Three-Dimensional Printed Total Talus Replacement with a Concurrent Total Ankle Arthroplasty as a Personalized Approach for Advanced Ankle Osteoarthritis A Case Repor.

Ankle arthritis is becoming more common and can be pain-ful and debilitating. As the disease progresses, degenera-tive cystic changes may be found in the distal fibula, distal tibia, and talus. After failure of non-operative modalities, arthrodesis is often considered the surgical intervention of choice, but this leaves the patient with reduced range of motion, altered gait, and can negatively impact adjacent joints of the foot. Total ankle arthroplasty has been found to be an effective surgical option for ankle arthritis but is contraindicated in patients with talar collapse. When this is the case, a more personalized approach for preserving ankle motion is necessary. We present the case of a 65-year-old male with severe right ankle arthritis and talar collapse treated with a custom three-dimensionally printed talus and concurrent total ankle replacement with 2-year follow-up.

The Incidence of Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome and Labral Pathology Increased by 85% Between 2011 and 2018 in the United States.

PURPOSE: The purpose of this study was to investigate the incidence of hip arthroscopy in patients with labral pathology in the United States from 2011-2018 using a large national database. METHODS: Patients who underwent hip arthroscopy from 2011-2018 were identified using Current Procedural Terminology (CPT) codes in the PearlDiver Patients Records Database (Colorado Springs, CO), which is a national database of orthopedic insurance records, including Medicare patients. The incidence of surgeries, age, and gender were all recorded. Groups were analyzed using SPSS version 24 (IBM, Armonk NY). CPT codes 29914/15/16 were introduced January 1, 2011 which is when we began our analysis. CPT-29999 and laterality were not assessed. RESULTS: In total, 35,966 arthroscopies were identified between 2011 and 2018 from a randomly selected sample of 30 million orthopaedic patients from the PearlDiver Mariner dataset. The incidence increased by 85% from 2011 to 2018 (7.31 cases vs 13.54 cases per 100,000 patients). The distribution of the age of patients undergoing hip arthroscopy was bimodal with the mode of each peak at 18 years old and 42 years old, respectively. Females underwent surgery more frequently (67.9%) than males (32.1%). The most common CPT code for hip arthroscopy was 29914 (43.9) which corresponds to a hip arthroscopy with femoroplasty. CONCLUSIONS: Our findings corroborate those of previous studies and support the increase in incidence of hip arthroscopy in the United States. We indicate an overall increase of 85% from 2011 to 2018 and support previous trends, such as higher incidence of hip arthroscopy in women. Our study also supports a decreasing mean age for patients, likely due to improved diagnostics and surgeon familiarity and comfort with the procedure. LEVEL OF EVIDENCE: Level 3, Retrospective Comparative Study.

Meniscal Root Tears A Comprehensive Review.

The management of meniscal root injuries continues to improve as techniques and understanding of the biomechanics advance. Meniscal root injury compromises the load dissipation across the knee joint and decreases the surface area undergoing load. This predisposes patients to early degenerative changes that alters their activities of daily life. Hence, repair of meniscal roots has become an increasingly utilized tool for the orthopedic surgeon. However, in order to effectively repair a torn root, a fundamental knowledge of the anatomy and biomechanics is paramount. Hence, this review discusses important anatomic and biomechanical factors and summarizes currently available imaging guidelines, surgical techniques, and outcomes.

Does Concomitant Lumbar Spine Disease Adversely Affect the Outcomes of Patients Undergoing Hip Arthroscopy?

BACKGROUND: The practice of hip arthroscopy is increasing in popularity, which has highlighted the importance of identifying risk factors that predict hip arthroscopy outcomes. The literature suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip arthroplasty; however, the effect of lumbar spine disease on hip arthroscopy outcomes has not been fully investigated. At present, there is a paucity of literature investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip arthroscopy. PURPOSE: To evaluate the outcomes of hip arthroscopy in patients with concomitant lumbar spine disease compared with those without a history of lumbar spine disease. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a prospectively collected, single-surgeon database was performed to identify patients who underwent hip arthroscopy with subjective and objective evidence of lumbar disease. Patients were included if they were skeletally mature; had hip disease that failed nonoperative treatment; had symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery; and had advanced imaging of the lumbar spine (computed tomography or magnetic resonance imaging) confirming lumbar spine disease. Patients were excluded if they had any previous hip surgery or evidence of osteoarthritis of Tönnis grade 2 or higher. The hip-spine cohort was matched by age, sex, and body mass index in a 1:3 fashion to a control cohort consisting of patients without symptoms of low back pain, lumbar radiculopathy, or lumbar stenosis at the time of surgery or a history of lumbar spine disease who underwent hip arthroscopy over the same time period. Baseline preoperative modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were compared with scores at 3-, 6-, 12-, and 24-month follow-up, and rates of revision arthroscopy or total hip arthroplasty were assessed. Statistical analysis was performed with the Student t test. RESULTS: A total of 38 patients with radiographically confirmed lumbar disease were matched with 111 control patients. Preoperative mHHS and NAHS were significantly lower in the hip-spine cohort (P = .01 and P = .02, respectively); however, no significant differences were found in mHHS or NAHS between the cohorts at 3, 6, 12, and 24 months postoperatively. A 89.8% increase in mHHS was found in the hip-spine cohort, compared with a 74.4% increase in the control cohort (P = .0475). No significant differences in the rates of revision or total hip arthroplasty conversion were identified between the hip-spine and control cohorts (23.7% vs 18.0%, respectively; P = .44). CONCLUSION: Patients with known lumbar spine disease who underwent hip arthroscopy had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease.

Outcomes of Preoperative Opioid Usage in Hip Arthroscopy: A Comparison With Opioid-Naïve Patients.

PURPOSE: To compare postoperative outcomes between opioid-naïve patients and patients with a history of preoperative opioid usage undergoing hip arthroscopy. The secondary purpose is to determine whether preoperative opioid users consumed more oral morphine milligram equivalents than opioid-naïve patients following surgery. METHODS: This is a single-center, retrospective analysis comparing outcomes and postoperative opioid usage between patients with and without a history of preoperative opioid use. Inclusion criteria included patients ≥18 years, Tönnis grade 0 or 1, imaging consistent with FAI or labral pathology, and a diagnosis of symptomatic FAI requiring hip arthroscopy. Patient outcomes were compared throughout a 2-year follow-up using the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale (VAS). RESULTS: In total, 17 patients were evaluated in each cohort. The mean age of the study cohort and control cohort were 52.0 ± 9.4 years and 51.2 ± 12.2 years, respectively. Female patients were 58.8% (n = 10) of both cohorts. Non-naïve patients had a lower preoperative Nonarthritic Hip Score (P = .05) and a greater VAS at their 6-month and 1-year (P < .001) postoperative visits. Naïve patients reported greater modified Harris Hip Scores 2 years postoperatively (P < .001). The study cohort was prescribed greater levels of oral morphine equivalents at the postoperative 1-year visit (P = .05). Opioid-naïve patients were more likely to reach minimally clinically important difference and patient acceptable symptom state of VAS at a faster rate. At the 2-year follow-up, 11.8% of opioid-naïve patients continued to take opioids compared with 58.8% from the non-naïve group for persistent hip pain (P < .001). CONCLUSIONS: We determined that preoperative opioid usage in patients undergoing hip arthroscopy is associated with inferior outcomes compared with opioid-naïve patients. In addition, preoperative opioid users are likely to continue the use of opioid medications postoperatively and at greater doses than opioid-naïve patients. LEVEL OF EVIDENCE: 3, retrospective comparative study.

Staged Bilateral Hip Arthroscopy Compared With a Matched Unilateral Hip Arthroscopy Group: Minimum 2-Year Follow-Up.

PURPOSE: To determine the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) at 2-year follow up in patients who underwent staged bilateral hip arthroscopy versus age-, sex-, and body mass index-matched patients who underwent unilateral hip arthroscopy. METHODS: Patients who underwent staged bilateral primary hip arthroscopy between January 2007 and December 2017 for the indication of femoroacetabular impingement (FAI) with a minimum 2-year follow-up were identified. The control group comprised patients who underwent a unilateral hip arthroscopy for FAI. The mHHS and the NAHS were analyzed. RESULTS: Forty-two patients (84 hips) in the bilateral group were matched with 84 patients (84 hips) in the unilateral group. Both groups had significantly improved mHHS and NAHS when comparing preoperative scores with postoperative scores (bilateral group mHHS: 45.5 ± 15.1 to 81.7 ± 17.6, P < .0001, bilateral group NAHS: 49.5 ± 13.8 to 83.6 ± 20.0, P < .0001, unilateral group mHHS 48.5 ± 13.8 to 83.6 ± 15.9, P < .0001, unilateral group NAHS 48.8 ± 12.0 to 85.0 ± 16.6, P < .0001). The patient-acceptable symptomatic state was achieved in 57 hips (68%) in the bilateral group versus 62 hips (74%) in the unilateral group, P = .4. Patients with bilateral hip arthroscopy who had <17 months between index procedure and contralateral hip arthroscopy had significantly better mHHS and NAHS (85.5 ± 18.4 vs 75.71 ± 14.4, P = .013 for mHHS and 88.1 ± 17.1 vs 76.2 ± 22.4, P = .0074 for NAHS). CONCLUSIONS: Bilateral hip arthroscopy for the indication of FAI has improved mHHS and NAHS at 2 years of follow up compared to baseline. There was no difference in 2-year mHHS and NAHS in patients who underwent bilateral hip arthroscopy and unilateral hip arthroscopy. Patients in the bilateral hip arthroscopy group that had the contralateral surgery longer than 17 months from index procedure had lower 2 year follow up mHHS and NAHS scores than those that underwent the second surgery within 17 months of the index procedure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Postoperative complications in underweight patients undergoing total hip arthroplasty: A comparative analysis to normal weight patients.

BACKGROUND: Underweight patients undergoing total hip arthroplasty have been largely overlooked. The purpose of this study was to evaluate their complications profiles compared to normal weight individuals. METHODS: Patients were selected from the NSQIP database, matched, and arranged into 2 groups based on BMI. Complications were recorded and analyzed to determine differences in outcomes. RESULTS: Multivariate analysis demonstrated increased length of hospital stay (LOS) (p = 0.006) for underweight patients but failed to demonstrate higher rates of medical or surgical complications. CONCLUSION: There are no increased rates of infectious or medical complications in underweight patients undergoing THA. However, increased LOS was demonstrated.

Postoperative Complications of Total Joint Arthroplasty in Obese Patients Stratified by BMI.

BACKGROUND: High body mass index (BMI) is associated with significant complications in patients undergoing total joint arthroplasty. Many studies have evaluated this trend, but few have looked at the rates of complications based on BMI as a continuous variable. The purpose of this study was to stratify obese patients into 3 BMI categories and evaluate their rates of complications and gauge whether transitioning from higher to lower BMI category lowers complication. METHODS: Patients undergoing primary total joint arthroplasty were selected from the National Surgical Quality Improvement Program database from 2008-2015 and arranged into 3 groups based on BMI: O1 (BMI 30-34.9 kg/m2), O2 (BMI 35-39.9 kg/m2), and O3 (BMI >40 kg/m2). Thirty-day complications were recorded and evaluated utilizing univariate and multivariate analyses stratified by BMI. RESULTS: A total of 268,663 patients were identified. Patients with a BMI >30 kg/m2 had more infectious and medical complications compared with nonobese patients. Furthermore, there were increased complications as the BMI categories increased. Patients with a BMI >40 kg/m2 (O3) had longer operating times, length of stay, higher rates of readmissions, reoperations, deep venous thrombosis, renal insufficiency, superficial infections, deep infections, and wound dehiscence. These trends were present when comparing the O2 with O1 category as well. CONCLUSION: We have demonstrated increased rates of medical and surgical complications in obese patients. Furthermore, we demonstrated a stepwise increase in complication rates when transitioning to higher BMI groups. Based on our data, we believe that preoperative counseling and interventions to decrease BMI should be explored before offering elective surgery to obese patients.

Pharmacokinetic and pharmacodynamic comparability study of moxetumomab pasudotox, an immunotoxin targeting CD22, in cynomolgus monkeys.

Moxetumomab pasudotox is an immunotoxin currently being investigated in patients for the treatment of CD22-expressing B-cell malignancies. A single-cycle pharmacokinetic (PK)-pharmacodynamic (PD) study was conducted in cynomolgus monkeys for PK comparability assessment and population PK-PD modeling after major manufacturing process and site changes. Primates were randomized by body weight and baseline CD22 lymphocyte counts to receive intravenous administrations of 1 mg/kg moxetumomab pasudotox (n = 12/group) on Days 1, 3, and 5. PK and B-lymphocyte count data were modeled using a population approach. The 90% confidence intervals of the geometric mean ratios of PK exposure were within the 80%-125% range. The B lymphocytes were depleted to a similar extent, and the immunogenicity incidences were similar across the two groups. The B-cell depletion was described by a novel lifespan model in which moxetumomab pasudotox induced random destruction of B cells in each aging compartment. The endogenous de novo influx from bone marrow was subject to a negative feedback mechanism. The estimated B cell apparent lifespan was 51 days. Covariate analysis confirmed that the manufacturing change had no impact on PK or PD of moxetumomab pasudotox. Results from this study supported continued clinical investigation of moxetumomab pasudotox using the new material.

Mechanistic modeling of antigen sink effect for mavrilimumab following intravenous administration in patients with rheumatoid arthritis.

Mavrilimumab is a fully human monoclonal antibody that binds to granulocyte-macrophage colony stimulating factor receptor α (GM-CSFRα) with high affinity and specificity and has potential application in various inflammatory diseases. The objective of this investigation was to develop a mechanistic population model to characterize the pharmacokinetics of mavrilimumab, the GM-CSFRα-mediated clearance, and receptor occupancy following single intravenous dosing to patients with rheumatoid arthritis. The internalization rate of mavrilimumab-GM-CSFRα complex was fixed to a value determined from quantitative confocal fluorescent imaging. The estimated typical first-order clearance and the central and peripheral distribution volumes were 3.79 mL/kg/d, 39.6 mL/kg, and 50.3 mL/kg, respectively. The systemic GM-CSFRα expression level was estimated to be 0.0782 nM, and the equilibrium dissociation constant (0.103 nM) was in good agreement with the monovalent affinity determined by surface plasmon resonance. By fitting to the observed pharmacokinetic data, the mechanistic model predicted that systemically greater than 90% GM-CSFRα blockade by mavrilimumab was achieved and maintained up to 4, 7, and 11 weeks following single 1-, 3-, and 10-mg/kg administrations, respectively. Posterior visual predictive check and bootstrapping suggest that the mechanistic model is reasonably robust and can be used to predict mavrilimumab exposure under various scenarios for future clinical trial design.