Sestrin2-mediated unfolded protein response (UPR) may be a general protective mechanism against ER stress-associated diseases.