Shoulder Arthroplasty After Previous Nonarthroplasty Surgery: A Systematic Review and Meta-Analysis of Clinical Outcomes and Complications.

BACKGROUND: Many patients who undergo shoulder arthroplasty (SA) have had at least 1 nonarthroplasty shoulder surgery before the surgery. There is conflicting evidence regarding the effects of previous shoulder surgery on the outcome of SA. A systematic review was conducted to compare functional outcomes and complications between SA patients with and without prior non-SA surgery on the ipsilateral shoulder. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE/PubMed, Embase, Scopus, and Web of Science comprehensively from inception to January 2023. Based on 9,279 records reviewed, 26 comparative studies were included in the meta-analysis consisting of 5,431 shoulders with prior nonarthroplasty procedures (cases) and 55,144 shoulders without previous surgery (controls). Variables such as functional scores, complications, and range of motion were compared between cases and controls using Review Manager Software. In addition, subgroup analysis was conducted based on prior surgery type (rotator cuff repair [RCR], open reduction and internal fixation [ORIF], soft tissue repairs, and not specified) and type of SA (hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty [RTSA]). The results were presented as odds ratios (ORs) or standardized mean differences (SMDs). RESULTS: Except for a higher rate of periprosthetic joint infection (PJI) in patients who had undergone previous arthroscopic surgery (OR, 2.58; 95% confidence interval [CI], 1.66-4.01; p < 0.01), a higher rate of complications was only observed in patients with previous ORIF. These complications included aseptic loosening (OR, 3.43; 95% CI, 2.14-5.50; p < 0.01), shoulder dislocation (OR, 2.25; 95% CI, 1.05-4.84; p = 0.04), overall complication (OR, 3.95; 95% CI, 2.38-6.55; p < 0.01), and revision (OR, 2.52; 95% CI, 1.28-4.97; p = 0.01). Patients with a history of previous surgery demonstrated inferior functional outcomes in comparison with the control group, including American Shoulder and Elbow Surgeons (SMD, -0.39; 95% CI, -0.51 to -0.27; p < 0.01; I2 = 36%), Constant-Murley score (SMD, -0.34; 95% CI, -0.44 to -0.24; p < 0.01; I2 = 0%), abduction (SMD, -0.26; 95% CI, -0.45 to -0.08; p = 0.01; I2 = 54%), and flexion (SMD, -0.33; 95% CI, -0.46 to -0.21; p < 0.01; I2 = 40%). Subgroup analysis by previous type of surgery was not possible regarding functional outcomes. CONCLUSION: Patients who have had prior fracture surgery are at a higher risk of complications, reoperations, and revisions after SA than controls. The normal shoulder anatomy may be disrupted by prior surgery, which makes arthroplasty technically challenging, particularly when it comes to soft tissue balance. On the other hand, RCR before SA did not negatively affect clinical outcomes after RTSA and did not have a higher rate of overall complications (except PJI). LEVEL OF EVIDENCE: Level III (Treatment Studies). See Instructions for Authors for a complete description of levels of evidence.

Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure.

BACKGROUND: Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair. METHODS: Using our prospective hip preservation database, 164 patients (178 hips) who had undergone FAO between January 2005 and April 2009 were identified. Patient demographic characteristics, clinical history, duration of preoperative symptoms, radiographic parameters (preoperative and postoperative alpha angles, hip dysplasia and retroversion, Tönnis grade for osteoarthritis), and intraoperative findings were reviewed and compared between the success and failure groups. At a minimum 10-year follow-up, clinical functional outcomes (modified Harris hip score [mHHS] and Short Form-36 [SF-36] at 6 weeks, 6 months, 1 year, and 10 years) and failure rates (conversion to total hip arthroplasty [THA]) were collected. RESULTS: The mean patient age (and standard deviation) was 34.3 ± 8.4 years, and 65 patients (40%) were female. After the surgical procedure, there was significant improvement in the mean mHHS (59.3 ± 7.3 points preoperatively to 88.4 ± 7.3 points postoperatively) and the mean SF-36 (61.3 ± 8.4 points preoperatively to 89.1 ± 7.2 points postoperatively). At a mean follow-up of 12.5 years, 12% (22 hips) required conversion to THA, with a mean time to THA of 5.3 ± 2.0 years. Older age, longer preoperative symptomatic period, higher preoperative and postoperative alpha angles, presence of hip dysplasia, a higher Tönnis grade, joint space narrowing, and a full-thickness acetabular chondral lesion at the time of the FAO were identified as risk factors for failure and conversion to THA. CONCLUSIONS: Patients with symptomatic FAI who undergo a surgical procedure experience pain relief and functional improvement that appear to endure over a decade in the majority of patients. This study on a relatively large cohort with a long-term follow-up has also identified patients who are at a higher risk for treatment failure. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Red Cell Distribution Width: Commonly Performed Test Predicts Mortality in Primary Total Joint Arthroplasty.

INTRODUCTION: Mortality after total joint arthroplasty (TJA) has been thoroughly explored. Short and long-term mortality appear to be correlated with patient comorbidities. Red Cell Distribution Width (RDW) is a commonly performed test that reflects the variation in red blood cell size. This study investigated the utility of RDW, when combined with comorbidity indices, in predicting mortality after TJA. METHODS: Using a single institutional database, 30,437 primary TJA were identified. Patient demographics (age, gender, body mass index (BMI), pre-operative hemoglobin, RDW, and Charlson Comorbidity Index(CCI)) were queried. The primary outcome was 1-year mortality after TJA. Anemia was defined as hemoglobin <12g/dL for women and <13 g/dL for men. The normal range for RDW is 11.5-14.5%. A preliminary analysis assessed the bivariate association between demographics, preoperative anemia, RDW, CCI, and all-cause mortality within 1-year after TJA. A multivariate regression model was conducted to determine independent predictors of 1-year mortality. Finally, ROC curves were used to compare AUC of RDW, CCI and the combination of both in predicting 1-year mortality. RESULTS: The mean RDW was 13.6% ± 1.2. Eighteen percent of patients had pre-operative anemia. The mean CCI was 0.4 ± 0.9. RDW, anemia, CCI, and age were significantly associated with a higher incidence of 1-year mortality. RDW, CCI, age, and male sex were found to be independent risk factors for 1-year mortality. RDW (AUC = 0.68) was a better predictor of mortality compared to CCI (AUC = 0.66). The combination of RDW and CCI (AUC = 0.76) predicted 1-year mortality more accurately than CCI or RDW alone. CONCLUSION: RDW appears to be a useful parameter that, when combined with CCI, can predict the risk for 1-year mortality after TJA.

Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review.

BACKGROUND: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter and the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatment medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be treated surgically, and the complications are considerable. METHODS: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently extracted data from the studies and rated their quality.Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society for Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma, pathological fracture, or malignancy-related fractures were excluded. RESULTS: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years, and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric, respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and the most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the studies did not have a high level of evidence. CONCLUSION: An increase in the rate of atypical femoral fracture with its challenging management makes it an important issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found that extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.

Pelvic region bone density, soft tissue mass, and injury frequency in female professional ballet dancers and soccer athletes.

We recently observed a high prevalence of low pelvic bone mineral density (BMD) in female professional ballet performers. Because this population is susceptible to musculoskeletal overuse injuries, we aimed to determine which regions of the pelvis may be at greatest risk compared to general population females (GENPOP) as well as professional female soccer players (SOCCER, a comparison to other elite athletes regularly subjected to high degrees of loading). Three groups of age-matched females [(GENPOP; n = 38, 27±1yrs), (BALLET; single company, n = 36, 26±3yrs), (SOCCER; single NWSL® club, n = 34, 25±1yrs)] consented to have their BMD and body composition assessed (DEXA, GE®). In addition to soft tissue and total and regional BMD analyses, a segmental analysis of the pelvis was performed to determine site-specific BMD for the iliac fossa, iliac fossa/iliac crest/ilium combined, pubic bone, ischium, and sacrum. A mixed-model ANOVA followed by a Tukey's post-hoc test was used to compare the groups (Type-I error; α = 0.05). The BALLET group had lower pelvic BMD for all measures (Avg.%Diff. = 15%-27%, p<0.001) compared to the SOCCER group and for the ischium (Avg.%Diff.= 8%; p=0.007) and sacrum (Avg.%Diff. â€‹= â€‹7%; p = 0.028) compared to the GENPOP group. The BALLET group had lower lean mass for all measures compared to the other groups (Avg.%Diff. = 12%-18%; p < 0.01). Professional ballet performers exhibit reduced pelvic region soft tissue and site-specific BMD not previously detected using standard DEXA analyses. These findings highlight which pelvic regions may benefit from preventative strength training and/or nutritional interventions.

High Risk of Conversion to THA After Femoroacetabular Osteoplasty for Femoroacetabular Impingement in Patients Older than 40 Years.

BACKGROUND: Femoroacetabular impingement (FAI) is a recognized cause of hip pain and decreased quality of life and has been linked to primary idiopathic hip osteoarthritis (OA). Although the operative indications for FAI have expanded to include older patients, we do not know whether there is an increased risk of conversion to THA after femoroacetabular osteoplasty (FAO) via the mini-open approach for FAI in patients older than 40 years compared with younger patients, after controlling for other confounding variables. QUESTIONS/PURPOSES: (1) After matching for gender, BMI, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of chondral lesion, are patients older than 40 years who undergo FAO for FAI more likely to be revised to THA at a minimum of 2 years' follow-up than are patients younger than 40? (2) Is there a difference in delta (postoperative minus preoperative) improvement in functional outcome scores in those patients who did not go on to THA between patients older than and younger than 40 years? METHODS: Between 2003 and 2017, one surgeon performed 281 FAOs via the mini-open approach in patients older than 40 years and 544 of the same procedure in patients younger than 40 years. During that period, the general indications for FAO were the same in both age groups: (1) history and physical exam consistent with FAI, (2) radiographic evidence of focal impingement (cam, pincer, or both), (3) evidence of labral or chondrolabral tears, and (4) minimal to no arthritic changes (all four criteria required). In general, age was not used as a contraindication for surgery. A total of 86% (241 of 281) of patients older than 40 and 91% (494 of 544) of those younger than 40 were available for minimum of 2 years' follow-up, had complete datasets (radiographs as well as preoperative and most recent patient-reported outcomes scores) at a minimum of 2 years after surgery, and were considered eligible for the match. Propensity score matching was used to match for BMI, gender, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of intraoperative chondral lesion. We matched at a 1:2 ratio 130 patients older than age 40 with 260 patients younger than age 40. The mean ± SD follow-up duration for both groups was 5 ± 2 years. The mean age of the cohort of interest was 47 ± 5 years compared with 28 ± 7 years in the control. Fifty-four percent (70 of 130) of patients older than 40 years were women and 46% (60 of 130) were men; for those younger than 40, 51% (133 of 260) of participants were women and 49% (127 of 260) were men. Tönnis grade distribution for patients older than 40 was as follows: 46% (60 of 130) had Grade 0, 42% (55 of 130) had Grade 1, and 12% (15 of 130) had Grade 2. In comparison, Tönnis grade for patients younger than 40 was as follows: 52% (136 of 260) had Grade 0, 38% (100 of 260) had Grade 1, and 9% (24 of 260) had Grade 2 (p = 0.49). Chondral lesion degree was determined intraoperatively as none, a partial-thickness tear, or a full-thickness tear. Tönnis grade was determined based on preoperative plain AP hip radiographs. We then compared the percentage of patients who converted to THA during the surveillance period (our primary study outcome). We also compared the difference in delta (preoperative minus postoperative) improvement in functional outcome scores using the modified Harris Hip Score (mHHS) between the groups, excluding those who had already been converted to THA. RESULTS: In patients older than 40 years, 16% (21 of 130) converted to THA at a mean time to conversion of 2 ± 1 years compared with 7% (17 of 260) at a mean time of 2 ± 2 years in patients younger than 40 years (p = 0.01). At a mean of 5 ± 2 years after FAO, among those patients who had not undergone conversion to THA, the mean delta mHHS score for patients older than 40 was 11 ± 17, compared with 20 ± 26 for patients younger than 40 (p = 0.04). CONCLUSION: Since approximately 1 in 6 patients older than 40 years in this series who underwent FAO for FAI opted for early conversion to THA at a mean time of 2 years after the osteoplasty procedure, and the remaining patients who did not undergo THA reported lower improvement in functional outcomes, we recommend surgeons avoid this procedure in patients in this age group until or unless we can better refine our indications. This is especially true because loss to follow-up causes us to believe that, if anything, our estimates of the risk of conversion to THA are conservative. LEVEL OF EVIDENCE: Level III, therapeutic study.

Prior Femoroacetabular Osteoplasty Does Not Compromise the Clinical Outcome of Subsequent Total Hip Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) is the most effective treatment option for patients with symptomatic osteoarthritis after a prior femoroacetabular osteoplasty (FAO). This study evaluated clinical outcomes of THA after a prior FAO and compared the results with a matched group of patients who underwent THA with no prior surgical procedures in the affected hip. METHODS: By reviewing our prospectively maintained database, we identified 74 hips (69 patients) that underwent THA after previous FAO between 2004 and 2017. They were matched 1:3 to a control group of primary THA with no history of any procedures on the same hip based on age, sex, body mass index, date of surgery, Charlson comorbidity index, surgical approach, and acetabular and femoral component type. At minimum 2-year follow-up, modified Harris Hip Score, 90-day readmission, and revision THA for any reason were compared between the groups. RESULTS: The median time interval between FAO and subsequent THA was 1.64 years. There was no significant difference in preoperative Harris Hip Score between patients in the case and control cohorts. At the latest follow-up, the median modified Harris Hip Score was 77.6 in the case group and 96.2 in the control, and the difference was not statistically significant. None of the patients in the case group developed infection. 7 patients in the case group required additional procedures at any point, compared with 15 in the control. CONCLUSION: THA after prior FAO has similar outcomes to primary THA in patients with no prior procedures in the affected hip. THA can be performed safely with excellent outcome in patients with a history of FAO.

Does a History of Slipped Capital Femoral Epiphysis in Patients Undergoing Femoroacetabular Osteoplasty for Femoroacetabular Impingement Affect Outcomes Scores or Risk of Reoperation?

BACKGROUND: Femoroacetabular impingement (FAI) can occur after slipped capital femoral epiphysis (SCFE) regardless of slip severity and even after in situ pinning. These patients represent a rare and unique demographic that is largely unreported on. It is important to further characterize the clinical presentation of these patients, associated treatment modalities, and the efficacy of these treatment modalities. QUESTIONS/PURPOSES: (1) How do patients with post-SCFE FAI typically present in terms of radiographic and surgical findings? (2) How do their hip-specific and general-health outcomes scores after mini-open femoroacetabular osteoplasty compare with those obtained in a matched group of patients with FAI caused by other etiologies? (3) How do those groups compare in terms of the proportion who undergo conversion to THA? METHODS: Between 2013 and 2017, 20 patients had femoroacetabular osteoplasty for post-SCFE FAI. During that time, general indications for this procedure were symptomatic FAI demonstrated on radiographs and physical exam. Of those, none was lost to follow-up before a minimum of 2 years, leaving all 20 available for matching, and all 20 had suitable matches in our database for patients who underwent femoroacetabular osteoplasty for other diagnoses. Matching was performed by surgeon, patient age, patient gender, and BMI. The matching group was drawn from a large database of patients who had the same procedure during the same period. We matched in a 1:3 ratio to arrive at 60 randomly selected control patients in this retrospective, comparative study. Patient demographics, medical history, clinical presentation, radiographic parameters, and intraoperative findings were compared between the two groups. At a minimum of 2 years of follow-up, the latest clinical functional outcome scores (Hip Disability and Osteoarthritis Outcome Score Jr and SF-12) and proportions of conversion to THA were compared between the groups. RESULTS: A greater percentage of patients with a history of SCFE than those without prior SCFE demonstrated full chondral lesions intraoperatively (90% [18 of 20] versus 32% [19 of 60], odds ratio 7 [95% confidence interval 1 to 178]; p < 0.01). A greater percentage of patients with a history of SCFE also demonstrated labral calcifications intraoperatively compared with those without prior SCFE (65% [13 of 20] versus 35% [21 of 60], OR 3 [95% CI 1 to 10]; p = 0.04). Radiographically, patients with SCFE had greater preoperative alpha angles than did patients without SCFE (94° ± 13° versus 72° ± 22°; p = 0.01) as well as lower lateral center-edge angles (25° ± 8° versus 31° ± 8°; p = 0.04). There was no difference in postoperative follow-up between patients with a history of SCFE and patients without a history of SCFE (4 ± 2 years versus 4 ± 2 years; p = 0.32). There was no difference in the mean postoperative outcome scores between patients with a history of SCFE and patients without (Hip Disability and Osteoarthritis Outcome Score Jr: 75 ± 28 points versus 74 ± 17 points; p = 0.95; SF-12 physical score: 40 ± 11 points versus 39 ± 8 points; p = 0.79). There was no difference with the numbers available in the percentage of patients who underwent conversion to THA (15% [3 of 20] versus 12% [7 of 60], OR 1.36 [95% CI 0 to 6]; p = 0.71). CONCLUSION: Patients with FAI after SCFE present with a greater degree of labral and chondral disease than do patients without a history of SCFE. However, at short-term follow-up, the proportion of patients who underwent conversion to THA and patients' postoperative outcome scores did not differ in this small, comparative series between patients with and without SCFE. Further evaluation with long-term follow-up is needed, especially given the more severe chondral damage we observed in patients with SCFE at the time of surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up.

PURPOSE: No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA). METHODS: Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty-one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft-tissue release procedure. Mean age at intervention was 60 years (range 46-78 years). Mean preoperative knee range of motion (ROM) was - 27° extension (range - 20° to - 40°) to 100° flexion (range 90°-115°). All radiographs were evaluated for proper component sizing and signs of loosening. RESULTS: Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow-up of 31 months (range 24-49 months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70-90) when compared with preoperative KSS (mean 45, range 25-65) (p = 0.008). CONCLUSION: The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2-year follow-up. LEVEL OF EVIDENCE: IV, retrospective case series.

Mini-Open Femoroacetabular Osteoplasty: Risk Factors for Failure and Conversion to Hip Arthroplasty.

BACKGROUND: Surgical treatment of femoroacetabular impingement (FAI) has been increasing over the past decade with reports of favorable results in alleviating patient symptoms. However, progression of osteoarthritis in these patients may necessitate total hip arthroplasty (THA) for the treatment of unresolved or recurrent hip pain and accompanying disability. Identifying the risk factors for disease progression and treatment failure can help orthopaedic surgeons to select the appropriate patients for joint-preservation procedures and allow more informative discussions. METHODS: With use of the prospective database of hip-preservation surgery at our institution, 652 patients (324 men and 328 women) with FAI who had undergone femoroacetabular osteoplasty (FAO) between December 2004 and April 2016 were identified. Treatment failure was defined as the need for THA. At the latest follow-up, 68 (9.08%)of 749 hips had undergone THA because of the recurrence of symptoms and the development of osteoarthritis. The groups of patients who had or had not undergone conversion to THA were compared with respect to age, sex, body mass index (BMI), surgeon experience, duration of preoperative symptoms, preoperative and postoperative alpha angles, radiographic parameters of hip dysplasia, a perioperative chondral lesion, labral abnormalities and interventions, acetabular retroversion, and severity of osteoarthritis (Tönnis grade). RESULTS: The mean age (and standard deviation) at the time of the index FAO was 41.9 ± 10.5 years for patients who had had a failure of FAO, compared with 33.4 ± 11.1 years for those who had not. Risk factors for treatment failure included a longer mean symptomatic period before the FAO procedure, older age, higher mean BMI, the presence of hip dysplasia, acetabular retroversion, higher preoperative alpha angle, a full-thickness acetabular chondral lesion, Tönnis grade-1 and 2 osteoarthritis, labral hypertrophy, and total labral resection during FAO. The rate of failure was related to the experience of the surgeon, with fewer failures occurring in the later years of surgery as compared with the earlier years. CONCLUSIONS: The present study identified a number of variables that influence the outcome of FAO. Surgeons performing hip-preservation procedures should be aware of these risk factors for failure, and a more cautious approach is recommended for patients with these risk factors. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Greater Knee Soft Tissue Thickness Predisposes Patients to Subsequent Periprosthetic Joint Infection After Total Knee Arthroplasty.

BACKGROUND: Although obesity is a risk factor for periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), the role of soft tissue thickness (STT) at the surgical site has not been well studied. This study examined if increased STT in the medial and anterior aspects of the knee are independent risk factors for PJI. METHODS: A retrospective study was conducted on 206 patients who underwent 2-stage exchange arthroplasty for PJI from 2000 to 2015. They were matched 1:3 to a control group of primary, noninfected TKA patients with minimum 2 years infection-free survival by age, gender, age-adjusted Charlson Comorbidity Index, date of surgery, and body mass index (BMI). Two blinded orthopedic surgeons measured the medial STT from the medial aspect of the knee at the level of the joint line on an anteroposterior radiograph, and anterior STT 8 cm above the joint line on a lateral radiograph from the skin to the quadriceps tendon. RESULTS: Increased STT was significantly associated with a higher risk for PJI. The mean anterior STT was 29.74 ± 13.76 mm in the PJI group and 24.88 ± 9.76 mm in the control group. The mean medial STT was 42.42 ± 14.66 mm for PJI and 37.27 ± 12.51 mm for control. Both STT measurements were significantly higher in PJI cases with BMI <30 kg/m2 vs control patients with BMI <30 kg/m2. CONCLUSION: Anterior and medial knee STT was an independent risk factor for PJI after primary TKA and represents a simple radiographic method to assess postoperative infection risk. Excess adipose tissue around the surgical site can predispose patients to PJI after TKA regardless of BMI.

Elephant's ear sign: a new radiographic finding indicative of acetabular retroversion.

Acetabular retroversion is a relatively common condition affecting the hip that can result in symptoms in some patients. Diagnosis of acetabular retroversion relies on obtaining a proper anteroposterior radiograph of the pelvis. Cross-over, posterior wall, and ischial spine signs are usually present in patients on the radiographs of patients with acetabular retroversion. In this illustrative case report, we describe an additional radiographic sign, elephant's ear sign, associated with acetabular retroversion that we have seen to be present in patients with acetabular retroversion. A review of 26 acetabular retroversion case series by 2 independent reviewers showed 100% consensus on the presence of elephant's ear sign in patients with evidence of all other radiographic signs of this hip abnormality. This simple and previously unreported radiographic Elephant's ear sign, in which flared iliac wings appear as elephant's ears, highlights the presence of acetabular retroversion.

Available Findings Fail to Provide Strong Evidence of the Role of Bone Morphogenic Protein-2 in Femoral Head Osteonecrosis.

Despite widespread research on non-traumatic femoral head osteonecrosis (FHON), there is no consensus about preventative treatment options. Insufficient blood supply and increased intra-osseous pressure are the initiating events in the majority of cases. BMPs are growth factors that belong to the transforming growth factor ß (TGFß) superfamily. Two specific formulations of BMPs have already been approved by the FDA: 1. BMP-2 (Infused, Medtronic) for the treatment of tibial open fractures and spinal fusion; 2. BMP-7 (OP-1, Stryker) in the setting of long bone non-unions. To our knowledge there is no published work reviewing the utility of BMP-2 in the setting of FHON. Online databases (EMBASE, Cochrane, MEDLINE and PubMed) for literature relating to the use of BMP-2 in the treatment of FHON on 2nd June 2017. Animal studies: A total of 169 animal subjects with induced FHON were treated with BMP-2 in all the included in vivo studies. Improved histological parameters, areas of revascularization, areas of new bone formation and osteoid deposition were seen in all studies. The number of osteoclasts decreased post operatively, in the ibandronate and BMP-2 group. Human studies: In combination, 96 human hips were treated in two studies utilizing BMP-2 and mean follow-up was at least five years. Success rate of BMP-2 was above 80 % (based on Harris score and WOMAC score) in both studies. Both are level III studies. The present review of animal and clinical studies could not find well-designed prospective comparable studies with large sample size and preliminary evidence is not sufficient to supports the utilization of BMP-2, and its impact on the midterm outcomes of FHON.

Irrigation, Débridement, and Implant Retention for Recurrence of Periprosthetic Joint Infection Following Two-Stage Revision Total Knee Arthroplasty: A Matched Cohort Study.

BACKGROUND: We investigated clinical/functional outcomes and implant survivorship in patients who underwent 2-stage revision total knee arthroplasty (TKA) after periprosthetic joint infection (PJI), experienced acute PJI recurrence, and underwent irrigation, débridement, and polyethylene exchange (IDPE) with retention of stable implant. METHODS: Twenty-four patients (24 knees) were identified who underwent 2-stage revision TKA for PJI, experienced acute PJI recurrence, and then underwent IDPE between 2005 and 2016 (minimum 2-year follow-up). After IDPE, intravenous antibiotics (6 weeks) and oral suppression therapy (minimum 6 months) were administered. Data were compared with 1:2 matched control group that underwent 2-stage revision TKA for chronic PJI and did not receive IDPE. RESULTS: Average IDPE group follow-up was 3.8 years (range, 2.4-7.2). Reinfection rate after IDPE was 29% (n = 7): 3 of 7 underwent second IDPE (2 of 3 had no infection recurrence) and 5 (one was patient who had recurrent infection after second IDPE) underwent another 2-stage revision TKA. Control group reinfection rate was 27% (n = 13) (P = .85). For IDPE group, mean time to reinfection after 2-stage revision TKA was 4.6 months (range, 1-8 months) (patients presented with acute symptoms less than 3 weeks duration). At latest follow-up, mean Knee Society Score was 70 (range, 35-85) in IDPE group and 75 (range, 30-85) in control group (P = .53). CONCLUSION: IDPE for acute reinfection following 2-stage revision TKA with well-fixed implants had a 71% success rate. These patients had comparable functional outcome as patients with no IDPE after 2-stage revision TKA. IDPE followed by long-term suppression antibiotic therapy should be considered in patients with acute infection and stable components.

Acetabular Retroversion Is a Risk Factor for Less Optimal Outcome After Femoroacetabular Impingement Surgery.

BACKGROUND: Patients with acetabular retroversion are at risk of labral tear and hip pain. It is unknown whether femoroacetabular osteoplasty (FAO) without reverse periacetabular osteotomy can be used in these patients. This study evaluated the outcome of mini-open FAO in patients with acetabular retroversion and compared that to patients without acetabular retroversion. METHODS: Fifty-one patients (29 male, 22 female) with acetabular retroversion who had undergone FAO between 2007 and 2015 were identified. The minimum 2-year clinical and radiological outcome was compared with 550 patients without dysplasia or retroversion who underwent FAO by the same surgeon. The preoperative and postoperative alpha angle, center-edge angle, Tonnis grade, joint space, and presence of labral tear and chondral lesion were determined. RESULTS: The mean age in the retroversion cohort was 27.4 ± 9.5 years compared to 34.5 ± 11.2 years in the control. The mean follow-up was 4.8 ± 1.5 years for retroversion and 4.1 ± 1.2 years for the control. The mean preoperative Short-Form 36 Health Survey and modified Harris hip score were not different between the cohorts. At the latest follow-up, the mean modified Harris hip score and Short-Form 36 Health Survey were significantly lower in the retroversion group (75.4 and 76.5) compared to the control (83.4 and 85.6). There was a higher percentage of failure among retroversion patients (13.7%) compared to the control (2.5%). CONCLUSION: Acetabular retroversion resulting in femoroacetabular impingent may be treated by FAO, but the outcome appears to be less optimal compared to patients with femoroacetabular impingent and no evidence of dysplasia and acetabular retroversion. Hip preservation surgeons should be aware of this anatomic variation and possible inferior treatment results after FAO in these patients.

Bilateral Femoroacetabular Impingement: What is the Fate of the Asymptomatic Hip?

BACKGROUND: Bilateral symptomatic femoroacetabular impingement (FAI) is common. However, the fate of asymptomatic hip in patients with the radiographic diagnosis of bilateral FAI and unilateral symptoms remains unknown. QUESTIONS/PURPOSES: (1) What is the likelihood of the asymptomatic hip becoming painful in patients with unilateral symptoms but with radiographic evidence of bilateral femoroacetabular impingement? (2) What radiological and clinical factors are associated with the development of symptoms in an asymptomatic hip diagnosed with FAI? METHODS: A longitudinally maintained institutional FAI database was queried to collect relevant data for this retrospective study. To answer our research questions, we created a cohort of patients with bilateral radiographic signs of FAI but only unilateral symptoms at the time of initial presentation. Between 2004 and 2016, a senior surgeon (JP) at one institution treated 652 patients for hip pain determined to be from FAI, a diagnosis we made based on clinical symptoms, physical exam, and diagnostic imaging. We excluded 95 patients (15%) because of inadequate data or other diagnoses, which left 557 patients. Of those, 170 patients (31%) had bilateral radiological diagnosis of FAI, and 88 (52%) of them had bilateral hip symptoms, and so were excluded. Of the remaining 82 patients, eight (10%) underwent bilateral FAI surgery under the same anesthetic despite having only unilateral symptoms, leaving 74 for analysis in this study. Patients were followed with annual clinic visits, or contacted by phone and electronically. We defined onset of symptoms using a modified Harris Hip Score (mHHS) or the University of California at Los Angeles (UCLA) activity scale, and used a logistic regression model to identify factors associated with the development of symptoms. RESULTS: Of the 74 patients with bilateral FAI and an asymptomatic hip at initial presentation, 60 (81%) became symptomatic at a mean 2 years (range, 0.3-11 years) followup. Of these 60 patients, 43 (72%) eventually underwent subsequent surgical intervention. After controlling for potential confounding variables such as sex, age, BMI, history of trauma we identified that reduced neck-shaft angle (r = -0.243, p = 0.009), increased lateral center-edge angle (r = 0.123, p = 0.049), increased alpha angle (r = 0.069, p = 0.025), and younger age (r = -0.071, p = 0.046) were associated with the development of symptoms in the contralateral hip. With the numbers available, none of the other examined variables such as sex, BMI, history of trauma, psychiatric condition, employment, Tönnis grade, Tönnis angle, crossover sign, type of impingement, and joint congruency were found to be associated with symptom progression. CONCLUSIONS: Bilateral FAI may be observed about one-third of patients. Most patients with unilateral symptomatic FAI and radiographic diagnosis of bilateral FAI in this cohort became symptomatic relatively quickly and most of them underwent subsequent surgical intervention in the contralateral hip. Reduced neck-shaft angle, increased lateral center-edge angle, increased alpha angle, and younger age were associated with symptom development in the contralateral hip. Hip preservation surgeons may use the finding of this study to counsel patients who present with bilateral FAI but only unilateral symptoms about the natural history of their condition. LEVEL OF EVIDENCE: Level III, therapeutic study.

Higher Prevalence of Concomitant Shoulder Labral Tears in Patients With Femoroacetabular Impingement.

PURPOSE: To examine the prevalence of concomitant symptomatic glenoid labral tears in patients with femoroacetabular impingement (FAI) in comparison to a control group of patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: We retrospectively identified 1,644 patients who underwent femoroacetabular osteoplasty (FAO) and labrum repair from January 2007 to September 2016 and 1,055 patients who underwent arthroscopic ACL reconstruction from January 2012 to December 2014, which acted as our control group. An electronic questionnaire, including 8 questions regarding history of shoulder pathology, was sent to all patients in both groups. Symptomatic shoulder labral tears were identified on the basis of a positive magnetic resonance imaging scan or history of labral repair by reviewing patients' medical records and the filled questionnaire. Continuous variables were compared by use of a Mann-Whitney U test, and categorical variables were compared using Fisher's exact test. The Holm-Bonferroni sequential correction method was used to adjust P values for multiple comparisons of the presence of shoulder pathology. RESULTS: A total of 443 patients (405 cam lesion) in the FAO group and 307 patients in the ACL reconstruction group completed the prepared questionnaire and were included in the study. Patients in the FAO group were slightly older (36.3 years [range, 15.4-61.7] vs 32.3 years [range, 16.3-75.7]) and more commonly female in the FAO group (58.0%, n = 257) compared with those in the ACL group (48.9%, n = 150). The prevalence of shoulder labral tear was 12.0% (95% confidence interval [CI], 9.3%-15.3%) for the FAO group compared with only 3.3% (95% CI, 1.8%-5.9%) for the ACL group. This represents a 3.7-fold (95% CI, 1.9-7.1) increase in the risk of shoulder labral tear for patients in the FAO group. Furthermore, shoulder labral tears were reported to be traumatic in only 43.4% of patients in the FAO group compared with 80.0% of patients in the ACL group. A similar proportion of patients in both groups (66.0% for FAO vs 60.0% for ACL) underwent a shoulder labral repair procedure. CONCLUSION: There appears to be an association between acetabular labral tear caused by FAI and shoulder labral lesions. Patients in the FAI group had a 3.7-fold increase in the risk of shoulder labral tear compared with the ACL group. Future studies are needed to examine a possible cause behind the current findings. LEVEL OF EVIDENCE: Level III, comparative trial study.

Hip Dysplasia Compromises the Outcome of Femoroacetabular Impingement Surgery.

BACKGROUND: The optimal treatment for patients with symptomatic hip dysplasia presenting with labral tear is unknown. Although femoroacetabular osteoplasty (FAO) has excellent outcome for most femoroacetabular impingement patients, the presence of concomitant hip dysplasia has been implicated as an adverse prognostic factor. This study evaluated the outcome of FAO in a group of dysplastic hips and compared the outcome to a cohort of patients without dysplasia. METHODS: Seventy-three patients (38 males, 35 females) with hip dysplasia who underwent FAO between 2007 and 2015 were identified. The minimum 2-year clinical, functional (modified Harris Hip Score and Short-Form 36 Health Survey), and radiological outcome was compared with 550 patients without dysplasia who underwent FAO by the same surgeon. The preoperative and postoperative alpha angle, Tonnis grade, joint space, and presence of chondral lesion were determined and compared. Conversion to total hip arthroplasty or revision FAO was considered as treatment failure. RESULTS: The mean age in the dysplasia cohort was 30.7 ± 11.8 years compared to 34.5 ± 11.2 in the nondysplastic group. The mean follow-up was 4.3 years for dysplasia cohort and 4.1 for the nondysplastic group. The mean modified Harris Hip Score and Short-Form 36 Health Survey6 was significantly lower in the dysplastic group at 75.1 and 74.3 compared to 83.4 and 85.6 for the comparison group. There was a higher percentage of failure at 28.8% among dysplasia patients compared to 2.5% in the nondysplastic group. CONCLUSION: Although labral repair and FAO may be an option for patients with hip dysplasia, the outcome in this population appears to be less optimal compared to femoroacetabular impingement patients with no evidence of dysplasia. Labral repair and osteoplasty should be limited to those with mild and borderline dysplasia.

Acetabular Labral Tears Are Common in Asymptomatic Contralateral Hips With Femoroacetabular Impingement.

BACKGROUND: The number of patients undergoing hip arthroscopy for labral tears has increased, but labral tears are sometimes seen in asymptomatic patients with femoroacetabular impingement (FAI). The frequency of this finding, however, has not been well characterized nor is the proportion of patients with previously asymptomatic labral tears who may later become symptomatic. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) the prevalence of labral tears and other intraarticular pathology in the asymptomatic contralateral hip of patients undergoing surgery for symptomatic FAI; (2) the likelihood that the asymptomatic hip had become symptomatic at latest followup; and (3) any association between MRI findings and age, sex, and body mass index (BMI) in both symptomatic and asymptomatic sides. METHODS: This study included patients who were diagnosed with unilateral symptomatic FAI between 2013 and 2015 and who had an available MRI of both hips. The study included 100 patients (47 females, 53 males) with a mean age of 33 years (range, 17-57 years). Patients with a symptomatic contralateral hip (n = 56) or an unsuitable MRI for review based on both reviewers' consensus (n = 344) were excluded. The MRI of both hips was independently evaluated by two orthopaedic surgeons and interobserver reliability tested. The interobserver reliability for the two surgeons' MRI ratings was almost perfect (κ ≥ 0.85). The presence of a labral tear, an acetabular chondral lesion, subchondral acetabular cysts, and fibrocystic changes in the femoral head-neck junction was documented for both hips. At latest followup, asymptomatic hips were investigated for any symptomatic labral tears or surgical procedures resulting from FAI. RESULTS: A labral tear was recorded in 97 (97%) and 96 (96%) of symptomatic hips, respectively, for each surgeon's evaluation. A labral tear was also detected in 41 (41%) and 43 (43%) of asymptomatic hips. In addition, an acetabular chondral lesion was detected in 32 (32%) and 35 (35%) of the symptomatic hips and 15 (15%) and 17 (17%) of the asymptomatic hips. At latest followup, nine of the patients were diagnosed with symptomatic labral tears in the contralateral asymptomatic hip and were treated. None of the radiologic parameters examined demonstrated an association with patient age, sex, or BMI in either symptomatic or asymptomatic hips. CONCLUSIONS: Labral tears and acetabular chondral lesions are common in the asymptomatic contralateral hip of patients undergoing surgery for FAI. The incidence of a symptomatic labral tear in these asymptomatic hips was 9% during 2 years of followup. We suggest that the decision to perform chondral or labral surgery in patients with FAI should be made with caution considering the relatively high prevalence of labral tears in asymptomatic hips and the low chance of development of symptoms. LEVEL OF EVIDENCE: Level IV, case-series study.