HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery

There is increased emphasis on efficiently administering patient-reported outcome measures (PROMs). The International Hip Outcome Tool-12 (iHOT-12) is a short-form version of the iHOT-33, and relatively little is known about clinically significant outcomes using the iHOT-12.

The purpose of this study was to define minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the iHOT-12 and to identify predictors for achieving these psychometric end points in patients undergoing arthroscopic treatment of femoroacetabular impingement (FAI).

Data was prospectively collected and retrospectively analyzed as part of an institutional hip preservation repository. One hundred and twenty patients were included; mean age and body mass index (BMI) were 38.7 years and 25.9, respectively. A majority of patients were female (67.5%) and white (81.7%) and participated in recreational sports (79.2%). The iHOT-12 was administered pre-operatively and at 1-year follow-up to patients undergoing primary hip arthroscopy for FAI. The following anchor question was also asked at 1-year follow-up: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?” MCID was calculated using a distribution-based method. Receiver-operating characteristic analysis with area under the curve was used to confirm the significance of the PASS threshold.

Mean iHOT-12 scores improved from 35.6 at pre-operative assessment to 70.7 at 1-year follow-up. Patients indicating satisfaction with their outcome improved from 37.5 pre-operatively to 79.0 at 1-year follow-up. MCID value for the iHOT-12 was 13.0. The PASS threshold was 63.0, indicating an excellent predictive value that patients scoring above this threshold were likely to have met an acceptable symptom state. Worker's compensation patients and those with increased BMI were less likely to achieve PASS; lower pre-operative iHOT-12 score was predictive for achieving MCID, and achieving MCID was predictive for achieving PASS.

This is the first study to define PASS and MCID for the iHOT-12, which measures clinically significant outcome improvement comparably to that of other commonly used hip PROMs. As its use becomes more widespread, the iHOT-12 data-points presented in this study can be used to determine clinically significant improvement of patient-reported outcomes.

Carbon-fiber-reinforced (CFR) polymer has produced great excitement in the orthopedic community as a material that will reduce bone healing times and provide improved image quality. Osteotomy stabilized with an intramedullary (IM) nail has become a common technique to address post-traumatic malalignment of the lower extremity.

The following questions were asked: (1) Did CFR polymer nails provide a rapid healing time after long bone osteotomy, shortening, or fracture? (2) Did the CFR polymer nails produce unexpected complications?

A retrospective review was conducted in patients who received CFR polymer IM nails for various indications, from April 2016 to January 2017 in a deformity and trauma practice, using patient charts and radiographs. The primary outcomes were time to union and incidence of complications including nonunion, hardware failure, neurovascular injury, venous thromboembolism, and infection.

Twelve patients who received CFR polymer IM nails in 16 limbs for various indications were included in our analysis. Patients were followed for an average of 16.9 months. Eleven limbs underwent realignment and were corrected an average of 23° through a diaphyseal osteotomy. Three limbs underwent limb-shortening surgery, an average of 25 mm, through an open, excisional osteotomy of the femoral diaphysis. Two diaphyseal, closed tibia fractures underwent routine IM nailing. The average time to union was 107.6 days, which included all limbs that united (11/16, 69%). Nonunion occurred in 5/16 (31%) of limbs. Complications recorded included nonunion and hardware failure, most of which resulted in unplanned surgery.

The use of the CFR polymer IM nail was associated with loss of fixation and nonunion after surgeries that have traditionally healed uneventfully. The increased elasticity of the CFR polymer allows for more motion at the osteotomy/fracture interface than the stiffer titanium counterparts, exposing long-bone osteotomies to delayed union and nonunion, a finding seen with CFR polymer plates. The overwhelmingly poor early results of this device applied to a long-bone deformity practice have led these authors to abandon the use of this implant.

Operative indications for supination-external rotation (SER) ankle fractures depend on the integrity of the medial structures. Despite the importance of assessing deep deltoid ligament injuries, the accuracy of common diagnostic tests has not been established.

The objective of this study was to compare the ability of injury (non-stress) and stress radiographs and magnetic resonance imaging (MRI) to diagnose deep deltoid ligament ruptures in operative SER ankle fractures.

Patients were included who underwent surgical fixation of SER ankle fractures and had appropriate injury and manual stress test radiographs, pre-operative ankle MRI, and intra-operative assessment of deep deltoid integrity by direct visualization. The medial clear space (MCS) was considered positive for all values over 5 mm on the injury or stress mortise radiographs. MRI analysis of the deep deltoid ligament injury was performed by blinded fellowship-trained musculoskeletal radiologists. Intra-operative direct visualization and assessment of the deltoid was performed using a direct medial ankle approach at the time of operative fracture fixation.

Using intra-operative visualization as the gold standard, MCS measurements and MRI had differing abilities to diagnose a deep deltoid rupture. In cases where the MCS was less than 5 mm on injury radiographs and stress tests were performed, MCS measurements were much less accurate than MRI in predicting deltoid ruptures (46% versus 79%, respectively) with a high false positive rate (80%). In contrast, an MCS measurement of greater than 5 mm on injury radiographs was a strong predictor of deep deltoid rupture (accuracy of 95%).

Compared with direct visualization of the deltoid ligament intra-operatively, these data support proceeding with surgery when the MCS on injury radiographs is greater than 5 mm without any additional stress tests or advanced imaging. When the MCS is less than 5 mm, we recommend MRI analysis because of its increased accuracy and decreased false positive rate. Improving our ability to diagnose deltoid ruptures will contribute to more effective management of patients with SER ankle fractures.

Measures of long-term success of total hip arthroplasty (THA) over the past 50 years have focused primarily on implant survival, with less evidence on long-term functional outcomes.

We aimed to study 20-to-40-year functional outcomes after primary THA. We investigated the extent to which (1) functional outcomes after THA are maintained long term; (2) patient characteristics such as age, hip disease diagnosis, and comorbidities affect recovery of function and survivorship after THA; and (3) patients’ overall function after THA is affected by the need for revision, the aging process, and associated comorbidities.

We retrospectively reviewed outcomes of the senior author's patients between 1968 and 1993. Of 1207 patients, we identified 167 patients (99 female, 68 male; 276 primary THAs) who were at least 65 years old at follow-up and had at least 20 years of follow-up. Mean age at surgery was 55 years; mean follow-up time was 27 years. Bilateral THAs were performed in 109 patients (65%), and revisions in 81 patients (48.5%). Clinical outcomes including pain level, walking ability, range of motion, and overall function were determined by the Hospital for Special Surgery (HSS) hip scoring system. Contralateral and revision surgery, as well as patient age, sex, and body mass index, were included as covariates. To account for unequally spaced follow-up time points and competing causes of functional decline (e.g., age, contralateral hip disease, and need for revision THA), a latent class mixed model approach was used to identify unobserved classes of patients who had similar outcomes. Linear, quadratic, and piecewise-polynomial growth models were considered for class identification. The best fitting model was determined based on Bayesian information criterion.

A four-class model of this patient population was identified: (1) the Elderly Class, who had a mean age of 62 years at the time of primary THA; (2) the Bilateral Class, who underwent simultaneous or staged bilateral THA; (3) the Revision Class, who required at least one revision; and (4) the Youngest Class, who had a mean age of 49 years. After an initial period of improvement in all groups, the functional trajectory diverged according to classifications. Age was the strongest determinant of long-term outcome, with HSS hip scores in the Elderly Class declining after about 20 years. The Youngest Class maintained good-to-excellent hip function for over 30 years. Revision THA and contralateral THA accounted for a temporary decline in function, after which overall good function was regained for the long term.

All classes in the study population enjoyed good-to-excellent outcomes after THA for about 20 years. Thereafter, functional decline was attributed more to aging than to the need for revision. One or more revision THA did not negatively influence long-term clinical outcomes, suggesting that, even for younger patients, symptoms, rather than the avoidance of possible revision, should be the primary determining factor when indicating THA.

Rotator cuff (RTC) repair is performed using open/mini-open or arthroscopic procedures, and the use of arthroscopic techniques is increasing. The extent to which surgery has transitioned from open to arthroscopic techniques has yet to be elucidated.

The purpose of this study was to evaluate trends in open and arthroscopic rotator cuff repair in the USA and describe tendencies in treatment across gender, age, and geographic region. We hypothesized that surgeons would be more likely to perform arthroscopic rotator cuff repair, with similar trends across the USA.

A retrospective review of a comprehensive national insurance database (Humana) was performed using the PearlDiver software for all patients who underwent RTC repair between January 2007 and June 2015. Patients were identified by Current Procedural Terminology (CPT) codes. χ ² tests evaluated the proportion of arthroscopic surgeries by gender and geographic region; logistic regression analysis assessed differences from 2007 to 2015.

In the study period, 54, 740 patients underwent RTC repair (68% arthroscopic, 52% male), with the highest frequency of RTC repair in patients between 65 and 69 years old. The proportion of open RTC repair increased with increasing patient age, with no significant difference between men and women. The proportion of arthroscopic RTC surgeries increased from 56.9% in 2007 to 75.1% in 2015. The overall trend was 188% increase in total RTC repairs. Arthroscopic repair was more frequent than open repair in all US regions, with the highest proportion in the South.

Arthroscopic RTC surgery predominates and continues to rise. With increasing patient age, there was an increase in the proportion of open repair. The majority of RTC repairs were performed in patients between 65 and 69 years of age.

Fixation of scaphoid fractures is recommended in elite athletes to hasten healing and return-to-sport times. Complications such as nonunion negatively affect athletic performance.

The purpose of this study was to examine the prevalence and impact of scaphoid repair on National Football League (NFL) participation during athletes’ first season in the NFL, while identifying significant predictors for development of carpal arthritis and scaphoid nonunion.

A total of 1311 football athletes invited to the NFL Scouting Combine from 2012 to 2015 were evaluated for history of scaphoid fracture repair. Athlete demographics, surgical history, and imaging and physical examination findings were recorded. Future NFL participation based on draft status, games played, and games started during athletes’ first season were gathered using publicly available databases.

Nineteen (1.4%) athletes underwent 24 operations for scaphoid repair. Limitations in wrist range of motion or strength were present in 47.4% of athletes with a history of repair. Arthritic changes were present in 32% of wrists, while radiographic nonunion was present in two athletes following scaphoid fracture. Defensive backs were observed to have a higher incidence for arthritic changes following repair compared to other positions. No significant difference in prospective NFL participation was found in athletes with a history of scaphoid repair than in those without.

Athletes with a history of scaphoid repair are not at significant risk for diminished participation during their first season in the NFL.

Carpal tunnel release (CTR) has traditionally been performed through an open approach, although in recent years endoscopic CTR has gained in popularity.

We sought to assess whether a difference exists between the rates of nerve repair surgery following open versus endoscopic CTR in New York State (NYS).

Patients undergoing endoscopic and open CTR from 1997 to 2013 were identified from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health using Current Procedural Terminology, 4th Revision (CPT-4) codes 29848 and 64721, respectively. The primary outcome measure was subsequent nerve repair surgery (as identified using CPT-4 codes 64831–64837, 64856, 64857, 64859, 64872, 64874, and 64876). Other variables analyzed included patient age, sex, payer, and surgery year.

There were 294, 616 CTRs performed in NYS from 1997 to 2013. While the incidence of open CTR remained higher than endoscopic CTR, the proportion of endoscopic CTR steadily increased, from 16% (2984/19, 089) in 2007 to 25% (5594/22, 271) in 2013. For the 134, 143 patients having a single CTR, the rate of subsequent nerve repair was significantly higher following endoscopic CTR (0.09%) compared to open CTR (0.04%). The Cox model showed that factors significantly associated with a higher risk of subsequent nerve repair surgery were endoscopic CTR and younger age.

Endoscopic CTR has been increasingly performed in NYS and associated with a higher rate of subsequent nerve repair. This rate likely underestimates the incidence of nerve injuries because it only captures those patients who had subsequent surgery. While this catastrophic complication remains rare, further investigation is warranted, given the rise of endoscopic CTR in the setting of equivalent outcomes, but favorable reimbursement, versus open CTR.

The effect of a pre-operative compromised acromion on reverse shoulder arthroplasty (RSA) is not well-studied.

We sought to determine the effect of a pre-operative compromised acromion on outcomes following RSA.

We conducted a retrospective case-control study of consecutive patients who underwent RSA over a 6-year period (June 2007 to June 2013) with a diagnosis of rotator cuff tear arthropathy. Pre-operative plain radiographs were examined to determine the presence of acromion compromise (n = 11). Acromion compromise was defined as (1) less than 25% of the normal acromion thickness (8.8 mm), (2) less than 50% of the normal acromion anteroposterior width (46.1 mm), (3) presence of an os acromiale, or (4) presence of acromial fragmentation. An age- and sex-matched control cohort without acromial compromise was also identified (n = 33). The primary outcome variable was the final minimum 2-year American Shoulder and Elbow Surgeons (ASES) score. Secondary outcomes included final minimum 2-year scores on the 12-Item Short-Form Health Survey (SF-12), with the physical component score (PCS) and mental component score (MCS); 2-year Marx shoulder activity scale scores; and final 2-year satisfaction scores.

At 2 years post-operatively, there were no significant differences in final scores using ASES, SF-12 PCS or MCS, or Marx shoulder activity scale. There were no significant differences between groups for satisfaction scores in any of the assessed domains. No complications were reported at 2 years’ follow-up in any of the study patients or controls.

Between patients with and without pre-operative acromion compromise, there were no differences in clinical outcomes, satisfaction levels, or complication rates after RSA. Our findings suggest that surgeons performing RSA in the setting of pre-operative acromion compromise, including os acromiale, acromial fragmentation, or severe thinning, should not expect poor post-operative clinical outcomes.

Infants previously treated for developmental dysplasia of the hips (DDH) are routinely imaged with ultrasound initially and reimaged with an anteroposterior (AP) pelvis X-ray at 6 months of age to assess for dysplasia. It has become convention to transition from ultrasound to AP X-ray at 6 months of age, but no study has demonstrated that ultrasound is inadequate at this age.

The purpose of this study was to confirm that ultrasound for the 6-month DDH evaluation is a feasible alternative to the standard X-ray.

Thirty-one 5- to 7-month-old infants undergoing AP pelvis X-ray related to previous Pavlik harness treatment for DDH or to a history of breech presentation were prospectively enrolled. All patients were imaged with an AP pelvis X-ray and bilateral hip ultrasounds. Three senior orthopedic surgeons unfamiliar with the patient histories evaluated both types of imaging for standard measures of hip dysplasia, including acetabular index (AI), alpha angle, and bony rim percent coverage of the femoral head. Pearson correlation coefficients were calculated for the X-ray and ultrasound measures.

Good quality ultrasound images were obtained in all patients, despite the presence of the ossific nucleus in 66% of the hips. All three reviewers correctly diagnosed the one dislocated hip via both X-ray and ultrasound. There were no false negatives on ultrasound, and none of the patients with negative ultrasounds required treatment during the mean 26 months of follow up. An increased AI on X-ray was correlated with lower percent coverage of the femoral head on ultrasound.

Ultrasound is a technically feasible DDH imaging modality that can be used as an alternative to X-ray for 6-month-olds.

Prior reports suggest that osteoarticular infections may be increasing over time.

We sought to determine if incidence rates, median in-hospital costs, and length of stay (LOS) of osteomyelitis, septic arthritis (SA), and combined infections have changed over time for pediatric patients, and how they compare to previously reported rates.

The Kids’ Inpatient Database (KID), a US national sample of pediatric hospital discharge records from 1997, 2000, 2003, 2006, 2009, and 2012, was used to determine yearly estimated counts of infections in children 20 years of age or younger. US census data was used to calculate yearly incidence rates. Trend tests using linear contrast analysis were used to compare estimated median LOS and inflation-adjusted median costs over time for each type of infection.

From 1997 through 2012, the incidence rate of osteomyelitis increased from 7.9 to 10.5 per 100, 000, SA was unchanged from 5.3 to 5.2 per 100, and combined infections increased from 0.8 to 1.3 per 100, 000. Median LOS from 1997 to 2012 showed no significant change for osteomyelitis (5.0 to 4.9 days), SA (4.4 to 4.1 days), or combined infections (6.5 to 6.8 days). Median in-hospital costs from 1997 to 2012 increased for osteomyelitis ($7735 to $11, 823), SA ($5041 to $10, 574), and combined infections ($12, 691 to $16, 260).

In pediatric patients, the estimated incidence rate of SA appeared stable, while rates of osteomyelitis and combined infections increased. These estimated rates fall within previously reported ranges. Despite stable LOS, costs have increased over time.

General anesthesia with neuromuscular blockade may facilitate total shoulder arthroplasty but appears to increase risk of cerebral oxygen desaturation. Cerebral desaturation is undesirable and is a proxy for risk of stroke.

This study tested the hypothesis that cerebral oxygen desaturation occurs frequently during general anesthesia with neuromuscular blockade and positive-pressure ventilation but does not occur with spontaneous ventilation. Correlations were sought among cerebral oxygen saturation, blood pressure, and cardiac index.

We designed a prospective, observational, cohort study to measure cerebral oxygenation in 25 patients during general anesthesia, both with and without positive-pressure ventilation. Patients undergoing elective shoulder arthroplasty in the sitting position received an arterial catheter, near-infrared spectroscopic measurement of cerebral oxygenation, and non-invasive cardiac output measurement. Moderate hypotension was allowed. Blood pressure was supported as needed with ephedrine or low-dose epinephrine (but avoiding phenylephrine). Hypercapnia (45 to 55 mmHg) was targeted during positive-pressure ventilation.

No cerebral oxygen desaturations occurred, regardless of ventilation mode. Under positive-pressure ventilation, the median (interquartile range: Q1, Q3) cerebral oxygenation was 110% of baseline (104, 113), the mean arterial pressure was 62% of baseline (59, 69), and the cardiac index was 82% of baseline (71, 104). Cerebral oxygenation did not correlate with blood pressure or cardiac index but had moderate correlation with end-tidal carbon dioxide. No strokes occurred.

There were no signs of inadequate brain perfusion during general anesthesia using paralytic agents. Positive-pressure ventilation with moderate hypotension in the sitting position does not endanger patients, in the context of moderate hypercapnia and hemodynamic support using ephedrine or epinephrine.

The incidence of primary anterior cruciate ligament reconstruction (ACLR) failure ranges from 10 to 20% in the USA. Many patient and surgical factors may lead to re-rupture after ACLR. Some authors have suggested that not correcting excessive posterior tibial slope may be a significant contributing factor to ACLR failure.

We sought to systematically review the literature on outcomes, indications, and complications in patients undergoing simultaneous high tibial osteotomy (HTO) and ACLR revision.

PubMed, Medline, and Embase were searched in February 2018 for articles addressing simultaneous HTO and ACLR revision in skeletally mature patients. Major orthopedic conferences were screened in duplicate to find gray literature. All studies were assessed using the Methodological Index for Non-Randomized Studies. Descriptive statistics are presented where applicable.

Seven studies satisfied inclusion. Seventy-seven patients underwent combined HTO and ACLR revision. The main indications were a posterior slope of more than 12° or severe varus malalignment. Graft types included hamstring tendon autograft (58.4%; n = 45) and quadriceps tendon graft (16.9%; n = 13). Mean delay between primary and revision surgery was 9 years. Rehabilitation protocol dictated return to running at 4 months and return to sport at 4 to 9 months. Visual analog scale pain scores reduced on average by 30 points. Subjective International Knee Documentation Committee, Tegner–Lysholm, and Tegner activity scores also improved. Fifty-eight percent (35/60) of patients showed osteoarthritis signs post-operatively. One patient (1.3%) received an arthroscopic arthrolysis of adhesions for stiffness. There were no reported incidences of graft re-rupture.

This systematic review found that the use of HTO for ACLR revision produces good post-operative functional outcomes, low complication rates, and no reported re-ruptures. The main indications for combined HTO with ACLR revision was a posterior slope of more than 12° or severe varus malalignment. Future studies with large sample sizes and long-term follow-up are required to corroborate these results.

Isolated distal semitendinosus tears and avulsions sustained during sporting activities are uncommon.

We sought to systematically review the literature to identify athletes sustaining distal semitendinosus tears and avulsions during sporting activities and to better understand injury mechanisms, management, and return-to-sport timing.

PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE databases were searched from January 1970 to January 2018 using the search terms distal hamstring, semitendinosus, sport, athlete, tear, rupture, and avulsion. Inclusion criteria were studies documenting (1) isolated, complete distal semitendinosus tears and avulsions during sporting activity, (2) injury management, and (3) athlete outcome. Exclusion criteria were studies reporting (1) partial tears, (2) injuries from non-sporting activities, or (3) athlete sustaining injury with concomitant injuries about the knee. Sporting activities, tear location, management strategy, time from injury to surgery, and return-to-sport timing were analyzed. Statistical analysis was used to evaluate return-to-sport timing based on treatment type and tear location.

Four studies met the inclusion criteria, comprising a total of 23 cases of complete, isolated distal semitendinosus avulsions or tears. Injuries were sustained predominantly while running or sprinting and most commonly were avulsions off the tibia. Injuries were treated surgically in 70% of cases. Overall time to return to sport was 2.5 ± 1.4 months with athletes treated conservatively returning significantly more quickly (1.5 ± 0.8 months) than athletes undergoing surgery (3.0 ± 1.3 months). Return-to-sport time was significantly shorter in athletes with complete avulsions (2.2 ± 1.3 months) than in those sustaining tears at the musculotendinous junction (3.8 ± 0.8 months). No significant correlation between time to surgery and return-to-sport time was appreciated.

Isolated, complete distal semitendinosus tears and avulsions remain infrequently reported during sporting activities and, in this review, occurred predominantly during non-contact activity. Athletes treated conservatively were found to return to sport more quickly, although additional studies are needed to determine the clinical relevance of treatment option, tear location, and concurrent injuries.

Obesity is an independent risk factor for osteoarthritis and has been associated with increased rate of complications following lower-extremity total joint arthroplasty (TJA). Bariatric surgery (BS) is a surgical option for weight loss and for reducing obesity-related comorbidities in morbidly obese patients.

The goal of this systematic review was to answer the following questions: (1) Does BS prior to TJA correlate with lower post-operative complication rates in morbidly obese patients undergoing TJA? (2) Does BS have an impact on revision rates following TJA?

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist, a systematic review of medical databases (PubMed/ MEDLINE, Cochrane Library, Web of Science, and Clinicaltrials.gov) was undertaken for articles published in English from January 1990 to September 2018. Inclusion criteria were studies that included at least ten patients who underwent BS prior to TJA, collected data on complications or other outcomes, and followed patients for at least 90 days after TJA. A descriptive and critical analysis of the results was performed.

From 799 studies, 13 met inclusion criteria. A total of 11, 770 patients who had undergone bariatric surgery prior to TJA were analyzed. The quality of the evidence ranged between moderate and high. There was no consensus on the effect of previous BS on early- to short-term outcomes reported after TJA.

The literature remains conflicted on the impact of BS prior to TJA on early, short-term, and long-term complications after TJA. Additional well-matched, observational studies may further our understanding of the impact of BS prior to TJA on outcomes. In particular the effect of various types of BS prior to TJA on outcomes has yet to be elucidated. Ideally, prospective studies with higher level of evidence will be more definitive on the effects of BS prior to TJA.

Prospero Registration Number: CRD42016043025.