Particulated juvenile cartilage allograft for the treatment of osteochondral lesions of the talus is associated with a high complication rate and a high failure rate at short-term follow-up: A systematic review.

PURPOSE: The purpose of this systematic review was to evaluate the clinical and radiological outcomes together with the complication rates and failure rates at short-term follow-up following particulated juvenile cartilage allograft (PJCA) for the management of osteochondral lesions of the talus (OLT). METHODS: During October 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following PJCA for the management of OLTs. Data regarding study characteristics, patient demographics, lesion characteristics, subjective clinical outcomes, radiological outcomes, complications and failures were extracted and analysed. RESULTS: Twelve studies were included. In total, 241 patients underwent PJCA for the treatment of OLT at a weighted mean follow-up of 29.0 ± 24.9 months. The weighted mean lesion size was 138.3 ± 59.6 mm2 . Prior surgical intervention was recorded in seven studies, the most common of which was microfracture (65.9%). The weighted mean American Orthopaedic Foot and Ankle Society score improved from a preoperative score of 58.5 ± 3.2 to a postoperative score of 83.9 ± 5.3. The weighted mean postoperative magnetic resonance observation of cartilage repair tissue (MOCART) score was 48.2 ± 3.3. The complication rate was 25.2%, the most common of which was allograft hypertrophy (13.2%). Thirty failures (12.4%) were observed at a weighted mean time of 9.8 ± 9.6 months following the index procedure. CONCLUSION: This systematic review demonstrated a moderate improvement in subjective clinical outcomes following PJCA for the treatment of OLT at short term follow-up. However, postoperative MOCART scores were reported as poor. In addition, a high complication rate (25.2%) and a high failure rate (12.4%) at short-term follow-up was observed, calling into question the efficacy of PJCA for the treatment of large OLTs. In light of the available evidence, PJCA for the treatment of large OLTs cannot be currently recommended. LEVEL OF EVIDENCE: Level IV.

Factors influencing patient selection of orthopaedic surgeons for total hip (THA) and total knee arthroplasty (TKA).

INTRODUCTION: The importance of identifying how patients choose their healthcare providers has grown with the prevalence of consumer-centric health insurance plans. There is currently a lack of studies exploring the factors associated with how patients select their hip and knee joint arthroplasty surgeons. The purpose of this study was to determine how patients find their arthroplasty providers and the relative importance of various arthroplasty surgeon characteristics. METHODS: An electronic mail survey was sent to 3522 patients who had visited our institution for an arthroplasty surgeon office visit between August 2022 and January 2023. The survey consisted of multiple-choice questions, which aimed to inquire about the patients' referral sources for their current arthroplasty surgeon. In addition, patients were requested to rate the significance of 22 surgeon-related factors, on a scale of 1 (Not Important At All) to 5 (Very Important), in choosing their arthroplasty surgeon. RESULTS: Of the 3522 patients that received the survey, 538 patients responded (15.3%). The most common referral sources were physician referral (50.2%), family/friend referral (27.7%), and self-guided research (24.5%). Of those that were referred by a physician, 54.4% of respondents were referred by another orthopaedic provider. Patients rated board certification (4.72 ± 0.65), in-network insurance status (4.66 ± 0.71), fellowship training (4.50 ± 0.81), bedside manner/personality (4.32 ± 0.86), and facility appearance (4.26 ± 0.81) as the five most important factors in picking an arthroplasty surgeon. Television (1.42 ± 0.83), print (1.50 ± 0.88), and online (1.58 ± 0.93) advertisements, along with social media presence (1.83 ± 1.08), and practice group size (2.97 ± 1.13) were rated as the five least important factors. CONCLUSION: Patients are most likely to select an arthroplasty surgeon based on referral from other physicians, namely orthopedic surgeons, in addition to board certification status, in-network insurance, and fellowship training. Overall, these findings highlight the importance of physician credentials and reputation within the orthopaedic community in order to attract and retain patients.

How Does Surgical Approach Affect Characteristics of Dislocation After Primary Total Hip Arthroplasty?

BACKGROUND: Concerns have been voiced regarding how surgical approach impacts risk of dislocation after total hip arthroplasty (THA). This study investigated how surgical approach impacts rate, direction, and timing of dislocations following THA. METHODS: We conducted a retrospective review of 13,335 primary THAs from 2011 to 2020 and identified 118 patients with prosthetic hip dislocation. Patients were stratified into cohorts by surgical approach used during primary THA. Patient demographics, index THA acetabular cup positioning, number, direction, timing of dislocations, and subsequent revisions were collected. RESULTS: Dislocation rate differed significantly between posterior approach (PA), direct anterior approach (DAA), and laterally-based approach (LA) (1.1 versus 0.7% versus 0.5%, P = .026). Rate of hips dislocating anteriorly was lowest in the PA group (19.2%) compared to LA (50.0%) and DAA groups (38.2%, P = .044). There was no difference in rate of hips dislocating posteriorly (P = .159) or multidirectional (P = .508) instability; notably 58.8% of dislocations in the DAA cohort occurred posteriorly. There were no differences in dislocation timing or revision rate. Acetabular anteversion was highest in the PA cohort compared to DAA and LA (21.5 versus 19.2 versus 11.7 degrees, P = .049). CONCLUSION: After THA, patients in the PA group had a slightly higher dislocation rate compared to the DAA and LA groups. The PA group had a lower rate of anterior dislocation and nearly 60% of DAA dislocations occurred posteriorly. However, with no differences in other parameters including revision rates or timing, our data suggests surgical approach may impact dislocation characteristics to a lesser degree than previous studies have suggested.

Comparing Articulating Spacers for Periprosthetic Joint Infection After Primary Total Hip Arthroplasty: All-Cement Versus Real-Component Articulating Spacers.

BACKGROUND: There are a variety of methods available to treat periprosthetic joint infection (PJI), including 2-stage revision with the use of an antibiotic spacer. This study compares the outcomes of real-component (RC) and all-cement (AC) articulating spacers for total hip arthroplasty (THA) PJI treatment. METHODS: This multicenter retrospective study assessed all articulating spacers placed for THA PJI between April 2011 and August 2020. Patients were dichotomized based on spacer type (RC vs AC). RESULTS: One hundred four patients received articulating spacer constructs (RC group = 75, AC group = 29). Leg-length discrepancy was significantly greater in the AC group after the second stage (3.58 vs 12.00 mm, P = .023). There were no significant differences in reoperation rates following first-stage spacer placement (P = .752) and time to reimplantation (P = .127) between the groups. There were no significant differences in reinfection rates (RC group = 10.0%, AC group = 7.1%, P = 1.000) and reoperation rates following second-stage revision THA (RC group = 11.7%, AC group = 10.7%, P = 1.000). Hospital length of stay (in days) had a trend toward being shorter following the first (7.35 vs 11.96, P = .166) and second stage (3.95 vs 5.43, P = .107) for patients in the RC group. Patients in the RC group were more likely to be discharged home following the first (P = .020) and second (P = .039) stages. CONCLUSION: Given that there were no differences in reinfection and reoperation rates between the 2 spacer constructs, RC articulating spacers may provide a significant benefit for patient comfort during 2-stage exchange treatment of PJI while adding no increase in risk profile.

Comparing the Efficacy of Articulating Spacer Constructs for Knee Periprosthetic Joint Infection Eradication: All-Cement vs Real-Component Spacers.

BACKGROUND: The most common treatment for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a 2-stage revision. Few studies have compared different articulating spacer constructs. This study compares the outcomes of real-component and all-cement articulating spacers for TKA PJI treatment. METHODS: This retrospective observational study examined the arthroplasty database at 3 academic hospitals for articulating spacers placed for TKA PJIs between April 2011 and August 2020. Patients were categorized as receiving a real-component or an all-cement articulating spacer. Data on demographics, surgical information, and outcomes were collected. RESULTS: One-hundred sixty-four spacers were identified: 72 all-cement and 92 real-component spacers. Patients who received real-component spacers were older (67 ± 10 vs 63 ± 12 years; P = .04) and more likely to be former smokers (50.0% vs 28.6%; P = .02). Real-component spacers had greater range of motion (ROM) after Stage 1 (84° ± 28° vs 58° ± 28°; P < .01) and shorter hospital stays after Stage 1 (5.8 ± 4.3 vs 8.4 ± 6.8 days; P < .01). There was no difference in time to reimplantation, change in ROM from pre-Stage 1 to most recent follow-up, or reinfection. Real-component spacers had shorter hospital stays (3.3 ± 1.7 vs 5.4 ± 4.9 days; P < .01) and operative times during Stage 2 (162.2 ± 47.5 vs 188.0 ± 66.0 minutes; P = .01). CONCLUSION: Real-component spacers had improved ROM after Stage 1 and lower blood loss, shorter operative time, and shorter hospital stays after Stage 2 compared to all-cement articulating spacers. The 2 spacer constructs had the same ultimate change in ROM and no difference in reinfection rates, indicating that both articulating spacer types may be safe and effective options for 2-stage revision TKA. LEVEL OF EVIDENCE: III, retrospective observational analysis.

Notch signaling inhibition protects against LPS mediated osteolysis.

Chronic inflammatory responses have profound effects on the differentiation and activity of both the bone-forming osteoblasts and bone-resorbing osteoclasts. Importantly, inflammatory bone diseases characterized by clinical osteolysis promote bone resorption and decrease bone formation by uncoupling the process in favor of excess resorption. Notch signaling regulates osteoclast development and thus its manipulation has the potential to suppress resorptive potential. Here, we have utilized a genetic model of Notch inhibition in osteoclasts by expression of dnMAML to prevent formation of transcriptional complex essential for downstream Notch signaling. Using this model and LPS as a tool for experimental inflammatory osteolysis, we have demonstrated that dnMAML-expressing osteoclasts exhibited significantly lower maturation and resorption/functional potential ex vivo using TRAP staining and calcium phosphate coated surfaces. Moreover, we observed that while LPS stimulated the formation of wildtype osteoclasts pre-treated with RANKL, dnMAML expression produced resistance to osteoclast maturation after LPS stimulation. Genetically, Notch-inhibited animals showed a significantly lower TRAP and CTX-1 levels in serum after LPS treatment compared to the control groups in addition to a marked reduction in osteoclast surfaces in calvaria sections. This report provides evidence for modulation of Notch signaling activity to protect against inflammatory osteolysis. Taken together, the findings of this study will help guide the development of Notch signaling-based therapeutic approaches to prevent bone loss.

MCP-1 in synovial fluid as a predictor of inferior clinical outcomes after meniscectomy.

PURPOSE: To evaluate knee intra-articular cytokine concentrations in patients undergoing isolated meniscectomy and determine if these concentrations are associated with clinical outcomes. METHODS: Concentrations of ten biomarkers were quantified in synovial fluid aspirated from the operative knees of patients who underwent isolated meniscectomy from 10/2011-12/2019. Patients completed a survey at final follow-upincluding VAS, Lysholm, Tegner, and KOOS Physical Function Short Form (KOOS-PS). Failure was defined as subsequent TKA or non-achievement of the Patient Acceptable Symptom State (PASS) for knee pain defined as VAS > 27/100. Regression analysis investigating the relationship between cytokine concentrations and failure was performed. RESULTS: The study consisted of 100 patients, including 50 males (50.0%) with a mean age of 51.1 ± 11.7 years, a median BMI of 28.9 kg/m2 [25.5, 32.4], and a mean follow-up of 8.0 ± 2.2 years. There were no demographic or clinical differences between failures (n = 41) and non-failures (n = 59) at baseline. Monocyte Chemotactic Protein 1 (MCP-1) concentration was significantly higher in failures than in non-failures (344.3 pg/ml vs. 268.6 pg/ml, p = 0.016). In a regression analysis controlling for age, sex, BMI, symptom duration, length of follow-up, and ICRS grade, increased MCP-1 was associated with increased odds of failure (p = 0.002). CONCLUSIONS: The concentration of MCP-1 on the day of arthroscopic meniscectomy was predictive of failure as defined by an unacceptable pain level at intermediate- to long-term follow-up. This finding may help identify patients at high risk for poor postoperative outcomes following isolated meniscectomy and serve as a target for future postoperative immunomodulation research.

Reduced opioid prescribing following arthroscopic meniscectomy does not negatively impact patient satisfaction.

BACKGROUND: Prior research has demonstrated that physician desire to optimize patient satisfaction is a cause of over-prescription of opioid medications in the healthcare setting. The purpose of this study was to investigate what effect, if any, decreased opioid prescribing following arthroscopic meniscectomy had on Press-Ganey (PG) satisfaction survey scores. METHODS: A retrospective review of prospectively-collected data was conducted on patients who underwent arthroscopic meniscectomy between October2014-October2019. Inclusion criteria consisted of complete PG information, no history of trauma, connective tissue disease, or prior knee surgery. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy which occurred on October 1, 2018. Prescriptions were converted to milligram-morphine-equivalents (MME) for direct comparison between opioids. Minimal-Detectable-Change (MDC) was calculated to evaluate clinical significance of any statistically significant findings. RESULTS: 554 patients were included in this analysis (452pre-protocol, 102post-protocol). The groups did not differ statistically (p > 0.05) with respect to any patient demographics (age, BMI, sex, prior opioid use, opioid naivete) with the exception of smoking history; 54.4% in the pre-protocol group and 32.4%in the post-protocol group; p < 0.001. Mean discharge dose for the pre-protocol group was 229.3 ± 141MME, and 80.05 ± 82.7MME post-protocol; P < 0.0001. There were no statistically significant differences between pre-and-post-protocol satisfaction with pain control scores; P = 0.15. The differences between satisfaction with pain control did not meet clinical or statistical significance, based on a calculated MDC = 0.368. Among pre-protocol patients, 372(82.3%) gave a "top box" response to the question "degree-to-which-your-pain-was-controlled", compared to 91(89.2%) from the post-protocol group; P = 0.10. CONCLUSION: A reduction in opioids prescribed after arthroscopic meniscectomy was not associated with any difference in patient satisfaction with pain management, as measured by the Press-Ganey survey. LOE: 3.

Institutional Reductions in Opioid Prescribing Following Hip Arthroscopy Do Not Change Patient Satisfaction Scores.

PURPOSE: To investigate what effect decreased opioid prescribing following hip arthroscopy had on Press-Ganey satisfaction survey scores. METHODS: A retrospective review of prospectively collected data was conducted on patients who underwent primary hip arthroscopy for femoroacetabular impingement between October 2014 and October 2019. Inclusion criteria consisted of complete Press-Ganey survey information, no history of trauma, fracture, connective tissue disease, developmental hip dysplasia, autoimmune disease, or previous hip arthroscopy. Groups were separated based on date of surgery relative to implementation of an institutional opioid reduction policy that occurred in October 2018. Prescriptions were converted to milligram morphine equivalents (MME) for direct comparison between different opioids. RESULTS: A total of 113 patients met inclusion criteria, 88 preprotocol and 25 postprotocol. There were no statistically significant differences between groups with respect to patient demographics or intraoperative pathologies (P > .05). Average opioid prescription dropped from 249.6 ± 152 MME (equivalent to 33.3 tablets of oxycodone 5 mg) preprotocol to 108.6 ± 84.7 MME (equivalent to 14.5 tablets of oxycodone 5 mg) postprotocol; P = .0002. There were no statistically significant differences in Press-Ganey survey scores between pre- and postprotocol groups (P > .05). CONCLUSIONS: A reduction in opioids prescribed after a hip arthroscopy is not associated with any statistically significant difference in patient satisfaction with pain management, as measured by the Press-Ganey survey. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Suppression of Notch Signaling in Osteoclasts Improves Bone Regeneration and Healing.

Owing to the central role of osteoclasts in bone physiology and remodeling, manipulation of their maturation process provides a potential therapeutic strategy for treating bone diseases. To investigate this, we genetically inhibited the Notch signaling pathway in the myeloid lineage, which includes osteoclast precursors, using a dominant negative form of MAML (dnMAML) that inhibits the transcriptional complex required for downstream Notch signaling. Osteoclasts derived from dnMAML mice showed no significant differences in early osteoclastic gene expression compared to the wild type. Further, these demonstrated significantly lowered resorption activity using bone surfaces while retaining their osteoblast stimulating ability using ex vivo techniques. Using in vivo approaches, we detected significantly higher bone formation rates and osteoblast gene expression in dnMAML cohorts. Further, these mice exhibited increased bone/tissue mineral density compared to wild type and larger bony calluses in later stages of fracture healing. These observations suggest that therapeutic suppression of osteoclast Notch signaling could reduce, but not eliminate, osteoclastic resorption without suppression of restorative bone remodeling and, therefore, presents a balanced paradigm for increasing bone formation, regeneration, and healing. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2089-2103, 2019.

Ecto-5'-nucleotidase (CD73) regulates bone formation and remodeling during intramembranous bone repair in aging mice.

Ecto-5'-nucleotidase (CD73) generates adenosine, an osteoblast activator and key regulator of skeletal growth. It is unknown, however, if CD73 regulates osteogenic differentiation during fracture healing in adulthood, and in particular how CD73 activity regulates intramembranous bone repair in the elderly. Monocortical tibial defects were created in 46-52-week-old wild type (WT) and CD73 knock-out mice (CD73-/-) mice. Injury repair was analyzed at post-operative days 5, 7, 14 and 21 by micro-computed tomography (micro-CT), histomorphometry, proliferating cell nuclear antigen (PCNA) immunostaining, alkaline phosphatase (ALP) and tartrate-resistant acid phosphatase (TRAP) histochemistry. Middle-aged CD73 knock-out mice exhibited delayed bone regeneration and significantly reduced bone matrix deposition detected by histomorphometry and micro-CT. Cell proliferation, ALP activity and osteoclast number were reduced in the CD73-/- mice, suggesting a combined defect in bone formation and resorption due the absence of CD73 activity in this model of intramembranous bone repair. Results from this study demonstrate that osteoblast activation through CD73 activity is essential during bone repair in aging mice, and it may present a drugable target for future biomimetic therapeutic approaches that aim at enhancing bone formation in the elderly patients.