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5 Points on Meniscal Allograft Transplantation
ABSTRACT
Meniscus allograft transplantation (MAT) has yielded excellent long-term functional outcomes when performed in properly indicated patients. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency. Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure. Once an ideal candidate is identified, graft selection and preparation are critical steps to ensure a proper fit and long-term viability of the meniscus. When selecting the graft, accurate measurements must be taken, and this is most commonly performed using plain radiographs for this. Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.
Continue to: Meniscus tears are common in the young, athletic patient population...
Meniscus tears are common in the young, athletic patient population. In the United States alone, approximately 700,000 meniscectomies are performed annually.1 Given discouraging long-term clinical results following subtotal meniscectomy in young patients, meniscal repair is preferred whenever possible.2 Despite short-term symptom relief if subtotal meniscectomy is required, some patients often go on to develop localized pain in the affected compartment, effusions, and eventual development of osteoarthritis. In such patients with symptomatic meniscal deficiency, meniscal allograft transplantation (MAT) has yielded excellent long-term functional outcomes.3-5 Three recently published systematic reviews describe the outcomes of MAT in thousands of patients, noting positive outcomes in regard to pain and function for the majority of patients.6-8 Specifically, in a review conducted by Elattar and colleagues7 consisting of 44 studies comprising 1136 grafts in 1068 patients, the authors reported clinical improvement in Lysholm Knee Scoring Scale score (44 to 77), visual analog scale (48 mm to 17 mm), and International Knee Documentation Committee (84% normal/nearly normal, 89% satisfaction), among other outcomes measures. Additionally, the complication (21.3%) and failure rates (10.6%) were considered acceptable by all authors. The purpose of this article is to review indications, operative preparation, critical aspects of surgical technique, and additional concomitant procedures commonly performed alongside MAT.
1. PATIENT SELECTION
When used with the proper indications, MAT offers improved functional outcomes and reduced pain for patients with symptomatic meniscal deficiency. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency who does not have (1) evidence of diffuse osteoarthritis (Outerbridge grade <2), including the absence of significant bony flattening or osteophytes in the involved compartment; (2) inflammatory arthritis; (3) active or previous joint infection; (4) mechanical axis malalignment; or (5) morbid obesity (Table). Long-leg weight-bearing anterior-posterior alignment radiographs are important in the work-up of any patient being considered for MAT, and consideration for concomitant or staged realignment high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) should be given for patients in excessive varus or valgus, respectively. Although the decision to perform a realignment osteotomy is made on a patient-specific basis, if the weight-bearing line passes medial to the medial tibial spine or lateral to the lateral tibial spine, HTO or DFO, respectively, should be considered. Importantly, MAT is not typically recommended in the asymptomatic patient.9 Although some recent evidence suggests MAT may have chondroprotective effects on articular cartilage following meniscectomy, there is insufficient long-term outcome data to support the use of MAT as a prophylactic measure, especially given the fact that graft deterioration inevitably occurs at 7 to 10 years, with patients having to consider avoiding meniscus-dependent activities following transplant to protect their graft from traumatic failure.10,11
Table. Summary of Indications and Contraindications for Meniscal Allograft Transplant (MAT)
Indications | Contraindicationsa |
Patients younger than 50 years old with a chief complaint of pain limiting their desired activities | Diffuse femoral and/or tibial articular cartilage wear |
Body mass index <35 kg/m2 | Radiographic evidence of arthritis |
Previous meniscectomy (or non-viable meniscus state) with pain localized to the affected compartment | Inflammatory arthritis conditions |
Normal or correctable coronal and sagittal alignment | MAT performed as a prophylactic measure in the absence of appropriate symptoms is highly controversial |
Normal or correctable ligamentous stability |
|
Normal or correctable articular cartilage |
|
Willingness to comply with rehabilitation protocol |
|
Realistic post-surgical activity expectations |
|
aContraindications for MAT are controversial, as the available literature discussing contraindications is very limited. This list is based on the experience of the senior author.
Long-term prospective studies have shown high graft survival and predominantly positive functional results after MAT. Age indications have expanded, with 1 recent study reporting 6% reoperation rate and zero failures in a cohort of 37 adolescent MAT patients.12 High survival rates hold even among an athletic population, where rates of return to play after MAT have been reported to be >75% for those competing at a high school level or higher.13 In an active military population, <2% of patients progressed to revision MAT or total knee arthroplasty at minimum 2-year follow-up, but 22% of patients were unable to return to military duty owing to residual knee limitations.14 In this series, tobacco use correlated with failure, whereas MAT by high-volume, fellowship-trained orthopedic surgeons decreased rates of failure.
2. GRAFT SELECTION
In preparation for MAT, accurate measurements must be taken for appropriate size matching. Several measurement techniques have been described, including using plain radiographs, 3D computed tomography (CT), and magnetic resonance imaging (MRI).15-18 There is limited data regarding the consequences of an improperly sized donor meniscus; however, an oversized lateral meniscus has been shown to increase the contact forces across the articular cartilage.19 Additionally, an undersized allograft may result in normal forces across the articular cartilage but greater forces across the meniscus.19
When sizing the recipient knee for MAT, accurate width and length measurements are critical. The most common technique used today includes measurements using anteroposterior and lateral radiographic images as described by Pollard and colleagues.15 The width of the meniscus is determined by the distance between 2 vertical lines perpendicular to the joint line, 1 of them tangential to the margin of the tibia metaphysis and the other between the medial and lateral tibial eminence in both knees (Figures 1A,1B). The length of the meniscus is measured on a lateral radiograph. A line is drawn at the level of the articular line between the anterior surface of the tibia above the tuberosity and a parallel line that is tangential to the posterior margin of the tibial plateau. Percent corrections are performed for these dimensions as described in previous publications.
Other techniques have been described to obtain accurate measurements of the recipient knee. For example, obtaining an MRI of the contralateral knee may provide a reproducible method of measuring both the width and length of the medial and lateral menisci.20 CT has been used to measure the lateral meniscus independently, and it has been shown to exhibit less error in the measure of the tibial plateau when compared with X-rays.18 Both CT and MRI are more expensive than simple radiographs, and CT exposes the patient to an increased amount of radiation. Current evidence does not support standard use of these advanced imaging modalities for meniscal sizing.
Continue to: GRAFT PREPARATION AND PLACEMENT...
3. GRAFT PREPARATION AND PLACEMENT
At the time of surgery, the meniscus allograft is thawed in sterile saline and prepared on the back table. This can be done before or after the diagnostic arthroscopy and bone-slot preparation. Excess soft tissue surrounding the meniscal rim and/or anterior and posterior horns should be removed. Several techniques for MAT have been described, but we generally prefer a bridge-in-slot technique for both medial and lateral MAT.21 To prepare the meniscus allograft for a bridge-in-slot technique, the graft is cut with an oscillating saw to a width of 7 mm, with care taken to ensure that the bony insertions of both meniscal horns are preserved. Next, a transverse cut is made 10 mm below the meniscal horns to set the depth of the bone bridge. To assist with the sizing of the bone bridge, a rectangular sizing block and cutting jig is used (Figures 2A-2C). After marking the middle and posterior thirds of the meniscus, a No. 2 non-absorbable suture is placed at the junction of the posterior and middle thirds of the meniscus. This completes preparation of the allograft prior to implantation.
Attention is then turned to back the arthroscopy. A standard posteromedial (medial meniscus) or posterolateral (lateral meniscus) accessory incision is made, and a Henning retractor is carefully placed in order to receive the sutures that will be placed through the meniscus allograft via a standard inside-out repair technique. First, a zone-specific cannula is used to place a nitinol wire out the accessory incision. The looped end of the wire is pulled out of the anterior arthrotomy incision that will be used to shuttle the meniscus allograft into the joint. In order to pass the meniscal allograft into the joint, the passing suture previously placed through the meniscus is shuttled through the nitinol wire, and the wire is then pulled out the accessory incision, advancing the meniscus through the anteiror arthrotomy. As the meniscus is introduced, the traction suture is then gently tensioned to get the allograft completely into the joint. Next, the bone bridge is seated into the previously created bone slot, as the soft tissue component is manually pushed beneath the ipsilateral femoral condyle. Under direct visualization, the soft tissue component is reduced with a probe using firm, constant traction. To aid in reduction, it may be useful to apply compartment-specific varus or valgus stress and to cycle the knee once the meniscal complex is reduced.
4. GRAFT FIXATION
Once the graft has been passed completely into the joint, with the bone bridge seated into the bone slot, the long end of an Army-Navy retractor is placed firmly through the arthrotomy on the meniscal bone bridge, maintaining a downward force to allow the bridge to remain slotted. To lever down on the posterior aspect of the graft, a freer elevator is used from anterosuperior to posteroinferior. The bone bridge is then secured using a bioabsorbable interference screw, placed central to the bone bridge opposing the block to the ipsilateral compartment. The remainder of the meniscus is secured with an inside-out repair technique, working from posterior to anterior through a standard medial or lateral meniscal repair approach. In total, approximately 6 to 10 vertical mattress sutures are placed, and these can be placed both superiorly and inferiorly on the meniscus. Posteriorly, an all-inside suture repair device may be helpful. Finally, the anterior aspect of the meniscus is repaired to the capsule in an open fashion prior to closing the arthrotomy. Sutures are tied with the leg in extension. The meniscal repair incision is closed in a standard fashion using layers.
5. CONCOMITANT PATHOLOGY AND MAT
The presence of concomitant knee pathology in the context of meniscus deficiency is a challenging problem that requires careful attention to all aspects of the underlying condition of the knee. In cases where MAT is indicated, issues of malalignment, cartilage defects, and/or ligamentous instability may also need to be addressed either concomitantly or in staged fashion. For example, medial meniscal deficiency in the setting of varus alignment can be addressed with a concomitant HTO, whereas lateral meniscal deficiency in the setting of valgus malalignment can be addressed with a concomitant DFO. In both cases, the osteotomy corrects an abnormal mechanical axis, offloading the diseased compartment. This accomplishes 2 goals, namely to preserve the new MAT graft and to protect underlying articular cartilage.22-24 The osteotomy is an important contributor to additional pain relief by offloading the compartment, and clinical studies have demonstrated that failure to address malalignment in the setting of surgical intervention for cartilage and meniscal insufficiency leads to inferior clinical outcomes and poor survival of transplanted tissue.25-28
Continue to: In a meniscus-deficient patient with chondral lesions...
In a meniscus-deficient patient with chondral lesions (Outerbridge grade 3 or 4), concomitant MAT and cartilage restoration should be considered. Depending on the size and location of the chondral lesion, options include marrow stimulation, autologous chondrocyte implantation, osteochondral autograft transfer, as well as chondral and/or osteochondral allograft transplantation. In a systematic review of concomitant MAT and cartilage restoration procedures, Harris and colleagues25 found that failure rates of the combined surgery were similar to those of either surgery in isolation.
Young athletes sustaining anterior cruciate ligament (ACL) tears commonly also have meniscal pathology that must be addressed. Most cases are treated with meniscal repair or partial meniscectomy, but occasionally patients present with ACL tear and symptomatic meniscal deficiency. Specifically, MAT survival relies largely on a knee with ligamentous stability, whereas outcomes of ACL reconstruction are improved with intact and functional menisci.29 The surgical technique for MAT is modified slightly in the setting of performing a concomitant ACL reconstruction, with the ACL tibial tunnel drilled to avoid the meniscal bone slot if possible, followed by femoral tunnel creation. Femoral fixation of the ACL graft is accomplished after preparation of the meniscal slot. The meniscal graft is set into place (sutures are not yet tied), and tibial fixation of the ACL graft is performed next. We typically use an Achilles allograft for the ACL reconstruction, with the bone block used for femoral fixation to avoid bony impingement between the MAT bone bridge/block and the ACL graft. With the knee in full extension, the MAT sutures are tied at the conclusion of the surgical procedure. Concomitant MAT and ACL reconstruction has yielded positive long-term clinical outcomes, improved joint stability, and findings similar to historical results of ACL reconstruction or MAT performed in isolation.30,31
CONCLUSION
When used with the proper indications, MAT has demonstrated the ability to restore function and reduce pain. Successful meniscal transplant requires attention to the patient’s past medical and surgical history. Similarly, care must be taken to address any concomitant knee pathology, such as coronal realignment, ligament reconstruction, or cartilage restoration.
1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep. 2009;11(11):1-25.
2. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
3. Saltzman BM, Bajaj S, Salata M, et al. Prospective long-term evaluation of meniscal allograft transplantation procedure: a minimum of 7-year follow-up. J Knee Surg. 2012;25(2):165-175. doi:10.1055/s-0032-1313738.
4. van der Wal RJ, Thomassen BJ, van Arkel ER. Long-term clinical outcome of open meniscal allograft transplantation. Am J Sports Med. 2009;37(11):2134-2139. doi:10.1177/0363546509336725.
5. Vundelinckx B, Vanlauwe J, Bellemans J. Long-term subjective, clinical, and radiographic outcome evaluation of meniscal allograft transplantation in the knee. Am J Sports Med. 2014;42(7):1592-1599. doi:10.1177/0363546514530092.
6. Hergan D, Thut D, Sherman O, Day MS. Meniscal allograft transplantation. Arthroscopy. 2011;27(1):101-112. doi:10.1016/j.arthro.2010.05.019.
7. Elattar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):147-157. doi:10.1007/s00167-010-1351-6.
8. Verdonk R, Volpi P, Verdonk P, et al. Indications and limits of meniscal allografts. Injury. 2013;44(Suppl 1):S21-S27. doi:10.1016/S0020-1383(13)70006-8.
9. Frank RM, Yanke A, Verma NN, Cole BJ. Immediate versus delayed meniscus allograft transplantation: letter to the editor. Am J Sports Med. 2015;43(5):NP8-NP9. doi:10.1177/0363546515571065.
10. Aagaard H, Jørgensen U, Bojsen-Møller F. Immediate versus delayed meniscal allograft transplantation in sheep. Clin Orthop Relat Res. 2003;406(406):218-227. doi:10.1097/01.blo.0000030066.92399.7f.
11. Jiang D, Ao YF, Gong X, Wang YJ, Zheng ZZ, Yu JK. Comparative study on immediate versus delayed meniscus allograft transplantation: 4- to 6-year follow-up. Am J Sports Med. 2014;42(10):2329-2337. doi:10.1177/0363546514541653.
12. Riboh JC, Tilton AK, Cvetanovich GL, Campbell KA, Cole BJ. Meniscal allograft transplantation in the adolescent population. Arthroscopy. 2016;32(6):1133-1140.e1. doi:10.1016/j.arthro.2015.11.041.
13. Chalmers PN, Karas V, Sherman SL, Cole BJ. Return to high-level sport after meniscal allograft transplantation. Arthroscopy. 2013;29(3):539-544. doi:10.1016/j.arthro.2012.10.027.
14. Waterman BR, Rensing N, Cameron KL, Owens BD, Pallis M. Survivorship of meniscal allograft transplantation in an athletic patient population. Am J Sports Med. 2016;44(5):1237-1242. doi:10.1177/0363546515626184.
15. Pollard ME, Kang Q, Berg EE. Radiographic sizing for meniscal transplantation. Arthroscopy. 1995;11(6):684-687. doi:10.1016/0749-8063(95)90110-8.
16. Haut TL, Hull ML, Howell SM. Use of roentgenography and magnetic resonance imaging to predict meniscal geometry determined with a three-dimensional coordinate digitizing system. J Orthop Res. 2000;18(2):228-237. doi:10.1002/jor.1100180210.
17. Van Thiel GS, Verma N, Yanke A, Basu S, Farr J, Cole B. Meniscal allograft size can be predicted by height, weight, and gender. Arthroscopy. 2009;25(7):722-727. doi:10.1016/j.arthro.2009.01.004.
18. McConkey M, Lyon C, Bennett DL, et al. Radiographic sizing for meniscal transplantation using 3-D CT reconstruction. J Knee Surg. 2012;25(3):221-225. doi:10.1055/s-0031-1292651.
19. Dienst M, Greis PE, Ellis BJ, Bachus KN, Burks RT. Effect of lateral meniscal allograft sizing on contact mechanics of the lateral tibial plateau: an experimental study in human cadaveric knee joints. Am J Sports Med. 2007;35(1):34-42. doi:10.1177/0363546506291404.
20. Yoon JR, Jeong HI, Seo MJ, et al. The use of contralateral knee magnetic resonance imaging to predict meniscal size during meniscal allograft transplantation. Arthroscopy. 2014;30(10):1287-1293. doi:10.1016/j.arthro.2014.05.009.
21. Lee AS, Kang RW, Kroin E, Verma NN, Cole BJ. Allograft meniscus transplantation. Sports Med Arthrosc. 2012;20(2):106-114. doi:10.1097/JSA.0b013e318246f005.
22. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23(8):852-861. doi:10.1016/j.arthro.2007.05.018.
23. Loening AM, James IE, Levenston ME, et al. Injurious mechanical compression of bovine articular cartilage induces chondrocyte apoptosis. Arch Biochem Biophys. 2000;381(2):205-212. doi:10.1006/abbi.2000.1988.
24. Mina C, Garrett WE Jr, Pietrobon R, Glisson R, Higgins L. High tibial osteotomy for unloading osteochondral defects in the medial compartment of the knee. Am J Sports Med. 2008;36(5):949-955. doi:10.1177/0363546508315471.
25. Harris JD, Cavo M, Brophy R, Siston R, Flanigan D. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy: 2011;27(3):409-418. doi:10.1016/j.arthro.2010.08.007.
26. Rue JP, Yanke AB, Busam ML, McNickle AG, Cole BJ. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up. Am J Sports Med. 2008;36(9):1770-1778. doi:10.1177/0363546508317122.
27. Kazi HA, Abdel-Rahman W, Brady PA, Cameron JC. Meniscal allograft with or without osteotomy: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):303-309. doi:10.1007/s00167-014-3291-z.
28. Verdonk PC, Verstraete KL, Almqvist KF, et al. Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):694-706. doi:10.1007/s00167-005-0033-2.
29. Shelbourne KD, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med. 2000;28(4):446-452. doi:10.1177/03635465000280040201.
30. Graf KW Jr, Sekiya JK, Wojtys EM; Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA. Long-term results after combined medial meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy. 2004;20(2):129-140. doi:10.1016/j.arthro.2003.11.032.
31. Binnet MS, Akan B, Kaya A. Lyophilised medial meniscus transplantations in ACL-deficient knees: a 19-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):109-113. doi:10.1007/s00167-011-1556-3.
ABSTRACT
Meniscus allograft transplantation (MAT) has yielded excellent long-term functional outcomes when performed in properly indicated patients. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency. Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure. Once an ideal candidate is identified, graft selection and preparation are critical steps to ensure a proper fit and long-term viability of the meniscus. When selecting the graft, accurate measurements must be taken, and this is most commonly performed using plain radiographs for this. Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.
Continue to: Meniscus tears are common in the young, athletic patient population...
Meniscus tears are common in the young, athletic patient population. In the United States alone, approximately 700,000 meniscectomies are performed annually.1 Given discouraging long-term clinical results following subtotal meniscectomy in young patients, meniscal repair is preferred whenever possible.2 Despite short-term symptom relief if subtotal meniscectomy is required, some patients often go on to develop localized pain in the affected compartment, effusions, and eventual development of osteoarthritis. In such patients with symptomatic meniscal deficiency, meniscal allograft transplantation (MAT) has yielded excellent long-term functional outcomes.3-5 Three recently published systematic reviews describe the outcomes of MAT in thousands of patients, noting positive outcomes in regard to pain and function for the majority of patients.6-8 Specifically, in a review conducted by Elattar and colleagues7 consisting of 44 studies comprising 1136 grafts in 1068 patients, the authors reported clinical improvement in Lysholm Knee Scoring Scale score (44 to 77), visual analog scale (48 mm to 17 mm), and International Knee Documentation Committee (84% normal/nearly normal, 89% satisfaction), among other outcomes measures. Additionally, the complication (21.3%) and failure rates (10.6%) were considered acceptable by all authors. The purpose of this article is to review indications, operative preparation, critical aspects of surgical technique, and additional concomitant procedures commonly performed alongside MAT.
1. PATIENT SELECTION
When used with the proper indications, MAT offers improved functional outcomes and reduced pain for patients with symptomatic meniscal deficiency. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency who does not have (1) evidence of diffuse osteoarthritis (Outerbridge grade <2), including the absence of significant bony flattening or osteophytes in the involved compartment; (2) inflammatory arthritis; (3) active or previous joint infection; (4) mechanical axis malalignment; or (5) morbid obesity (Table). Long-leg weight-bearing anterior-posterior alignment radiographs are important in the work-up of any patient being considered for MAT, and consideration for concomitant or staged realignment high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) should be given for patients in excessive varus or valgus, respectively. Although the decision to perform a realignment osteotomy is made on a patient-specific basis, if the weight-bearing line passes medial to the medial tibial spine or lateral to the lateral tibial spine, HTO or DFO, respectively, should be considered. Importantly, MAT is not typically recommended in the asymptomatic patient.9 Although some recent evidence suggests MAT may have chondroprotective effects on articular cartilage following meniscectomy, there is insufficient long-term outcome data to support the use of MAT as a prophylactic measure, especially given the fact that graft deterioration inevitably occurs at 7 to 10 years, with patients having to consider avoiding meniscus-dependent activities following transplant to protect their graft from traumatic failure.10,11
Table. Summary of Indications and Contraindications for Meniscal Allograft Transplant (MAT)
Indications | Contraindicationsa |
Patients younger than 50 years old with a chief complaint of pain limiting their desired activities | Diffuse femoral and/or tibial articular cartilage wear |
Body mass index <35 kg/m2 | Radiographic evidence of arthritis |
Previous meniscectomy (or non-viable meniscus state) with pain localized to the affected compartment | Inflammatory arthritis conditions |
Normal or correctable coronal and sagittal alignment | MAT performed as a prophylactic measure in the absence of appropriate symptoms is highly controversial |
Normal or correctable ligamentous stability |
|
Normal or correctable articular cartilage |
|
Willingness to comply with rehabilitation protocol |
|
Realistic post-surgical activity expectations |
|
aContraindications for MAT are controversial, as the available literature discussing contraindications is very limited. This list is based on the experience of the senior author.
Long-term prospective studies have shown high graft survival and predominantly positive functional results after MAT. Age indications have expanded, with 1 recent study reporting 6% reoperation rate and zero failures in a cohort of 37 adolescent MAT patients.12 High survival rates hold even among an athletic population, where rates of return to play after MAT have been reported to be >75% for those competing at a high school level or higher.13 In an active military population, <2% of patients progressed to revision MAT or total knee arthroplasty at minimum 2-year follow-up, but 22% of patients were unable to return to military duty owing to residual knee limitations.14 In this series, tobacco use correlated with failure, whereas MAT by high-volume, fellowship-trained orthopedic surgeons decreased rates of failure.
2. GRAFT SELECTION
In preparation for MAT, accurate measurements must be taken for appropriate size matching. Several measurement techniques have been described, including using plain radiographs, 3D computed tomography (CT), and magnetic resonance imaging (MRI).15-18 There is limited data regarding the consequences of an improperly sized donor meniscus; however, an oversized lateral meniscus has been shown to increase the contact forces across the articular cartilage.19 Additionally, an undersized allograft may result in normal forces across the articular cartilage but greater forces across the meniscus.19
When sizing the recipient knee for MAT, accurate width and length measurements are critical. The most common technique used today includes measurements using anteroposterior and lateral radiographic images as described by Pollard and colleagues.15 The width of the meniscus is determined by the distance between 2 vertical lines perpendicular to the joint line, 1 of them tangential to the margin of the tibia metaphysis and the other between the medial and lateral tibial eminence in both knees (Figures 1A,1B). The length of the meniscus is measured on a lateral radiograph. A line is drawn at the level of the articular line between the anterior surface of the tibia above the tuberosity and a parallel line that is tangential to the posterior margin of the tibial plateau. Percent corrections are performed for these dimensions as described in previous publications.
Other techniques have been described to obtain accurate measurements of the recipient knee. For example, obtaining an MRI of the contralateral knee may provide a reproducible method of measuring both the width and length of the medial and lateral menisci.20 CT has been used to measure the lateral meniscus independently, and it has been shown to exhibit less error in the measure of the tibial plateau when compared with X-rays.18 Both CT and MRI are more expensive than simple radiographs, and CT exposes the patient to an increased amount of radiation. Current evidence does not support standard use of these advanced imaging modalities for meniscal sizing.
Continue to: GRAFT PREPARATION AND PLACEMENT...
3. GRAFT PREPARATION AND PLACEMENT
At the time of surgery, the meniscus allograft is thawed in sterile saline and prepared on the back table. This can be done before or after the diagnostic arthroscopy and bone-slot preparation. Excess soft tissue surrounding the meniscal rim and/or anterior and posterior horns should be removed. Several techniques for MAT have been described, but we generally prefer a bridge-in-slot technique for both medial and lateral MAT.21 To prepare the meniscus allograft for a bridge-in-slot technique, the graft is cut with an oscillating saw to a width of 7 mm, with care taken to ensure that the bony insertions of both meniscal horns are preserved. Next, a transverse cut is made 10 mm below the meniscal horns to set the depth of the bone bridge. To assist with the sizing of the bone bridge, a rectangular sizing block and cutting jig is used (Figures 2A-2C). After marking the middle and posterior thirds of the meniscus, a No. 2 non-absorbable suture is placed at the junction of the posterior and middle thirds of the meniscus. This completes preparation of the allograft prior to implantation.
Attention is then turned to back the arthroscopy. A standard posteromedial (medial meniscus) or posterolateral (lateral meniscus) accessory incision is made, and a Henning retractor is carefully placed in order to receive the sutures that will be placed through the meniscus allograft via a standard inside-out repair technique. First, a zone-specific cannula is used to place a nitinol wire out the accessory incision. The looped end of the wire is pulled out of the anterior arthrotomy incision that will be used to shuttle the meniscus allograft into the joint. In order to pass the meniscal allograft into the joint, the passing suture previously placed through the meniscus is shuttled through the nitinol wire, and the wire is then pulled out the accessory incision, advancing the meniscus through the anteiror arthrotomy. As the meniscus is introduced, the traction suture is then gently tensioned to get the allograft completely into the joint. Next, the bone bridge is seated into the previously created bone slot, as the soft tissue component is manually pushed beneath the ipsilateral femoral condyle. Under direct visualization, the soft tissue component is reduced with a probe using firm, constant traction. To aid in reduction, it may be useful to apply compartment-specific varus or valgus stress and to cycle the knee once the meniscal complex is reduced.
4. GRAFT FIXATION
Once the graft has been passed completely into the joint, with the bone bridge seated into the bone slot, the long end of an Army-Navy retractor is placed firmly through the arthrotomy on the meniscal bone bridge, maintaining a downward force to allow the bridge to remain slotted. To lever down on the posterior aspect of the graft, a freer elevator is used from anterosuperior to posteroinferior. The bone bridge is then secured using a bioabsorbable interference screw, placed central to the bone bridge opposing the block to the ipsilateral compartment. The remainder of the meniscus is secured with an inside-out repair technique, working from posterior to anterior through a standard medial or lateral meniscal repair approach. In total, approximately 6 to 10 vertical mattress sutures are placed, and these can be placed both superiorly and inferiorly on the meniscus. Posteriorly, an all-inside suture repair device may be helpful. Finally, the anterior aspect of the meniscus is repaired to the capsule in an open fashion prior to closing the arthrotomy. Sutures are tied with the leg in extension. The meniscal repair incision is closed in a standard fashion using layers.
5. CONCOMITANT PATHOLOGY AND MAT
The presence of concomitant knee pathology in the context of meniscus deficiency is a challenging problem that requires careful attention to all aspects of the underlying condition of the knee. In cases where MAT is indicated, issues of malalignment, cartilage defects, and/or ligamentous instability may also need to be addressed either concomitantly or in staged fashion. For example, medial meniscal deficiency in the setting of varus alignment can be addressed with a concomitant HTO, whereas lateral meniscal deficiency in the setting of valgus malalignment can be addressed with a concomitant DFO. In both cases, the osteotomy corrects an abnormal mechanical axis, offloading the diseased compartment. This accomplishes 2 goals, namely to preserve the new MAT graft and to protect underlying articular cartilage.22-24 The osteotomy is an important contributor to additional pain relief by offloading the compartment, and clinical studies have demonstrated that failure to address malalignment in the setting of surgical intervention for cartilage and meniscal insufficiency leads to inferior clinical outcomes and poor survival of transplanted tissue.25-28
Continue to: In a meniscus-deficient patient with chondral lesions...
In a meniscus-deficient patient with chondral lesions (Outerbridge grade 3 or 4), concomitant MAT and cartilage restoration should be considered. Depending on the size and location of the chondral lesion, options include marrow stimulation, autologous chondrocyte implantation, osteochondral autograft transfer, as well as chondral and/or osteochondral allograft transplantation. In a systematic review of concomitant MAT and cartilage restoration procedures, Harris and colleagues25 found that failure rates of the combined surgery were similar to those of either surgery in isolation.
Young athletes sustaining anterior cruciate ligament (ACL) tears commonly also have meniscal pathology that must be addressed. Most cases are treated with meniscal repair or partial meniscectomy, but occasionally patients present with ACL tear and symptomatic meniscal deficiency. Specifically, MAT survival relies largely on a knee with ligamentous stability, whereas outcomes of ACL reconstruction are improved with intact and functional menisci.29 The surgical technique for MAT is modified slightly in the setting of performing a concomitant ACL reconstruction, with the ACL tibial tunnel drilled to avoid the meniscal bone slot if possible, followed by femoral tunnel creation. Femoral fixation of the ACL graft is accomplished after preparation of the meniscal slot. The meniscal graft is set into place (sutures are not yet tied), and tibial fixation of the ACL graft is performed next. We typically use an Achilles allograft for the ACL reconstruction, with the bone block used for femoral fixation to avoid bony impingement between the MAT bone bridge/block and the ACL graft. With the knee in full extension, the MAT sutures are tied at the conclusion of the surgical procedure. Concomitant MAT and ACL reconstruction has yielded positive long-term clinical outcomes, improved joint stability, and findings similar to historical results of ACL reconstruction or MAT performed in isolation.30,31
CONCLUSION
When used with the proper indications, MAT has demonstrated the ability to restore function and reduce pain. Successful meniscal transplant requires attention to the patient’s past medical and surgical history. Similarly, care must be taken to address any concomitant knee pathology, such as coronal realignment, ligament reconstruction, or cartilage restoration.
ABSTRACT
Meniscus allograft transplantation (MAT) has yielded excellent long-term functional outcomes when performed in properly indicated patients. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency. Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure. Once an ideal candidate is identified, graft selection and preparation are critical steps to ensure a proper fit and long-term viability of the meniscus. When selecting the graft, accurate measurements must be taken, and this is most commonly performed using plain radiographs for this. Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.
Continue to: Meniscus tears are common in the young, athletic patient population...
Meniscus tears are common in the young, athletic patient population. In the United States alone, approximately 700,000 meniscectomies are performed annually.1 Given discouraging long-term clinical results following subtotal meniscectomy in young patients, meniscal repair is preferred whenever possible.2 Despite short-term symptom relief if subtotal meniscectomy is required, some patients often go on to develop localized pain in the affected compartment, effusions, and eventual development of osteoarthritis. In such patients with symptomatic meniscal deficiency, meniscal allograft transplantation (MAT) has yielded excellent long-term functional outcomes.3-5 Three recently published systematic reviews describe the outcomes of MAT in thousands of patients, noting positive outcomes in regard to pain and function for the majority of patients.6-8 Specifically, in a review conducted by Elattar and colleagues7 consisting of 44 studies comprising 1136 grafts in 1068 patients, the authors reported clinical improvement in Lysholm Knee Scoring Scale score (44 to 77), visual analog scale (48 mm to 17 mm), and International Knee Documentation Committee (84% normal/nearly normal, 89% satisfaction), among other outcomes measures. Additionally, the complication (21.3%) and failure rates (10.6%) were considered acceptable by all authors. The purpose of this article is to review indications, operative preparation, critical aspects of surgical technique, and additional concomitant procedures commonly performed alongside MAT.
1. PATIENT SELECTION
When used with the proper indications, MAT offers improved functional outcomes and reduced pain for patients with symptomatic meniscal deficiency. When evaluating a patient for potential MAT, it is imperative to evaluate past medical history and past surgical procedures. The ideal MAT candidate is a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency who does not have (1) evidence of diffuse osteoarthritis (Outerbridge grade <2), including the absence of significant bony flattening or osteophytes in the involved compartment; (2) inflammatory arthritis; (3) active or previous joint infection; (4) mechanical axis malalignment; or (5) morbid obesity (Table). Long-leg weight-bearing anterior-posterior alignment radiographs are important in the work-up of any patient being considered for MAT, and consideration for concomitant or staged realignment high tibial osteotomy (HTO) or distal femoral osteotomy (DFO) should be given for patients in excessive varus or valgus, respectively. Although the decision to perform a realignment osteotomy is made on a patient-specific basis, if the weight-bearing line passes medial to the medial tibial spine or lateral to the lateral tibial spine, HTO or DFO, respectively, should be considered. Importantly, MAT is not typically recommended in the asymptomatic patient.9 Although some recent evidence suggests MAT may have chondroprotective effects on articular cartilage following meniscectomy, there is insufficient long-term outcome data to support the use of MAT as a prophylactic measure, especially given the fact that graft deterioration inevitably occurs at 7 to 10 years, with patients having to consider avoiding meniscus-dependent activities following transplant to protect their graft from traumatic failure.10,11
Table. Summary of Indications and Contraindications for Meniscal Allograft Transplant (MAT)
Indications | Contraindicationsa |
Patients younger than 50 years old with a chief complaint of pain limiting their desired activities | Diffuse femoral and/or tibial articular cartilage wear |
Body mass index <35 kg/m2 | Radiographic evidence of arthritis |
Previous meniscectomy (or non-viable meniscus state) with pain localized to the affected compartment | Inflammatory arthritis conditions |
Normal or correctable coronal and sagittal alignment | MAT performed as a prophylactic measure in the absence of appropriate symptoms is highly controversial |
Normal or correctable ligamentous stability |
|
Normal or correctable articular cartilage |
|
Willingness to comply with rehabilitation protocol |
|
Realistic post-surgical activity expectations |
|
aContraindications for MAT are controversial, as the available literature discussing contraindications is very limited. This list is based on the experience of the senior author.
Long-term prospective studies have shown high graft survival and predominantly positive functional results after MAT. Age indications have expanded, with 1 recent study reporting 6% reoperation rate and zero failures in a cohort of 37 adolescent MAT patients.12 High survival rates hold even among an athletic population, where rates of return to play after MAT have been reported to be >75% for those competing at a high school level or higher.13 In an active military population, <2% of patients progressed to revision MAT or total knee arthroplasty at minimum 2-year follow-up, but 22% of patients were unable to return to military duty owing to residual knee limitations.14 In this series, tobacco use correlated with failure, whereas MAT by high-volume, fellowship-trained orthopedic surgeons decreased rates of failure.
2. GRAFT SELECTION
In preparation for MAT, accurate measurements must be taken for appropriate size matching. Several measurement techniques have been described, including using plain radiographs, 3D computed tomography (CT), and magnetic resonance imaging (MRI).15-18 There is limited data regarding the consequences of an improperly sized donor meniscus; however, an oversized lateral meniscus has been shown to increase the contact forces across the articular cartilage.19 Additionally, an undersized allograft may result in normal forces across the articular cartilage but greater forces across the meniscus.19
When sizing the recipient knee for MAT, accurate width and length measurements are critical. The most common technique used today includes measurements using anteroposterior and lateral radiographic images as described by Pollard and colleagues.15 The width of the meniscus is determined by the distance between 2 vertical lines perpendicular to the joint line, 1 of them tangential to the margin of the tibia metaphysis and the other between the medial and lateral tibial eminence in both knees (Figures 1A,1B). The length of the meniscus is measured on a lateral radiograph. A line is drawn at the level of the articular line between the anterior surface of the tibia above the tuberosity and a parallel line that is tangential to the posterior margin of the tibial plateau. Percent corrections are performed for these dimensions as described in previous publications.
Other techniques have been described to obtain accurate measurements of the recipient knee. For example, obtaining an MRI of the contralateral knee may provide a reproducible method of measuring both the width and length of the medial and lateral menisci.20 CT has been used to measure the lateral meniscus independently, and it has been shown to exhibit less error in the measure of the tibial plateau when compared with X-rays.18 Both CT and MRI are more expensive than simple radiographs, and CT exposes the patient to an increased amount of radiation. Current evidence does not support standard use of these advanced imaging modalities for meniscal sizing.
Continue to: GRAFT PREPARATION AND PLACEMENT...
3. GRAFT PREPARATION AND PLACEMENT
At the time of surgery, the meniscus allograft is thawed in sterile saline and prepared on the back table. This can be done before or after the diagnostic arthroscopy and bone-slot preparation. Excess soft tissue surrounding the meniscal rim and/or anterior and posterior horns should be removed. Several techniques for MAT have been described, but we generally prefer a bridge-in-slot technique for both medial and lateral MAT.21 To prepare the meniscus allograft for a bridge-in-slot technique, the graft is cut with an oscillating saw to a width of 7 mm, with care taken to ensure that the bony insertions of both meniscal horns are preserved. Next, a transverse cut is made 10 mm below the meniscal horns to set the depth of the bone bridge. To assist with the sizing of the bone bridge, a rectangular sizing block and cutting jig is used (Figures 2A-2C). After marking the middle and posterior thirds of the meniscus, a No. 2 non-absorbable suture is placed at the junction of the posterior and middle thirds of the meniscus. This completes preparation of the allograft prior to implantation.
Attention is then turned to back the arthroscopy. A standard posteromedial (medial meniscus) or posterolateral (lateral meniscus) accessory incision is made, and a Henning retractor is carefully placed in order to receive the sutures that will be placed through the meniscus allograft via a standard inside-out repair technique. First, a zone-specific cannula is used to place a nitinol wire out the accessory incision. The looped end of the wire is pulled out of the anterior arthrotomy incision that will be used to shuttle the meniscus allograft into the joint. In order to pass the meniscal allograft into the joint, the passing suture previously placed through the meniscus is shuttled through the nitinol wire, and the wire is then pulled out the accessory incision, advancing the meniscus through the anteiror arthrotomy. As the meniscus is introduced, the traction suture is then gently tensioned to get the allograft completely into the joint. Next, the bone bridge is seated into the previously created bone slot, as the soft tissue component is manually pushed beneath the ipsilateral femoral condyle. Under direct visualization, the soft tissue component is reduced with a probe using firm, constant traction. To aid in reduction, it may be useful to apply compartment-specific varus or valgus stress and to cycle the knee once the meniscal complex is reduced.
4. GRAFT FIXATION
Once the graft has been passed completely into the joint, with the bone bridge seated into the bone slot, the long end of an Army-Navy retractor is placed firmly through the arthrotomy on the meniscal bone bridge, maintaining a downward force to allow the bridge to remain slotted. To lever down on the posterior aspect of the graft, a freer elevator is used from anterosuperior to posteroinferior. The bone bridge is then secured using a bioabsorbable interference screw, placed central to the bone bridge opposing the block to the ipsilateral compartment. The remainder of the meniscus is secured with an inside-out repair technique, working from posterior to anterior through a standard medial or lateral meniscal repair approach. In total, approximately 6 to 10 vertical mattress sutures are placed, and these can be placed both superiorly and inferiorly on the meniscus. Posteriorly, an all-inside suture repair device may be helpful. Finally, the anterior aspect of the meniscus is repaired to the capsule in an open fashion prior to closing the arthrotomy. Sutures are tied with the leg in extension. The meniscal repair incision is closed in a standard fashion using layers.
5. CONCOMITANT PATHOLOGY AND MAT
The presence of concomitant knee pathology in the context of meniscus deficiency is a challenging problem that requires careful attention to all aspects of the underlying condition of the knee. In cases where MAT is indicated, issues of malalignment, cartilage defects, and/or ligamentous instability may also need to be addressed either concomitantly or in staged fashion. For example, medial meniscal deficiency in the setting of varus alignment can be addressed with a concomitant HTO, whereas lateral meniscal deficiency in the setting of valgus malalignment can be addressed with a concomitant DFO. In both cases, the osteotomy corrects an abnormal mechanical axis, offloading the diseased compartment. This accomplishes 2 goals, namely to preserve the new MAT graft and to protect underlying articular cartilage.22-24 The osteotomy is an important contributor to additional pain relief by offloading the compartment, and clinical studies have demonstrated that failure to address malalignment in the setting of surgical intervention for cartilage and meniscal insufficiency leads to inferior clinical outcomes and poor survival of transplanted tissue.25-28
Continue to: In a meniscus-deficient patient with chondral lesions...
In a meniscus-deficient patient with chondral lesions (Outerbridge grade 3 or 4), concomitant MAT and cartilage restoration should be considered. Depending on the size and location of the chondral lesion, options include marrow stimulation, autologous chondrocyte implantation, osteochondral autograft transfer, as well as chondral and/or osteochondral allograft transplantation. In a systematic review of concomitant MAT and cartilage restoration procedures, Harris and colleagues25 found that failure rates of the combined surgery were similar to those of either surgery in isolation.
Young athletes sustaining anterior cruciate ligament (ACL) tears commonly also have meniscal pathology that must be addressed. Most cases are treated with meniscal repair or partial meniscectomy, but occasionally patients present with ACL tear and symptomatic meniscal deficiency. Specifically, MAT survival relies largely on a knee with ligamentous stability, whereas outcomes of ACL reconstruction are improved with intact and functional menisci.29 The surgical technique for MAT is modified slightly in the setting of performing a concomitant ACL reconstruction, with the ACL tibial tunnel drilled to avoid the meniscal bone slot if possible, followed by femoral tunnel creation. Femoral fixation of the ACL graft is accomplished after preparation of the meniscal slot. The meniscal graft is set into place (sutures are not yet tied), and tibial fixation of the ACL graft is performed next. We typically use an Achilles allograft for the ACL reconstruction, with the bone block used for femoral fixation to avoid bony impingement between the MAT bone bridge/block and the ACL graft. With the knee in full extension, the MAT sutures are tied at the conclusion of the surgical procedure. Concomitant MAT and ACL reconstruction has yielded positive long-term clinical outcomes, improved joint stability, and findings similar to historical results of ACL reconstruction or MAT performed in isolation.30,31
CONCLUSION
When used with the proper indications, MAT has demonstrated the ability to restore function and reduce pain. Successful meniscal transplant requires attention to the patient’s past medical and surgical history. Similarly, care must be taken to address any concomitant knee pathology, such as coronal realignment, ligament reconstruction, or cartilage restoration.
1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep. 2009;11(11):1-25.
2. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
3. Saltzman BM, Bajaj S, Salata M, et al. Prospective long-term evaluation of meniscal allograft transplantation procedure: a minimum of 7-year follow-up. J Knee Surg. 2012;25(2):165-175. doi:10.1055/s-0032-1313738.
4. van der Wal RJ, Thomassen BJ, van Arkel ER. Long-term clinical outcome of open meniscal allograft transplantation. Am J Sports Med. 2009;37(11):2134-2139. doi:10.1177/0363546509336725.
5. Vundelinckx B, Vanlauwe J, Bellemans J. Long-term subjective, clinical, and radiographic outcome evaluation of meniscal allograft transplantation in the knee. Am J Sports Med. 2014;42(7):1592-1599. doi:10.1177/0363546514530092.
6. Hergan D, Thut D, Sherman O, Day MS. Meniscal allograft transplantation. Arthroscopy. 2011;27(1):101-112. doi:10.1016/j.arthro.2010.05.019.
7. Elattar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):147-157. doi:10.1007/s00167-010-1351-6.
8. Verdonk R, Volpi P, Verdonk P, et al. Indications and limits of meniscal allografts. Injury. 2013;44(Suppl 1):S21-S27. doi:10.1016/S0020-1383(13)70006-8.
9. Frank RM, Yanke A, Verma NN, Cole BJ. Immediate versus delayed meniscus allograft transplantation: letter to the editor. Am J Sports Med. 2015;43(5):NP8-NP9. doi:10.1177/0363546515571065.
10. Aagaard H, Jørgensen U, Bojsen-Møller F. Immediate versus delayed meniscal allograft transplantation in sheep. Clin Orthop Relat Res. 2003;406(406):218-227. doi:10.1097/01.blo.0000030066.92399.7f.
11. Jiang D, Ao YF, Gong X, Wang YJ, Zheng ZZ, Yu JK. Comparative study on immediate versus delayed meniscus allograft transplantation: 4- to 6-year follow-up. Am J Sports Med. 2014;42(10):2329-2337. doi:10.1177/0363546514541653.
12. Riboh JC, Tilton AK, Cvetanovich GL, Campbell KA, Cole BJ. Meniscal allograft transplantation in the adolescent population. Arthroscopy. 2016;32(6):1133-1140.e1. doi:10.1016/j.arthro.2015.11.041.
13. Chalmers PN, Karas V, Sherman SL, Cole BJ. Return to high-level sport after meniscal allograft transplantation. Arthroscopy. 2013;29(3):539-544. doi:10.1016/j.arthro.2012.10.027.
14. Waterman BR, Rensing N, Cameron KL, Owens BD, Pallis M. Survivorship of meniscal allograft transplantation in an athletic patient population. Am J Sports Med. 2016;44(5):1237-1242. doi:10.1177/0363546515626184.
15. Pollard ME, Kang Q, Berg EE. Radiographic sizing for meniscal transplantation. Arthroscopy. 1995;11(6):684-687. doi:10.1016/0749-8063(95)90110-8.
16. Haut TL, Hull ML, Howell SM. Use of roentgenography and magnetic resonance imaging to predict meniscal geometry determined with a three-dimensional coordinate digitizing system. J Orthop Res. 2000;18(2):228-237. doi:10.1002/jor.1100180210.
17. Van Thiel GS, Verma N, Yanke A, Basu S, Farr J, Cole B. Meniscal allograft size can be predicted by height, weight, and gender. Arthroscopy. 2009;25(7):722-727. doi:10.1016/j.arthro.2009.01.004.
18. McConkey M, Lyon C, Bennett DL, et al. Radiographic sizing for meniscal transplantation using 3-D CT reconstruction. J Knee Surg. 2012;25(3):221-225. doi:10.1055/s-0031-1292651.
19. Dienst M, Greis PE, Ellis BJ, Bachus KN, Burks RT. Effect of lateral meniscal allograft sizing on contact mechanics of the lateral tibial plateau: an experimental study in human cadaveric knee joints. Am J Sports Med. 2007;35(1):34-42. doi:10.1177/0363546506291404.
20. Yoon JR, Jeong HI, Seo MJ, et al. The use of contralateral knee magnetic resonance imaging to predict meniscal size during meniscal allograft transplantation. Arthroscopy. 2014;30(10):1287-1293. doi:10.1016/j.arthro.2014.05.009.
21. Lee AS, Kang RW, Kroin E, Verma NN, Cole BJ. Allograft meniscus transplantation. Sports Med Arthrosc. 2012;20(2):106-114. doi:10.1097/JSA.0b013e318246f005.
22. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23(8):852-861. doi:10.1016/j.arthro.2007.05.018.
23. Loening AM, James IE, Levenston ME, et al. Injurious mechanical compression of bovine articular cartilage induces chondrocyte apoptosis. Arch Biochem Biophys. 2000;381(2):205-212. doi:10.1006/abbi.2000.1988.
24. Mina C, Garrett WE Jr, Pietrobon R, Glisson R, Higgins L. High tibial osteotomy for unloading osteochondral defects in the medial compartment of the knee. Am J Sports Med. 2008;36(5):949-955. doi:10.1177/0363546508315471.
25. Harris JD, Cavo M, Brophy R, Siston R, Flanigan D. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy: 2011;27(3):409-418. doi:10.1016/j.arthro.2010.08.007.
26. Rue JP, Yanke AB, Busam ML, McNickle AG, Cole BJ. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up. Am J Sports Med. 2008;36(9):1770-1778. doi:10.1177/0363546508317122.
27. Kazi HA, Abdel-Rahman W, Brady PA, Cameron JC. Meniscal allograft with or without osteotomy: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):303-309. doi:10.1007/s00167-014-3291-z.
28. Verdonk PC, Verstraete KL, Almqvist KF, et al. Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):694-706. doi:10.1007/s00167-005-0033-2.
29. Shelbourne KD, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med. 2000;28(4):446-452. doi:10.1177/03635465000280040201.
30. Graf KW Jr, Sekiya JK, Wojtys EM; Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA. Long-term results after combined medial meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy. 2004;20(2):129-140. doi:10.1016/j.arthro.2003.11.032.
31. Binnet MS, Akan B, Kaya A. Lyophilised medial meniscus transplantations in ACL-deficient knees: a 19-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):109-113. doi:10.1007/s00167-011-1556-3.
1. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Rep. 2009;11(11):1-25.
2. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
3. Saltzman BM, Bajaj S, Salata M, et al. Prospective long-term evaluation of meniscal allograft transplantation procedure: a minimum of 7-year follow-up. J Knee Surg. 2012;25(2):165-175. doi:10.1055/s-0032-1313738.
4. van der Wal RJ, Thomassen BJ, van Arkel ER. Long-term clinical outcome of open meniscal allograft transplantation. Am J Sports Med. 2009;37(11):2134-2139. doi:10.1177/0363546509336725.
5. Vundelinckx B, Vanlauwe J, Bellemans J. Long-term subjective, clinical, and radiographic outcome evaluation of meniscal allograft transplantation in the knee. Am J Sports Med. 2014;42(7):1592-1599. doi:10.1177/0363546514530092.
6. Hergan D, Thut D, Sherman O, Day MS. Meniscal allograft transplantation. Arthroscopy. 2011;27(1):101-112. doi:10.1016/j.arthro.2010.05.019.
7. Elattar M, Dhollander A, Verdonk R, Almqvist KF, Verdonk P. Twenty-six years of meniscal allograft transplantation: is it still experimental? A meta-analysis of 44 trials. Knee Surg Sports Traumatol Arthrosc. 2011;19(2):147-157. doi:10.1007/s00167-010-1351-6.
8. Verdonk R, Volpi P, Verdonk P, et al. Indications and limits of meniscal allografts. Injury. 2013;44(Suppl 1):S21-S27. doi:10.1016/S0020-1383(13)70006-8.
9. Frank RM, Yanke A, Verma NN, Cole BJ. Immediate versus delayed meniscus allograft transplantation: letter to the editor. Am J Sports Med. 2015;43(5):NP8-NP9. doi:10.1177/0363546515571065.
10. Aagaard H, Jørgensen U, Bojsen-Møller F. Immediate versus delayed meniscal allograft transplantation in sheep. Clin Orthop Relat Res. 2003;406(406):218-227. doi:10.1097/01.blo.0000030066.92399.7f.
11. Jiang D, Ao YF, Gong X, Wang YJ, Zheng ZZ, Yu JK. Comparative study on immediate versus delayed meniscus allograft transplantation: 4- to 6-year follow-up. Am J Sports Med. 2014;42(10):2329-2337. doi:10.1177/0363546514541653.
12. Riboh JC, Tilton AK, Cvetanovich GL, Campbell KA, Cole BJ. Meniscal allograft transplantation in the adolescent population. Arthroscopy. 2016;32(6):1133-1140.e1. doi:10.1016/j.arthro.2015.11.041.
13. Chalmers PN, Karas V, Sherman SL, Cole BJ. Return to high-level sport after meniscal allograft transplantation. Arthroscopy. 2013;29(3):539-544. doi:10.1016/j.arthro.2012.10.027.
14. Waterman BR, Rensing N, Cameron KL, Owens BD, Pallis M. Survivorship of meniscal allograft transplantation in an athletic patient population. Am J Sports Med. 2016;44(5):1237-1242. doi:10.1177/0363546515626184.
15. Pollard ME, Kang Q, Berg EE. Radiographic sizing for meniscal transplantation. Arthroscopy. 1995;11(6):684-687. doi:10.1016/0749-8063(95)90110-8.
16. Haut TL, Hull ML, Howell SM. Use of roentgenography and magnetic resonance imaging to predict meniscal geometry determined with a three-dimensional coordinate digitizing system. J Orthop Res. 2000;18(2):228-237. doi:10.1002/jor.1100180210.
17. Van Thiel GS, Verma N, Yanke A, Basu S, Farr J, Cole B. Meniscal allograft size can be predicted by height, weight, and gender. Arthroscopy. 2009;25(7):722-727. doi:10.1016/j.arthro.2009.01.004.
18. McConkey M, Lyon C, Bennett DL, et al. Radiographic sizing for meniscal transplantation using 3-D CT reconstruction. J Knee Surg. 2012;25(3):221-225. doi:10.1055/s-0031-1292651.
19. Dienst M, Greis PE, Ellis BJ, Bachus KN, Burks RT. Effect of lateral meniscal allograft sizing on contact mechanics of the lateral tibial plateau: an experimental study in human cadaveric knee joints. Am J Sports Med. 2007;35(1):34-42. doi:10.1177/0363546506291404.
20. Yoon JR, Jeong HI, Seo MJ, et al. The use of contralateral knee magnetic resonance imaging to predict meniscal size during meniscal allograft transplantation. Arthroscopy. 2014;30(10):1287-1293. doi:10.1016/j.arthro.2014.05.009.
21. Lee AS, Kang RW, Kroin E, Verma NN, Cole BJ. Allograft meniscus transplantation. Sports Med Arthrosc. 2012;20(2):106-114. doi:10.1097/JSA.0b013e318246f005.
22. Agneskirchner JD, Hurschler C, Wrann CD, Lobenhoffer P. The effects of valgus medial opening wedge high tibial osteotomy on articular cartilage pressure of the knee: a biomechanical study. Arthroscopy. 2007;23(8):852-861. doi:10.1016/j.arthro.2007.05.018.
23. Loening AM, James IE, Levenston ME, et al. Injurious mechanical compression of bovine articular cartilage induces chondrocyte apoptosis. Arch Biochem Biophys. 2000;381(2):205-212. doi:10.1006/abbi.2000.1988.
24. Mina C, Garrett WE Jr, Pietrobon R, Glisson R, Higgins L. High tibial osteotomy for unloading osteochondral defects in the medial compartment of the knee. Am J Sports Med. 2008;36(5):949-955. doi:10.1177/0363546508315471.
25. Harris JD, Cavo M, Brophy R, Siston R, Flanigan D. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy: 2011;27(3):409-418. doi:10.1016/j.arthro.2010.08.007.
26. Rue JP, Yanke AB, Busam ML, McNickle AG, Cole BJ. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up. Am J Sports Med. 2008;36(9):1770-1778. doi:10.1177/0363546508317122.
27. Kazi HA, Abdel-Rahman W, Brady PA, Cameron JC. Meniscal allograft with or without osteotomy: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2015;23(1):303-309. doi:10.1007/s00167-014-3291-z.
28. Verdonk PC, Verstraete KL, Almqvist KF, et al. Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):694-706. doi:10.1007/s00167-005-0033-2.
29. Shelbourne KD, Gray T. Results of anterior cruciate ligament reconstruction based on meniscus and articular cartilage status at the time of surgery. Five- to fifteen-year evaluations. Am J Sports Med. 2000;28(4):446-452. doi:10.1177/03635465000280040201.
30. Graf KW Jr, Sekiya JK, Wojtys EM; Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA. Long-term results after combined medial meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy. 2004;20(2):129-140. doi:10.1016/j.arthro.2003.11.032.
31. Binnet MS, Akan B, Kaya A. Lyophilised medial meniscus transplantations in ACL-deficient knees: a 19-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2012;20(1):109-113. doi:10.1007/s00167-011-1556-3.
TAKE-HOME POINTS
- Patient selection is critical for obtaining long-term functional outcome improvements and reduced pain, with the ideal MAT candidate being a chronologically and physiologically young patient (<50 years) with symptomatic meniscal deficiency.
- Existing pathology in the knee needs to be carefully considered and issues such as malalignment, cartilage defects, and/or ligamentous instability may require a staged or concomitant procedure.
- Accurate graft width and length measurements are vital, and the most common technique used today includes measuring the meniscus on anteroposterior and lateral radiographic images.
- When preparing the graft for the bone-bridge technique, the bone is fashioned to create a bone bridge 10 mm in depth by approximately 7 mm in width, incorporating the anterior and posterior horns of the meniscus.
- Graft fixation can be accomplished by placing vertical mattress sutures and tying those down with the knee in full extension.
Reasons for Readmission Following Primary Total Shoulder Arthroplasty
ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
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- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
ABSTRACT
An increasing interest focuses on the rates and risk factors for hospital readmission. However, little is known regarding the readmission following total shoulder arthroplasty (TSA). This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA. Patients undergoing TSA (anatomic or reverse) as part of the American College of Surgeons National Surgical Quality Improvement Program in 2011 to 2013 were identified. The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. Using multivariate regression, demographic and comorbidity factors were tested for independent association with readmission. Finally, the reasons for readmission were characterized. A total of 3627 patients were identified. Among the admitted patients, 93 (2.56%) were readmitted within 30 days of surgery. The independent risk factors for readmission included old age (for age 60-69 years, relative risk [RR] = 1.6; for age 70-79 years, RR = 2.3; for age ≥80 years, RR = 23.1; P = .042), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission comprised pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%). Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at higher risk for readmission and should be counseled and monitored accordingly.
Continue to: Total shoulder arthroplasty...
Total shoulder arthroplasty (TSA) is performed with increasing frequency in the United States and is considered to be cost-effective.1-4 Following the procedure, patients generally achieve shoulder function and pain relief.5-8 Despite the success of the procedure, the growing literature on TSA has also reported rates of complications between 3.6% and 25% of the treated patients.9-16
In recent years, an increasing interest has focused on the rates and risk factors for unplanned hospital readmissions; these variables may not only reflect the quality of patient care but also result in considerable costs to the healthcare system. For instance, among Medicare patients, readmissions within 30 days of discharge occur in almost 20% of cases, costing $17.4 billion per year.17 Readmission rates increasingly factor into hospital performance metrics and reimbursement, including the Hospital Readmissions Reduction Program of the Patient Protection and Affordable Care Act that reduces Centers for Medicare and Medicaid Services payments to hospitals with high 30-day readmission rates.18
To date, only a few studies have evaluated readmission following TSA, with 30- to 90-day readmission rates ranging from 4.5% to 7.3%.19-23 These studies comprised single institution series20,22 and analyses of administrative databases.19,21,23 Most studies have shown that readmission occurs more often for medical than surgical reasons, with surgical reasons most commonly including infection and dislocation.19-23 However, only limited analyses have been conducted regarding risk factors for readmission.21,23 To date and to our knowledge, no study has investigated reasons for readmission following TSA using nationwide data.
This study aims to determine the rates, risk factors, and reasons for hospital readmission following primary TSA in the United States using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.
METHODS
DATA SOURCE
The NSQIP database was utilized to address the study purpose. NSQIP is a nationwide prospective surgical registry established by the American College of Surgeons and reports data from academic and community hospitals across the United States.24 Patients undertaking surgery at these centers are followed by the surgical clinical reviewers at the participating NSQIP sites prospectively for 30 days following the procedure to record complications including readmission. Preoperative and surgical data, such as demographics, medical comorbid diseases, and operative time, are also included. Previous studies have analyzed the complications of various orthopedic surgeries using the NSQIP data.14,16,25-30
DATA COLLECTION
We retrospectively identified from NSQIP the patients who underwent primary TSA (anatomic or reverse) in 2013 to 2014. The timeframe 2013 to 2014 was used because NSQIP only began recording reasons for readmission in 2013. The inclusion criteria were as follows: Current Procedural Terminology (CPT) code for TSA (23472); preoperative diagnosis according to the International Classification of Diseases, Ninth Revision (ICD-9) codes 714.0, 715.11, 715.31, 715.91, 715.21, 715.89, 716.xx 718.xx, 719.xx, 726.x, 727.xx, and 733.41 (where x is a wild card digit); and no missing demographic, comorbidity, or outcome data. Anatomic and reverse TSA were analyzed together because they share the same CPT code, and the NSQIP database prevents searching by the ICD-9 procedure code.
The rate of unplanned readmission to the hospital within 30 postoperative days was characterized. The reasons for readmission in this 30-day period were only available in 2013 and were determined using the ICD-9 diagnosis codes. Patient demographics were recorded for use in identifying potential risk factors for readmission; the demographic data included sex, age, smoking status, body mass index (BMI), and comorbidities, including end-stage renal disease, dyspnea on exertion, congestive heart failure, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD).
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analyses were performed using Stata version 13.1 (StataCorp). First, using bivariate and multivariate regression, demographic and comorbidity factors were tested for independent association with readmission to the hospital within 30 days of surgery. Second, among the readmitted patients, the reasons for readmission were tabulated. Of note, the reasons for readmission were only documented for the procedures performed in 2013. All tests were 2-tailed and conducted at an α level of 0.05.
RESTULTS
A total of 3627 TSA patients were identified. The mean age (± standard deviation) was 69.4 ± 9.5 years, 55.8% of patients were female, and mean BMI was 30.1 ± 7.0 years. Table 1 provides the additional demographic data. Of the 3627 included patients, 93 (2.56%) were readmitted within 30 days of surgery. The 95% confidence interval for the estimated rate of readmission reached 2.05% to 3.08%.
Table 1. Patient Population
| Number | Percent |
Total | 3627 | 100.0% |
Age |
|
|
18-59 | 539 | 14.9% |
60-69 | 1235 | 34.1% |
70-79 | 1317 | 36.3% |
≥80 | 536 | 14.8% |
Sex |
|
|
Male | 1603 | 44.2% |
Female | 2024 | 55.8% |
Body mass index |
|
|
Normal (<25 kg/m2) | 650 | 17.9% |
Overweight (25-30 kg/m2) | 1147 | 31.6% |
Obese (≥30 kg/m2) | 1830 | 50.5% |
Functional status |
|
|
Independent | 3544 | 97.7% |
Dependent | 83 | 2.3% |
Diabetes mellitus |
|
|
No | 3022 | 83.3% |
Yes | 605 | 16.7% |
Dyspnea on exertion |
|
|
No | 3393 | 93.6% |
Yes | 234 | 6.5% |
Hypertension |
|
|
No | 1192 | 32.9% |
Yes | 2435 | 67.1% |
COPD |
|
|
No | 3384 | 93.3% |
Yes | 243 | 6.7% |
Current smoker |
|
|
No | 3249 | 89.6% |
Yes | 378 | 10.4% |
Anemia |
|
|
No | 3051 | 84.1% |
Yes | 576 | 15.9% |
Abbreviation: COPD, chronic obstructive pulmonary disease.
In the bivariate analyses (Table 2), the following factors were positively associated readmission: older age (60-69 years, relative risk [RR] = 1.6; 70-79 years, RR = 2.2; ≥80 years, RR = 3.3; P = .011), dependent functional status (RR = 2.9, P = .008), and anemia (RR = 2.2, P < .001).
Table 2. Bivariate Analysis of Risk Factors for Readmission
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.011 |
18-59 | 1.30% | Ref. | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.2 | 1.0-4.9 |
|
≥80 | 4.29% | 3.3 | 1.4-7.6 |
|
Sex |
|
|
| 0.099 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.4 | 0.9-2.1 |
|
Body mass index |
|
|
| 0.764 |
Normal (<25 kg/m2) | 2.92% | Ref. | - |
|
Overweight (25-30 kg/m2) | 2.35% | 0.8 | 0.5-1.4 |
|
Obese (≥30 kg/m2) | 2.57% | 0.9 | 0.5-1.5 |
|
Functional status |
|
|
| 0.008 |
Independent | 2.45% | Ref. | - |
|
Dependent | 7.23% | 2.9 | 1.3-6.5 |
|
Diabetes mellitus |
|
|
| 0.483 |
No | 2.48% | Ref. | - |
|
Yes | 2.98% | 1.2 | 0.7-2.0 |
|
Dyspnea on exertion |
|
|
| 0.393 |
No | 2.51% | Ref. | - |
|
Yes | 3.42% | 1.4 | 0.7-2.8 |
|
Hypertension |
|
|
| 0.145 |
No | 2.01% | Ref. | - |
|
Yes | 2.83% | 1.4 | 0.9-2.2 |
|
COPD |
|
|
| 0.457 |
No | 2.51% | Ref. | - |
|
Yes | 3.29% | 1.3 | 0.6-2.7 |
|
Current smoker |
|
|
| 0.116 |
No | 2.71% | Ref. | - |
|
Yes | 1.32% | 0.5 | 0.2-1.2 |
|
Anemia |
|
|
| <0.001 |
No | 2.16% | Ref. | - |
|
Yes | 4.69% | 2.2 | 1.4-3.4 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
In the multivariate analyses (Table 3), the following factors were independent risk factors for readmission: older age (60-69 years, RR = 1.6; 70-79 years, RR = 2.3; ≥80 years, RR = 3.1; P =.027), male sex (RR = 1.6, P = .025), anemia (RR = 1.9, P = .005), and dependent functional status (RR = 2.8, P = .012). Interestingly, readmission showed no independent association with diabetes, dyspnea on exertion, BMI, COPD, hypertension, or current smoking status (P > .05 for each).
Table 3. Independent Risk Factors for Readmission on Multivariate Analysis
| Rate | RR | 95% CI | P-value |
Age |
|
|
| 0.027 |
18-59 | 1.30% | Ref | - |
|
60-69 | 2.02% | 1.6 | 0.7-3.6 |
|
70-79 | 2.89% | 2.3 | 1.0-5.1 |
|
≥80 | 4.29% | 3.1 | 1.3-7.4 |
|
Sex |
|
|
| 0.025 |
Female | 2.17% | Ref. | - |
|
Male | 3.06% | 1.6 | 1.1-2.4 |
|
Anemia |
|
|
| 0.005 |
No | 2.16% | Ref | - |
|
Yes | 4.69% | 1.9 | 1.2-3.0 |
|
Functional status |
|
|
| 0.012 |
Independent | 2.45% | Ref | - |
|
Dependent | 7.23% | 2.8 | 1.3-6.2 |
|
Abbreviations: CI, confidence interval; COPD, chronic obstructive pulmonary disease; RR, relative risk.
Continue to: Table 4...
The reasons for readmission were available for 84 of the 93 readmitted patients. The most common reasons for readmission included pneumonia (14 cases, 16.7%), dislocation (7 cases, 8.3%), pulmonary embolism (7 cases, 8.3%), and surgical site infection (6 cases, 7.1%) (Table 4).
Table 4. Reasons for Readmission
| Number | Percent |
Pneumonia | 14 | 16.7% |
Dislocation | 7 | 8.3% |
Pulmonary embolism | 7 | 8.3% |
Surgical site infection | 6 | 7.1% |
Atrial fibrillation | 4 | 4.8% |
Hematoma | 4 | 4.8% |
Altered mental status | 3 | 3.6% |
Chest pain | 3 | 3.6% |
Renal insufficiency/kidney failure | 3 | 3.6% |
Urinary tract infection | 3 | 3.6% |
Acute gastric or duodenal ulcer | 2 | 2.4% |
Dermatitis/other allergic reaction | 2 | 2.4% |
Orthostatic hypotension/syncope | 2 | 2.4% |
Pain | 2 | 2.4% |
Respiratory distress | 2 | 2.4% |
Sepsis | 2 | 2.4% |
Urinary retention | 2 | 2.4% |
Acute cholecystitis | 1 | 1.2% |
Cerebrovascular accident | 1 | 1.2% |
Constipation | 1 | 1.2% |
Contusion of shoulder | 1 | 1.2% |
Deep venous thrombosis requiring therapy | 1 | 1.2% |
Gastrointestinal hemorrhage | 1 | 1.2% |
Gout | 1 | 1.2% |
Hepatic encephalopathy | 1 | 1.2% |
Intestinal infection | 1 | 1.2% |
Narcotic overdose | 1 | 1.2% |
Nausea/vomiting | 1 | 1.2% |
Proximal humerus fracture | 1 | 1.2% |
Rotator cuff tear | 1 | 1.2% |
Seroma | 1 | 1.2% |
Unspecified disease of pericardium | 1 | 1.2% |
Weakness | 1 | 1.2% |
DISCUSSION
Our analysis of 3042 TSAs from the NSQIP database suggests that unplanned readmission to the hospital occurs following about 1 in 40 cases of TSA. The study also suggests that the most common reasons for readmission encompass pneumonia, dislocation, pulmonary embolism, and surgical site infection. Old age, male sex, anemia, and dependent functional status serve as risk factors for readmission, and patients with such factors should be counseled and monitored accordingly.
In recent years, an increasing emphasis has centered on reducing rates of hospital readmission, with programs such as the Hospital Readmissions Reduction Program of the Affordable Care Act cutting reimbursements for hospitals with high 30-day readmission rates.17,18 To date, only a few studies have evaluated the reasons for readmission and readmission rates for TSA.19-23 Initial reports consisted of single-institution TSA registry reviews. For example, Mahoney and colleagues20 retrospectively evaluated shoulder arthroplasty procedures at their institution to document the readmission rates, finding a 5.9% readmission rate at 30 days. Readmission occurred more frequently in the first 30 days following discharge than in the 30- to 90-day period, with the most common reasons for readmission including medical complications, infection, and dislocation. Streubel and colleagues22 evaluated reoperation rates from their institution’s TSA registry, finding a 0.6% reoperation rate for primary TSA at 30 days and 1.5% for revision TSA. Instability and infection were the most common indications for reoperation. Our findings confirm these single-institution results and demonstrate their application to a nationwide sample of TSA, not just to high-volume academic centers. We similarly observed that dislocation, surgical site infection, and medical complications (mostly pneumonia and pulmonary embolism) were common causes of readmission, and that the 30-day readmission rate was about 1 in 40.
Several authors have since used statewide databases to analyze and determine risk factors for readmission following TSA. Lyman and colleagues19 used the New York State Database to show that higher hospital TSA surgical volume was associated with a lower rate of readmission when age and comorbidities were controlled for in a multivariate model. Old age was also associated with an increased readmission rate in their multivariate analysis, but comorbidities (as measured by the Charlson comorbidity index) presented a nonsignificant associative trend. These authors opted not to determine specific causes of readmission. Schairer and colleagues21 used State Inpatient Databases from 7 states, finding a 90-day readmission rate of 7.3%, 82% of which were due to medical complications and 18% of which were due to surgical complications (mostly infection and dislocation). Their multivariate regression revealed that male sex, reverse TSA, Medicaid insurance, patients discharged to inpatient rehabilitation or nursing facilities, medical comorbidities, and low-volume TSA hospitals were associated with readmission. Zhang and colleagues23 used the same source to show that the 90-day readmission rate reached 14% for surgically treated proximal humerus fractures and higher for patients who underwent open reduction internal fixation, were female, were African American, were discharged to a nursing facility, possessed Medicaid insurance, or experienced medical comorbidities. Most recently, Basques and colleagues31 analyzed 1505 TSA cases from 2011 and 2012 in the NSQIP database, finding a 3.3% rate of readmission, with heart disease and hypertension as risk factors for readmission. Although the limitations of the NSQIP database prevented us from analyzing surgeon and hospital TSA volume or reverse vs anatomic TSA, our results confirm that the findings from statewide database studies apply to the United States nationwide NSQIP database. Old patient age, male sex, and medical comorbidities (anemia and dependent functional status) are independent risk factors for TSA readmission. We identified pneumonia, dislocation, pulmonary embolism, and surgical site infection as the most common reasons for readmission.
This study features several limitations that should be considered when interpreting the results. Anatomic and reverse TSA share a CPT code and were not separated using NSQIP data. A number of studies have reported that reverse TSA may place patients at higher risk for readmission;20,21 however, confounding by other patient factors could play a role in this finding. The 30-day timeframe for readmission is another potential limitation; however, this timeframe is frequently used in other studies and is the relevant timeframe for the reduced reimbursement penalties from the Hospital Readmissions Reduction Program of the Affordable Care Act.18 Furthermore, the NSQIP database contains no information on surgeon or hospital TSA volume, which is a result of safeguards for patient and provider privacy. Additionally, readmission data were only available for 2011 to 2013, with causes of readmission only present in 2013. Although provided with such current information, we cannot analyze readmission trends over time, such as in response to the Affordable Care Act of 2010. Finally, although NSQIP surgical clinical reviewers strive to identify readmissions to other hospitals during their reviews of outpatient medical records, proportions of these readmissions are possibly missed. Therefore, our 30-day readmission rate may slightly underestimate the true rate.
Despite these limitations, the NSQIP database offers a unique opportunity to examine risk factors and reasons for readmission following TSA. The prior literature on readmission following TSA stemmed either from limited samples or administrative data, which feature known limitations.32 By utilizing a large, prospective, non-administrative, nationwide sample, our findings are probably both more reliable and generalizable to the country as a whole.
CONCLUSION
Unplanned readmission occurs following about 1 in 40 cases of TSA. The most common causes of readmission include pneumonia, dislocation, pulmonary embolism, and surgical site infection. Patients with old age, male sex, anemia, and dependent functional status are at a higher risk for readmission and should be counseled and monitored accordingly.
This paper will be judged for the Resident Writer’s Award.
- Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
- Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
- Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994. doi:10.2106/JBJS.J.01994.
- Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
- Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
- Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
- Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
- Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
- Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
- Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
- Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
- Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
- Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
- Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
- Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
- Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
- Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
- Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
- Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
- Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
- American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
- Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
- Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
- Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
- Adams JE, Sperling JW, Hoskin TL, Melton LJ, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg.2006;15(1):50-55. doi:10.1016/j.jse.2005.04.009.
- Jain NB, Higgins LD, Guller U, Pietrobon R, Katz JN. Trends in the epidemiology of total shoulder arthroplasty in the United States from 1990-2000. Arthritis Rheum.2006;55(4):591-597. doi:10.1002/art.22102.
- Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93(24):2249-2254. doi:10.2106/JBJS.J.01994. doi:10.2106/JBJS.J.01994.
- Mather RC, Watters TS, Orlando LA, Bolognesi MP, Moorman CT. Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty. J Shoulder Elbow Surg.2010;19(3):325-334. doi:10.1016/j.jse.2009.11.057.
- Carter MJ, Mikuls TR, Nayak S, Fehringer EV, Michaud K. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. J Bone Joint Surg Am. 2012;94(17):e127. doi:10.2106/JBJS.K.00204.
- Deshmukh AV, Koris M, Zurakowski D, Thornhill TS. Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005;14(5):471-479. doi:10.1016/j.jse.2005.02.009.
- Montoya F, Magosch P, Scheiderer B, Lichtenberg S, Melean P, Habermeyer P. Midterm results of a total shoulder prosthesis fixed with a cementless glenoid component. J Shoulder Elbow Surg. 2013;22(5):628-635. doi:10.1016/j.jse.2012.07.005.
- Raiss P, Bruckner T, Rickert M, Walch G. Longitudinal observational study of total shoulder replacements with cement: fifteen to twenty-year follow-up. J Bone Joint Surg Am.2014;96(3):198-205. doi:10.2106/JBJS.M.00079.
- Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88(10):2279-2292. doi:10.2106/JBJS.F.00125.
- Chalmers PN, Gupta AK, Rahman Z, Bruce B, Romeo AA, Nicholson GP. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29(4):856-860. doi:10.1016/j.arth.2013.07.002.
- Cheung E, Willis M, Walker M, Clark R, Frankle MA. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-449.
- Papadonikolakis A, Neradilek MB, Matsen FA. Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012. J Bone Joint Surg Am. 2013;95(24):2205-2212. doi:10.2106/JBJS.L.00552.
- Saltzman BM, Chalmers PN, Gupta AK, Romeo AA, Nicholson GP. Complication rates comparing primary with revision reverse total shoulder arthroplasty. J Shoulder Elbow Surg.2014;23(11):1647-1654. doi:10.1016/j.jse.2014.04.015.
- Shields E, Iannuzzi JC, Thorsness R, Noyes K, Voloshin I. Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent. J Shoulder Elbow Surg. 2014;23(10):1449-1453. doi:10.1016/j.jse.2014.01.052.
- Sperling JW, Hawkins RJ, Walch G, Mahoney AP, Zuckerman JD. Complications in total shoulder arthroplasty. Instr Course Lect. 2013;62:135-141.
- Shields E, Thirukumaran C, Thorsness R, Noyes K, Voloshin I. An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery. Arthroscopy. 2015;31(5):807-815. doi:10.1016/j.arthro.2014.12.011.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428. doi:10.1056/NEJMsa0803563.
- Centers for Medicare & Medicaid Services. Readmissions reduction program (HRRP). . Updated April 27, 2018. Accessed June 29, 2018.
- Lyman S, Jones EC, Bach PB, Peterson MG, Marx RG. The association between hospital volume and total shoulder arthroplasty outcomes. Clin Orthop Relat Res. 2005;432:132-137. doi:10.1097/01.blo.0000150571.51381.9a.
- Mahoney A, Bosco JA, Zuckerman JD. Readmission after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(3):377-381. doi:10.1016/j.jse.2013.08.007.
- Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(9):1349-1355. doi:10.1016/j.jse.2013.12.004.
- Streubel PN, Simone JP, Sperling JW, Cofield R. Thirty and ninety-day reoperation rates after shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(3):e17. doi:10.2106/JBJS.M.00127.
- Zhang AL, Schairer WW, Feeley BT. Hospital readmissions after surgical treatment of proximal humerus fractures: is arthroplasty safer than open reduction internal fixation? Clin Orthop Relat Res. 2014;472(8):2317-2324. doi:10.1007/s11999-014-3613-y.
- American College of Surgeons. ACS National Surgical Quality Improvement Program. http://www.acsnsqip.org. Accessed July 15, 2015.
- Basques BA, Gardner EC, Varthi AG, et al. Risk factors for short-term adverse events and readmission after arthroscopic meniscectomy: does age matter? Am J Sports Med.2015;43(1):169-175. doi:10.1177/0363546514551923.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Does resident involvement impact post-operative complications following primary total knee arthroplasty? An analysis of 24,529 cases. J Arthroplasty. 2014;29(7):1468-1472.e2. doi:10.1016/j.arth.2014.02.036.
- Haughom BD, Schairer WW, Hellman MD, Yi PH, Levine BR. Resident involvement does not influence complication after total hip arthroplasty: an analysis of 13,109 cases. J Arthroplasty. 2014;29(10):1919-1924. doi:10.1016/j.arth.2014.06.003.
- Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22(12):1667-1675.e1. doi:10.1016/j.jse.2013.06.022.
- Martin CT, Pugely AJ, Gao Y, Wolf BR. Risk factors for thirty-day morbidity and mortality following knee arthroscopy: a review of 12,271 patients from the national surgical quality improvement program database. J Bone Joint Surg Am. 2013;95(14):e98 1-10. doi:10.2106/JBJS.L.01440.
- Waterman BR, Dunn JC, Bader J, Urrea L, Schoenfeld AJ, Belmont PJ. Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors. J Shoulder Elbow Surg. 2015;24(1):24-30. doi:10.1016/j.jse.2014.05.016.
- Basques BA, Gardner EC, Toy JO, Golinvaux NS, Bohl DD, Grauer JN. Length of stay and readmission after total shoulder arthroplasty: an analysis of 1505 cases. Am J Orthop.2015;44(8):E268-E271.
- Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193. doi:10.2106/JBJS.M.01490.
TAKE-HOME POINTS
- Shoulder arthroplasty is an increasingly commonly performed procedure for shoulder arthritis and other conditions.
- Unplanned readmission in the 30 days after shoulder arthroplasty occurred in about 1 of 40 cases.
- Increasing age was associated with readmission, particularly age >80 years.
- Other risk factors for readmission were male sex, anemia, and dependent functional status.
- The most common reasons for readmission were pneumonia, dislocation, pulmonary embolism, and surgical site infection.
Impact of Sagittal Rotation on Axial Glenoid Width Measurement in the Setting of Glenoid Bone Loss
ABSTRACT
Standard 2-dimensional (2-D) computed tomography (CT) scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula, which may challenge the ability to accurately measure glenoid width and glenoid bone loss (GBL). The purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial anterior-posterior (AP) glenoid width measurements in the setting of anterior GBL.
Forty-three CT scans from consecutive patients with anterior GBL (minimum 10%) were reformatted utilizing open-source DICOM software (OsiriX MD). Patients were grouped according to extent of GBL: I, 10% to 14.9% (N = 12); II, 15% to 19.9% (N = 16); and III, >20% (N = 15). The uncorrected (UNCORR) and corrected (CORR) images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width.
For groups I and III, UNCORR scans underestimated axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated). In Group II, axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut; while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
UNCORR 2-D CT scans inaccurately estimated glenoid width and the degree of anterior GBL. This data suggests that corrected 2D CT scans or a 3-dimensional (3-D) reconstruction can help in accurately defining the anterior GBL in patients with shoulder instability.
The treatment of glenohumeral instability has substantially evolved over the past several decades. The understanding of glenoid bone loss (GBL), in particular, has advanced to such a level that we utilize the quantification of GBL for surgical decision-making. Unrecognized and/or untreated GBL is associated with recurrent instability, pain, and disability. Controversy exists, however, regarding the precise amount of anterior GBL that is significant enough to warrant surgical treatment. While historically, 25%1,2 of anterior GBL was thought to be the critical number required to warrant osseous augmentation, studies that are more recent have highlighted the need to perform osseous glenoid reconstruction with lesser degrees of GBL, particularly in the contact athlete.3-9 As small differences in the amount of GBL can change surgical decision-making from an all-soft tissue repair to an osseous reconstruction, it is paramount that we have accurate, valid, and reproducible methods for calculating GBL.
Continue to: Historically, plain radiographs...
Historically, plain radiographs have been the mainstay for evaluating the glenohumeral joint, including Grashey and axillary views, allowing clinicians to evaluate the congruency of the glenohumeral joint and to assess bone loss on both the glenoid and humeral head.1,10 While large, acute fractures of the glenoid are fairly evident on radiographs, including the Grashey view,11 shoulders with chronic and/or attritional anterior GBL are more difficult to evaluate, and often do not provide the information necessary to guide surgical decision-making.
Computed tomography (CT) of the shoulder has become the most commonly utilized imaging modality in the evaluation of patients with shoulder instability associated with GBL. Standard 2-dimensional (2-D) CT scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula/glenoid, as standard protocols often fail to account for the anterior sagittal rotation of the scapula/glenoid, similar to the disadvantage of standard radiographs. While 3-dimensional (3-D) CT reconstructions eliminate the effect of gantry angles, and thus allow for an en face view of the glenoid, 3-D reconstructions are not always available, and cannot always be measured.12-14 Thus, improved methodology for utilizing standard 2D scans is warranted, as the ability to correctly align the axial CT scan to the axis of the glenoid may allow for more accurate GBL measurements, which will ultimately impact surgical decision-making. Recently, Gross and colleagues15 reported the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version in normal glenoids, without bone loss, and found that the mean angle of correction needed to align the sagittal plane was 20.1° ± 1.2° of rotation. To the authors’ knowledge, this same methodology has not been applied to patients with clinically meaningful anterior GBL. Given that the average glenoid width in human shoulders is 24.4 mm ± 2.9 mm,16 1 mm of glenoid bone loss (GBL) corresponds to approximately 4% of the glenoid width, and thus even subtle differences in the interpretation of GBL may have substantial clinical implications. Therefore, the purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial AP glenoid width measurements in the setting of clinically significant anterior GBL.
METHODS
This study was approved by Massachusetts General Hospital Institutional Review Board. A retrospective review of consecutive patients with a diagnosis of anterior shoulder instability between 2009 and 2013 was conducted. Inclusion criteria comprised patients with a minimum of 10% anterior GBL, an available CT scan of the affected shoulder, and no history of prior ipsilateral surgeries. Exclusion criteria comprised evidence of degenerative changes to the glenoid and/or humeral head, as well as prior ipsilateral shoulder surgery. Sixty consecutive patients were originally identified as having anterior shoulder instability, and 17 were excluded based on the inclusion/exclusion criteria, leaving 43 patients (43 shoulders) available for inclusion. Shoulder CT scans from all 43 patients were reformatted utilizing open-source DICOM software (OsiriX MD, version 2.5.1 65-bit) multi-planar reconstruction (MPR).
CT PROTOCOL
All patients underwent a standard glenohumeral CT scan using a Siemens Sensation 64 Scanner (Siemens), a 64-detector scanner. Scans were acquired with 0.6 mm of collimation, 140 kV, and 300 mA-seconds. Slice thickness was set to 2 mm. All patient information was de-identified for analysis.
The uncorrected (UNCORR) scans were defined as the default orientation on the scanner. In the UNCORR scans, the axial, coronal, and sagittal views were oriented relative to the scanner gantry table, as opposed to the anatomy of the glenoid. The corrected (CORR) CT scans were aligned in all 3 planes relative to the glenoid face, and thus the cuts were perpendicular to the long axis of the glenoid.15 This resulted in sagittal cuts perpendicular to the 12-o’clock to 6-o’clock axis in the sagittal plane (Figure 1).
Continue to: In a de-identified fashion...
IMAGE ANALYSIS AND REFORMATTING
In a de-identified fashion, all CT scans were imported and analyzed using open-source Digital Imaging and Communications in Medicine (DICOM) software (OsiriX MD, version 2.5.1 64-bit). By following a previously developed method, CT scans were reformatted using OsiriX MPR. The OsiriX software has an MPR function that allows simultaneous manipulation of 2-D CT scans in 3 orthogonal planes: axial, sagittal, and coronal. In the MPR mode, the alternation of 1 plane directly affects the orientation of the remaining 2 planes. Thus, by using an MPR, one can analyze the impact that a default CT scan performed relative to the gantry of the table, UNCORR, has on the axial images.
First, the en face view was obtained via a 2-step process: alignment of the axial plane to account for the scapular angle, followed by alignment of the coronal plane to adjust for the glenoid inclination.15 These 2 adjustments provided a true en face sagittal glenoid view. The final adjustment step was a sagittal en face rotation of the glenoid such that the superior and inferior glenoid tubercles were placed on the 12-o’clock to 6-o’clock axis (CORR scan). Previous studies have identified a central longitudinal axis that was used in this method to align the supraglenoid tubercle with the 12-o’clock to 6-o’clock axis on the glenoid face.15,17,18 The standard error of mean was 1.21°. This new CORR view resulted in axial cuts through the glenoid that were oriented perpendicular to the 12-o’clock to 6-o’clock axis. The UNCORR and CORR images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width by 2 independent observers in a blinded, randomized fashion. When the measured AP width of the UNCORR scan was less than that measured on the CORR scan, the AP width of the glenoid was considered underestimated, and the degree of GBL was considered overestimated (Figure 2).
SCAPULAR ANGLE
Scapular angle measurements were performed on the axial view as the angle between a line through the long axis of the body of the scapula, and a line parallel to the CT gantry table.15,19 Subsequently, the axial plane was aligned to the glenoid surface.
CORONAL INCLINATION
Coronal inclination measurements were performed on the sagittal view as the angle between a line tangential to the face of the glenoid and a line perpendicular to the CT gantry table. Positive values represented superior inclination, while negative values represented inferior glenoid inclination.15
SAGITTAL ROTATION
Sagittal rotation measurements were performed using the built-in angle measurement tool in OsiriX in the sagittal plane since the degree of rotation required aligning the long axis of the glenoid to the 12-o’clock to 6-o’clock axis. The amount of rotation was defined as the rotation angle.15
Continue to: Similarly, as described by Gross...
GLENOID WIDTH
Similarly, as described by Gross and colleagues,15 the sagittal en face view was divided via 5 cuts, throughout a superimposed best-fit circle that closely represents the glenoid.9,15,20 For both the UNCORR and CORR, glenoid width (AP distance) was measured on the axial image at the widest point from AP cortex across the glenoid face.
PATIENT GROUPS
Utilizing the en face 3-D CT reconstruction view of the glenoid as the gold standard, patients were placed into 1 of 3 groups according to the degree of anterior GBL measured via the surface method.9,20 The groups were as follows:
I. 10% to 14.9% (N = 12)
II. 15% to 19.9% (N = 16)
III. >20% (N = 15)
STATISTICAL METHODS
Paired t-tests were used to compare all measurements between CORR and UNCORR scans for each of the 5 cuts. A P-value of .05 was used as the threshold for statistical significance in 2-tailed comparisons. Mean and standard errors are presented with standard deviations throughout the study. For interobserver reliability, the measurements between the observers, the intraclass correlation coefficient was calculated. All statistics were performed with SPSS (Version 22).
RESULTS
The study cohort was comprised of 19 left shoulders (44%) and 24 right shoulders (56%), including 36 male patients (84%) and 7 female patients (16%). The average age was 27.8 years (range, 21-40 years). The variability in measured difference, with respect to AP width, was 1.05 mm. The UNCORR CT scans required a mean correction for coronal inclination of 7.0° ± 5.8° (range, -8°-6°). The UNCORR CT scans required a mean correction for scapular angle of 30.2° ± 8.0° (range, 15°-49°). The mean angle of sagittal rotation required to align the glenoid face with the 12-o’clock to 6-o’clock axis was 24.2° ± 5.1 ° (range, 13°-30°). These results are summarized in Table 1.
Table 1. Mean Correction Values Required to Correct the Uncorrected Images to the Corrected Images | |||
Anatomic alignment | Mean (degrees) | Range (degrees) | SD (degrees) |
Scapular angle | 30.2 | 15-49 | 8.0 |
Coronal Inclination | 7.0 | -8-6 | 5.8 |
Sagittal rotation | 24.2 | 13-30 | 5.1 |
For all measurements, the intraclass correlation coefficient for independent observers for all cuts within the 3 groups was r >.900 in all cases.
On an optimized CT scan, over 5 standardized cuts across a best-fit circle of the inferior glenoid, there was a statistically significant absolute mean difference of 12.6% in axial AP glenoid width (2.86 mm ± 2.00 mm, P =.016) when compared with the UNCORR scan. This corresponds to a 3% to 21% error in measurement of the AP width of the glenoid.
Continue to: For the entire cohort...
For the entire cohort of 43 patients, the UNCORR scans underestimated the axial AP width (and thus overestimated GBL) in cut 1 (P =.003), and overestimated the axial AP width (and thus underestimated GBL) in cuts 3 to 5 (P < .001 for all) compared with that of the CORR scans. There was no significant difference between the UNCORR and CORR scans in cut 2 (P = .331).
For groups I (10%-14.9% GBL) and III (>20% GBL), the UNCORR scans underestimated the axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated) (Tables 2, 3). In Group II (15%-19.9% GBL), the axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut, while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
Table 2. Absolute Mean Difference in Axial AP Width (mm) Between Corrected and Uncorrected Images (% difference) | |||||
Cut 1 (Caudal) | Cut 2 | Cut 3 (Center) | Cut 4 | Cut 5 (Cephalad) | |
Group I: 10%-14.9% GBL | 2.4 mm (15.3%) | 1.8 mm (9.0%) | 1.8 mm (7.7%) | 3.0 mm (11.7%) | 4.0 mm (16.8%) |
Group II: 15%-19.9% GBL | 1.8 mm (13.1%) | 1.7 mm (7.9%) | 2.8 mm (10.6%) | 4.1 mm (14.4%) | 4.8 mm (16.9%) |
Group III: >20% | 2.8 mm (16.1%) | 1.9 mm (8.0%) | 2.3 mm (10.3) | 4.4 mm (16.6%) | 5.2 mm (17.0%) |
Abbreviations: AP, anterior-posterior; GBL, glenoid bone loss.
Table 3. Mean AP Glenoid Width Based on CORR and UNCORR Images for the Entire Cohort of 43 Patients | |||||
Axial cut | Mean AP width (mm) | Mean AP width (mm) | Absolute mean AP width difference (mm) | Absolute mean AP width difference (%) | P value |
(Caudal) 1 | 16.6208 | 18.4958 | -1.875 | 14.7768 | .0029565 |
2 | 20.6558 | 21.3166 | -0.661 | 3.6137 | .3310965 |
3 | 24.2583 | 22.3125 | 1.946 | 7.8042 | <.0001 |
4 | 26.1291 | 21.8916 | 4.238 | 15.8449 | <.0001 |
(Rostral) 5 | 26.0875 | 20.4875 | 5.6 | 20.9717 | <.0001 |
Abbreviations: AP, anterior-posterior; CORR, corrected; UNCORR, uncorrected.
DISCUSSION
The principle findings of this study demonstrate that UNCORR conventional 2-D CT scans inaccurately estimate glenoid width as well as inaccurately quantify the degree of anterior GBL. Underestimations of GBL may lead to insufficient treatment of clinically meaningful GBL, thereby increasing the risk of instability recurrence; whereas overestimations of GBL may lead to unnecessary treatment, subjecting patients to increased surgical morbidity. Therefore, the authors recommend correcting the orientation of the scapula in cases wherein clinical decisions are entirely based on 2-D CT, or using alternative methods for quantifying GBL, specifically in the form of 3-D reconstructions.
The use of axial imaging, with CT scans and/or magnetic resonance imaging, is growing in popularity for evaluation of both glenoid anatomy and GBL. Nevertheless, despite our improved ability to critically evaluate the glenoid using these advanced imaging modalities, the images themselves require scrutiny by clinicians to determine if the images accurately depict the true anatomy of the glenoid. As demonstrated by Gross and colleagues,15 conventional 2D CT scan protocols are not optimized to the anatomy of the glenohumeral joint, even in patients without GBL. Due to the alignment of the image relative to the plane of the scapula as opposed to the plane of the glenoid, UNCORR scans result in significantly different measurements of glenoid version (2.0° ± 0.1°) and AP glenoid width (1.2 mm ± 0.42 mm) compared with corrected scans, requiring an average 20.1° ± 1.2° of correction to align the sagittal plane. In the present study involving the patients with GBL, we also found that conventional, UNCORR 2-D CT scan protocols inaccurately estimate glenoid width and the degree of anterior GBL. In particular, AP glenoid width was consistently underestimated in the more caudal cuts, while AP glenoid width was consistently overestimated in the more cephalad cuts. Thus, anterior GBL was overestimated (AP glenoid width was underestimated) in the more caudal cuts, whereas anterior GBL was underestimated in the more cranial cuts (AP glenoid width was overestimated). Given that approximately 1 mm of glenoid bone corresponds to approximately 4% of glenoid width,16 even subtle differences in the interpretation of GBL may lead to gross overestimation/underestimation of bone loss, with significant clinical implications.
In the anterior instability patient population, clinical decision-making is often based on the degree of GBL as determined by advanced imaging modalities. In addition to other patient-specific factors, including age, gender, activity level, type of sport, and number of prior dislocations and/or prior surgeries, the quantity of GBL will often determine which surgical procedure needs to be performed. Typically, patients with >20% to 25% anterior GBL are indicated for a glenoid reconstruction procedure, most commonly via the Latarjet procedure (coracoid transfer).21-27 The Latarjet procedure remains an excellent technique for appropriately indicated patients, with historically good clinical outcomes and low recurrence rates. Complications associated with the Latarjet procedure, however, are not uncommon, including devastating neuropraxia of the axillary and musculocutaneous nerves, and occasionally permanent neurologic deficits.28 Thus, it is critical to avoid overtreating patients with recurrent instability and GBL. As demonstrated by this study, depending on the cranial-to-caudal location on the glenoid, current 2-D CT techniques may underestimate AP glenoid width, resulting in an overestimation of GBL, potentially leading to the decision to proceed with glenoid bone reconstruction when such a procedure is not required. On the contrary, overestimation of AP glenoid width, which occurs in the more cephalad cuts of the glenoid, is perhaps more worrisome, as the resulting underestimation of GBL may lead to inadequate treatment of patients with recurrent instability. Certainly, one of the main risk factors for failed soft tissue shoulder stabilization is a failure to address GBL. If clinical decisions are made based on UNCORR 2-D CT scans, which are often inaccurate with respect to AP glenoid width by an average 2.86 mm ± 2.00 mm (equivalent to 12.6% ± 6.9% GBL) as determined in this study, patients who truly require osseous glenoid reconstructions may be indicated for only soft tissue stabilization, based on the underestimation of GBL.
Continue to: The current gold standard...
The current gold standard for GBL measurement is a perfect-fit circle performed on a 3-D CT scan.22 To that end, it would have been useful to measure the glenoids from this study on 3-D CT scans and compare the data with both UNCORR and CORR measurements. This would have provided a better understanding to what extent the CORR measurements on 2-D scans are relatable with the gold standard. As 3-D CT scans provide a better en face view of the glenoid, more accurate GBL measurements, and ease of 3-D manipulation, they have become more widely used across the country.29,30 Nevertheless, in situations where 3-D imaging is more challenging to obtain because of technology or cost limitations, having a strategy for ensuring proper orientation of 2-D scans would have a substantial impact on clinical decision-making. If such corrections are not made, the inaccuracy of current 2-D scanning protocols justifies the cost 3-D reconstruction protocols. The difference in GBL measurements are critical in cases of increasingly large degrees of GBL, as in these instances, the inferior glenoid becomes more of an inverted-pear shape as opposed to a perfect circle, and differences in CORR and UNCORR images are likely to be more profound.
LIMITATIONS
This study has limitations, such as the relatively small sample size and the selection bias by the reviewers with potential differences in interobserver reliability. Further, minor modifications during the reformatting process may be found with each attempt to manipulate the images and may result in minor, insignificant differences in AP width measurements. Performing 1 or more additional CT scans on the same cohort of patients would have been helpful; however, due to the increased risk of radiation exposure, this was not performed. Performing CT scans on cadaveric specimens with GBL and applying the study methodology would also have been helpful to provide independent verification of our clinical findings; however, specimens were not available for this study. Another limitation of this study is that we did not compare our findings with the findings of glenoid width, and bone loss, as determined using the circle method, which is commonly utilized when 3-D reconstructions are available. In this study, the purpose was to utilize only the 2-D reformatted images, with the assumption that 3-D reconstructions are not always available, and cannot always be measured. To minimize selection bias, the investigators measured the correction effects within groups of patients with similar degrees of GBL (10%-14.9%, 15%-19.9%, and >20%). In addition, not all the selected patients showed degenerative glenoid changes or irregular glenoid shape indicating previous bone augmentation.
CONCLUSIONS
UNCORR 2D CT scans inaccurately estimate glenoid width and the degree of anterior GBL. The clinical implications of these findings are profound and suggest corrected 2D CT scans or 3D reconstruction allow measurements to be taken in the axis of the glenoid to accurately define the anatomy and quantity of anterior GBL in patients with shoulder instability.
1. Cerciello S, Edwards TB, Walch G. Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure. J Orthop Traumatol. 2012;13(4):197-202. doi:10.1007/s10195-012-0201-3.
2. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82(1):35-46.
3. Bhatia S, Ghodadra NS, Romeo AA, et al. The importance of the recognition and treatment of glenoid bone loss in an athletic population. Sports Health. 2011;3(5):435-440. doi:10.1177/1941738111414126.
4. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004;20(2):169-174. doi:10.1016/j.arthro.2003.11.036.
5. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35(8):1276-1283. doi:10.1177/0363546507300262.
6. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.
7. Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(suppl 2):133-151. doi:10.2106/JBJS.J.00906.
8. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984;66(2):159-168.
9. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003;85-A(5):878-884.
10. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy. 2003;19(7):732-739.
11. Jankauskas L, Rudiger HA, Pfirrmann CW, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder Elbow Surg. 2010;19(1):151-156. doi:10.1016/j.jse.2009.04.013.
12. Altan E, Ozbaydar MU, Tonbul M, Yalcin L. Comparison of two different measurement methods to determine glenoid bone defects: area or width? J Shoulder Elbow Surg. 2014;23(8):1215-1222. doi:10.1016/j.jse.2013.11.029.
13. Bishop JY, Jones GL, Rerko MA, Donaldson C, Group MS. 3-D CT is the most reliable imaging modality when quantifying glenoid bone loss. Clin Orthop Relat Res. 2013;471(4):1251-1256. doi:10.1007/s11999-012-2607-x.
14. Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy. 2008; 24(4):376-382. doi:10.1016/j.arthro.2007.10.008.
15. Gross DJ, Golijanin P, Dumont GD, et al. The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging. J Shoulder Elbow Surg. 2016;25(1):61-68. doi:10.1016/j.jse.2015.06.017.
16. Lenart BA, Freedman R, Van Thiel GS, et al. Magnetic resonance imaging evaluation of normal glenoid length and width: an anatomic study. Arthroscopy. 2014;30(8):915-920. doi:10.1016/j.arthro.2014.03.006.
17. Bois AJ, Fening SD, Polster J, Jones MH, Miniaci A. Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques. Am J Sports Med. 2012;40(11):2569-2577. doi:10.1177/0363546512458247.
18. Griffith JF, Antonio GE, Tong CW, Ming CK. Anterior shoulder dislocation: quantification of glenoid bone loss with CT. AJR Am J Roentgenol. 2003;180(5):1423-1430. doi:10.2214/ajr.180.5.1801423.
19. Hoenecke HR Jr, Hermida JC, Flores-Hernandez C, D'Lima DD. Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(2):166-171. doi:10.1016/j.jse.2009.08.009.
20. Huijsmans PE, de Witte PB, de Villiers RV, et al. Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making. Skeletal Radiol. 2011;40(10):1329-1334. doi:10.1007/s00256-011-1184-5.
21. Bhatia S, Frank RM, Ghodadra NS, et al. The outcomes and surgical techniques of the latarjet procedure. Arthroscopy. 2014;30(2):227-235. doi:10.1016/j.arthro.2013.10.013.
22. Cunningham G, Benchouk S, Kherad O, Ladermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc. 2015;24(2):540-545. doi:10.1007/s00167-015-3910-3.
23. Fedorka CJ, Mulcahey MK. Recurrent anterior shoulder instability: a review of the Latarjet procedure and its postoperative rehabilitation. Phys Sportsmed. 2015;43(1):73-79. doi:10.1080/00913847.2015.1005543.
24. Flinkkila T, Sirniö K. Open Latarjet procedure for failed arthroscopic Bankart repair. Orthop Traumatol Surg Res. 2015;101(1):35-38. doi:10.1016/j.otsr.2014.11.005.
25. Hovelius L, Sandström B, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006;15(3):279-289. doi:10.1016/j.jse.2005.09.014.
26. Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results. J Shoulder Elbow Surg. 2004;13(5):509-516. doi:10.1016/S1058274604000916.
27. Hovelius L, Vikerfors O, Olofsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elbow Surg. 2011;20(7):1095-1101. doi:10.1016/j.jse.2011.02.005.
28. Gupta A, Delaney R, Petkin K, Lafosse L. Complications of the Latarjet procedure. Curr Rev Musculoskelet Med. 2015;8(1):59-66. doi:10.1007/s12178-015-9258-y.
29. Kwon YW, Powell KA, Yum JK, Brems JJ, Iannotti JP. Use of three-dimensional computed tomography for the analysis of the glenoid anatomy. J Shoulder Elbow Surg. 2005;14(1):85-90. doi:10.1016/j.jse.2004.04.011.
30. Saito H, Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med. 2005;33(6):889-893. doi:10.1177/0363546504271521.
ABSTRACT
Standard 2-dimensional (2-D) computed tomography (CT) scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula, which may challenge the ability to accurately measure glenoid width and glenoid bone loss (GBL). The purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial anterior-posterior (AP) glenoid width measurements in the setting of anterior GBL.
Forty-three CT scans from consecutive patients with anterior GBL (minimum 10%) were reformatted utilizing open-source DICOM software (OsiriX MD). Patients were grouped according to extent of GBL: I, 10% to 14.9% (N = 12); II, 15% to 19.9% (N = 16); and III, >20% (N = 15). The uncorrected (UNCORR) and corrected (CORR) images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width.
For groups I and III, UNCORR scans underestimated axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated). In Group II, axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut; while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
UNCORR 2-D CT scans inaccurately estimated glenoid width and the degree of anterior GBL. This data suggests that corrected 2D CT scans or a 3-dimensional (3-D) reconstruction can help in accurately defining the anterior GBL in patients with shoulder instability.
The treatment of glenohumeral instability has substantially evolved over the past several decades. The understanding of glenoid bone loss (GBL), in particular, has advanced to such a level that we utilize the quantification of GBL for surgical decision-making. Unrecognized and/or untreated GBL is associated with recurrent instability, pain, and disability. Controversy exists, however, regarding the precise amount of anterior GBL that is significant enough to warrant surgical treatment. While historically, 25%1,2 of anterior GBL was thought to be the critical number required to warrant osseous augmentation, studies that are more recent have highlighted the need to perform osseous glenoid reconstruction with lesser degrees of GBL, particularly in the contact athlete.3-9 As small differences in the amount of GBL can change surgical decision-making from an all-soft tissue repair to an osseous reconstruction, it is paramount that we have accurate, valid, and reproducible methods for calculating GBL.
Continue to: Historically, plain radiographs...
Historically, plain radiographs have been the mainstay for evaluating the glenohumeral joint, including Grashey and axillary views, allowing clinicians to evaluate the congruency of the glenohumeral joint and to assess bone loss on both the glenoid and humeral head.1,10 While large, acute fractures of the glenoid are fairly evident on radiographs, including the Grashey view,11 shoulders with chronic and/or attritional anterior GBL are more difficult to evaluate, and often do not provide the information necessary to guide surgical decision-making.
Computed tomography (CT) of the shoulder has become the most commonly utilized imaging modality in the evaluation of patients with shoulder instability associated with GBL. Standard 2-dimensional (2-D) CT scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula/glenoid, as standard protocols often fail to account for the anterior sagittal rotation of the scapula/glenoid, similar to the disadvantage of standard radiographs. While 3-dimensional (3-D) CT reconstructions eliminate the effect of gantry angles, and thus allow for an en face view of the glenoid, 3-D reconstructions are not always available, and cannot always be measured.12-14 Thus, improved methodology for utilizing standard 2D scans is warranted, as the ability to correctly align the axial CT scan to the axis of the glenoid may allow for more accurate GBL measurements, which will ultimately impact surgical decision-making. Recently, Gross and colleagues15 reported the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version in normal glenoids, without bone loss, and found that the mean angle of correction needed to align the sagittal plane was 20.1° ± 1.2° of rotation. To the authors’ knowledge, this same methodology has not been applied to patients with clinically meaningful anterior GBL. Given that the average glenoid width in human shoulders is 24.4 mm ± 2.9 mm,16 1 mm of glenoid bone loss (GBL) corresponds to approximately 4% of the glenoid width, and thus even subtle differences in the interpretation of GBL may have substantial clinical implications. Therefore, the purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial AP glenoid width measurements in the setting of clinically significant anterior GBL.
METHODS
This study was approved by Massachusetts General Hospital Institutional Review Board. A retrospective review of consecutive patients with a diagnosis of anterior shoulder instability between 2009 and 2013 was conducted. Inclusion criteria comprised patients with a minimum of 10% anterior GBL, an available CT scan of the affected shoulder, and no history of prior ipsilateral surgeries. Exclusion criteria comprised evidence of degenerative changes to the glenoid and/or humeral head, as well as prior ipsilateral shoulder surgery. Sixty consecutive patients were originally identified as having anterior shoulder instability, and 17 were excluded based on the inclusion/exclusion criteria, leaving 43 patients (43 shoulders) available for inclusion. Shoulder CT scans from all 43 patients were reformatted utilizing open-source DICOM software (OsiriX MD, version 2.5.1 65-bit) multi-planar reconstruction (MPR).
CT PROTOCOL
All patients underwent a standard glenohumeral CT scan using a Siemens Sensation 64 Scanner (Siemens), a 64-detector scanner. Scans were acquired with 0.6 mm of collimation, 140 kV, and 300 mA-seconds. Slice thickness was set to 2 mm. All patient information was de-identified for analysis.
The uncorrected (UNCORR) scans were defined as the default orientation on the scanner. In the UNCORR scans, the axial, coronal, and sagittal views were oriented relative to the scanner gantry table, as opposed to the anatomy of the glenoid. The corrected (CORR) CT scans were aligned in all 3 planes relative to the glenoid face, and thus the cuts were perpendicular to the long axis of the glenoid.15 This resulted in sagittal cuts perpendicular to the 12-o’clock to 6-o’clock axis in the sagittal plane (Figure 1).
Continue to: In a de-identified fashion...
IMAGE ANALYSIS AND REFORMATTING
In a de-identified fashion, all CT scans were imported and analyzed using open-source Digital Imaging and Communications in Medicine (DICOM) software (OsiriX MD, version 2.5.1 64-bit). By following a previously developed method, CT scans were reformatted using OsiriX MPR. The OsiriX software has an MPR function that allows simultaneous manipulation of 2-D CT scans in 3 orthogonal planes: axial, sagittal, and coronal. In the MPR mode, the alternation of 1 plane directly affects the orientation of the remaining 2 planes. Thus, by using an MPR, one can analyze the impact that a default CT scan performed relative to the gantry of the table, UNCORR, has on the axial images.
First, the en face view was obtained via a 2-step process: alignment of the axial plane to account for the scapular angle, followed by alignment of the coronal plane to adjust for the glenoid inclination.15 These 2 adjustments provided a true en face sagittal glenoid view. The final adjustment step was a sagittal en face rotation of the glenoid such that the superior and inferior glenoid tubercles were placed on the 12-o’clock to 6-o’clock axis (CORR scan). Previous studies have identified a central longitudinal axis that was used in this method to align the supraglenoid tubercle with the 12-o’clock to 6-o’clock axis on the glenoid face.15,17,18 The standard error of mean was 1.21°. This new CORR view resulted in axial cuts through the glenoid that were oriented perpendicular to the 12-o’clock to 6-o’clock axis. The UNCORR and CORR images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width by 2 independent observers in a blinded, randomized fashion. When the measured AP width of the UNCORR scan was less than that measured on the CORR scan, the AP width of the glenoid was considered underestimated, and the degree of GBL was considered overestimated (Figure 2).
SCAPULAR ANGLE
Scapular angle measurements were performed on the axial view as the angle between a line through the long axis of the body of the scapula, and a line parallel to the CT gantry table.15,19 Subsequently, the axial plane was aligned to the glenoid surface.
CORONAL INCLINATION
Coronal inclination measurements were performed on the sagittal view as the angle between a line tangential to the face of the glenoid and a line perpendicular to the CT gantry table. Positive values represented superior inclination, while negative values represented inferior glenoid inclination.15
SAGITTAL ROTATION
Sagittal rotation measurements were performed using the built-in angle measurement tool in OsiriX in the sagittal plane since the degree of rotation required aligning the long axis of the glenoid to the 12-o’clock to 6-o’clock axis. The amount of rotation was defined as the rotation angle.15
Continue to: Similarly, as described by Gross...
GLENOID WIDTH
Similarly, as described by Gross and colleagues,15 the sagittal en face view was divided via 5 cuts, throughout a superimposed best-fit circle that closely represents the glenoid.9,15,20 For both the UNCORR and CORR, glenoid width (AP distance) was measured on the axial image at the widest point from AP cortex across the glenoid face.
PATIENT GROUPS
Utilizing the en face 3-D CT reconstruction view of the glenoid as the gold standard, patients were placed into 1 of 3 groups according to the degree of anterior GBL measured via the surface method.9,20 The groups were as follows:
I. 10% to 14.9% (N = 12)
II. 15% to 19.9% (N = 16)
III. >20% (N = 15)
STATISTICAL METHODS
Paired t-tests were used to compare all measurements between CORR and UNCORR scans for each of the 5 cuts. A P-value of .05 was used as the threshold for statistical significance in 2-tailed comparisons. Mean and standard errors are presented with standard deviations throughout the study. For interobserver reliability, the measurements between the observers, the intraclass correlation coefficient was calculated. All statistics were performed with SPSS (Version 22).
RESULTS
The study cohort was comprised of 19 left shoulders (44%) and 24 right shoulders (56%), including 36 male patients (84%) and 7 female patients (16%). The average age was 27.8 years (range, 21-40 years). The variability in measured difference, with respect to AP width, was 1.05 mm. The UNCORR CT scans required a mean correction for coronal inclination of 7.0° ± 5.8° (range, -8°-6°). The UNCORR CT scans required a mean correction for scapular angle of 30.2° ± 8.0° (range, 15°-49°). The mean angle of sagittal rotation required to align the glenoid face with the 12-o’clock to 6-o’clock axis was 24.2° ± 5.1 ° (range, 13°-30°). These results are summarized in Table 1.
Table 1. Mean Correction Values Required to Correct the Uncorrected Images to the Corrected Images | |||
Anatomic alignment | Mean (degrees) | Range (degrees) | SD (degrees) |
Scapular angle | 30.2 | 15-49 | 8.0 |
Coronal Inclination | 7.0 | -8-6 | 5.8 |
Sagittal rotation | 24.2 | 13-30 | 5.1 |
For all measurements, the intraclass correlation coefficient for independent observers for all cuts within the 3 groups was r >.900 in all cases.
On an optimized CT scan, over 5 standardized cuts across a best-fit circle of the inferior glenoid, there was a statistically significant absolute mean difference of 12.6% in axial AP glenoid width (2.86 mm ± 2.00 mm, P =.016) when compared with the UNCORR scan. This corresponds to a 3% to 21% error in measurement of the AP width of the glenoid.
Continue to: For the entire cohort...
For the entire cohort of 43 patients, the UNCORR scans underestimated the axial AP width (and thus overestimated GBL) in cut 1 (P =.003), and overestimated the axial AP width (and thus underestimated GBL) in cuts 3 to 5 (P < .001 for all) compared with that of the CORR scans. There was no significant difference between the UNCORR and CORR scans in cut 2 (P = .331).
For groups I (10%-14.9% GBL) and III (>20% GBL), the UNCORR scans underestimated the axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated) (Tables 2, 3). In Group II (15%-19.9% GBL), the axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut, while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
Table 2. Absolute Mean Difference in Axial AP Width (mm) Between Corrected and Uncorrected Images (% difference) | |||||
Cut 1 (Caudal) | Cut 2 | Cut 3 (Center) | Cut 4 | Cut 5 (Cephalad) | |
Group I: 10%-14.9% GBL | 2.4 mm (15.3%) | 1.8 mm (9.0%) | 1.8 mm (7.7%) | 3.0 mm (11.7%) | 4.0 mm (16.8%) |
Group II: 15%-19.9% GBL | 1.8 mm (13.1%) | 1.7 mm (7.9%) | 2.8 mm (10.6%) | 4.1 mm (14.4%) | 4.8 mm (16.9%) |
Group III: >20% | 2.8 mm (16.1%) | 1.9 mm (8.0%) | 2.3 mm (10.3) | 4.4 mm (16.6%) | 5.2 mm (17.0%) |
Abbreviations: AP, anterior-posterior; GBL, glenoid bone loss.
Table 3. Mean AP Glenoid Width Based on CORR and UNCORR Images for the Entire Cohort of 43 Patients | |||||
Axial cut | Mean AP width (mm) | Mean AP width (mm) | Absolute mean AP width difference (mm) | Absolute mean AP width difference (%) | P value |
(Caudal) 1 | 16.6208 | 18.4958 | -1.875 | 14.7768 | .0029565 |
2 | 20.6558 | 21.3166 | -0.661 | 3.6137 | .3310965 |
3 | 24.2583 | 22.3125 | 1.946 | 7.8042 | <.0001 |
4 | 26.1291 | 21.8916 | 4.238 | 15.8449 | <.0001 |
(Rostral) 5 | 26.0875 | 20.4875 | 5.6 | 20.9717 | <.0001 |
Abbreviations: AP, anterior-posterior; CORR, corrected; UNCORR, uncorrected.
DISCUSSION
The principle findings of this study demonstrate that UNCORR conventional 2-D CT scans inaccurately estimate glenoid width as well as inaccurately quantify the degree of anterior GBL. Underestimations of GBL may lead to insufficient treatment of clinically meaningful GBL, thereby increasing the risk of instability recurrence; whereas overestimations of GBL may lead to unnecessary treatment, subjecting patients to increased surgical morbidity. Therefore, the authors recommend correcting the orientation of the scapula in cases wherein clinical decisions are entirely based on 2-D CT, or using alternative methods for quantifying GBL, specifically in the form of 3-D reconstructions.
The use of axial imaging, with CT scans and/or magnetic resonance imaging, is growing in popularity for evaluation of both glenoid anatomy and GBL. Nevertheless, despite our improved ability to critically evaluate the glenoid using these advanced imaging modalities, the images themselves require scrutiny by clinicians to determine if the images accurately depict the true anatomy of the glenoid. As demonstrated by Gross and colleagues,15 conventional 2D CT scan protocols are not optimized to the anatomy of the glenohumeral joint, even in patients without GBL. Due to the alignment of the image relative to the plane of the scapula as opposed to the plane of the glenoid, UNCORR scans result in significantly different measurements of glenoid version (2.0° ± 0.1°) and AP glenoid width (1.2 mm ± 0.42 mm) compared with corrected scans, requiring an average 20.1° ± 1.2° of correction to align the sagittal plane. In the present study involving the patients with GBL, we also found that conventional, UNCORR 2-D CT scan protocols inaccurately estimate glenoid width and the degree of anterior GBL. In particular, AP glenoid width was consistently underestimated in the more caudal cuts, while AP glenoid width was consistently overestimated in the more cephalad cuts. Thus, anterior GBL was overestimated (AP glenoid width was underestimated) in the more caudal cuts, whereas anterior GBL was underestimated in the more cranial cuts (AP glenoid width was overestimated). Given that approximately 1 mm of glenoid bone corresponds to approximately 4% of glenoid width,16 even subtle differences in the interpretation of GBL may lead to gross overestimation/underestimation of bone loss, with significant clinical implications.
In the anterior instability patient population, clinical decision-making is often based on the degree of GBL as determined by advanced imaging modalities. In addition to other patient-specific factors, including age, gender, activity level, type of sport, and number of prior dislocations and/or prior surgeries, the quantity of GBL will often determine which surgical procedure needs to be performed. Typically, patients with >20% to 25% anterior GBL are indicated for a glenoid reconstruction procedure, most commonly via the Latarjet procedure (coracoid transfer).21-27 The Latarjet procedure remains an excellent technique for appropriately indicated patients, with historically good clinical outcomes and low recurrence rates. Complications associated with the Latarjet procedure, however, are not uncommon, including devastating neuropraxia of the axillary and musculocutaneous nerves, and occasionally permanent neurologic deficits.28 Thus, it is critical to avoid overtreating patients with recurrent instability and GBL. As demonstrated by this study, depending on the cranial-to-caudal location on the glenoid, current 2-D CT techniques may underestimate AP glenoid width, resulting in an overestimation of GBL, potentially leading to the decision to proceed with glenoid bone reconstruction when such a procedure is not required. On the contrary, overestimation of AP glenoid width, which occurs in the more cephalad cuts of the glenoid, is perhaps more worrisome, as the resulting underestimation of GBL may lead to inadequate treatment of patients with recurrent instability. Certainly, one of the main risk factors for failed soft tissue shoulder stabilization is a failure to address GBL. If clinical decisions are made based on UNCORR 2-D CT scans, which are often inaccurate with respect to AP glenoid width by an average 2.86 mm ± 2.00 mm (equivalent to 12.6% ± 6.9% GBL) as determined in this study, patients who truly require osseous glenoid reconstructions may be indicated for only soft tissue stabilization, based on the underestimation of GBL.
Continue to: The current gold standard...
The current gold standard for GBL measurement is a perfect-fit circle performed on a 3-D CT scan.22 To that end, it would have been useful to measure the glenoids from this study on 3-D CT scans and compare the data with both UNCORR and CORR measurements. This would have provided a better understanding to what extent the CORR measurements on 2-D scans are relatable with the gold standard. As 3-D CT scans provide a better en face view of the glenoid, more accurate GBL measurements, and ease of 3-D manipulation, they have become more widely used across the country.29,30 Nevertheless, in situations where 3-D imaging is more challenging to obtain because of technology or cost limitations, having a strategy for ensuring proper orientation of 2-D scans would have a substantial impact on clinical decision-making. If such corrections are not made, the inaccuracy of current 2-D scanning protocols justifies the cost 3-D reconstruction protocols. The difference in GBL measurements are critical in cases of increasingly large degrees of GBL, as in these instances, the inferior glenoid becomes more of an inverted-pear shape as opposed to a perfect circle, and differences in CORR and UNCORR images are likely to be more profound.
LIMITATIONS
This study has limitations, such as the relatively small sample size and the selection bias by the reviewers with potential differences in interobserver reliability. Further, minor modifications during the reformatting process may be found with each attempt to manipulate the images and may result in minor, insignificant differences in AP width measurements. Performing 1 or more additional CT scans on the same cohort of patients would have been helpful; however, due to the increased risk of radiation exposure, this was not performed. Performing CT scans on cadaveric specimens with GBL and applying the study methodology would also have been helpful to provide independent verification of our clinical findings; however, specimens were not available for this study. Another limitation of this study is that we did not compare our findings with the findings of glenoid width, and bone loss, as determined using the circle method, which is commonly utilized when 3-D reconstructions are available. In this study, the purpose was to utilize only the 2-D reformatted images, with the assumption that 3-D reconstructions are not always available, and cannot always be measured. To minimize selection bias, the investigators measured the correction effects within groups of patients with similar degrees of GBL (10%-14.9%, 15%-19.9%, and >20%). In addition, not all the selected patients showed degenerative glenoid changes or irregular glenoid shape indicating previous bone augmentation.
CONCLUSIONS
UNCORR 2D CT scans inaccurately estimate glenoid width and the degree of anterior GBL. The clinical implications of these findings are profound and suggest corrected 2D CT scans or 3D reconstruction allow measurements to be taken in the axis of the glenoid to accurately define the anatomy and quantity of anterior GBL in patients with shoulder instability.
ABSTRACT
Standard 2-dimensional (2-D) computed tomography (CT) scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula, which may challenge the ability to accurately measure glenoid width and glenoid bone loss (GBL). The purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial anterior-posterior (AP) glenoid width measurements in the setting of anterior GBL.
Forty-three CT scans from consecutive patients with anterior GBL (minimum 10%) were reformatted utilizing open-source DICOM software (OsiriX MD). Patients were grouped according to extent of GBL: I, 10% to 14.9% (N = 12); II, 15% to 19.9% (N = 16); and III, >20% (N = 15). The uncorrected (UNCORR) and corrected (CORR) images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width.
For groups I and III, UNCORR scans underestimated axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated). In Group II, axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut; while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
UNCORR 2-D CT scans inaccurately estimated glenoid width and the degree of anterior GBL. This data suggests that corrected 2D CT scans or a 3-dimensional (3-D) reconstruction can help in accurately defining the anterior GBL in patients with shoulder instability.
The treatment of glenohumeral instability has substantially evolved over the past several decades. The understanding of glenoid bone loss (GBL), in particular, has advanced to such a level that we utilize the quantification of GBL for surgical decision-making. Unrecognized and/or untreated GBL is associated with recurrent instability, pain, and disability. Controversy exists, however, regarding the precise amount of anterior GBL that is significant enough to warrant surgical treatment. While historically, 25%1,2 of anterior GBL was thought to be the critical number required to warrant osseous augmentation, studies that are more recent have highlighted the need to perform osseous glenoid reconstruction with lesser degrees of GBL, particularly in the contact athlete.3-9 As small differences in the amount of GBL can change surgical decision-making from an all-soft tissue repair to an osseous reconstruction, it is paramount that we have accurate, valid, and reproducible methods for calculating GBL.
Continue to: Historically, plain radiographs...
Historically, plain radiographs have been the mainstay for evaluating the glenohumeral joint, including Grashey and axillary views, allowing clinicians to evaluate the congruency of the glenohumeral joint and to assess bone loss on both the glenoid and humeral head.1,10 While large, acute fractures of the glenoid are fairly evident on radiographs, including the Grashey view,11 shoulders with chronic and/or attritional anterior GBL are more difficult to evaluate, and often do not provide the information necessary to guide surgical decision-making.
Computed tomography (CT) of the shoulder has become the most commonly utilized imaging modality in the evaluation of patients with shoulder instability associated with GBL. Standard 2-dimensional (2-D) CT scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula/glenoid, as standard protocols often fail to account for the anterior sagittal rotation of the scapula/glenoid, similar to the disadvantage of standard radiographs. While 3-dimensional (3-D) CT reconstructions eliminate the effect of gantry angles, and thus allow for an en face view of the glenoid, 3-D reconstructions are not always available, and cannot always be measured.12-14 Thus, improved methodology for utilizing standard 2D scans is warranted, as the ability to correctly align the axial CT scan to the axis of the glenoid may allow for more accurate GBL measurements, which will ultimately impact surgical decision-making. Recently, Gross and colleagues15 reported the effect of sagittal rotation of the glenoid on axial measurements of anterior-posterior (AP) glenoid width and glenoid version in normal glenoids, without bone loss, and found that the mean angle of correction needed to align the sagittal plane was 20.1° ± 1.2° of rotation. To the authors’ knowledge, this same methodology has not been applied to patients with clinically meaningful anterior GBL. Given that the average glenoid width in human shoulders is 24.4 mm ± 2.9 mm,16 1 mm of glenoid bone loss (GBL) corresponds to approximately 4% of the glenoid width, and thus even subtle differences in the interpretation of GBL may have substantial clinical implications. Therefore, the purpose of this study is to determine the effect of sagittal rotation of the glenoid on axial AP glenoid width measurements in the setting of clinically significant anterior GBL.
METHODS
This study was approved by Massachusetts General Hospital Institutional Review Board. A retrospective review of consecutive patients with a diagnosis of anterior shoulder instability between 2009 and 2013 was conducted. Inclusion criteria comprised patients with a minimum of 10% anterior GBL, an available CT scan of the affected shoulder, and no history of prior ipsilateral surgeries. Exclusion criteria comprised evidence of degenerative changes to the glenoid and/or humeral head, as well as prior ipsilateral shoulder surgery. Sixty consecutive patients were originally identified as having anterior shoulder instability, and 17 were excluded based on the inclusion/exclusion criteria, leaving 43 patients (43 shoulders) available for inclusion. Shoulder CT scans from all 43 patients were reformatted utilizing open-source DICOM software (OsiriX MD, version 2.5.1 65-bit) multi-planar reconstruction (MPR).
CT PROTOCOL
All patients underwent a standard glenohumeral CT scan using a Siemens Sensation 64 Scanner (Siemens), a 64-detector scanner. Scans were acquired with 0.6 mm of collimation, 140 kV, and 300 mA-seconds. Slice thickness was set to 2 mm. All patient information was de-identified for analysis.
The uncorrected (UNCORR) scans were defined as the default orientation on the scanner. In the UNCORR scans, the axial, coronal, and sagittal views were oriented relative to the scanner gantry table, as opposed to the anatomy of the glenoid. The corrected (CORR) CT scans were aligned in all 3 planes relative to the glenoid face, and thus the cuts were perpendicular to the long axis of the glenoid.15 This resulted in sagittal cuts perpendicular to the 12-o’clock to 6-o’clock axis in the sagittal plane (Figure 1).
Continue to: In a de-identified fashion...
IMAGE ANALYSIS AND REFORMATTING
In a de-identified fashion, all CT scans were imported and analyzed using open-source Digital Imaging and Communications in Medicine (DICOM) software (OsiriX MD, version 2.5.1 64-bit). By following a previously developed method, CT scans were reformatted using OsiriX MPR. The OsiriX software has an MPR function that allows simultaneous manipulation of 2-D CT scans in 3 orthogonal planes: axial, sagittal, and coronal. In the MPR mode, the alternation of 1 plane directly affects the orientation of the remaining 2 planes. Thus, by using an MPR, one can analyze the impact that a default CT scan performed relative to the gantry of the table, UNCORR, has on the axial images.
First, the en face view was obtained via a 2-step process: alignment of the axial plane to account for the scapular angle, followed by alignment of the coronal plane to adjust for the glenoid inclination.15 These 2 adjustments provided a true en face sagittal glenoid view. The final adjustment step was a sagittal en face rotation of the glenoid such that the superior and inferior glenoid tubercles were placed on the 12-o’clock to 6-o’clock axis (CORR scan). Previous studies have identified a central longitudinal axis that was used in this method to align the supraglenoid tubercle with the 12-o’clock to 6-o’clock axis on the glenoid face.15,17,18 The standard error of mean was 1.21°. This new CORR view resulted in axial cuts through the glenoid that were oriented perpendicular to the 12-o’clock to 6-o’clock axis. The UNCORR and CORR images were assessed in the axial plane at 5 standardized cuts and measured for AP glenoid width by 2 independent observers in a blinded, randomized fashion. When the measured AP width of the UNCORR scan was less than that measured on the CORR scan, the AP width of the glenoid was considered underestimated, and the degree of GBL was considered overestimated (Figure 2).
SCAPULAR ANGLE
Scapular angle measurements were performed on the axial view as the angle between a line through the long axis of the body of the scapula, and a line parallel to the CT gantry table.15,19 Subsequently, the axial plane was aligned to the glenoid surface.
CORONAL INCLINATION
Coronal inclination measurements were performed on the sagittal view as the angle between a line tangential to the face of the glenoid and a line perpendicular to the CT gantry table. Positive values represented superior inclination, while negative values represented inferior glenoid inclination.15
SAGITTAL ROTATION
Sagittal rotation measurements were performed using the built-in angle measurement tool in OsiriX in the sagittal plane since the degree of rotation required aligning the long axis of the glenoid to the 12-o’clock to 6-o’clock axis. The amount of rotation was defined as the rotation angle.15
Continue to: Similarly, as described by Gross...
GLENOID WIDTH
Similarly, as described by Gross and colleagues,15 the sagittal en face view was divided via 5 cuts, throughout a superimposed best-fit circle that closely represents the glenoid.9,15,20 For both the UNCORR and CORR, glenoid width (AP distance) was measured on the axial image at the widest point from AP cortex across the glenoid face.
PATIENT GROUPS
Utilizing the en face 3-D CT reconstruction view of the glenoid as the gold standard, patients were placed into 1 of 3 groups according to the degree of anterior GBL measured via the surface method.9,20 The groups were as follows:
I. 10% to 14.9% (N = 12)
II. 15% to 19.9% (N = 16)
III. >20% (N = 15)
STATISTICAL METHODS
Paired t-tests were used to compare all measurements between CORR and UNCORR scans for each of the 5 cuts. A P-value of .05 was used as the threshold for statistical significance in 2-tailed comparisons. Mean and standard errors are presented with standard deviations throughout the study. For interobserver reliability, the measurements between the observers, the intraclass correlation coefficient was calculated. All statistics were performed with SPSS (Version 22).
RESULTS
The study cohort was comprised of 19 left shoulders (44%) and 24 right shoulders (56%), including 36 male patients (84%) and 7 female patients (16%). The average age was 27.8 years (range, 21-40 years). The variability in measured difference, with respect to AP width, was 1.05 mm. The UNCORR CT scans required a mean correction for coronal inclination of 7.0° ± 5.8° (range, -8°-6°). The UNCORR CT scans required a mean correction for scapular angle of 30.2° ± 8.0° (range, 15°-49°). The mean angle of sagittal rotation required to align the glenoid face with the 12-o’clock to 6-o’clock axis was 24.2° ± 5.1 ° (range, 13°-30°). These results are summarized in Table 1.
Table 1. Mean Correction Values Required to Correct the Uncorrected Images to the Corrected Images | |||
Anatomic alignment | Mean (degrees) | Range (degrees) | SD (degrees) |
Scapular angle | 30.2 | 15-49 | 8.0 |
Coronal Inclination | 7.0 | -8-6 | 5.8 |
Sagittal rotation | 24.2 | 13-30 | 5.1 |
For all measurements, the intraclass correlation coefficient for independent observers for all cuts within the 3 groups was r >.900 in all cases.
On an optimized CT scan, over 5 standardized cuts across a best-fit circle of the inferior glenoid, there was a statistically significant absolute mean difference of 12.6% in axial AP glenoid width (2.86 mm ± 2.00 mm, P =.016) when compared with the UNCORR scan. This corresponds to a 3% to 21% error in measurement of the AP width of the glenoid.
Continue to: For the entire cohort...
For the entire cohort of 43 patients, the UNCORR scans underestimated the axial AP width (and thus overestimated GBL) in cut 1 (P =.003), and overestimated the axial AP width (and thus underestimated GBL) in cuts 3 to 5 (P < .001 for all) compared with that of the CORR scans. There was no significant difference between the UNCORR and CORR scans in cut 2 (P = .331).
For groups I (10%-14.9% GBL) and III (>20% GBL), the UNCORR scans underestimated the axial AP width (and thus overestimated anterior GBL) in cuts 1 and 2, while in cuts 3 to 5, the axial AP width was overestimated (GBL was underestimated) (Tables 2, 3). In Group II (15%-19.9% GBL), the axial AP width was underestimated (GBL was overestimated), while in cuts 2 to 5, the axial AP width was overestimated (GBL was underestimated). Overall, AP glenoid width was consistently underestimated in cut 1, the most caudal cut, while AP glenoid width was consistently overestimated in cuts 3 to 5, the more cephalad cuts.
Table 2. Absolute Mean Difference in Axial AP Width (mm) Between Corrected and Uncorrected Images (% difference) | |||||
Cut 1 (Caudal) | Cut 2 | Cut 3 (Center) | Cut 4 | Cut 5 (Cephalad) | |
Group I: 10%-14.9% GBL | 2.4 mm (15.3%) | 1.8 mm (9.0%) | 1.8 mm (7.7%) | 3.0 mm (11.7%) | 4.0 mm (16.8%) |
Group II: 15%-19.9% GBL | 1.8 mm (13.1%) | 1.7 mm (7.9%) | 2.8 mm (10.6%) | 4.1 mm (14.4%) | 4.8 mm (16.9%) |
Group III: >20% | 2.8 mm (16.1%) | 1.9 mm (8.0%) | 2.3 mm (10.3) | 4.4 mm (16.6%) | 5.2 mm (17.0%) |
Abbreviations: AP, anterior-posterior; GBL, glenoid bone loss.
Table 3. Mean AP Glenoid Width Based on CORR and UNCORR Images for the Entire Cohort of 43 Patients | |||||
Axial cut | Mean AP width (mm) | Mean AP width (mm) | Absolute mean AP width difference (mm) | Absolute mean AP width difference (%) | P value |
(Caudal) 1 | 16.6208 | 18.4958 | -1.875 | 14.7768 | .0029565 |
2 | 20.6558 | 21.3166 | -0.661 | 3.6137 | .3310965 |
3 | 24.2583 | 22.3125 | 1.946 | 7.8042 | <.0001 |
4 | 26.1291 | 21.8916 | 4.238 | 15.8449 | <.0001 |
(Rostral) 5 | 26.0875 | 20.4875 | 5.6 | 20.9717 | <.0001 |
Abbreviations: AP, anterior-posterior; CORR, corrected; UNCORR, uncorrected.
DISCUSSION
The principle findings of this study demonstrate that UNCORR conventional 2-D CT scans inaccurately estimate glenoid width as well as inaccurately quantify the degree of anterior GBL. Underestimations of GBL may lead to insufficient treatment of clinically meaningful GBL, thereby increasing the risk of instability recurrence; whereas overestimations of GBL may lead to unnecessary treatment, subjecting patients to increased surgical morbidity. Therefore, the authors recommend correcting the orientation of the scapula in cases wherein clinical decisions are entirely based on 2-D CT, or using alternative methods for quantifying GBL, specifically in the form of 3-D reconstructions.
The use of axial imaging, with CT scans and/or magnetic resonance imaging, is growing in popularity for evaluation of both glenoid anatomy and GBL. Nevertheless, despite our improved ability to critically evaluate the glenoid using these advanced imaging modalities, the images themselves require scrutiny by clinicians to determine if the images accurately depict the true anatomy of the glenoid. As demonstrated by Gross and colleagues,15 conventional 2D CT scan protocols are not optimized to the anatomy of the glenohumeral joint, even in patients without GBL. Due to the alignment of the image relative to the plane of the scapula as opposed to the plane of the glenoid, UNCORR scans result in significantly different measurements of glenoid version (2.0° ± 0.1°) and AP glenoid width (1.2 mm ± 0.42 mm) compared with corrected scans, requiring an average 20.1° ± 1.2° of correction to align the sagittal plane. In the present study involving the patients with GBL, we also found that conventional, UNCORR 2-D CT scan protocols inaccurately estimate glenoid width and the degree of anterior GBL. In particular, AP glenoid width was consistently underestimated in the more caudal cuts, while AP glenoid width was consistently overestimated in the more cephalad cuts. Thus, anterior GBL was overestimated (AP glenoid width was underestimated) in the more caudal cuts, whereas anterior GBL was underestimated in the more cranial cuts (AP glenoid width was overestimated). Given that approximately 1 mm of glenoid bone corresponds to approximately 4% of glenoid width,16 even subtle differences in the interpretation of GBL may lead to gross overestimation/underestimation of bone loss, with significant clinical implications.
In the anterior instability patient population, clinical decision-making is often based on the degree of GBL as determined by advanced imaging modalities. In addition to other patient-specific factors, including age, gender, activity level, type of sport, and number of prior dislocations and/or prior surgeries, the quantity of GBL will often determine which surgical procedure needs to be performed. Typically, patients with >20% to 25% anterior GBL are indicated for a glenoid reconstruction procedure, most commonly via the Latarjet procedure (coracoid transfer).21-27 The Latarjet procedure remains an excellent technique for appropriately indicated patients, with historically good clinical outcomes and low recurrence rates. Complications associated with the Latarjet procedure, however, are not uncommon, including devastating neuropraxia of the axillary and musculocutaneous nerves, and occasionally permanent neurologic deficits.28 Thus, it is critical to avoid overtreating patients with recurrent instability and GBL. As demonstrated by this study, depending on the cranial-to-caudal location on the glenoid, current 2-D CT techniques may underestimate AP glenoid width, resulting in an overestimation of GBL, potentially leading to the decision to proceed with glenoid bone reconstruction when such a procedure is not required. On the contrary, overestimation of AP glenoid width, which occurs in the more cephalad cuts of the glenoid, is perhaps more worrisome, as the resulting underestimation of GBL may lead to inadequate treatment of patients with recurrent instability. Certainly, one of the main risk factors for failed soft tissue shoulder stabilization is a failure to address GBL. If clinical decisions are made based on UNCORR 2-D CT scans, which are often inaccurate with respect to AP glenoid width by an average 2.86 mm ± 2.00 mm (equivalent to 12.6% ± 6.9% GBL) as determined in this study, patients who truly require osseous glenoid reconstructions may be indicated for only soft tissue stabilization, based on the underestimation of GBL.
Continue to: The current gold standard...
The current gold standard for GBL measurement is a perfect-fit circle performed on a 3-D CT scan.22 To that end, it would have been useful to measure the glenoids from this study on 3-D CT scans and compare the data with both UNCORR and CORR measurements. This would have provided a better understanding to what extent the CORR measurements on 2-D scans are relatable with the gold standard. As 3-D CT scans provide a better en face view of the glenoid, more accurate GBL measurements, and ease of 3-D manipulation, they have become more widely used across the country.29,30 Nevertheless, in situations where 3-D imaging is more challenging to obtain because of technology or cost limitations, having a strategy for ensuring proper orientation of 2-D scans would have a substantial impact on clinical decision-making. If such corrections are not made, the inaccuracy of current 2-D scanning protocols justifies the cost 3-D reconstruction protocols. The difference in GBL measurements are critical in cases of increasingly large degrees of GBL, as in these instances, the inferior glenoid becomes more of an inverted-pear shape as opposed to a perfect circle, and differences in CORR and UNCORR images are likely to be more profound.
LIMITATIONS
This study has limitations, such as the relatively small sample size and the selection bias by the reviewers with potential differences in interobserver reliability. Further, minor modifications during the reformatting process may be found with each attempt to manipulate the images and may result in minor, insignificant differences in AP width measurements. Performing 1 or more additional CT scans on the same cohort of patients would have been helpful; however, due to the increased risk of radiation exposure, this was not performed. Performing CT scans on cadaveric specimens with GBL and applying the study methodology would also have been helpful to provide independent verification of our clinical findings; however, specimens were not available for this study. Another limitation of this study is that we did not compare our findings with the findings of glenoid width, and bone loss, as determined using the circle method, which is commonly utilized when 3-D reconstructions are available. In this study, the purpose was to utilize only the 2-D reformatted images, with the assumption that 3-D reconstructions are not always available, and cannot always be measured. To minimize selection bias, the investigators measured the correction effects within groups of patients with similar degrees of GBL (10%-14.9%, 15%-19.9%, and >20%). In addition, not all the selected patients showed degenerative glenoid changes or irregular glenoid shape indicating previous bone augmentation.
CONCLUSIONS
UNCORR 2D CT scans inaccurately estimate glenoid width and the degree of anterior GBL. The clinical implications of these findings are profound and suggest corrected 2D CT scans or 3D reconstruction allow measurements to be taken in the axis of the glenoid to accurately define the anatomy and quantity of anterior GBL in patients with shoulder instability.
1. Cerciello S, Edwards TB, Walch G. Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure. J Orthop Traumatol. 2012;13(4):197-202. doi:10.1007/s10195-012-0201-3.
2. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82(1):35-46.
3. Bhatia S, Ghodadra NS, Romeo AA, et al. The importance of the recognition and treatment of glenoid bone loss in an athletic population. Sports Health. 2011;3(5):435-440. doi:10.1177/1941738111414126.
4. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004;20(2):169-174. doi:10.1016/j.arthro.2003.11.036.
5. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35(8):1276-1283. doi:10.1177/0363546507300262.
6. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.
7. Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(suppl 2):133-151. doi:10.2106/JBJS.J.00906.
8. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984;66(2):159-168.
9. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003;85-A(5):878-884.
10. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy. 2003;19(7):732-739.
11. Jankauskas L, Rudiger HA, Pfirrmann CW, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder Elbow Surg. 2010;19(1):151-156. doi:10.1016/j.jse.2009.04.013.
12. Altan E, Ozbaydar MU, Tonbul M, Yalcin L. Comparison of two different measurement methods to determine glenoid bone defects: area or width? J Shoulder Elbow Surg. 2014;23(8):1215-1222. doi:10.1016/j.jse.2013.11.029.
13. Bishop JY, Jones GL, Rerko MA, Donaldson C, Group MS. 3-D CT is the most reliable imaging modality when quantifying glenoid bone loss. Clin Orthop Relat Res. 2013;471(4):1251-1256. doi:10.1007/s11999-012-2607-x.
14. Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy. 2008; 24(4):376-382. doi:10.1016/j.arthro.2007.10.008.
15. Gross DJ, Golijanin P, Dumont GD, et al. The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging. J Shoulder Elbow Surg. 2016;25(1):61-68. doi:10.1016/j.jse.2015.06.017.
16. Lenart BA, Freedman R, Van Thiel GS, et al. Magnetic resonance imaging evaluation of normal glenoid length and width: an anatomic study. Arthroscopy. 2014;30(8):915-920. doi:10.1016/j.arthro.2014.03.006.
17. Bois AJ, Fening SD, Polster J, Jones MH, Miniaci A. Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques. Am J Sports Med. 2012;40(11):2569-2577. doi:10.1177/0363546512458247.
18. Griffith JF, Antonio GE, Tong CW, Ming CK. Anterior shoulder dislocation: quantification of glenoid bone loss with CT. AJR Am J Roentgenol. 2003;180(5):1423-1430. doi:10.2214/ajr.180.5.1801423.
19. Hoenecke HR Jr, Hermida JC, Flores-Hernandez C, D'Lima DD. Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(2):166-171. doi:10.1016/j.jse.2009.08.009.
20. Huijsmans PE, de Witte PB, de Villiers RV, et al. Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making. Skeletal Radiol. 2011;40(10):1329-1334. doi:10.1007/s00256-011-1184-5.
21. Bhatia S, Frank RM, Ghodadra NS, et al. The outcomes and surgical techniques of the latarjet procedure. Arthroscopy. 2014;30(2):227-235. doi:10.1016/j.arthro.2013.10.013.
22. Cunningham G, Benchouk S, Kherad O, Ladermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc. 2015;24(2):540-545. doi:10.1007/s00167-015-3910-3.
23. Fedorka CJ, Mulcahey MK. Recurrent anterior shoulder instability: a review of the Latarjet procedure and its postoperative rehabilitation. Phys Sportsmed. 2015;43(1):73-79. doi:10.1080/00913847.2015.1005543.
24. Flinkkila T, Sirniö K. Open Latarjet procedure for failed arthroscopic Bankart repair. Orthop Traumatol Surg Res. 2015;101(1):35-38. doi:10.1016/j.otsr.2014.11.005.
25. Hovelius L, Sandström B, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006;15(3):279-289. doi:10.1016/j.jse.2005.09.014.
26. Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results. J Shoulder Elbow Surg. 2004;13(5):509-516. doi:10.1016/S1058274604000916.
27. Hovelius L, Vikerfors O, Olofsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elbow Surg. 2011;20(7):1095-1101. doi:10.1016/j.jse.2011.02.005.
28. Gupta A, Delaney R, Petkin K, Lafosse L. Complications of the Latarjet procedure. Curr Rev Musculoskelet Med. 2015;8(1):59-66. doi:10.1007/s12178-015-9258-y.
29. Kwon YW, Powell KA, Yum JK, Brems JJ, Iannotti JP. Use of three-dimensional computed tomography for the analysis of the glenoid anatomy. J Shoulder Elbow Surg. 2005;14(1):85-90. doi:10.1016/j.jse.2004.04.011.
30. Saito H, Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med. 2005;33(6):889-893. doi:10.1177/0363546504271521.
1. Cerciello S, Edwards TB, Walch G. Chronic anterior glenohumeral instability in soccer players: results for a series of 28 shoulders treated with the Latarjet procedure. J Orthop Traumatol. 2012;13(4):197-202. doi:10.1007/s10195-012-0201-3.
2. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82(1):35-46.
3. Bhatia S, Ghodadra NS, Romeo AA, et al. The importance of the recognition and treatment of glenoid bone loss in an athletic population. Sports Health. 2011;3(5):435-440. doi:10.1177/1941738111414126.
4. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004;20(2):169-174. doi:10.1016/j.arthro.2003.11.036.
5. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007;35(8):1276-1283. doi:10.1177/0363546507300262.
6. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009;17(8):482-493.
7. Provencher MT, Bhatia S, Ghodadra NS, et al. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(suppl 2):133-151. doi:10.2106/JBJS.J.00906.
8. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984;66(2):159-168.
9. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am. 2003;85-A(5):878-884.
10. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthroscopy. 2003;19(7):732-739.
11. Jankauskas L, Rudiger HA, Pfirrmann CW, Jost B, Gerber C. Loss of the sclerotic line of the glenoid on anteroposterior radiographs of the shoulder: a diagnostic sign for an osseous defect of the anterior glenoid rim. J Shoulder Elbow Surg. 2010;19(1):151-156. doi:10.1016/j.jse.2009.04.013.
12. Altan E, Ozbaydar MU, Tonbul M, Yalcin L. Comparison of two different measurement methods to determine glenoid bone defects: area or width? J Shoulder Elbow Surg. 2014;23(8):1215-1222. doi:10.1016/j.jse.2013.11.029.
13. Bishop JY, Jones GL, Rerko MA, Donaldson C, Group MS. 3-D CT is the most reliable imaging modality when quantifying glenoid bone loss. Clin Orthop Relat Res. 2013;471(4):1251-1256. doi:10.1007/s11999-012-2607-x.
14. Chuang TY, Adams CR, Burkhart SS. Use of preoperative three-dimensional computed tomography to quantify glenoid bone loss in shoulder instability. Arthroscopy. 2008; 24(4):376-382. doi:10.1016/j.arthro.2007.10.008.
15. Gross DJ, Golijanin P, Dumont GD, et al. The effect of sagittal rotation of the glenoid on axial glenoid width and glenoid version in computed tomography scan imaging. J Shoulder Elbow Surg. 2016;25(1):61-68. doi:10.1016/j.jse.2015.06.017.
16. Lenart BA, Freedman R, Van Thiel GS, et al. Magnetic resonance imaging evaluation of normal glenoid length and width: an anatomic study. Arthroscopy. 2014;30(8):915-920. doi:10.1016/j.arthro.2014.03.006.
17. Bois AJ, Fening SD, Polster J, Jones MH, Miniaci A. Quantifying glenoid bone loss in anterior shoulder instability: reliability and accuracy of 2-dimensional and 3-dimensional computed tomography measurement techniques. Am J Sports Med. 2012;40(11):2569-2577. doi:10.1177/0363546512458247.
18. Griffith JF, Antonio GE, Tong CW, Ming CK. Anterior shoulder dislocation: quantification of glenoid bone loss with CT. AJR Am J Roentgenol. 2003;180(5):1423-1430. doi:10.2214/ajr.180.5.1801423.
19. Hoenecke HR Jr, Hermida JC, Flores-Hernandez C, D'Lima DD. Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(2):166-171. doi:10.1016/j.jse.2009.08.009.
20. Huijsmans PE, de Witte PB, de Villiers RV, et al. Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making. Skeletal Radiol. 2011;40(10):1329-1334. doi:10.1007/s00256-011-1184-5.
21. Bhatia S, Frank RM, Ghodadra NS, et al. The outcomes and surgical techniques of the latarjet procedure. Arthroscopy. 2014;30(2):227-235. doi:10.1016/j.arthro.2013.10.013.
22. Cunningham G, Benchouk S, Kherad O, Ladermann A. Comparison of arthroscopic and open Latarjet with a learning curve analysis. Knee Surg Sports Traumatol Arthrosc. 2015;24(2):540-545. doi:10.1007/s00167-015-3910-3.
23. Fedorka CJ, Mulcahey MK. Recurrent anterior shoulder instability: a review of the Latarjet procedure and its postoperative rehabilitation. Phys Sportsmed. 2015;43(1):73-79. doi:10.1080/00913847.2015.1005543.
24. Flinkkila T, Sirniö K. Open Latarjet procedure for failed arthroscopic Bankart repair. Orthop Traumatol Surg Res. 2015;101(1):35-38. doi:10.1016/j.otsr.2014.11.005.
25. Hovelius L, Sandström B, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study II-the evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006;15(3):279-289. doi:10.1016/j.jse.2005.09.014.
26. Hovelius L, Sandström B, Sundgren K, Saebö M. One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I--clinical results. J Shoulder Elbow Surg. 2004;13(5):509-516. doi:10.1016/S1058274604000916.
27. Hovelius L, Vikerfors O, Olofsson A, Svensson O, Rahme H. Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up. J Shoulder Elbow Surg. 2011;20(7):1095-1101. doi:10.1016/j.jse.2011.02.005.
28. Gupta A, Delaney R, Petkin K, Lafosse L. Complications of the Latarjet procedure. Curr Rev Musculoskelet Med. 2015;8(1):59-66. doi:10.1007/s12178-015-9258-y.
29. Kwon YW, Powell KA, Yum JK, Brems JJ, Iannotti JP. Use of three-dimensional computed tomography for the analysis of the glenoid anatomy. J Shoulder Elbow Surg. 2005;14(1):85-90. doi:10.1016/j.jse.2004.04.011.
30. Saito H, Itoi E, Sugaya H, Minagawa H, Yamamoto N, Tuoheti Y. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med. 2005;33(6):889-893. doi:10.1177/0363546504271521.
TAKE-HOME POINTS
- Standard 2-D CT scans of the shoulder are often aligned to the plane of the body as opposed to the plane of the scapula, which may challenge the ability to accurately measure glenoid width and GBL.
- Underestimations of GBL may lead to insufficient treatment of clinically meaningful GBL, thereby increasing the risk of instability recurrence; whereas overestimations of GBL may lead to unnecessary treatment, subjecting patients to increased surgical morbidity.
- AP glenoid width was consistently underestimated in uncorrected axial cut 1, the most caudal cut.
- AP glenoid width was consistently overestimated in uncorrected axial cuts 3 to 5, the more cephalad cuts.
- CORR 2-D CT scans or a 3-D reconstruction can help in accurately defining the anterior GBL in patients with shoulder instability.
Reoperation Rates After Cartilage Restoration Procedures in the Knee: Analysis of a Large US Commercial Database
ABSTRACT
The purpose of this study is to describe the rate of return to the operating room (OR) following microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and osteochondral allograft (OCA) procedures at 90 days, 1 year, and 2 years. Current Procedural Terminology codes for all patients undergoing MFX, ACI, OATS, and OCA were used to search a prospectively collected, commercially available private payer insurance company database from 2007 to 2011. Within 90 days, 1 year, and 2 years after surgery, the database was searched for the occurrence of these same patients undergoing knee diagnostic arthroscopy with biopsy, lysis of adhesions, synovectomy, arthroscopy for infection or lavage, arthroscopy for removal of loose bodies, chondroplasty, MFX, ACI, OATS, OCA, and/or knee arthroplasty. Descriptive statistical analysis and contingency table analysis were performed. A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX, 640 ACI, 386 open OATS, 997 arthroscopic OATS, 714 open OCA, and 894 arthroscopic OCA procedures. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. At 2 years, patients who underwent MFX, ACI, OATS, OCA had reoperation rates of 14.65%, 29.69%, 8.82%, and 12.22%, respectively. There was a statistically significantly increased risk for ACI return to OR within all intervals (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative treatment options. With a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
Continue to: Symptomatic, full-thickness articular cartilage
Symptomatic, full-thickness articular cartilage defects in the knee are difficult to manage, particularly in the young, athletic patient population. Fortunately, a variety of cartilage repair (direct repair of the cartilage or those procedures which attempt to generate fibrocartilage) and restoration (those aimed at restoring hyaline cartilage) procedures are available, with encouraging short- and long-term clinical outcomes. After failure of nonoperative management, several surgical options are available for treating symptomatic focal chondral defects, including microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and open and arthroscopic osteochondral allograft (OCA) transplantation procedures.1,2 When appropriately indicated, each of these techniques has demonstrated good to excellent clinical outcomes with respect to reducing pain and improving function.3-5
While major complications following cartilage surgery are uncommon, the need for reoperation following an index articular cartilage operation is poorly understood. Recently, McCormick and colleagues6 found that reoperation within the first 2 years following meniscus allograft transplantation (MAT) is associated with an increased likelihood of revision MAT or future arthroplasty. Given the association between early reoperation following meniscus restoration surgery and subsequent failure, an improved understanding of the epidemiology and implications of reoperations following cartilage restoration surgery is warranted. Further, in deciding which treatment option is best suited to a particular patient, the rate of return to the operating room (OR) should be taken into consideration, as this could potentially influence surgical decision-making as to which procedure to perform, especially in value-based care decision-making environments.
The purpose of this study is to describe the rate of return to the OR for knee procedures following cartilage restoration at intervals of 90 days, 1 year, and 2 years across a large-scale US patient database. The authors hypothesize that the rate of return to the OR following knee cartilage repair or restoration procedures will be under 20% during the first post-operative year, with increasing reoperation rates over time. A secondary hypothesis is that there will be no difference in reoperation rates according to sex, but that younger patients (those younger than 40 years) will have higher reoperation rates than older patients.
METHODS
We performed a retrospective analysis of a prospectively collected, large-scale, and commercially available private payer insurance company database (PearlDiver) from 2007 to 2011. The PearlDiver database is a Health Insurance Portability and Accountability Act (HIPAA) compliant, publicly available national database consisting of a collection of private payer records, with United Health Group representing the contributing health plan. The database has more than 30 million patient records and contains Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes related to orthopedic procedures. From 2007 to 2011, the private payer database captured between 5.9 million and 6.2 million patients per year.
Our search was based on the CPT codes for MFX (29879), ACI (27412), OATS (29866, 29867), and OCA (27415, 27416). Return to the OR for revision surgery for the above-mentioned procedures was classified as patients with a diagnosis of diagnostic arthroscopy with biopsy (CPT 29870), lysis of adhesions (CPT 29884), synovectomy (29875, 29876), arthroscopy for infection or lavage (CPT 29871), arthroscopy for removal of loose bodies (29874), chondroplasty (29877), unicompartmental knee arthroplasty (27446), total knee arthroplasty (27447), and/or patellar arthroplasty (27438). Patient records were followed for reoperations occurring within 90 days, 1 year, and 2 years after the index cartilage procedure. All data were compared based on patient age and sex.
Table 1. Breakdown of MFX, ACI, OATS, and OCA Procedures by Sex | ||||||
MFX | ACI | Open OATS | Arthroscopic OATS | Open OCA | Arthroscopic OCA | |
Females | 20,589 | 276 | 167 | 401 | 275 | 350 |
Males | 22,987 | 364 | 219 | 596 | 439 | 544 |
Total | 43,576 | 640 | 386 | 997 | 714 | 894 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analysis of this study was primarily descriptive to demonstrate the incidence for each code at each time interval. One-way analysis of variance, Chi-square analysis, and contingency tables were used to compare the incidence of each type of procedure throughout the various time intervals. A P-value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v.20 (International Business Machines).
RESULTS
A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX (92.3%) 640 ACI (1.4%), 386 open OATS (0.82%), 997 arthroscopic OATS (2.11%), 714 open OCA (1.51%), and 894 arthroscopic OCA (1.89%) procedures. A summary of the procedures performed, broken down by age and sex, is provided in Tables 1 and 2. A total of 25,149 male patients (53.3%) underwent surgical procedures compared to 22,058 female patients (46.7%). For each category of procedure (MFX, ACI, OATS, OCA), there was a significantly higher proportion of males than females undergoing surgery (P < .0001 for all). Surgical treatment with MFX was consistently the most frequently performed surgery across all age groups (92.31%), while cell-based therapy with ACI was the least frequently performed procedure across all age ranges (1.36%). Restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not utilized in patients over 64 years of age (Table 2).
Table 2. Breakdown of MFX, ACI, OATS, and OCA Procedures by Age | ||||
Age (y) | MFX | ACI | OATS | OCA |
10 to 14 | 572 | 22 | 74 | 47 |
15 to 19 | 1984 | 83 | 254 | 235 |
20 to 24 | 1468 | 54 | 140 | 144 |
25 to 29 | 1787 | 74 | 152 | 176 |
30 to 34 | 2824 | 114 | 152 | 204 |
35 to 39 | 4237 | 96 | 153 | 210 |
40 to 44 | 5441 | 103 | 166 | 217 |
45 to 49 | 7126 | 57 | 149 | 180 |
50 to 54 | 7004 | 25 | 83 | 140 |
55 to 59 | 6410 | 12 | 40 | 40 |
60 to 64 | 4409 | 0 | 20 | 15 |
65 to 69 | 269 | 0 | 0 | 0 |
70 to 74 | 45 | 0 | 0 | 0 |
Total | 43,576 | 640 | 1383 | 1608 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
A summary of all reoperation data is provided in Tables 3 to 7 and Figures 1 and 2. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. Patients who underwent MFX had reoperation rates of 6.05% at 90 days, 11.80% at 1 year, and 14.65% at 2 years. Patients who underwent ACI had reoperation rates of 4.53% at 90 days, 23.28% at 1 year, and 29.69% at 2 years. Patients who had open and arthroscopic OATS had reoperation rates of 3.122% and 5.12% at 90 days, 6.74% and 8.53% at 1 year, and 7.51% and 10.13% at 2 years, respectively. Patients who underwent open and arthroscopic OCA had reoperation rates of 2.52% and 3.91% at 90 days, 7.14% and 6.60% at 1 year, and 13.59% and 10.85% at 2 years (Table 3). There was a statistically significantly increased risk for reoperation following ACI within all intervals compared to all other surgical techniques (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty at 6.70%. There was no significant difference between failure rates (revision OATS/OCA or conversion to arthroplasty) between the restorative treatment options, with 14 failures for OATS (9.52% of reoperations at 2 years) compared to 22 failures for OCA (12.7% of reoperations at 2 years, P = .358). Among the entire cohort of cartilage surgery patients, arthroscopic chondroplasty was the most frequent procedure performed at the time of reoperation at all time points assessed, notably accounting for 33.08% of reoperations 2 years following microfracture, 51.58% of reoperations at 2 years following ACI, 53.06% of reoperations at 2 years following OATS, and 54.07% of reoperations at 2 years following OCA (Figure 3, Tables 4–7).
Table 3. Comparison of Return to OR Following MFX, ACI, OCA, and OATS | |||||||
Procedure | Total No. of Cases in Study Period | No. of Reoperations at 90 Days | Return to OR Rate at 90 Days | No. of Reoperations at 1 Year | Return to OR Rate at 1 Year | No. of Reoperations at 2 Years | Return to OR Rate at 2 Years |
MFX | 43,576 | 2636 | 6.05% | 5142 | 11.80% | 6385 | 14.65% |
ACI | 640 | 29 | 4.53% | 149 | 23.28% | 190 | 29.69% |
Open OATS | 386 | 12 | 3.12% | 26 | 6.74% | 29 | 7.51% |
Arthroscopic OATS | 997 | 51 | 5.12% | 85 | 8.53% | 101 | 10.13% |
Open OCA | 714 | 18 | 2.52% | 51 | 7.14% | 97 | 13.59% |
Arthroscopic OCA | 894 | 161 | 3.91% | 59 | 6.60% | 97 | 10.85% |
Weighted average for all procedures |
| 5.87% |
| 11.94% |
| 14.90% |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation; OR, operating room.
Table 4. Rate of Return to OR Following MFX (n = 43,574) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 54 | 122 | 162 |
Knee arthroscopic drainage and lavage | 29871 | 84 | 102 | 104 |
Arthroscopic adhesions débridement | 29874 | 300 | 468 | 549 |
Arthroscopic synovectomy | 29875 | 324 | 528 | 611 |
Major arthroscopic synovectomy | 29876 | 557 | 926 | 1087 |
Knee arthroscopic chondroplasty | 29877 | 1063 | 1722 | 2112 |
Arthroscopic lysis of adhesions | 29884 | 61 | 129 | 171 |
Patellar arthroplasty | 27438 | 0 | 38 | 49 |
Medial or lateral knee arthroplasty | 27446 | 51 | 242 | 328 |
Medial and lateral knee arthroplasty | 27447 | 142 | 865 | 1212 |
Total | 2636 | 5142 | 6385 | |
Return to OR | 6.05% | 11.80% | 14.65% |
Abbreviations: CPT, Current Procedural Terminology; MFX, microfracture; OR, operating room.
Table 5. Rate of Return to OR Following ACI (n = 640) | ||||
Procedure | CPT Code | 90 Daysa | 1 Yeara | 2 Yearsa |
Revision ACI | 27412 | 29 | 33 | 35 |
Knee arthroscopy | 29870 | -1 | -1 | -1 |
Knee arthroscopic drainage and lavage | 29871 | -1 | -1 | -1 |
Arthroscopic adhesions débridement | 29874 | 0 | -1 | -1 |
Arthroscopic synovectomy | 29875 | -1 | -1 | -1 |
Major arthroscopic synovectomy | 29876 | -1 | 12 | 20 |
Knee arthroscopic chondroplasty | 29877 | -1 | 71 | 98 |
Arthroscopic lysis of adhesions | 29884 | -1 | 33 | 37 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | -1 | -1 |
Medial and lateral knee arthroplasty | 27447 | 0 | -1 | -1 |
Total | 29 | 149 | 190 | |
Return to OR | 4.53% | 23.28% | 29.69% |
aA -1 denotes No. <11 within the PearlDiver database, and exact numbers are not reported due to patient privacy considerations.
Abbreviations: ACI, autologous chondrocyte implantation; CPT, Current Procedural Terminology; OR, operating room.
Table 6. Rate of Return to OR Following OATS (n = 1320) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 12 | 13 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 14 |
Major arthroscopic synovectomy | 29876 | 16 | 25 | 28 |
Knee arthroscopic chondroplasty | 29877 | 17 | 58 | 78 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 14 |
Total | 33 | 95 | 147 | |
Return to OR | 2.50% | 7.20% | 11.14% |
Abbreviations: CPT, Current Procedural Terminology; OATS, osteochondral autograft transplantation; OR, operating room.
Table 7. Rate of Return to OR Following OCA Transplantation (n = 1531) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Year |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 15 | 19 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 0 |
Major arthroscopic synovectomy | 29876 | 0 | 20 | 38 |
Knee arthroscopic chondroplasty | 29877 | 22 | 59 | 93 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 22 |
Total | 22 | 94 | 172 | |
Return to OR | 1.44% | 6.14% | 11.23% |
Abbreviations: CPT, Current Procedural Terminology; OCA, osteochondral allograft; OR, operating room.
Continue to: Discussion...
DISCUSSION
The principle findings of this study demonstrate that there is an overall reoperation rate of 14.90% at 2 years following cartilage repair/restoration surgery, with the highest reoperation rates following MFX at 90 days, and ACI at both 1 year and 2 years following the index procedure. Also, patients undergoing index MFX as the index procedure have the highest risk for conversion to arthroplasty, reoperation rates for all cartilage surgeries increase over time, and arthroscopic chondroplasty is the most frequent procedure performed at the time of reoperation.
The management of symptomatic articular cartilage knee pathology is extremely challenging. With improvements in surgical technique, instrumentation, and clinical decision-making, indications are constantly evolving. Techniques that may work for “small” defects, though there is some debate as to what constitutes a “small” defect, are not necessarily going to be successful for larger defects, and this certainly varies depending on where the defect is located within the knee joint (distal femur vs patella vs trochlea, etc.). Recently, in a 2015 analysis of 3 level I or II studies, Miller and colleagues7 demonstrated both MFX and OATS to be viable, cost-effective, first-line treatment options for articular cartilage injuries, with similar clinical outcomes at 8.7 years. The authors noted cumulative reoperation rates of 29% among patients undergoing MFX compared to 13% among patients undergoing OATS. While ACI and OCA procedures were not included in their study, the reported reoperation rates of 29% following MFX and 13% following OATS at nearly 10 years suggest a possible increased need for reoperation following MFX over time (approximately 15% at 2 years in our study) and a stable rate of reoperation following OATS (approximately 11% at 2 years in our study). This finding is significant, as one of the goals with these procedures is to deliver effective, long-lasting pain relief and restoration of function. Interestingly, in this study, restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not performed in patients older than 64 years. This may be explained by the higher prevalence of acute traumatic injuries and osteochondritis dissecans diagnoses in younger patients compared with older patients, as these diagnoses are more often indicated to undergo restorative procedures as opposed to marrow stimulation.
In a 2016 systematic review of 20 studies incorporating 1117 patients, Campbell and colleagues8 assessed return-to-play rates following MFX, ACI, OATS, and OCA. The authors noted that return to sport (RTS) rates were greatest following OATS (89%), followed by OCA (88%), ACI (84%), and MFX (75%). Positive prognostic factors for RTS included younger age, shorter duration of preoperative symptoms, no history of prior ipsilateral knee surgery, and smaller chondral defects. Reoperation rates between the 4 techniques were not statistically compared in their study. Interestingly, in 2013, Chalmers and colleagues9 conducted a separate systematic review of 20 studies comprising 1375 patients undergoing MFX, ACI, or OATS. In their study, the authors found significant advantages following ACI and OATS compared to MFX with respect to patient-reported outcome scores but noted significantly faster RTS rates with MFX. Reoperation rates were noted to be similar between the 3 procedures (25% for ACI, 21% for MFX, and 28% for OATS) at an average 3.7 years following the index procedure. When considering these 2 systematic reviews together, despite a faster RTS rate following MFX, a greater proportion of patients seem to be able to RTS over time following other procedures such as OATS, OCA, and ACI. Unfortunately, these reviews do not provide insight as to the role, if any, of reoperation on return to play rates nor on overall clinical outcome scores on patients undergoing articular cartilage surgery. However, this information is valuable when counseling athletes who are in season and would like to RTS as soon as possible as opposed to those who do not have tight time constraints for when they need to RTS.
Regardless of the cartilage technique chosen, the goals of surgery remain similar—to reduce pain and improve function. For athletes, the ultimate goal is to return to the same level of play that the athlete was able to achieve prior to injury. Certainly, the need for reoperation following a cartilage surgery has implications on pain, function, and ability to RTS. Our review of nearly 50,000 cartilage surgeries demonstrates that reoperations following cartilage repair surgery are not uncommon, with a rate of 14.90% at 2 years, and that while reoperation rates are the highest following ACI, the rate of conversion to knee arthroplasty is highest following MFX. Due to the limitations of the PearlDiver database, it is not possible to determine the clinical outcomes of patients undergoing reoperation following cartilage surgery, but certainly, given these data, reoperation is clearly not necessarily indicative of clinical failure. This is highlighted by the fact that the most common procedure performed at the time of reoperation is arthroscopic chondroplasty, which, despite being an additional surgical procedure, may be acceptable for patients who wish to RTS, particularly in the setting of an index ACI in which there may be graft hypertrophy. Ideally, additional studies incorporating a cost-effectiveness analysis of each of the procedures, incorporating reoperation rates as well as patient-reported clinical outcomes, would be helpful to truly determine the patient and societal implications of reoperation following cartilage repair/restoration.
Many of the advantages and disadvantages of the described cartilage repair/restoration procedures have been well described.10-17 Microfracture is the most commonly utilized first-line repair/restoration option for small articular cartilage lesions, mainly due to its low cost, low morbidity, and relatively low level of difficulty.18 Despite these advantages, MFX is not without limitations, and the need for revision cartilage restoration and/or conversion to arthroplasty is concerning. In 2013, Salzmann and colleagues19 evaluated a cohort of 454 patients undergoing MFX for a symptomatic knee defect and noted a reoperation rate of 26.9% (n = 123) within 2 years of the index surgery, with risk factors for reoperation noted to include an increased number of pre-MFX ipsilateral knee surgeries, patellofemoral lesions, smoking, and lower preoperative numeric analog scale scores. The definition of reoperation in their study is unfortunately not described, and thus the extent of reoperation (arthroscopy to arthroplasty) is unclear. In a 2009 systematic review of 3122 patients (28 studies) undergoing MFX conducted by Mithoefer and colleagues,20 revision rates were noted to range from 2% to 31% depending on the study analyzed, with increasing revision rates after 2 years. Unfortunately, the heterogeneity of the included studies makes it difficult to determine which patients tend to fail over time.
Continue to: OATS...
OATS is a promising cartilage restoration technique indicated for treatment of patients with large, uncontained chondral lesions, and/or lesions with both bone and cartilage loss.1 OCA is similar to OATS but uses allograft tissue instead of autograft tissue and is typically considered a viable treatment option in larger lesions (>2 cm2).21 Cell-based ACI therapy has evolved substantially over the past decade and is now available as a third-generation model utilizing biodegradable 3-dimensional scaffolds seeded with chondrocytes. Reoperation rates following ACI can often be higher than those following other cartilage treatments, particularly given the known complication of graft hypertrophy and/or delamination. Harris and colleagues22 conducted a systematic review of 5276 subjects undergoing ACI (all generations), noting an overall reoperation rate of 33%, but a failure rate of 5.8% at an average of 22 months following ACI. Risk factors for reoperation included periosteal-based ACI as well as open (vs arthroscopic) ACI. In this study, we found a modestly lower return to OR rate of 29.69% at 2 years.
When the outcomes of patients undergoing OATS or OCA are compared to those of patients undergoing MFX or ACI, it can be difficult to interpret the results, as the indications for performing these procedures tend to be very different. Further, the reasons for reoperation, as well as the procedures performed at the time of reoperation, are often poorly described, making it difficult to truly quantify the risk of reoperation and the implications of reoperation for patients undergoing any of these index cartilage procedures.
Overall, in this database, the return to the OR rate approaches 15% at 2 years following cartilage surgery, with cell-based therapy demonstrating higher reoperation rates at 2 years, without the risk of conversion to arthroplasty. Reoperation rates appear to stabilize at 1 year following surgery and consist mostly of minor arthroscopic procedures. These findings can help surgeons counsel patients as to the rate and type of reoperations that can be expected following cartilage surgery. Additional research incorporating patient-reported outcomes and patient-specific risk factors are needed to complement these data as to the impact of reoperations on overall clinical outcomes. Further, studies incorporating 90-day, 1-year, and 2-year costs associated with cartilage surgery will help to determine which index procedure is the most cost effective over the short- and long-term.
LIMITATIONS
This study is not without limitations. The PearlDiver database is reliant upon accurate CPT and ICD-9 coding, which creates a potential for a reporting bias. The overall reliability of the analyses is dependent on the quality of the available data, which, as noted in previous PearlDiver studies,18,23-28 may include inaccurate billing codes, miscoding, and/or non-coding by physicians as potential sources of error. At the time of this study, the PearlDiver database did not provide consistent data points on laterality, and thus it is possible that the reported rates of reoperation overestimate the true reoperation rate following a given procedure. Fortunately, the reoperation rates for each procedure analyzed in this database study are consistent with those previously presented in the literature. In addition, it is not uncommon for patients receiving one of these procedures to have previously been treated with one of the others. Due to the inherent limitations of the PearlDiver database, this study did not investigate concomitant procedures performed along with the index procedure, nor did it investigate confounding factors such as comorbidities. The PearlDiver database does not provide data on defect size, location within the knee, concomitant pathologies (eg, meniscus tear), prior surgeries, or patient comorbidities, and while important, these factors cannot be accounted for in our analysis. The inability to account for these important factors, particularly concomitant diagnoses, procedures, and lesion size/location, represents an important limitation of this study, as this is a source of selection bias and may influence the need for reoperation in a given patient. Despite these limitations, the results of this study are supported by previous and current literature. In addition, the PearlDiver database, as a HIPAA-compliant database, does not report exact numbers when the value of the outcome of interest is between 0 and 10, which prohibits analysis of any cartilage procedure performed in a cohort of patients greater than 1 and less than 11. Finally, while not necessarily a limitation, it should be noted that CPT 29879 is not specific for microfracture, as the code also includes abrasion arthroplasty and drilling. Due to the limitations of the methodology of searching the database for this code, it is unclear as to how many patients underwent actual microfracture vs abrasion arthroplasty.
CONCLUSION
Within a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference between failure/revision rates among the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
- Farr J, Cole B, Dhawan A, Kercher J, Sherman S. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-2705. doi:10.1007/s11999-010-1764-z.
- Alford JW, Cole BJ. Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306. doi:10.1177/03635465004273510.
- Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460. doi:10.1177/0363546505274578.
- Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508. doi:10.1177/0363546512458763.
- Saris DBF, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10-19. doi:10.1177/0363546509350694.
- McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014;42(4):892-897. doi:10.1177/0363546513520115.
- Miller DJ, Smith MV, Matava MJ, Wright RW, Brophy RH. Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur. Am J Sports Med. 2015;43(9):2175-2181. doi:10.1177/0363546515591261.
- Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 2016;32(4):651-668.
- Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013;4(3):193-203.
- Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. JBone Joint Surg Br. 2012;94(4):504-509. doi:10.1177/1947603513481603.
- Beris AE, Lykissas MG, Kostas-Agnantis I, Manoudis GN. Treatment of full-thickness chondral defects of the knee with autologous chondrocyte implantation: a functional evaluation with long-term follow-up. Am J Sports Med. 2012;40(3):562-567.
- Chahal J, Gross AE, Gross C, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013;29(3):575-588. doi:10.1177/0363546511428778.
- Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907-914. doi:10.1177/0363546507299932.
- Gudas R, Stankevičius E, Monastyreckienė E, Pranys D, Kalesinskas R. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):834-842. doi:10.1007/s00167-006-0067-0.
- Lynch TS, Patel RM, Benedick A, Amin NH, Jones MH, Miniaci A. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754. doi:10.1016/j.arthro.2014.11.018.
- Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes after first-generation autologous chondrocyte implantation for cartilage defects of the knee. Am J Sports Med. 2014;42(1):150-157. doi:10.1177/0363546513506593.
- Ulstein S, Årøen A, Røtterud J, Løken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1207-1215. doi:10.1007/s00167-014-2843-6.
- Montgomery S, Foster B, Ngo S, et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2070-2075. doi:10.1007/s00167-013-2614-9.
- Salzmann GM, Sah B, Südkamp NP, Niemeyer P. Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):365-371. doi:10.1007/s00167-012-1973-y.
- Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414.
- Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2):411-415. doi:10.1177/0363546512469091.
- Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation–a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791. doi:10.1016/j.joca.2011.02.010.
- Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
- Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665. doi:10.1016/j.arthro.2012.11.005.
- Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437-441. doi:10.1177/0363546513510686.
- Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014;30(4):436-443. doi:10.1016/j.arthro.2013.12.013.
- Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015;30(suppl 9):72-75. doi:10.1016/j.arth.2015.01.061.
- Carr JB 2nd, Werner BC, Browne JA. Trends and outcomes in the treatment of failed septic total knee arthroplasty: comparing arthrodesis and above-knee amputation. J Arthroplasty. 2016;31(7):1574-1577. doi:10.1016/j.arth.2016.01.010.
ABSTRACT
The purpose of this study is to describe the rate of return to the operating room (OR) following microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and osteochondral allograft (OCA) procedures at 90 days, 1 year, and 2 years. Current Procedural Terminology codes for all patients undergoing MFX, ACI, OATS, and OCA were used to search a prospectively collected, commercially available private payer insurance company database from 2007 to 2011. Within 90 days, 1 year, and 2 years after surgery, the database was searched for the occurrence of these same patients undergoing knee diagnostic arthroscopy with biopsy, lysis of adhesions, synovectomy, arthroscopy for infection or lavage, arthroscopy for removal of loose bodies, chondroplasty, MFX, ACI, OATS, OCA, and/or knee arthroplasty. Descriptive statistical analysis and contingency table analysis were performed. A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX, 640 ACI, 386 open OATS, 997 arthroscopic OATS, 714 open OCA, and 894 arthroscopic OCA procedures. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. At 2 years, patients who underwent MFX, ACI, OATS, OCA had reoperation rates of 14.65%, 29.69%, 8.82%, and 12.22%, respectively. There was a statistically significantly increased risk for ACI return to OR within all intervals (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative treatment options. With a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
Continue to: Symptomatic, full-thickness articular cartilage
Symptomatic, full-thickness articular cartilage defects in the knee are difficult to manage, particularly in the young, athletic patient population. Fortunately, a variety of cartilage repair (direct repair of the cartilage or those procedures which attempt to generate fibrocartilage) and restoration (those aimed at restoring hyaline cartilage) procedures are available, with encouraging short- and long-term clinical outcomes. After failure of nonoperative management, several surgical options are available for treating symptomatic focal chondral defects, including microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and open and arthroscopic osteochondral allograft (OCA) transplantation procedures.1,2 When appropriately indicated, each of these techniques has demonstrated good to excellent clinical outcomes with respect to reducing pain and improving function.3-5
While major complications following cartilage surgery are uncommon, the need for reoperation following an index articular cartilage operation is poorly understood. Recently, McCormick and colleagues6 found that reoperation within the first 2 years following meniscus allograft transplantation (MAT) is associated with an increased likelihood of revision MAT or future arthroplasty. Given the association between early reoperation following meniscus restoration surgery and subsequent failure, an improved understanding of the epidemiology and implications of reoperations following cartilage restoration surgery is warranted. Further, in deciding which treatment option is best suited to a particular patient, the rate of return to the operating room (OR) should be taken into consideration, as this could potentially influence surgical decision-making as to which procedure to perform, especially in value-based care decision-making environments.
The purpose of this study is to describe the rate of return to the OR for knee procedures following cartilage restoration at intervals of 90 days, 1 year, and 2 years across a large-scale US patient database. The authors hypothesize that the rate of return to the OR following knee cartilage repair or restoration procedures will be under 20% during the first post-operative year, with increasing reoperation rates over time. A secondary hypothesis is that there will be no difference in reoperation rates according to sex, but that younger patients (those younger than 40 years) will have higher reoperation rates than older patients.
METHODS
We performed a retrospective analysis of a prospectively collected, large-scale, and commercially available private payer insurance company database (PearlDiver) from 2007 to 2011. The PearlDiver database is a Health Insurance Portability and Accountability Act (HIPAA) compliant, publicly available national database consisting of a collection of private payer records, with United Health Group representing the contributing health plan. The database has more than 30 million patient records and contains Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes related to orthopedic procedures. From 2007 to 2011, the private payer database captured between 5.9 million and 6.2 million patients per year.
Our search was based on the CPT codes for MFX (29879), ACI (27412), OATS (29866, 29867), and OCA (27415, 27416). Return to the OR for revision surgery for the above-mentioned procedures was classified as patients with a diagnosis of diagnostic arthroscopy with biopsy (CPT 29870), lysis of adhesions (CPT 29884), synovectomy (29875, 29876), arthroscopy for infection or lavage (CPT 29871), arthroscopy for removal of loose bodies (29874), chondroplasty (29877), unicompartmental knee arthroplasty (27446), total knee arthroplasty (27447), and/or patellar arthroplasty (27438). Patient records were followed for reoperations occurring within 90 days, 1 year, and 2 years after the index cartilage procedure. All data were compared based on patient age and sex.
Table 1. Breakdown of MFX, ACI, OATS, and OCA Procedures by Sex | ||||||
MFX | ACI | Open OATS | Arthroscopic OATS | Open OCA | Arthroscopic OCA | |
Females | 20,589 | 276 | 167 | 401 | 275 | 350 |
Males | 22,987 | 364 | 219 | 596 | 439 | 544 |
Total | 43,576 | 640 | 386 | 997 | 714 | 894 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analysis of this study was primarily descriptive to demonstrate the incidence for each code at each time interval. One-way analysis of variance, Chi-square analysis, and contingency tables were used to compare the incidence of each type of procedure throughout the various time intervals. A P-value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v.20 (International Business Machines).
RESULTS
A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX (92.3%) 640 ACI (1.4%), 386 open OATS (0.82%), 997 arthroscopic OATS (2.11%), 714 open OCA (1.51%), and 894 arthroscopic OCA (1.89%) procedures. A summary of the procedures performed, broken down by age and sex, is provided in Tables 1 and 2. A total of 25,149 male patients (53.3%) underwent surgical procedures compared to 22,058 female patients (46.7%). For each category of procedure (MFX, ACI, OATS, OCA), there was a significantly higher proportion of males than females undergoing surgery (P < .0001 for all). Surgical treatment with MFX was consistently the most frequently performed surgery across all age groups (92.31%), while cell-based therapy with ACI was the least frequently performed procedure across all age ranges (1.36%). Restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not utilized in patients over 64 years of age (Table 2).
Table 2. Breakdown of MFX, ACI, OATS, and OCA Procedures by Age | ||||
Age (y) | MFX | ACI | OATS | OCA |
10 to 14 | 572 | 22 | 74 | 47 |
15 to 19 | 1984 | 83 | 254 | 235 |
20 to 24 | 1468 | 54 | 140 | 144 |
25 to 29 | 1787 | 74 | 152 | 176 |
30 to 34 | 2824 | 114 | 152 | 204 |
35 to 39 | 4237 | 96 | 153 | 210 |
40 to 44 | 5441 | 103 | 166 | 217 |
45 to 49 | 7126 | 57 | 149 | 180 |
50 to 54 | 7004 | 25 | 83 | 140 |
55 to 59 | 6410 | 12 | 40 | 40 |
60 to 64 | 4409 | 0 | 20 | 15 |
65 to 69 | 269 | 0 | 0 | 0 |
70 to 74 | 45 | 0 | 0 | 0 |
Total | 43,576 | 640 | 1383 | 1608 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
A summary of all reoperation data is provided in Tables 3 to 7 and Figures 1 and 2. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. Patients who underwent MFX had reoperation rates of 6.05% at 90 days, 11.80% at 1 year, and 14.65% at 2 years. Patients who underwent ACI had reoperation rates of 4.53% at 90 days, 23.28% at 1 year, and 29.69% at 2 years. Patients who had open and arthroscopic OATS had reoperation rates of 3.122% and 5.12% at 90 days, 6.74% and 8.53% at 1 year, and 7.51% and 10.13% at 2 years, respectively. Patients who underwent open and arthroscopic OCA had reoperation rates of 2.52% and 3.91% at 90 days, 7.14% and 6.60% at 1 year, and 13.59% and 10.85% at 2 years (Table 3). There was a statistically significantly increased risk for reoperation following ACI within all intervals compared to all other surgical techniques (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty at 6.70%. There was no significant difference between failure rates (revision OATS/OCA or conversion to arthroplasty) between the restorative treatment options, with 14 failures for OATS (9.52% of reoperations at 2 years) compared to 22 failures for OCA (12.7% of reoperations at 2 years, P = .358). Among the entire cohort of cartilage surgery patients, arthroscopic chondroplasty was the most frequent procedure performed at the time of reoperation at all time points assessed, notably accounting for 33.08% of reoperations 2 years following microfracture, 51.58% of reoperations at 2 years following ACI, 53.06% of reoperations at 2 years following OATS, and 54.07% of reoperations at 2 years following OCA (Figure 3, Tables 4–7).
Table 3. Comparison of Return to OR Following MFX, ACI, OCA, and OATS | |||||||
Procedure | Total No. of Cases in Study Period | No. of Reoperations at 90 Days | Return to OR Rate at 90 Days | No. of Reoperations at 1 Year | Return to OR Rate at 1 Year | No. of Reoperations at 2 Years | Return to OR Rate at 2 Years |
MFX | 43,576 | 2636 | 6.05% | 5142 | 11.80% | 6385 | 14.65% |
ACI | 640 | 29 | 4.53% | 149 | 23.28% | 190 | 29.69% |
Open OATS | 386 | 12 | 3.12% | 26 | 6.74% | 29 | 7.51% |
Arthroscopic OATS | 997 | 51 | 5.12% | 85 | 8.53% | 101 | 10.13% |
Open OCA | 714 | 18 | 2.52% | 51 | 7.14% | 97 | 13.59% |
Arthroscopic OCA | 894 | 161 | 3.91% | 59 | 6.60% | 97 | 10.85% |
Weighted average for all procedures |
| 5.87% |
| 11.94% |
| 14.90% |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation; OR, operating room.
Table 4. Rate of Return to OR Following MFX (n = 43,574) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 54 | 122 | 162 |
Knee arthroscopic drainage and lavage | 29871 | 84 | 102 | 104 |
Arthroscopic adhesions débridement | 29874 | 300 | 468 | 549 |
Arthroscopic synovectomy | 29875 | 324 | 528 | 611 |
Major arthroscopic synovectomy | 29876 | 557 | 926 | 1087 |
Knee arthroscopic chondroplasty | 29877 | 1063 | 1722 | 2112 |
Arthroscopic lysis of adhesions | 29884 | 61 | 129 | 171 |
Patellar arthroplasty | 27438 | 0 | 38 | 49 |
Medial or lateral knee arthroplasty | 27446 | 51 | 242 | 328 |
Medial and lateral knee arthroplasty | 27447 | 142 | 865 | 1212 |
Total | 2636 | 5142 | 6385 | |
Return to OR | 6.05% | 11.80% | 14.65% |
Abbreviations: CPT, Current Procedural Terminology; MFX, microfracture; OR, operating room.
Table 5. Rate of Return to OR Following ACI (n = 640) | ||||
Procedure | CPT Code | 90 Daysa | 1 Yeara | 2 Yearsa |
Revision ACI | 27412 | 29 | 33 | 35 |
Knee arthroscopy | 29870 | -1 | -1 | -1 |
Knee arthroscopic drainage and lavage | 29871 | -1 | -1 | -1 |
Arthroscopic adhesions débridement | 29874 | 0 | -1 | -1 |
Arthroscopic synovectomy | 29875 | -1 | -1 | -1 |
Major arthroscopic synovectomy | 29876 | -1 | 12 | 20 |
Knee arthroscopic chondroplasty | 29877 | -1 | 71 | 98 |
Arthroscopic lysis of adhesions | 29884 | -1 | 33 | 37 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | -1 | -1 |
Medial and lateral knee arthroplasty | 27447 | 0 | -1 | -1 |
Total | 29 | 149 | 190 | |
Return to OR | 4.53% | 23.28% | 29.69% |
aA -1 denotes No. <11 within the PearlDiver database, and exact numbers are not reported due to patient privacy considerations.
Abbreviations: ACI, autologous chondrocyte implantation; CPT, Current Procedural Terminology; OR, operating room.
Table 6. Rate of Return to OR Following OATS (n = 1320) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 12 | 13 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 14 |
Major arthroscopic synovectomy | 29876 | 16 | 25 | 28 |
Knee arthroscopic chondroplasty | 29877 | 17 | 58 | 78 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 14 |
Total | 33 | 95 | 147 | |
Return to OR | 2.50% | 7.20% | 11.14% |
Abbreviations: CPT, Current Procedural Terminology; OATS, osteochondral autograft transplantation; OR, operating room.
Table 7. Rate of Return to OR Following OCA Transplantation (n = 1531) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Year |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 15 | 19 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 0 |
Major arthroscopic synovectomy | 29876 | 0 | 20 | 38 |
Knee arthroscopic chondroplasty | 29877 | 22 | 59 | 93 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 22 |
Total | 22 | 94 | 172 | |
Return to OR | 1.44% | 6.14% | 11.23% |
Abbreviations: CPT, Current Procedural Terminology; OCA, osteochondral allograft; OR, operating room.
Continue to: Discussion...
DISCUSSION
The principle findings of this study demonstrate that there is an overall reoperation rate of 14.90% at 2 years following cartilage repair/restoration surgery, with the highest reoperation rates following MFX at 90 days, and ACI at both 1 year and 2 years following the index procedure. Also, patients undergoing index MFX as the index procedure have the highest risk for conversion to arthroplasty, reoperation rates for all cartilage surgeries increase over time, and arthroscopic chondroplasty is the most frequent procedure performed at the time of reoperation.
The management of symptomatic articular cartilage knee pathology is extremely challenging. With improvements in surgical technique, instrumentation, and clinical decision-making, indications are constantly evolving. Techniques that may work for “small” defects, though there is some debate as to what constitutes a “small” defect, are not necessarily going to be successful for larger defects, and this certainly varies depending on where the defect is located within the knee joint (distal femur vs patella vs trochlea, etc.). Recently, in a 2015 analysis of 3 level I or II studies, Miller and colleagues7 demonstrated both MFX and OATS to be viable, cost-effective, first-line treatment options for articular cartilage injuries, with similar clinical outcomes at 8.7 years. The authors noted cumulative reoperation rates of 29% among patients undergoing MFX compared to 13% among patients undergoing OATS. While ACI and OCA procedures were not included in their study, the reported reoperation rates of 29% following MFX and 13% following OATS at nearly 10 years suggest a possible increased need for reoperation following MFX over time (approximately 15% at 2 years in our study) and a stable rate of reoperation following OATS (approximately 11% at 2 years in our study). This finding is significant, as one of the goals with these procedures is to deliver effective, long-lasting pain relief and restoration of function. Interestingly, in this study, restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not performed in patients older than 64 years. This may be explained by the higher prevalence of acute traumatic injuries and osteochondritis dissecans diagnoses in younger patients compared with older patients, as these diagnoses are more often indicated to undergo restorative procedures as opposed to marrow stimulation.
In a 2016 systematic review of 20 studies incorporating 1117 patients, Campbell and colleagues8 assessed return-to-play rates following MFX, ACI, OATS, and OCA. The authors noted that return to sport (RTS) rates were greatest following OATS (89%), followed by OCA (88%), ACI (84%), and MFX (75%). Positive prognostic factors for RTS included younger age, shorter duration of preoperative symptoms, no history of prior ipsilateral knee surgery, and smaller chondral defects. Reoperation rates between the 4 techniques were not statistically compared in their study. Interestingly, in 2013, Chalmers and colleagues9 conducted a separate systematic review of 20 studies comprising 1375 patients undergoing MFX, ACI, or OATS. In their study, the authors found significant advantages following ACI and OATS compared to MFX with respect to patient-reported outcome scores but noted significantly faster RTS rates with MFX. Reoperation rates were noted to be similar between the 3 procedures (25% for ACI, 21% for MFX, and 28% for OATS) at an average 3.7 years following the index procedure. When considering these 2 systematic reviews together, despite a faster RTS rate following MFX, a greater proportion of patients seem to be able to RTS over time following other procedures such as OATS, OCA, and ACI. Unfortunately, these reviews do not provide insight as to the role, if any, of reoperation on return to play rates nor on overall clinical outcome scores on patients undergoing articular cartilage surgery. However, this information is valuable when counseling athletes who are in season and would like to RTS as soon as possible as opposed to those who do not have tight time constraints for when they need to RTS.
Regardless of the cartilage technique chosen, the goals of surgery remain similar—to reduce pain and improve function. For athletes, the ultimate goal is to return to the same level of play that the athlete was able to achieve prior to injury. Certainly, the need for reoperation following a cartilage surgery has implications on pain, function, and ability to RTS. Our review of nearly 50,000 cartilage surgeries demonstrates that reoperations following cartilage repair surgery are not uncommon, with a rate of 14.90% at 2 years, and that while reoperation rates are the highest following ACI, the rate of conversion to knee arthroplasty is highest following MFX. Due to the limitations of the PearlDiver database, it is not possible to determine the clinical outcomes of patients undergoing reoperation following cartilage surgery, but certainly, given these data, reoperation is clearly not necessarily indicative of clinical failure. This is highlighted by the fact that the most common procedure performed at the time of reoperation is arthroscopic chondroplasty, which, despite being an additional surgical procedure, may be acceptable for patients who wish to RTS, particularly in the setting of an index ACI in which there may be graft hypertrophy. Ideally, additional studies incorporating a cost-effectiveness analysis of each of the procedures, incorporating reoperation rates as well as patient-reported clinical outcomes, would be helpful to truly determine the patient and societal implications of reoperation following cartilage repair/restoration.
Many of the advantages and disadvantages of the described cartilage repair/restoration procedures have been well described.10-17 Microfracture is the most commonly utilized first-line repair/restoration option for small articular cartilage lesions, mainly due to its low cost, low morbidity, and relatively low level of difficulty.18 Despite these advantages, MFX is not without limitations, and the need for revision cartilage restoration and/or conversion to arthroplasty is concerning. In 2013, Salzmann and colleagues19 evaluated a cohort of 454 patients undergoing MFX for a symptomatic knee defect and noted a reoperation rate of 26.9% (n = 123) within 2 years of the index surgery, with risk factors for reoperation noted to include an increased number of pre-MFX ipsilateral knee surgeries, patellofemoral lesions, smoking, and lower preoperative numeric analog scale scores. The definition of reoperation in their study is unfortunately not described, and thus the extent of reoperation (arthroscopy to arthroplasty) is unclear. In a 2009 systematic review of 3122 patients (28 studies) undergoing MFX conducted by Mithoefer and colleagues,20 revision rates were noted to range from 2% to 31% depending on the study analyzed, with increasing revision rates after 2 years. Unfortunately, the heterogeneity of the included studies makes it difficult to determine which patients tend to fail over time.
Continue to: OATS...
OATS is a promising cartilage restoration technique indicated for treatment of patients with large, uncontained chondral lesions, and/or lesions with both bone and cartilage loss.1 OCA is similar to OATS but uses allograft tissue instead of autograft tissue and is typically considered a viable treatment option in larger lesions (>2 cm2).21 Cell-based ACI therapy has evolved substantially over the past decade and is now available as a third-generation model utilizing biodegradable 3-dimensional scaffolds seeded with chondrocytes. Reoperation rates following ACI can often be higher than those following other cartilage treatments, particularly given the known complication of graft hypertrophy and/or delamination. Harris and colleagues22 conducted a systematic review of 5276 subjects undergoing ACI (all generations), noting an overall reoperation rate of 33%, but a failure rate of 5.8% at an average of 22 months following ACI. Risk factors for reoperation included periosteal-based ACI as well as open (vs arthroscopic) ACI. In this study, we found a modestly lower return to OR rate of 29.69% at 2 years.
When the outcomes of patients undergoing OATS or OCA are compared to those of patients undergoing MFX or ACI, it can be difficult to interpret the results, as the indications for performing these procedures tend to be very different. Further, the reasons for reoperation, as well as the procedures performed at the time of reoperation, are often poorly described, making it difficult to truly quantify the risk of reoperation and the implications of reoperation for patients undergoing any of these index cartilage procedures.
Overall, in this database, the return to the OR rate approaches 15% at 2 years following cartilage surgery, with cell-based therapy demonstrating higher reoperation rates at 2 years, without the risk of conversion to arthroplasty. Reoperation rates appear to stabilize at 1 year following surgery and consist mostly of minor arthroscopic procedures. These findings can help surgeons counsel patients as to the rate and type of reoperations that can be expected following cartilage surgery. Additional research incorporating patient-reported outcomes and patient-specific risk factors are needed to complement these data as to the impact of reoperations on overall clinical outcomes. Further, studies incorporating 90-day, 1-year, and 2-year costs associated with cartilage surgery will help to determine which index procedure is the most cost effective over the short- and long-term.
LIMITATIONS
This study is not without limitations. The PearlDiver database is reliant upon accurate CPT and ICD-9 coding, which creates a potential for a reporting bias. The overall reliability of the analyses is dependent on the quality of the available data, which, as noted in previous PearlDiver studies,18,23-28 may include inaccurate billing codes, miscoding, and/or non-coding by physicians as potential sources of error. At the time of this study, the PearlDiver database did not provide consistent data points on laterality, and thus it is possible that the reported rates of reoperation overestimate the true reoperation rate following a given procedure. Fortunately, the reoperation rates for each procedure analyzed in this database study are consistent with those previously presented in the literature. In addition, it is not uncommon for patients receiving one of these procedures to have previously been treated with one of the others. Due to the inherent limitations of the PearlDiver database, this study did not investigate concomitant procedures performed along with the index procedure, nor did it investigate confounding factors such as comorbidities. The PearlDiver database does not provide data on defect size, location within the knee, concomitant pathologies (eg, meniscus tear), prior surgeries, or patient comorbidities, and while important, these factors cannot be accounted for in our analysis. The inability to account for these important factors, particularly concomitant diagnoses, procedures, and lesion size/location, represents an important limitation of this study, as this is a source of selection bias and may influence the need for reoperation in a given patient. Despite these limitations, the results of this study are supported by previous and current literature. In addition, the PearlDiver database, as a HIPAA-compliant database, does not report exact numbers when the value of the outcome of interest is between 0 and 10, which prohibits analysis of any cartilage procedure performed in a cohort of patients greater than 1 and less than 11. Finally, while not necessarily a limitation, it should be noted that CPT 29879 is not specific for microfracture, as the code also includes abrasion arthroplasty and drilling. Due to the limitations of the methodology of searching the database for this code, it is unclear as to how many patients underwent actual microfracture vs abrasion arthroplasty.
CONCLUSION
Within a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference between failure/revision rates among the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
ABSTRACT
The purpose of this study is to describe the rate of return to the operating room (OR) following microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and osteochondral allograft (OCA) procedures at 90 days, 1 year, and 2 years. Current Procedural Terminology codes for all patients undergoing MFX, ACI, OATS, and OCA were used to search a prospectively collected, commercially available private payer insurance company database from 2007 to 2011. Within 90 days, 1 year, and 2 years after surgery, the database was searched for the occurrence of these same patients undergoing knee diagnostic arthroscopy with biopsy, lysis of adhesions, synovectomy, arthroscopy for infection or lavage, arthroscopy for removal of loose bodies, chondroplasty, MFX, ACI, OATS, OCA, and/or knee arthroplasty. Descriptive statistical analysis and contingency table analysis were performed. A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX, 640 ACI, 386 open OATS, 997 arthroscopic OATS, 714 open OCA, and 894 arthroscopic OCA procedures. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. At 2 years, patients who underwent MFX, ACI, OATS, OCA had reoperation rates of 14.65%, 29.69%, 8.82%, and 12.22%, respectively. There was a statistically significantly increased risk for ACI return to OR within all intervals (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative treatment options. With a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference in failure/revision rates between the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
Continue to: Symptomatic, full-thickness articular cartilage
Symptomatic, full-thickness articular cartilage defects in the knee are difficult to manage, particularly in the young, athletic patient population. Fortunately, a variety of cartilage repair (direct repair of the cartilage or those procedures which attempt to generate fibrocartilage) and restoration (those aimed at restoring hyaline cartilage) procedures are available, with encouraging short- and long-term clinical outcomes. After failure of nonoperative management, several surgical options are available for treating symptomatic focal chondral defects, including microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral autograft transplantation (OATS), and open and arthroscopic osteochondral allograft (OCA) transplantation procedures.1,2 When appropriately indicated, each of these techniques has demonstrated good to excellent clinical outcomes with respect to reducing pain and improving function.3-5
While major complications following cartilage surgery are uncommon, the need for reoperation following an index articular cartilage operation is poorly understood. Recently, McCormick and colleagues6 found that reoperation within the first 2 years following meniscus allograft transplantation (MAT) is associated with an increased likelihood of revision MAT or future arthroplasty. Given the association between early reoperation following meniscus restoration surgery and subsequent failure, an improved understanding of the epidemiology and implications of reoperations following cartilage restoration surgery is warranted. Further, in deciding which treatment option is best suited to a particular patient, the rate of return to the operating room (OR) should be taken into consideration, as this could potentially influence surgical decision-making as to which procedure to perform, especially in value-based care decision-making environments.
The purpose of this study is to describe the rate of return to the OR for knee procedures following cartilage restoration at intervals of 90 days, 1 year, and 2 years across a large-scale US patient database. The authors hypothesize that the rate of return to the OR following knee cartilage repair or restoration procedures will be under 20% during the first post-operative year, with increasing reoperation rates over time. A secondary hypothesis is that there will be no difference in reoperation rates according to sex, but that younger patients (those younger than 40 years) will have higher reoperation rates than older patients.
METHODS
We performed a retrospective analysis of a prospectively collected, large-scale, and commercially available private payer insurance company database (PearlDiver) from 2007 to 2011. The PearlDiver database is a Health Insurance Portability and Accountability Act (HIPAA) compliant, publicly available national database consisting of a collection of private payer records, with United Health Group representing the contributing health plan. The database has more than 30 million patient records and contains Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes related to orthopedic procedures. From 2007 to 2011, the private payer database captured between 5.9 million and 6.2 million patients per year.
Our search was based on the CPT codes for MFX (29879), ACI (27412), OATS (29866, 29867), and OCA (27415, 27416). Return to the OR for revision surgery for the above-mentioned procedures was classified as patients with a diagnosis of diagnostic arthroscopy with biopsy (CPT 29870), lysis of adhesions (CPT 29884), synovectomy (29875, 29876), arthroscopy for infection or lavage (CPT 29871), arthroscopy for removal of loose bodies (29874), chondroplasty (29877), unicompartmental knee arthroplasty (27446), total knee arthroplasty (27447), and/or patellar arthroplasty (27438). Patient records were followed for reoperations occurring within 90 days, 1 year, and 2 years after the index cartilage procedure. All data were compared based on patient age and sex.
Table 1. Breakdown of MFX, ACI, OATS, and OCA Procedures by Sex | ||||||
MFX | ACI | Open OATS | Arthroscopic OATS | Open OCA | Arthroscopic OCA | |
Females | 20,589 | 276 | 167 | 401 | 275 | 350 |
Males | 22,987 | 364 | 219 | 596 | 439 | 544 |
Total | 43,576 | 640 | 386 | 997 | 714 | 894 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
Continue to: Statistical analysis...
STATISTICAL ANALYSIS
Statistical analysis of this study was primarily descriptive to demonstrate the incidence for each code at each time interval. One-way analysis of variance, Chi-square analysis, and contingency tables were used to compare the incidence of each type of procedure throughout the various time intervals. A P-value of < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS v.20 (International Business Machines).
RESULTS
A total of 47,207 cartilage procedures were performed from 2007 to 2011, including 43,576 MFX (92.3%) 640 ACI (1.4%), 386 open OATS (0.82%), 997 arthroscopic OATS (2.11%), 714 open OCA (1.51%), and 894 arthroscopic OCA (1.89%) procedures. A summary of the procedures performed, broken down by age and sex, is provided in Tables 1 and 2. A total of 25,149 male patients (53.3%) underwent surgical procedures compared to 22,058 female patients (46.7%). For each category of procedure (MFX, ACI, OATS, OCA), there was a significantly higher proportion of males than females undergoing surgery (P < .0001 for all). Surgical treatment with MFX was consistently the most frequently performed surgery across all age groups (92.31%), while cell-based therapy with ACI was the least frequently performed procedure across all age ranges (1.36%). Restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not utilized in patients over 64 years of age (Table 2).
Table 2. Breakdown of MFX, ACI, OATS, and OCA Procedures by Age | ||||
Age (y) | MFX | ACI | OATS | OCA |
10 to 14 | 572 | 22 | 74 | 47 |
15 to 19 | 1984 | 83 | 254 | 235 |
20 to 24 | 1468 | 54 | 140 | 144 |
25 to 29 | 1787 | 74 | 152 | 176 |
30 to 34 | 2824 | 114 | 152 | 204 |
35 to 39 | 4237 | 96 | 153 | 210 |
40 to 44 | 5441 | 103 | 166 | 217 |
45 to 49 | 7126 | 57 | 149 | 180 |
50 to 54 | 7004 | 25 | 83 | 140 |
55 to 59 | 6410 | 12 | 40 | 40 |
60 to 64 | 4409 | 0 | 20 | 15 |
65 to 69 | 269 | 0 | 0 | 0 |
70 to 74 | 45 | 0 | 0 | 0 |
Total | 43,576 | 640 | 1383 | 1608 |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation.
A summary of all reoperation data is provided in Tables 3 to 7 and Figures 1 and 2. The weighted average reoperation rates for all procedures were 5.87% at 90 days, 11.94% at 1 year, and 14.90% at 2 years following the index cartilage surgery. Patients who underwent MFX had reoperation rates of 6.05% at 90 days, 11.80% at 1 year, and 14.65% at 2 years. Patients who underwent ACI had reoperation rates of 4.53% at 90 days, 23.28% at 1 year, and 29.69% at 2 years. Patients who had open and arthroscopic OATS had reoperation rates of 3.122% and 5.12% at 90 days, 6.74% and 8.53% at 1 year, and 7.51% and 10.13% at 2 years, respectively. Patients who underwent open and arthroscopic OCA had reoperation rates of 2.52% and 3.91% at 90 days, 7.14% and 6.60% at 1 year, and 13.59% and 10.85% at 2 years (Table 3). There was a statistically significantly increased risk for reoperation following ACI within all intervals compared to all other surgical techniques (P < .0001); however, MFX had a greater risk factor (P < .0001) for conversion to arthroplasty at 6.70%. There was no significant difference between failure rates (revision OATS/OCA or conversion to arthroplasty) between the restorative treatment options, with 14 failures for OATS (9.52% of reoperations at 2 years) compared to 22 failures for OCA (12.7% of reoperations at 2 years, P = .358). Among the entire cohort of cartilage surgery patients, arthroscopic chondroplasty was the most frequent procedure performed at the time of reoperation at all time points assessed, notably accounting for 33.08% of reoperations 2 years following microfracture, 51.58% of reoperations at 2 years following ACI, 53.06% of reoperations at 2 years following OATS, and 54.07% of reoperations at 2 years following OCA (Figure 3, Tables 4–7).
Table 3. Comparison of Return to OR Following MFX, ACI, OCA, and OATS | |||||||
Procedure | Total No. of Cases in Study Period | No. of Reoperations at 90 Days | Return to OR Rate at 90 Days | No. of Reoperations at 1 Year | Return to OR Rate at 1 Year | No. of Reoperations at 2 Years | Return to OR Rate at 2 Years |
MFX | 43,576 | 2636 | 6.05% | 5142 | 11.80% | 6385 | 14.65% |
ACI | 640 | 29 | 4.53% | 149 | 23.28% | 190 | 29.69% |
Open OATS | 386 | 12 | 3.12% | 26 | 6.74% | 29 | 7.51% |
Arthroscopic OATS | 997 | 51 | 5.12% | 85 | 8.53% | 101 | 10.13% |
Open OCA | 714 | 18 | 2.52% | 51 | 7.14% | 97 | 13.59% |
Arthroscopic OCA | 894 | 161 | 3.91% | 59 | 6.60% | 97 | 10.85% |
Weighted average for all procedures |
| 5.87% |
| 11.94% |
| 14.90% |
Abbreviations: ACI, autologous chondrocyte implantation; MFX, microfracture; OCA, osteochondral allograft; OATS, osteochondral autograft transplantation; OR, operating room.
Table 4. Rate of Return to OR Following MFX (n = 43,574) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 54 | 122 | 162 |
Knee arthroscopic drainage and lavage | 29871 | 84 | 102 | 104 |
Arthroscopic adhesions débridement | 29874 | 300 | 468 | 549 |
Arthroscopic synovectomy | 29875 | 324 | 528 | 611 |
Major arthroscopic synovectomy | 29876 | 557 | 926 | 1087 |
Knee arthroscopic chondroplasty | 29877 | 1063 | 1722 | 2112 |
Arthroscopic lysis of adhesions | 29884 | 61 | 129 | 171 |
Patellar arthroplasty | 27438 | 0 | 38 | 49 |
Medial or lateral knee arthroplasty | 27446 | 51 | 242 | 328 |
Medial and lateral knee arthroplasty | 27447 | 142 | 865 | 1212 |
Total | 2636 | 5142 | 6385 | |
Return to OR | 6.05% | 11.80% | 14.65% |
Abbreviations: CPT, Current Procedural Terminology; MFX, microfracture; OR, operating room.
Table 5. Rate of Return to OR Following ACI (n = 640) | ||||
Procedure | CPT Code | 90 Daysa | 1 Yeara | 2 Yearsa |
Revision ACI | 27412 | 29 | 33 | 35 |
Knee arthroscopy | 29870 | -1 | -1 | -1 |
Knee arthroscopic drainage and lavage | 29871 | -1 | -1 | -1 |
Arthroscopic adhesions débridement | 29874 | 0 | -1 | -1 |
Arthroscopic synovectomy | 29875 | -1 | -1 | -1 |
Major arthroscopic synovectomy | 29876 | -1 | 12 | 20 |
Knee arthroscopic chondroplasty | 29877 | -1 | 71 | 98 |
Arthroscopic lysis of adhesions | 29884 | -1 | 33 | 37 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | -1 | -1 |
Medial and lateral knee arthroplasty | 27447 | 0 | -1 | -1 |
Total | 29 | 149 | 190 | |
Return to OR | 4.53% | 23.28% | 29.69% |
aA -1 denotes No. <11 within the PearlDiver database, and exact numbers are not reported due to patient privacy considerations.
Abbreviations: ACI, autologous chondrocyte implantation; CPT, Current Procedural Terminology; OR, operating room.
Table 6. Rate of Return to OR Following OATS (n = 1320) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Years |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 12 | 13 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 14 |
Major arthroscopic synovectomy | 29876 | 16 | 25 | 28 |
Knee arthroscopic chondroplasty | 29877 | 17 | 58 | 78 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 14 |
Total | 33 | 95 | 147 | |
Return to OR | 2.50% | 7.20% | 11.14% |
Abbreviations: CPT, Current Procedural Terminology; OATS, osteochondral autograft transplantation; OR, operating room.
Table 7. Rate of Return to OR Following OCA Transplantation (n = 1531) | ||||
Procedure | CPT Code | 90 Days | 1 Year | 2 Year |
Knee arthroscopy | 29870 | 0 | 0 | 0 |
Knee arthroscopic drainage and lavage | 29871 | 0 | 0 | 0 |
Arthroscopic adhesions débridement | 29874 | 0 | 15 | 19 |
Arthroscopic synovectomy | 29875 | 0 | 0 | 0 |
Major arthroscopic synovectomy | 29876 | 0 | 20 | 38 |
Knee arthroscopic chondroplasty | 29877 | 22 | 59 | 93 |
Arthroscopic lysis of adhesions | 29884 | 0 | 0 | 0 |
Patellar arthroplasty | 27438 | 0 | 0 | 0 |
Medial or lateral knee arthroplasty | 27446 | 0 | 0 | 0 |
Medial and lateral knee arthroplasty | 27447 | 0 | 0 | 22 |
Total | 22 | 94 | 172 | |
Return to OR | 1.44% | 6.14% | 11.23% |
Abbreviations: CPT, Current Procedural Terminology; OCA, osteochondral allograft; OR, operating room.
Continue to: Discussion...
DISCUSSION
The principle findings of this study demonstrate that there is an overall reoperation rate of 14.90% at 2 years following cartilage repair/restoration surgery, with the highest reoperation rates following MFX at 90 days, and ACI at both 1 year and 2 years following the index procedure. Also, patients undergoing index MFX as the index procedure have the highest risk for conversion to arthroplasty, reoperation rates for all cartilage surgeries increase over time, and arthroscopic chondroplasty is the most frequent procedure performed at the time of reoperation.
The management of symptomatic articular cartilage knee pathology is extremely challenging. With improvements in surgical technique, instrumentation, and clinical decision-making, indications are constantly evolving. Techniques that may work for “small” defects, though there is some debate as to what constitutes a “small” defect, are not necessarily going to be successful for larger defects, and this certainly varies depending on where the defect is located within the knee joint (distal femur vs patella vs trochlea, etc.). Recently, in a 2015 analysis of 3 level I or II studies, Miller and colleagues7 demonstrated both MFX and OATS to be viable, cost-effective, first-line treatment options for articular cartilage injuries, with similar clinical outcomes at 8.7 years. The authors noted cumulative reoperation rates of 29% among patients undergoing MFX compared to 13% among patients undergoing OATS. While ACI and OCA procedures were not included in their study, the reported reoperation rates of 29% following MFX and 13% following OATS at nearly 10 years suggest a possible increased need for reoperation following MFX over time (approximately 15% at 2 years in our study) and a stable rate of reoperation following OATS (approximately 11% at 2 years in our study). This finding is significant, as one of the goals with these procedures is to deliver effective, long-lasting pain relief and restoration of function. Interestingly, in this study, restorative OATS and OCA techniques were performed with the greatest frequency in the 15-year-old to 19-year-old age group, but were not performed in patients older than 64 years. This may be explained by the higher prevalence of acute traumatic injuries and osteochondritis dissecans diagnoses in younger patients compared with older patients, as these diagnoses are more often indicated to undergo restorative procedures as opposed to marrow stimulation.
In a 2016 systematic review of 20 studies incorporating 1117 patients, Campbell and colleagues8 assessed return-to-play rates following MFX, ACI, OATS, and OCA. The authors noted that return to sport (RTS) rates were greatest following OATS (89%), followed by OCA (88%), ACI (84%), and MFX (75%). Positive prognostic factors for RTS included younger age, shorter duration of preoperative symptoms, no history of prior ipsilateral knee surgery, and smaller chondral defects. Reoperation rates between the 4 techniques were not statistically compared in their study. Interestingly, in 2013, Chalmers and colleagues9 conducted a separate systematic review of 20 studies comprising 1375 patients undergoing MFX, ACI, or OATS. In their study, the authors found significant advantages following ACI and OATS compared to MFX with respect to patient-reported outcome scores but noted significantly faster RTS rates with MFX. Reoperation rates were noted to be similar between the 3 procedures (25% for ACI, 21% for MFX, and 28% for OATS) at an average 3.7 years following the index procedure. When considering these 2 systematic reviews together, despite a faster RTS rate following MFX, a greater proportion of patients seem to be able to RTS over time following other procedures such as OATS, OCA, and ACI. Unfortunately, these reviews do not provide insight as to the role, if any, of reoperation on return to play rates nor on overall clinical outcome scores on patients undergoing articular cartilage surgery. However, this information is valuable when counseling athletes who are in season and would like to RTS as soon as possible as opposed to those who do not have tight time constraints for when they need to RTS.
Regardless of the cartilage technique chosen, the goals of surgery remain similar—to reduce pain and improve function. For athletes, the ultimate goal is to return to the same level of play that the athlete was able to achieve prior to injury. Certainly, the need for reoperation following a cartilage surgery has implications on pain, function, and ability to RTS. Our review of nearly 50,000 cartilage surgeries demonstrates that reoperations following cartilage repair surgery are not uncommon, with a rate of 14.90% at 2 years, and that while reoperation rates are the highest following ACI, the rate of conversion to knee arthroplasty is highest following MFX. Due to the limitations of the PearlDiver database, it is not possible to determine the clinical outcomes of patients undergoing reoperation following cartilage surgery, but certainly, given these data, reoperation is clearly not necessarily indicative of clinical failure. This is highlighted by the fact that the most common procedure performed at the time of reoperation is arthroscopic chondroplasty, which, despite being an additional surgical procedure, may be acceptable for patients who wish to RTS, particularly in the setting of an index ACI in which there may be graft hypertrophy. Ideally, additional studies incorporating a cost-effectiveness analysis of each of the procedures, incorporating reoperation rates as well as patient-reported clinical outcomes, would be helpful to truly determine the patient and societal implications of reoperation following cartilage repair/restoration.
Many of the advantages and disadvantages of the described cartilage repair/restoration procedures have been well described.10-17 Microfracture is the most commonly utilized first-line repair/restoration option for small articular cartilage lesions, mainly due to its low cost, low morbidity, and relatively low level of difficulty.18 Despite these advantages, MFX is not without limitations, and the need for revision cartilage restoration and/or conversion to arthroplasty is concerning. In 2013, Salzmann and colleagues19 evaluated a cohort of 454 patients undergoing MFX for a symptomatic knee defect and noted a reoperation rate of 26.9% (n = 123) within 2 years of the index surgery, with risk factors for reoperation noted to include an increased number of pre-MFX ipsilateral knee surgeries, patellofemoral lesions, smoking, and lower preoperative numeric analog scale scores. The definition of reoperation in their study is unfortunately not described, and thus the extent of reoperation (arthroscopy to arthroplasty) is unclear. In a 2009 systematic review of 3122 patients (28 studies) undergoing MFX conducted by Mithoefer and colleagues,20 revision rates were noted to range from 2% to 31% depending on the study analyzed, with increasing revision rates after 2 years. Unfortunately, the heterogeneity of the included studies makes it difficult to determine which patients tend to fail over time.
Continue to: OATS...
OATS is a promising cartilage restoration technique indicated for treatment of patients with large, uncontained chondral lesions, and/or lesions with both bone and cartilage loss.1 OCA is similar to OATS but uses allograft tissue instead of autograft tissue and is typically considered a viable treatment option in larger lesions (>2 cm2).21 Cell-based ACI therapy has evolved substantially over the past decade and is now available as a third-generation model utilizing biodegradable 3-dimensional scaffolds seeded with chondrocytes. Reoperation rates following ACI can often be higher than those following other cartilage treatments, particularly given the known complication of graft hypertrophy and/or delamination. Harris and colleagues22 conducted a systematic review of 5276 subjects undergoing ACI (all generations), noting an overall reoperation rate of 33%, but a failure rate of 5.8% at an average of 22 months following ACI. Risk factors for reoperation included periosteal-based ACI as well as open (vs arthroscopic) ACI. In this study, we found a modestly lower return to OR rate of 29.69% at 2 years.
When the outcomes of patients undergoing OATS or OCA are compared to those of patients undergoing MFX or ACI, it can be difficult to interpret the results, as the indications for performing these procedures tend to be very different. Further, the reasons for reoperation, as well as the procedures performed at the time of reoperation, are often poorly described, making it difficult to truly quantify the risk of reoperation and the implications of reoperation for patients undergoing any of these index cartilage procedures.
Overall, in this database, the return to the OR rate approaches 15% at 2 years following cartilage surgery, with cell-based therapy demonstrating higher reoperation rates at 2 years, without the risk of conversion to arthroplasty. Reoperation rates appear to stabilize at 1 year following surgery and consist mostly of minor arthroscopic procedures. These findings can help surgeons counsel patients as to the rate and type of reoperations that can be expected following cartilage surgery. Additional research incorporating patient-reported outcomes and patient-specific risk factors are needed to complement these data as to the impact of reoperations on overall clinical outcomes. Further, studies incorporating 90-day, 1-year, and 2-year costs associated with cartilage surgery will help to determine which index procedure is the most cost effective over the short- and long-term.
LIMITATIONS
This study is not without limitations. The PearlDiver database is reliant upon accurate CPT and ICD-9 coding, which creates a potential for a reporting bias. The overall reliability of the analyses is dependent on the quality of the available data, which, as noted in previous PearlDiver studies,18,23-28 may include inaccurate billing codes, miscoding, and/or non-coding by physicians as potential sources of error. At the time of this study, the PearlDiver database did not provide consistent data points on laterality, and thus it is possible that the reported rates of reoperation overestimate the true reoperation rate following a given procedure. Fortunately, the reoperation rates for each procedure analyzed in this database study are consistent with those previously presented in the literature. In addition, it is not uncommon for patients receiving one of these procedures to have previously been treated with one of the others. Due to the inherent limitations of the PearlDiver database, this study did not investigate concomitant procedures performed along with the index procedure, nor did it investigate confounding factors such as comorbidities. The PearlDiver database does not provide data on defect size, location within the knee, concomitant pathologies (eg, meniscus tear), prior surgeries, or patient comorbidities, and while important, these factors cannot be accounted for in our analysis. The inability to account for these important factors, particularly concomitant diagnoses, procedures, and lesion size/location, represents an important limitation of this study, as this is a source of selection bias and may influence the need for reoperation in a given patient. Despite these limitations, the results of this study are supported by previous and current literature. In addition, the PearlDiver database, as a HIPAA-compliant database, does not report exact numbers when the value of the outcome of interest is between 0 and 10, which prohibits analysis of any cartilage procedure performed in a cohort of patients greater than 1 and less than 11. Finally, while not necessarily a limitation, it should be noted that CPT 29879 is not specific for microfracture, as the code also includes abrasion arthroplasty and drilling. Due to the limitations of the methodology of searching the database for this code, it is unclear as to how many patients underwent actual microfracture vs abrasion arthroplasty.
CONCLUSION
Within a large US commercial insurance database from 2007 to 2011, reparative procedures were favored for chondral injuries, but yielded an increased risk for conversion to arthroplasty. There was no difference between failure/revision rates among the restorative approaches, yet cell-based approaches yielded a significantly increased risk for a return to the OR.
- Farr J, Cole B, Dhawan A, Kercher J, Sherman S. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-2705. doi:10.1007/s11999-010-1764-z.
- Alford JW, Cole BJ. Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306. doi:10.1177/03635465004273510.
- Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460. doi:10.1177/0363546505274578.
- Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508. doi:10.1177/0363546512458763.
- Saris DBF, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10-19. doi:10.1177/0363546509350694.
- McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014;42(4):892-897. doi:10.1177/0363546513520115.
- Miller DJ, Smith MV, Matava MJ, Wright RW, Brophy RH. Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur. Am J Sports Med. 2015;43(9):2175-2181. doi:10.1177/0363546515591261.
- Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 2016;32(4):651-668.
- Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013;4(3):193-203.
- Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. JBone Joint Surg Br. 2012;94(4):504-509. doi:10.1177/1947603513481603.
- Beris AE, Lykissas MG, Kostas-Agnantis I, Manoudis GN. Treatment of full-thickness chondral defects of the knee with autologous chondrocyte implantation: a functional evaluation with long-term follow-up. Am J Sports Med. 2012;40(3):562-567.
- Chahal J, Gross AE, Gross C, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013;29(3):575-588. doi:10.1177/0363546511428778.
- Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907-914. doi:10.1177/0363546507299932.
- Gudas R, Stankevičius E, Monastyreckienė E, Pranys D, Kalesinskas R. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):834-842. doi:10.1007/s00167-006-0067-0.
- Lynch TS, Patel RM, Benedick A, Amin NH, Jones MH, Miniaci A. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754. doi:10.1016/j.arthro.2014.11.018.
- Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes after first-generation autologous chondrocyte implantation for cartilage defects of the knee. Am J Sports Med. 2014;42(1):150-157. doi:10.1177/0363546513506593.
- Ulstein S, Årøen A, Røtterud J, Løken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1207-1215. doi:10.1007/s00167-014-2843-6.
- Montgomery S, Foster B, Ngo S, et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2070-2075. doi:10.1007/s00167-013-2614-9.
- Salzmann GM, Sah B, Südkamp NP, Niemeyer P. Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):365-371. doi:10.1007/s00167-012-1973-y.
- Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414.
- Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2):411-415. doi:10.1177/0363546512469091.
- Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation–a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791. doi:10.1016/j.joca.2011.02.010.
- Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
- Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665. doi:10.1016/j.arthro.2012.11.005.
- Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437-441. doi:10.1177/0363546513510686.
- Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014;30(4):436-443. doi:10.1016/j.arthro.2013.12.013.
- Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015;30(suppl 9):72-75. doi:10.1016/j.arth.2015.01.061.
- Carr JB 2nd, Werner BC, Browne JA. Trends and outcomes in the treatment of failed septic total knee arthroplasty: comparing arthrodesis and above-knee amputation. J Arthroplasty. 2016;31(7):1574-1577. doi:10.1016/j.arth.2016.01.010.
- Farr J, Cole B, Dhawan A, Kercher J, Sherman S. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-2705. doi:10.1007/s11999-010-1764-z.
- Alford JW, Cole BJ. Cartilage restoration, part 1: basic science, historical perspective, patient evaluation, and treatment options. Am J Sports Med. 2005;33(2):295-306. doi:10.1177/03635465004273510.
- Alford JW, Cole BJ. Cartilage restoration, part 2: techniques, outcomes, and future directions. Am J Sports Med. 2005;33(3):443-460. doi:10.1177/0363546505274578.
- Gudas R, Gudaitė A, Pocius A, et al. Ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med. 2012;40(11):2499-2508. doi:10.1177/0363546512458763.
- Saris DBF, Vanlauwe J, Victor J, et al. Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med. 2009;37(suppl 1):10-19. doi:10.1177/0363546509350694.
- McCormick F, Harris JD, Abrams GD, et al. Survival and reoperation rates after meniscal allograft transplantation: analysis of failures for 172 consecutive transplants at a minimum 2-year follow-up. Am J Sports Med. 2014;42(4):892-897. doi:10.1177/0363546513520115.
- Miller DJ, Smith MV, Matava MJ, Wright RW, Brophy RH. Microfracture and osteochondral autograft transplantation are cost-effective treatments for articular cartilage lesions of the distal femur. Am J Sports Med. 2015;43(9):2175-2181. doi:10.1177/0363546515591261.
- Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to sport after articular cartilage repair in athletes' knees: a systematic review. Arthroscopy. 2016;32(4):651-668.
- Chalmers PN, Vigneswaran H, Harris JD, Cole BJ. Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage. 2013;4(3):193-203.
- Bentley G, Biant LC, Vijayan S, Macmull S, Skinner JA, Carrington RW. Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. JBone Joint Surg Br. 2012;94(4):504-509. doi:10.1177/1947603513481603.
- Beris AE, Lykissas MG, Kostas-Agnantis I, Manoudis GN. Treatment of full-thickness chondral defects of the knee with autologous chondrocyte implantation: a functional evaluation with long-term follow-up. Am J Sports Med. 2012;40(3):562-567.
- Chahal J, Gross AE, Gross C, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013;29(3):575-588. doi:10.1177/0363546511428778.
- Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907-914. doi:10.1177/0363546507299932.
- Gudas R, Stankevičius E, Monastyreckienė E, Pranys D, Kalesinskas R. Osteochondral autologous transplantation versus microfracture for the treatment of articular cartilage defects in the knee joint in athletes. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):834-842. doi:10.1007/s00167-006-0067-0.
- Lynch TS, Patel RM, Benedick A, Amin NH, Jones MH, Miniaci A. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754. doi:10.1016/j.arthro.2014.11.018.
- Niemeyer P, Porichis S, Steinwachs M, et al. Long-term outcomes after first-generation autologous chondrocyte implantation for cartilage defects of the knee. Am J Sports Med. 2014;42(1):150-157. doi:10.1177/0363546513506593.
- Ulstein S, Årøen A, Røtterud J, Løken S, Engebretsen L, Heir S. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1207-1215. doi:10.1007/s00167-014-2843-6.
- Montgomery S, Foster B, Ngo S, et al. Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc. 2014;22(9):2070-2075. doi:10.1007/s00167-013-2614-9.
- Salzmann GM, Sah B, Südkamp NP, Niemeyer P. Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc. 2013;21(2):365-371. doi:10.1007/s00167-012-1973-y.
- Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414.
- Wajsfisz A, Makridis KG, Djian P. Arthroscopic retrograde osteochondral autograft transplantation for cartilage lesions of the tibial plateau: a prospective study. Am J Sports Med. 2013;41(2):411-415. doi:10.1177/0363546512469091.
- Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation–a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791. doi:10.1016/j.joca.2011.02.010.
- Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. Am J Sports Med. 2013;41(10):2333-2339. doi:10.1177/0363546513495641.
- Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665. doi:10.1016/j.arthro.2012.11.005.
- Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437-441. doi:10.1177/0363546513510686.
- Zhang AL, Montgomery SR, Ngo SS, Hame SL, Wang JC, Gamradt SC. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy. 2014;30(4):436-443. doi:10.1016/j.arthro.2013.12.013.
- Werner BC, Carr JB, Wiggins JC, Gwathmey FW, Browne JA. Manipulation under anesthesia after total knee arthroplasty is associated with an increased incidence of subsequent revision surgery. J Arthroplasty. 2015;30(suppl 9):72-75. doi:10.1016/j.arth.2015.01.061.
- Carr JB 2nd, Werner BC, Browne JA. Trends and outcomes in the treatment of failed septic total knee arthroplasty: comparing arthrodesis and above-knee amputation. J Arthroplasty. 2016;31(7):1574-1577. doi:10.1016/j.arth.2016.01.010.
TAKE-HOME POINTS
- With a large US commercial insurance database analyzing techniques for cartilage restoration, reparative procedures were favored for chondral injuries compared to restorative approaches.
- Among patients undergoing microfracture, autologous chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft transplantation, the average 90-day reoperation rate is 6%.
- Among patients undergoing microfracture, autologous chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft transplantation, the average 2-year reoperation rate is 15%.
- Patients undergoing autologous chondrocyte implantation are more likely to experience reoperation at 90 days, 1 year, and 2 years compared to other cartilage restoration techniques including microfracture, osteochondral autograft transfer, and osteochondral allograft transplantation.
- Patients undergoing microfracture are more likely to experience an ultimate conversion to arthroplasty compared to other cartilage restoration techniques including autologous chondrocyte implantation, osteochondral autograft transfer, and osteochondral allograft transplantation.
Rates of Deep Vein Thrombosis Occurring After Osteotomy About the Knee
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
Take-Home Points
- DVT and PE are uncommon complications following osteotomies about the knee.
- Use of oral contraceptives can increase the risk of a patient sustaining a postoperative DVT and PE following osteotomies about the knee.
- In the absence of significant risk factors, postoperative chemical DVT prophylaxis may be unnecessary in patients undergoing osteotomies about the knee.
High tibial osteotomy (HTO), distal femoral osteotomy (DFO), and tibial tubercle osteotomy (TTO) are viable treatment options for deformities about the knee and patella maltracking.1-4 Although TTO can be performed in many ways (eg, anteriorization, anteromedialization, medialization), the basic idea is to move the tibial tubercle to improve patellar tracking or to offload a patellar facet that has sustained trauma or degenerated.2 DFO is a surgical option for treating a valgus knee deformity (the lateral tibiofemoral compartment is offloaded) or for protecting a knee compartment after cartilage or meniscal restoration (medial closing wedge or lateral opening wedge).1 Similarly, HTO is an option for treating a varus knee deformity or isolated medial compartment arthritis; the diseased compartment is offloaded, and any malalignment is corrected. Akin to DFO, HTO is often performed to protect a knee compartment, typically the medial tibiofemoral compartment, after cartilage or meniscal restoration.2-4
Compared to most arthroscopic knee surgeries, these osteotomies are much more involved, have longer operative times, and restrict postoperative weight-bearing and range of motion.2-4 The rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) after these osteotomies are not well documented. In addition, there is no documentation of the risks in patients who smoke, are obese, or are using oral contraceptives (OCs) at time of surgery, despite the increased DVT and PE risks posed by smoking, obesity, and OC use in other surgical procedures.5-7 Although the American Academy of Orthopaedic Surgeons (AAOS) issued clinical practice guidelines for DVT/PE prophylaxis after hip and knee arthroplasty, there is no standard prophylaxis guidelines for DVT/PE prevention after HTO, DFO, or TTO.8,9 Last, rates of DVT after total knee arthroplasty (TKA) are well defined; they range from 2% to 12%.10,11 These rates may be surrogates for osteotomies about the knee, but this is only conjecture.
We conducted a study to determine the rates of symptomatic DVT and PE after HTO, DFO, or TTO in patients who did not receive postoperative DVT/PE prophylaxis. We also wanted to determine if age, body mass index (BMI), and smoking status have associations with the risk of developing either DVT or PE after HTO, DFO, or TTO. We hypothesized that the DVT and PE rates would both be <1%.
Methods
After this study was approved by our university’s Institutional Review Board, we searched the surgical database of Dr. Cole, a sports medicine fellowship–trained surgeon, to identify all patients who had HTO, DFO, or TTO performed between September 1, 2009 and September 30, 2014. Current Procedural Terminology (CPT) codes were used for the search. The code for HTO was 27457: osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure). The code for DFO was 27450: osteotomy, femur, shaft or supracondylar; with fixation. Last, the code for TTO was 27418: anterior tibial tubercleplasty (eg, Maquet-type procedure). The 141 patients identified in the search were treated by Dr. Cole at a single institution and were included in the study. Study inclusion did not require a minimum follow-up. Follow-up duration was defined as the time between surgery and the final clinic note in the patient chart. No patient was excluded for lack of follow-up clinic visits, and none was lost to follow-up.
Age, BMI, smoking status, and OC use were recorded for all patients. For each procedure, the surgeon’s technique remained the same throughout the study period: HTO, medial opening-wedge osteotomy with plate-and-screw fixation; DFO, lateral opening-wedge osteotomy with plate-and-screw fixation; and TTO, mostly anteromedialization with screw fixation (though this was dictated by patellar contact pressures). A tourniquet was used in all cases. Each patient’s hospital electronic medical record and outpatient office notes were reviewed to determine if symptomatic DVT or PE developed after surgery. The diagnosis of symptomatic DVT was based on clinical symptoms and confirmatory ultrasound, and the PE diagnosis was based on computed tomography. Doppler ultrasound was performed only in symptomatic patients (ie, it was not routinely performed).
Per surgeon protocol, postoperative DVT prophylaxis was not administered. Patients were encouraged to begin dorsiflexion and plantar flexion of the ankle (ankle pumps) immediately and to mobilize as soon as comfortable. Each patient received a cold therapy machine with compression sleeve. Patients were allowed toe-touch weight-bearing for 6 weeks, and then progressed 25% per week for 4 weeks to full weight-bearing by 10 weeks. After surgery, each patient was placed in a brace, which was kept locked in extension for 10 days; when the brace was unlocked, the patient was allowed to range the knee.
Continuous variable data are reported as weighted means and weighted standard deviations. Categorical variable data are reported as frequencies and percentages.
Results
Our database search identified 141 patients (44% male, 56% female) who underwent HTO (47 patients, 33.3%), DFO (13 patients, 9.2%), or TTO (81 patients, 57.5%). Mean (SD) age was 34.28 (9.86) years, mean (SD) BMI was 26.88 (5.11) kg/m2, and mean (SD) follow-up was 17.1 (4.1) months. Of the female patients, 36.7% were using OCs at time of surgery. Of all patients, 13.48% were smokers.
Two patients (1.42%) had clinical symptoms consistent with DVT. In each case, the diagnosis was confirmed with Doppler ultrasound. The below-knee DVT was unilateral in 1 case and bilateral in the other.
The unilateral DVT occurred in a patient who underwent anteromedialization of the tibial tubercle and osteochondral allograft transfer to the lateral femoral condyle for patellar maltracking and a focal trochlear defect. The DVT was diagnosed 8 days after surgery and was treated with warfarin. Low-molecular-weight heparin (LMWH) was used as a bridge until the warfarin level was therapeutic (4 days). This male patient had no significant medical history.
The bilateral DVT with PE occurred in a patient who underwent a medial opening-wedge HTO for a varus deformity with right medial compartment osteoarthritis and a meniscal tear. The DVT and PE were diagnosed 48 hours after surgery, when the patient complained of lightheadedness and lost consciousness. She had no medical problems but was using OCs at time of surgery. The patient died 3 days after surgery and subsequently was found to have a maternal-side family history of DVT (the patient and her family physician had been unaware of this history).
Discussion
As the rates of DVT and PE after osteotomies about the knee have not been well studied, we wanted to determine these rates after HTO, DFO, and TTO in patients who did not receive postoperative DVT prophylaxis. We hypothesized that DVT and PE rates would both be <1%, and this hypothesis was partly confirmed: The rate of PE after HTO, DFO, and TTO was <1%, and the rate of symptomatic DVT was >1%. Similarly, the patients who developed these complications were nonsmokers and had a BMI no higher than that of the patients who did not develop DVT or PE. In addition, only 1 patient developed DVT and PE, and she was using OCs and had a family history of DVT. Last, the patients who developed these complications were on average 14 years older than the patients who did not develop DVT or PE.
Although there is a plethora of reports on the incidence of DVT and PE after TKA, there is little on the incidence after osteotomies about the knee.8,12 The rate of DVT after TKA varies, but many studies place it between 2% and 12%, and routinely find a PE rate of <0.5%.10,11,13,14 Although the AAOS issued a clinical practice guideline for postoperative DVT prophylaxis after TKA, and evaluated the best available evidence, it could not reach consensus on a specific type of DVT prophylaxis, though the workgroup did recommend that patients be administered postoperative DVT prophylaxis of some kind.8,9 Similarly, the American College of Chest Physicians (ACCP) issued clinical practice guidelines for preventing DVT and PE after elective TKA and total hip arthroplasty.15 According to the ACCP guidelines, patients should receive prophylaxis—LMWH, fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, aspirin, or an intermittent pneumatic compression device—for a minimum of 14 days. Unfortunately, though there are similarities between TKAs and peri-knee osteotomies, these procedures are markedly different, and it is difficult to extrapolate and adapt recommendations and produce a consensus statement for knee arthroplasties. In addition, guidelines exist for hospitalized patients who are being treated for medical conditions or have undergone surgery, but all the patients in the present study had their osteotomies performed on an outpatient basis.
Martin and colleagues16 reviewed 323 cases of medial opening-wedge HTO and found a DVT rate of 1.4% in the absence of routine DVT prophylaxis, except in patients with a history of DVT. Their rate is almost identical to ours, but we also included other osteotomies in our study. Miller and colleagues17 reviewed 46 cases of medial opening-wedge HTO and found a 4.3% DVT rate, despite routine prophylaxis with once-daily 325-mg aspirin and ankle pumps. This finding contrasts with our 1.42% DVT rate in the absence of postoperative chemical DVT prophylaxis. Motycka and colleagues18 reviewed 65 HTO cases in which DVT prophylaxis (oral anticoagulant) was given for 6 weeks, and they found a DVT rate of 9.7%. Turner and colleagues19 performed venous ultrasound on 81 consecutive patients who underwent HTO and received DVT prophylaxis (twice-daily subcutaneous heparin), and they found a DVT rate of 41% and a PE rate of 1.2%, though only 8.6% of the DVT cases were symptomatic. Of note, whereas the lowest postoperative DVT rate was for patients who did not receive postoperative DVT prophylaxis, the rate of symptomatic DVT after these osteotomies ranged from 1.4% to 8.6% in patients who received prophylaxis.16,19 Given this evidence and our study results, it appears routine chemical DVT prophylaxis after osteotomies about the knee may not be necessary, though higher level evidence is needed in order to make definitive recommendations.
In the present study, the 2 patients who developed symptomatic DVT (1 subsequently developed PE) were nonsmokers in good health. The female patient (DVT plus PE) was using OCs at time of surgery. Studies have shown that patients who smoke and who use OCs are at increased risk for developing DVT or PE after surgery.5,6,12 Given that only 2 of our patients developed DVT/PE, and neither was a smoker, smoking was not associated with increased DVT or PE risk in this study population, in which 13.48% of patients were smokers at time of surgery. In addition, given that the 1 female patient who developed DVT/PE was using OCs and that 36.7% of all female patients in the study were using OCs, it is difficult to conclude whether OC use increased the female patient’s risk for DVT or PE. Furthermore, neither the literature nor the AAOS consensus statement supports discontinuing OCs for this surgical procedure.
Patients in this study did not receive chemical or mechanical DVT prophylaxis after surgery. Regarding various post-TKA DVT prophylaxis regimens, aspirin is as effective as LMWH in preventing DVT, and the risk for postoperative blood loss and wound complications is lower with aspirin than with rivaroxaban.20,21 Given that the present study’s postoperative rates of DVT (1.42%) and PE (0.71%) are equal to or less than rates already reported in the literature, routine DVT prophylaxis after osteotomies about the knee may be unnecessary in the absence of other significant risk factors.16,19 However, our study considered only symptomatic DVT and PE, so it is possible that the number of asymptomatic DVT cases is higher in this patient population. Definitively answering our study’s clinical question will require a multicenter registry study (prospective cohort study).
Study Limitations
The strengths of this study include the large number of patients treated by a single surgeon using the same postoperative protocol. Limitations of this study include the lack of a control group. Although we found a DVT rate of 1.42% and a PE rate of 0.71%, the literature on the accepted risks for DVT and PE after HTO, DFO, and TTO is unclear. With our results stratified by procedure, the DVT rate was 2% in the HTO group, 0% in the DFO group, and 1% in the TTO group. However, we were unable to reliably stratify these results by each specific procedure, as the number of patients in each group would be too low. This study involved reviewing charts; as patients were not contacted, it is possible a patient developed DVT or PE, was treated at an outside facility, and then never followed up with the treating surgeon. Patients were identified by CPT codes, so, if a patient underwent HTO, DFO, or TTO that was recorded under a different CPT code, it is possible the patient was missed by our search. All patients were seen after surgery, and we reviewed the outpatient office notes that were taken, so unless the DVT or PE occurred after a patient’s final postoperative visit, it would have been recorded. Similarly, the DVT and PE rates reported here cannot be extrapolated to overall risks for DVT and PE after osteotomies about the knee in all patients—only in patients who did not receive DVT prophylaxis after surgery.
Conclusion
The rates of DVT and PE after HTO, DFO, and TTO in patients who did not receive chemical prophylaxis are low: 1.42% and 0.71%, respectively. After these osteotomies, DVT/PE prophylaxis in the absence of known risk factors may not be warranted.
Am J Orthop. 2017;46(1):E23-E27. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.
1. Rossi R, Bonasia DE, Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599.
2. Sherman SL, Erickson BJ, Cvetanovich GL, et al. Tibial tuberosity osteotomy: indications, techniques, and outcomes. Am J Sports Med. 2014;42(8):2006-2017.
3. Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg. 2005;13(4):279-289.
4. Cameron JI, McCauley JC, Kermanshahi AY, Bugbee WD. Lateral opening-wedge distal femoral osteotomy: pain relief, functional improvement, and survivorship at 5 years. Clin Orthop Relat Res. 2015;473(6):2009-2015.
5. Ng WM, Chan KY, Lim AB, Gan EC. The incidence of deep venous thrombosis following arthroscopic knee surgery. Med J Malaysia. 2005;60(suppl C):14-16.
6. Platzer P, Thalhammer G, Jaindl M, et al. Thromboembolic complications after spinal surgery in trauma patients. Acta Orthop. 2006;77(5):755-760.
7. Wallace G, Judge A, Prieto-Alhambra D, de Vries F, Arden NK, Cooper C. The effect of body mass index on the risk of post-operative complications during the 6 months following total hip replacement or total knee replacement surgery. Osteoarthritis Cartilage. 2014;22(7):918-927.
8. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013;95(19):1801-1811.
9. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778.
10. Kim YH, Kulkarni SS, Park JW, Kim JS. Prevalence of deep vein thrombosis and pulmonary embolism treated with mechanical compression device after total knee arthroplasty in Asian patients. J Arthroplasty. 2015;30(9):1633-1637.
11. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007;22(7):974-980.
12. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res. 2014;472(2):482-488.
13. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111.
14. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25(7):1053-1060.
15. Falck-Ytter Y, Francis CW, Johanson NA, et al; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e278S-e325S.
16. Martin R, Birmingham TB, Willits K, Litchfield R, Lebel ME, Giffin JR. Adverse event rates and classifications in medial opening wedge high tibial osteotomy. Am J Sports Med. 2014;42(5):1118-1126.
17. Miller BS, Downie B, McDonough EB, Wojtys EM. Complications after medial opening wedge high tibial osteotomy. Arthroscopy. 2009;25(6):639-646.
18. Motycka T, Eggerth G, Landsiedl F. The incidence of thrombosis in high tibial osteotomies with and without the use of a tourniquet. Arch Orthop Trauma Surg. 2000;120(3-4):157-159.
19. Turner RS, Griffiths H, Heatley FW. The incidence of deep-vein thrombosis after upper tibial osteotomy. A venographic study. J Bone Joint Surg Br. 1993;75(6):942-944.
20. Jiang Y, Du H, Liu J, Zhou Y. Aspirin combined with mechanical measures to prevent venous thromboembolism after total knee arthroplasty: a randomized controlled trial. Chin Med J (Engl). 2014;127(12):2201-2205.
21. Zou Y, Tian S, Wang Y, Sun K. Administering aspirin, rivaroxaban and low-molecular-weight heparin to prevent deep venous thrombosis after total knee arthroplasty. Blood Coagul Fibrinolysis. 2014;25(7):660-664.
Hip pain in active patients: What you may be missing
• Consider both musculoskeletal and nonmusculoskeletal causes in patients with vague complaints of hip and groin pain. B
• Use imaging studies to confirm a hip pain diagnosis. B
• Refer patients who fail to respond to nonsurgical treatment to a sports medicine specialist or an orthopedic surgeon. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Hip pain is a common complaint, and commonly misunderstood. Although the pain can be associated with a broad spectrum of conditions, the presentation is often vague and nonspecific.
Thus, hip pain and injury are frequently attributed, often incorrectly, to a “hip pointer”—a contusion of soft tissues against the iliac crest. It’s not unusual for patients who receive this diagnosis to be treated conservatively for prolonged periods, leading some previously active individuals to abandon their favorite sport or self-impose limits on the activities they engage in.1
But it doesn’t have to be this way.
Minimally invasive hip arthroscopy and advances in imaging, instrumentation, and devices have made it easier to identify and address underlying pathology associated with hip pain, helping patients return to their previous level of activity more rapidly.2,3 And, while many conditions associated with hip pain can be treated conservatively, family physicians—whom patients often go to first—should not hesitate to provide a referral when more aggressive treatment or diagnostic confirmation is needed.
We created this guide with family physicians in mind. Our focus here is primarily on anterior hip pain—the most common presentation—in active, or athletic, patients.
When did the pain begin? Where does it hurt?
Before performing a physical examination, find out as much as possible about the onset of pain and when and under what circumstances it occurs. (A review of hip anatomy is provided here.) Did it begin suddenly, after an acute injury or a particular physical maneuver? Or is the pain insidious, as was the case with one of our patients?
Osseous morphology of the hip includes the anterior superior iliac spine, the origin of the sartorius muscle and the ilioinguinal ligament. The anterior inferior iliac spine attaches to the rectus femoris, a major hip flexor and knee extender. The adductors of the hip originate in the anterior pelvic region.
The inguinal canal contains the ilioinguinal nerve, which is responsible for radiation of pain to the anterior hip. The hip joint itself is a spheroid comprising the femoral head and acetabulum, with most of the articular hip innervated by the femoral or obturator nerves.
Most intra-articular conditions radiate to the anterior groin or hip, although there are cases in which the pain is referred to either the lateral aspect of the hip or the buttocks. The iliopsoas muscle is the major hip flexor, and crosses under the ilioinguinal ligament to insert on the lesser tuberosity after crossing over the anterior capsule of the hip. A large bursa surrounds it, helping the tendon glide smoothly over the hip.
CASE Mack Q, a 27-year-old man with an 8-month history of right hip pain, sought care at our medical center for an achy pain in his right groin; he also described an occasional “clicking and popping sensation” in his groin but denied any trauma. The pain worsened with prolonged sitting and certain activities, such as squatting, twisting, and putting on shoes and socks. Our patient had stopped playing soccer because it hurt too much. He had tried physical therapy, oral anti-inflammatories, and a corticosteroid injection, with little relief.
Start with a gait assessment
The physical examination should begin with a gait assessment. Consider the patient’s ability to bear weight and his or her foot angle.
An individual with a stress fracture will have difficulty bearing weight on the affected side, resulting in a limp, or antalgic gait. A patient with femoral acetabular impingement (FAI) will often exhibit greater external rotation of the foot on the affected side compared with the other foot. And a patient with weakened abductor muscles, typically because of severe osteoarthritis, will exhibit the Trendelenburg sign—a pelvic tilt when the weight is shifted to the affected extremity.
Although most individuals with hip pain will not have an obvious gait abnormality, any patient who walks with a limp or needs crutches requires an immediate referral to an orthopedic surgeon.
Include these elements in the physical exam
Examine the hip with the patient sitting on the side of the exam table. Assess range of motion (ROM), comparing the range of flexion, extension, and internal/external rotation on the affected and unaffected sides. Include the following maneuvers:
Impingement testing. In patients with FAI and osteoarthritis, impingement testing—encompassing Flexion, ADDuction, and Internal Rotation (FADDIR)—will elicit pain. The maneuver can be tested starting at 45° of hip flexion, increasing to approximately 120°. Pain with <45° of hip flexion indicates that the impingement is severe.
Such testing can also reveal labral tears, which may be caused by FAI or other structural abnormalities. In a patient with anterior labral tears, FADDIR will produce groin pain; posterior labral tears will produce pain when the patient is sitting with legs hanging off the exam table and the contralateral leg is brought to the chest and the affected limb fully extended.
In patients with hip pain and bursitis, applying downward pressure will elicit a snapping sound as the iliopsoas snaps over the iliopectineal eminence or femoral head. Flexion, ABduction, and External Rotation (FABER) can also be used to diagnose iliopsoas tendonitis: The test is positive if it elicits pain in the affected extremity or in the sacroiliac joint on the opposite side.
Log roll. A painful response to this test, which involves internally and externally rotating the affected hip while it is relaxed and the knee fully extended, is an indication of synovitis of the hip caused by intra-articular pathology. To test hip stability, externally rotate the leg while it is extended. If the hip is stable, the leg will return to a neutral position; microinstability of the hip is likely if the leg remains in the rotated position.
Muscular strength testing. To assess for tendinopathy in the hip area, the patient should be in a seated position and contract the internal and external rotators and the adductor muscles while you apply resistance. To test abductor strength, have the patient assume a lateral position and hold and abduct the leg on the affected side while you apply resistance.
Hip flexion strength should be tested with the patient in both supine and seated positions. A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in the supine position vs the seated position; the opposite is true for a patient with iliopsoas tendonitis. (See “Did you know…? Hip pain facts and findings” on for additional diagnostic tips.)
- A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in a supine position vs a seated position. The opposite is true for a patient with iliopsoas tendonitis.
- Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest. Initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.”
- Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but magnetic resonance imaging is useful for evaluating earlier clinical presentations.
- Patients with labral tears often exhibit what has been called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.
- Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required, such as football, hockey, and soccer, and are generally able to tell you exactly what they were doing when the injury occurred.
- Unlike other hernias, a sports hernia (athletic pubalgia) does not involve a bulge of tissue protruding through one part of the body into another. Instead, it occurs when the oblique abdominal muscles strain or completely tear away from the pubis.
Perform a neurologic evaluation to rule out a back condition that might radiate pain into the anterior hip; ask the patient to do a sit-up while you apply resistance to test for abdominal wall pathology, as well.
Hip palpation. This aspect of the physical exam is important regardless of the cause of the pain but especially crucial for pediatric and adolescent patients, whose anterior hip pain may be related to apophyseal injury. Palpate the superior iliac spine (and over the inferior iliac spine in thin patients) to determine if the sartorius or rectus femoris has been injured. The area just lateral to the symphysis will be tender to palpation in patients with osteitis pubis.
Refer or treat? Here’s what to consider
While the history and physical should provide ample information for a differential diagnosis, imaging studies are generally required for confirmation. Clinical assessment— including physical exam, imaging, and intra-articular injection—of patients with hip pain is up to 98% accurate in identifying hip abnormalities, with arthroscopy as the gold standard.4
CASE On physical examination, Mr. Q had right hip extension to 0°, flexion to 110°, external rotation to 50°, and internal rotation to neutral; he also had positive impingement and subspine impingement tests, a painful arc of motion from 12 to 4 o’clock, tenderness over the hip adductor, and pain with resisted hip adduction. He did not walk with a limp.
Diagnostic studies included plain radiographs, which demonstrated that the joint space was well preserved. We identified subtle anatomical abnormalities on the femoral head-neck junction, known as a cam deformity. Magnetic resonance imaging (MRI) revealed an anterior superior labral tear with cartilage delamination.
Stress fractures affect runners, military recruits
In addition to long-distance runners who have recently increased the frequency, duration, or intensity of training,5,6 military recruits have a higher incidence of stress fractures due to the rapid onset of intensive training. Stress fractures can also occur in patients who do not have a history of intense activity but have metabolically weakened bone, in some cases as a result of an eating disorder.7
Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest; initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.” By the time such individuals seek treatment, they almost always have pain with weight bearing and an antalgic gait.
Symptoms consistent with a femoral neck stress fracture can be further evaluated with plain radiographs. However, x-rays are often negative for up to 4 weeks after the onset of pain.8 In cases in which radiographs are negative but the physical exam is suggestive of a stress fracture, MRI—which can detect an abnormality within a day or 2 of injury8,9—should be used to confirm the diagnosis (FIGURE 1).
FIGURE 1
MRI reveals a femoral neck stress fracture
Treatment. A complete femoral neck fracture portends impending displacement and requires emergent evaluation by an orthopedist, and superior neck changes, also known as tension-sided stress fractures, require urgent treatment with percutaneous screw fixation.9 However, compression-sided, or inferior, stress fractures can be treated with restricted weight bearing and activity modification. Gradual resumption of activity is allowed only after the patient has been asymptomatic for 6 weeks; recurrent pain indicates residual stress reaction, and signals that activities should be abated.
Osteonecrosis has many causes
Necrosis of the femoral head is a debilitating and progressive condition primarily affecting patients between the ages of 20 and 50 years.10 It has multiple (and diverse) causes, including trauma, steroids, alcohol, smoking, lupus, sickle cell anemia, and coagulopathies, as well as scuba diving. But about 20% of cases have no apparent cause.11,12
Patients with osteonecrosis of the hip typically present with groin pain, often described as a deep, intermittent ache that interferes with activities of daily living. Exam findings depend on the stage of presentation. Early on, pain will occur only with extreme ROM; in advanced cases, ROM is restricted and pain occurs even with limited motion.
Femoral head collapse due to loss of the structural integrity of the subchondral bone—which occurs in 80% of cases12—is thought to be caused by decreased blood flow. Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but MRI is useful for evaluating patients with earlier clinical presentations.
Treatment of osteonecrosis is dictated by the stage of the disease, but remains controversial because no intervention has been shown to prevent progression in all cases.12 All patients should be referred to a specialist. Those without collapse or cartilage damage can be treated surgically with core decompression, possibly with additional vascularized bone grafting,13,14 while those with more advanced disease typically require a total hip replacement at a relatively young age. Results for total hip replacement in patients with osteonecrosis are thought to be inferior to hip replacement in patients with osteoarthritis, although comparison is difficult because of the differences in age and activity levels in these 2 groups.15,16
Femoral acetabular impingement can occur on the cam or pincer side
FAI pathology can exist on either the femoral (cam) or acetabular (pincer) side,17 or both.18 In pure cam impingement, the anterior femoral neck loses its normal concave anatomy and develops a “bump,” which impinges on the anterosuperior labrum during hip flexion, causing labral tears and delamination of the adjacent cartilage.
Pure pincer impingement arises from a prominent acetabular rim, causing overcoverage of the femoral head. Acetabular labral tears result from the repetitive impaction with flexion and internal rotation.
Patients report an insidious onset of groin pain that is exacerbated by flexion-type sports, such as hockey, football, and golf,19 as well as activities of daily living. In patients with cartilage damage, even walking can be painful. Physical examination of patients with FAI reveals findings that are similar to those of patients with acetabular labral tears. Abnormally large cam lesions or acetabular overcoverage will result in restriction of hip ROM, especially internal rotation and flexion due to a mechanical block.
Radiographs (FIGURE 2) are essential to diagnose FAI and to distinguish this condition from an isolated labral tear.20 Cam impingement will be best demonstrated on a cross-table lateral radiograph, which shows an asphericity of the femoral head/neck junction anteriorly, while pincer impingement will show overcoverage of the femoral head on an AP radiograph. MRI or magnetic resonance arthrography (MRA) is frequently obtained to see whether any cartilage deterioration has occurred. Computed tomography, which can provide a 3-dimensional reproduction of the hip morphology, is often used for preoperative planning when surgical intervention is required.
FIGURE 2
Femoral acetabular impingement with a prominent pincer lesion
Treatment. Surgical intervention is often needed to correct or remove the abnormal anatomy, and both arthroscopic and open surgery are recommended.20 Both methods include osteoplasty at the femoral head/neck junction and/or the acetabular rim to allow the proximal femur to articulate with the acetabulum without injury to the labrum with flexion and internal rotation.21
Results of both open and arthroscopic osteoplasty of the femur and acetabulum are still preliminary, with only a few studies reporting mid-term results. Open surgery typically has longer recovery and rehabilitation, but advocates emphasize the improved ability to contour the femur or acetabulum. Both open and arthroscopic procedures have about an 8% to 13% rate of revision in short-term follow-up.17
Labral tears occur with trauma and certain sports
In addition to FAI, causes of labral tears include dysplasia, instability, trauma, and degeneration, as well as sports that require repetitive hip flexion and/or pivoting, such as hockey, soccer, and football.22,23
Patients with labral tears typically present with anterior hip pain radiating to the groin, worsening with twisting motions, running, walking, and sitting for prolonged periods. Clicking or catching may occur, as well. Patients may exhibit what one researcher called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.4 The work-up for labral tears includes radiographs and, often, MRA, which is nearly 100% specific.24
Treatment. Conservative treatment, which may include activity modification or rest and ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy, is often effective for labral tears; when such measures fail, surgical intervention is indicated. A systematic review found a 67% satisfaction rate after 3.5 years in patients who had undergone labral debridement, and complete resolution of mechanical symptoms in nearly 50%.25 Another study showed similar results for hip arthroscopy, with symptom relief continuing for 4.8 years after surgery, on average, and 84% of patients able to return to their previous level of activity.26
The long-term results of labral debridement are unknown, however, and the possibility of an association between this procedure and the development of arthritis remains. Most specialists prefer anatomic repair to restore normal hip kinematics and, potentially, long-term hip function,27,28 but structural abnormalities must also be addressed to prevent failure of the repair or recurrent tears.
Iliopsoas tendonitis: You know the snap
Often referred to as internal snapping of the hip or internal coxa saltans, iliopsoas tendonitis/bursitis can be a recalcitrant cause of anterior hip pain. Snapping of the iliopsoas leading to bursitis or tendonitis can occur at the iliopectineal eminence, the femoral head, or the lesser trochanter.29 Runners and ballet dancers are often affected.30,31
Snapping in itself is not an indication of pathology, but chronicity of symptoms is. Patients with relatively acute symptoms typically have only bursitis, while a longer duration of symptoms leads to tendonitis or tendinopathy.32
Treatment. First-line therapy is nonoperative, and includes activity modification, rest, ice, NSAIDs, and physical therapy. Advise patients to refrain from activities causing pain, and to apply ice to the affected every 20 minutes (with a 20- to 30-minute off period) for one to 2 hours. Physical therapy focuses on stretching the iliopsoas and rectus femoris muscles and strengthening the hamstring muscles to relieve the stress on the anterior pelvis. If such treatment is unsuccessful, ultrasound can be used to guide a therapeutic injection of cortisone.33 If this fails to bring relief, fractional lengthening of the iliopsoas tendon can be performed to eliminate snapping and relieve pain.34
Muscular strains/avulsion fractures: Sports and age play a role
Although strains can affect any of the anterior muscles around the hip, in active individuals the adductors are most commonly affected. Skeletally immature patients are an exception: apophyseal fractures at the origin of the sartorius and rectus femoris muscles are more common than muscular strains in this patient population.
Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required—eg, football, hockey, and soccer35—and generally are able to tell you exactly what they were doing when the injury occurred. Physical examination can reveal focal findings, with swelling and tenderness confined to the anteromedial aspect of the hip along the adductor muscle group. MRI can help differentiate the site of true pathology.36
Treatment of adductor strains is nonoperative, with rest, ice, and activity modification until the tendon heals. In the rare case in which complete tendon avulsion is found, surgical reattachment is needed.
Apophyseal fracture in skeletally immature patients typically occurs during participation in a sport that requires rapid acceleration and deceleration with the hip in an extended position. In such patients, stretching the affected muscle should reproduce the pain. Radiographs are diagnostic and will often show minimal displacement of the apophysis. Treatment is almost always nonoperative. Surgical intervention is rarely needed, and only indicated with displacement >2 cm.37
Athletic pubalgia: A challenging Dx
Also referred to as sports hernia, athletic pubalgia is an enigmatic cause of anterior hip pain in athletes. Diagnosis can be especially challenging, and patients may have lingering symptoms for years before the cause is discovered.38 A sports hernia, unlike other hernias, does not involve a bulge of tissue protruding through one body part into another. In contrast, a sports hernia occurs when the oblique abdominal muscles strain or completely tear away from the pubis. A recent systematic review found that the underlying etiology involves posterior inguinal wall weakening, which can be a result of poorly balanced hip adductor and abdominal muscle activation.39
Patients with sports hernia will often present with anterior hip and/or groin pain, especially with hip extension, twisting, and turning. In addition, patients can have pain in the lower abdomen and, in males, in the testicles. Physical examination will usually show pubic point tenderness, which is exacerbated by resisted hip adduction.40 MRI and ultrasound are extremely helpful in diagnosing and forming a treatment plan.39
The initial treatment of choice for sports hernias is nonoperative, and the first step is always activity modification or temporary avoidance of symptom-producing activities. Additional modalities include NSAIDs, ice, and physical therapy to strengthen the surrounding muscles. Surgical intervention, if needed, may be done laparoscopically or via an open approach with direct repair.40,41
Less common causes to consider
While the conditions detailed here account for most anterior hip etiologies, there are other less common causes to consider. One such cause is osteitis pubis, an umbrella term for conditions that affect the area surrounding the symphysis pubis. Patients with osteitis pubis present with pain over the anterior aspect of the pelvis that is worse with sit-ups, rising from a chair, or any activity where contraction of the rectus muscles occurs.29 Tenderness is found directly over and just lateral to the pubic symphysis. Radiographs are frequently negative, but occasionally chronic degenerative changes at the symphysis are present in addition to symphyseal narrowing. Additional imaging is often necessary for diagnosis.
Neuropathies. When history, physical examination, and imaging studies have ruled out other causes, neuropathies (ilioinguinal, genitofemoral, and obturator) should be considered, particularly in patients with vague, radiating anterior hip and/or groin pain.42 In pediatric patients, Legg-Calve-Perthes disease and slipped capital femoral epiphysis are possibilities, as well.
Getting patients back on track
Rehabilitation after hip injury resulting in anterior hip pain will be determined by the site, type, and mechanism of injury, as well as the severity. Restrictions in weight bearing and the use of an assistive device may be needed to prevent excessive stress on bone and supporting soft-tissue structures in the early stages of healing. Physical therapy, as needed, should initially focus on early controlled ROM of the hip joint to prevent both intra- and extra-articular adhesions and excessive scar tissue formation.2
For patients who undergo surgery, much of the focus will be on strengthening the supporting musculature—the hip abductor group, anterior and posterior thigh musculature, and core stabilizing muscles. Neuromuscular training may be needed to promote normal biomechanics and minimize compensatory movement patterns. For athletes, cardiovascular training and a return-to-play program should be implemented, as well.2,43,44
CASE Mr. Q was diagnosed with right hip pain due to a labral tear secondary to a cam femoral acetabular impingement. Given that he had failed nonoperative treatment and had long-standing pain, we recommended surgery for this patient. He underwent right hip arthroscopic labral repair, acetabular rim trimming, acetabular microfracture, femoral osteochondroplasty with capsular plication. At 12-month follow-up, he was doing well, with resolution of the presurgical pain and return to all athletic activities.
CORRESPONDENCE Rachel M. Frank, MD, Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612; rmfrank3@gmail.com
1. Margo K, Drezner J, Motzkin D. Evaluation and management of hip pain: an algorithmic approach. J Fam Pract. 2003;52:607-617.
2. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res. 2009;467:616-622.
3. Enseki KR, Martin RL, Draovitch P, et al. The hip joint: arthroscopic procedures and postoperative rehabilitation J Orthop Sports Phys Ther. 2006;36:516-525.
4. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004;32:1668-1674.
5. Fredericson M, Jennings F, Beaulieu C, et al. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17:309-325.
6. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15:46-58.
7. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6:391-396.
8. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25:53-62, viii.
9. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. 1997;5:293-302.
10. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77:459-474.
11. Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res. 1999;(367):172-180.
12. Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999;7:250-261.
13. Smith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am. 1995;77:674-680.
14. Fairbank AC, Bhatia D, Jinnah RH, et al. Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br. 1995;77:42-49.
15. Chandler HP, Reineck FT, Wixson RL, et al. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63:1426-1434.
16. Wei SY, Klimkiewicz JJ, Lai M, et al. Revision total hip arthroplasty in patients with avascular necrosis. Orthopedics. 1999;22:747-757.
17. Bedi A, Chen N, Robertson W, et al. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008;24:1135-1145.
18. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy. 2006;22:95-106.
19. Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement in 45 professional athletes: Knee Surg Sports Traumatol Arthrosc. 2007;15:908-914.
20. Sierra RJ, Trousdale RT, Ganz R, et al. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop Surg. 2008;16:689-703.
21. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2009;468:741-746.
22. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88:1448-1457.
23. Bare AA, Guanche CA. Hip impingement: the role of arthroscopy. Orthopedics. 2005;28:266-273.
24. Toomayan GA, Holman WR, Major NM, et al. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol. 2006;186:449-453.
25. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
26. Kamath AF, Componovo R, Baldwin K, et al. Hip arthroscopy for labral tears: review of clinical outcomes with 4.8-year mean follow-up. Am J Sports Med. 2009;37:1721-1727.
27. Larson CM, Giveans MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25:369-376.
28. Larson CM, Guanche CA, Kelly BT, et al. Advanced techniques in hip arthroscopy. Instr Course Lect. 2009;58:423-436.
29. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24:1407-1421.
30. Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247-252.
31. Winston P, Awan R, Cassidy JD, et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.
32. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip. Skeletal Radiol. 2006;35:565-571.
33. Adler RS, Buly R, Ambrose R, et al. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005;185:940-943.
34. Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. Am J Sports Med. 2008;36:2363-2371.
35. Maffey L, Emery C. What are the risk factors for groin strain injury in sport? Sports Med. 2007;37:881-894.
36. Verrall GM, Slavotinek JP, Fon GT, et al. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007;35:467-474.
37. Pointinger H, Munk P, Poeschl GP. Avulsion fracture of the anterior superior iliac spine following apophysitis. Br J Sports Med. 2003;37:361-362.
38. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J Orthop Sports Phys Ther. 2008;38:63-70.
39. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008;42:954-964.
40. Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: definition and surgical treatment. Ann Plast Surg. 2005;55:393-396.
41. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521-533.
42. Petchprapa CN, Rosenberg ZS, Sconfienza LM, et al. MR imaging of entrapment neuropathies of the lower extremity. Part I. Radiographs. 2010;30:983-1000.
43. Voight M, Robinson K, Gill L, et al. Postoperative guidelines for hip arthroscopy in the active population. Sports Health. 2010;2:222-230.
44. Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25:337-357.
• Consider both musculoskeletal and nonmusculoskeletal causes in patients with vague complaints of hip and groin pain. B
• Use imaging studies to confirm a hip pain diagnosis. B
• Refer patients who fail to respond to nonsurgical treatment to a sports medicine specialist or an orthopedic surgeon. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Hip pain is a common complaint, and commonly misunderstood. Although the pain can be associated with a broad spectrum of conditions, the presentation is often vague and nonspecific.
Thus, hip pain and injury are frequently attributed, often incorrectly, to a “hip pointer”—a contusion of soft tissues against the iliac crest. It’s not unusual for patients who receive this diagnosis to be treated conservatively for prolonged periods, leading some previously active individuals to abandon their favorite sport or self-impose limits on the activities they engage in.1
But it doesn’t have to be this way.
Minimally invasive hip arthroscopy and advances in imaging, instrumentation, and devices have made it easier to identify and address underlying pathology associated with hip pain, helping patients return to their previous level of activity more rapidly.2,3 And, while many conditions associated with hip pain can be treated conservatively, family physicians—whom patients often go to first—should not hesitate to provide a referral when more aggressive treatment or diagnostic confirmation is needed.
We created this guide with family physicians in mind. Our focus here is primarily on anterior hip pain—the most common presentation—in active, or athletic, patients.
When did the pain begin? Where does it hurt?
Before performing a physical examination, find out as much as possible about the onset of pain and when and under what circumstances it occurs. (A review of hip anatomy is provided here.) Did it begin suddenly, after an acute injury or a particular physical maneuver? Or is the pain insidious, as was the case with one of our patients?
Osseous morphology of the hip includes the anterior superior iliac spine, the origin of the sartorius muscle and the ilioinguinal ligament. The anterior inferior iliac spine attaches to the rectus femoris, a major hip flexor and knee extender. The adductors of the hip originate in the anterior pelvic region.
The inguinal canal contains the ilioinguinal nerve, which is responsible for radiation of pain to the anterior hip. The hip joint itself is a spheroid comprising the femoral head and acetabulum, with most of the articular hip innervated by the femoral or obturator nerves.
Most intra-articular conditions radiate to the anterior groin or hip, although there are cases in which the pain is referred to either the lateral aspect of the hip or the buttocks. The iliopsoas muscle is the major hip flexor, and crosses under the ilioinguinal ligament to insert on the lesser tuberosity after crossing over the anterior capsule of the hip. A large bursa surrounds it, helping the tendon glide smoothly over the hip.
CASE Mack Q, a 27-year-old man with an 8-month history of right hip pain, sought care at our medical center for an achy pain in his right groin; he also described an occasional “clicking and popping sensation” in his groin but denied any trauma. The pain worsened with prolonged sitting and certain activities, such as squatting, twisting, and putting on shoes and socks. Our patient had stopped playing soccer because it hurt too much. He had tried physical therapy, oral anti-inflammatories, and a corticosteroid injection, with little relief.
Start with a gait assessment
The physical examination should begin with a gait assessment. Consider the patient’s ability to bear weight and his or her foot angle.
An individual with a stress fracture will have difficulty bearing weight on the affected side, resulting in a limp, or antalgic gait. A patient with femoral acetabular impingement (FAI) will often exhibit greater external rotation of the foot on the affected side compared with the other foot. And a patient with weakened abductor muscles, typically because of severe osteoarthritis, will exhibit the Trendelenburg sign—a pelvic tilt when the weight is shifted to the affected extremity.
Although most individuals with hip pain will not have an obvious gait abnormality, any patient who walks with a limp or needs crutches requires an immediate referral to an orthopedic surgeon.
Include these elements in the physical exam
Examine the hip with the patient sitting on the side of the exam table. Assess range of motion (ROM), comparing the range of flexion, extension, and internal/external rotation on the affected and unaffected sides. Include the following maneuvers:
Impingement testing. In patients with FAI and osteoarthritis, impingement testing—encompassing Flexion, ADDuction, and Internal Rotation (FADDIR)—will elicit pain. The maneuver can be tested starting at 45° of hip flexion, increasing to approximately 120°. Pain with <45° of hip flexion indicates that the impingement is severe.
Such testing can also reveal labral tears, which may be caused by FAI or other structural abnormalities. In a patient with anterior labral tears, FADDIR will produce groin pain; posterior labral tears will produce pain when the patient is sitting with legs hanging off the exam table and the contralateral leg is brought to the chest and the affected limb fully extended.
In patients with hip pain and bursitis, applying downward pressure will elicit a snapping sound as the iliopsoas snaps over the iliopectineal eminence or femoral head. Flexion, ABduction, and External Rotation (FABER) can also be used to diagnose iliopsoas tendonitis: The test is positive if it elicits pain in the affected extremity or in the sacroiliac joint on the opposite side.
Log roll. A painful response to this test, which involves internally and externally rotating the affected hip while it is relaxed and the knee fully extended, is an indication of synovitis of the hip caused by intra-articular pathology. To test hip stability, externally rotate the leg while it is extended. If the hip is stable, the leg will return to a neutral position; microinstability of the hip is likely if the leg remains in the rotated position.
Muscular strength testing. To assess for tendinopathy in the hip area, the patient should be in a seated position and contract the internal and external rotators and the adductor muscles while you apply resistance. To test abductor strength, have the patient assume a lateral position and hold and abduct the leg on the affected side while you apply resistance.
Hip flexion strength should be tested with the patient in both supine and seated positions. A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in the supine position vs the seated position; the opposite is true for a patient with iliopsoas tendonitis. (See “Did you know…? Hip pain facts and findings” on for additional diagnostic tips.)
- A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in a supine position vs a seated position. The opposite is true for a patient with iliopsoas tendonitis.
- Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest. Initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.”
- Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but magnetic resonance imaging is useful for evaluating earlier clinical presentations.
- Patients with labral tears often exhibit what has been called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.
- Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required, such as football, hockey, and soccer, and are generally able to tell you exactly what they were doing when the injury occurred.
- Unlike other hernias, a sports hernia (athletic pubalgia) does not involve a bulge of tissue protruding through one part of the body into another. Instead, it occurs when the oblique abdominal muscles strain or completely tear away from the pubis.
Perform a neurologic evaluation to rule out a back condition that might radiate pain into the anterior hip; ask the patient to do a sit-up while you apply resistance to test for abdominal wall pathology, as well.
Hip palpation. This aspect of the physical exam is important regardless of the cause of the pain but especially crucial for pediatric and adolescent patients, whose anterior hip pain may be related to apophyseal injury. Palpate the superior iliac spine (and over the inferior iliac spine in thin patients) to determine if the sartorius or rectus femoris has been injured. The area just lateral to the symphysis will be tender to palpation in patients with osteitis pubis.
Refer or treat? Here’s what to consider
While the history and physical should provide ample information for a differential diagnosis, imaging studies are generally required for confirmation. Clinical assessment— including physical exam, imaging, and intra-articular injection—of patients with hip pain is up to 98% accurate in identifying hip abnormalities, with arthroscopy as the gold standard.4
CASE On physical examination, Mr. Q had right hip extension to 0°, flexion to 110°, external rotation to 50°, and internal rotation to neutral; he also had positive impingement and subspine impingement tests, a painful arc of motion from 12 to 4 o’clock, tenderness over the hip adductor, and pain with resisted hip adduction. He did not walk with a limp.
Diagnostic studies included plain radiographs, which demonstrated that the joint space was well preserved. We identified subtle anatomical abnormalities on the femoral head-neck junction, known as a cam deformity. Magnetic resonance imaging (MRI) revealed an anterior superior labral tear with cartilage delamination.
Stress fractures affect runners, military recruits
In addition to long-distance runners who have recently increased the frequency, duration, or intensity of training,5,6 military recruits have a higher incidence of stress fractures due to the rapid onset of intensive training. Stress fractures can also occur in patients who do not have a history of intense activity but have metabolically weakened bone, in some cases as a result of an eating disorder.7
Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest; initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.” By the time such individuals seek treatment, they almost always have pain with weight bearing and an antalgic gait.
Symptoms consistent with a femoral neck stress fracture can be further evaluated with plain radiographs. However, x-rays are often negative for up to 4 weeks after the onset of pain.8 In cases in which radiographs are negative but the physical exam is suggestive of a stress fracture, MRI—which can detect an abnormality within a day or 2 of injury8,9—should be used to confirm the diagnosis (FIGURE 1).
FIGURE 1
MRI reveals a femoral neck stress fracture
Treatment. A complete femoral neck fracture portends impending displacement and requires emergent evaluation by an orthopedist, and superior neck changes, also known as tension-sided stress fractures, require urgent treatment with percutaneous screw fixation.9 However, compression-sided, or inferior, stress fractures can be treated with restricted weight bearing and activity modification. Gradual resumption of activity is allowed only after the patient has been asymptomatic for 6 weeks; recurrent pain indicates residual stress reaction, and signals that activities should be abated.
Osteonecrosis has many causes
Necrosis of the femoral head is a debilitating and progressive condition primarily affecting patients between the ages of 20 and 50 years.10 It has multiple (and diverse) causes, including trauma, steroids, alcohol, smoking, lupus, sickle cell anemia, and coagulopathies, as well as scuba diving. But about 20% of cases have no apparent cause.11,12
Patients with osteonecrosis of the hip typically present with groin pain, often described as a deep, intermittent ache that interferes with activities of daily living. Exam findings depend on the stage of presentation. Early on, pain will occur only with extreme ROM; in advanced cases, ROM is restricted and pain occurs even with limited motion.
Femoral head collapse due to loss of the structural integrity of the subchondral bone—which occurs in 80% of cases12—is thought to be caused by decreased blood flow. Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but MRI is useful for evaluating patients with earlier clinical presentations.
Treatment of osteonecrosis is dictated by the stage of the disease, but remains controversial because no intervention has been shown to prevent progression in all cases.12 All patients should be referred to a specialist. Those without collapse or cartilage damage can be treated surgically with core decompression, possibly with additional vascularized bone grafting,13,14 while those with more advanced disease typically require a total hip replacement at a relatively young age. Results for total hip replacement in patients with osteonecrosis are thought to be inferior to hip replacement in patients with osteoarthritis, although comparison is difficult because of the differences in age and activity levels in these 2 groups.15,16
Femoral acetabular impingement can occur on the cam or pincer side
FAI pathology can exist on either the femoral (cam) or acetabular (pincer) side,17 or both.18 In pure cam impingement, the anterior femoral neck loses its normal concave anatomy and develops a “bump,” which impinges on the anterosuperior labrum during hip flexion, causing labral tears and delamination of the adjacent cartilage.
Pure pincer impingement arises from a prominent acetabular rim, causing overcoverage of the femoral head. Acetabular labral tears result from the repetitive impaction with flexion and internal rotation.
Patients report an insidious onset of groin pain that is exacerbated by flexion-type sports, such as hockey, football, and golf,19 as well as activities of daily living. In patients with cartilage damage, even walking can be painful. Physical examination of patients with FAI reveals findings that are similar to those of patients with acetabular labral tears. Abnormally large cam lesions or acetabular overcoverage will result in restriction of hip ROM, especially internal rotation and flexion due to a mechanical block.
Radiographs (FIGURE 2) are essential to diagnose FAI and to distinguish this condition from an isolated labral tear.20 Cam impingement will be best demonstrated on a cross-table lateral radiograph, which shows an asphericity of the femoral head/neck junction anteriorly, while pincer impingement will show overcoverage of the femoral head on an AP radiograph. MRI or magnetic resonance arthrography (MRA) is frequently obtained to see whether any cartilage deterioration has occurred. Computed tomography, which can provide a 3-dimensional reproduction of the hip morphology, is often used for preoperative planning when surgical intervention is required.
FIGURE 2
Femoral acetabular impingement with a prominent pincer lesion
Treatment. Surgical intervention is often needed to correct or remove the abnormal anatomy, and both arthroscopic and open surgery are recommended.20 Both methods include osteoplasty at the femoral head/neck junction and/or the acetabular rim to allow the proximal femur to articulate with the acetabulum without injury to the labrum with flexion and internal rotation.21
Results of both open and arthroscopic osteoplasty of the femur and acetabulum are still preliminary, with only a few studies reporting mid-term results. Open surgery typically has longer recovery and rehabilitation, but advocates emphasize the improved ability to contour the femur or acetabulum. Both open and arthroscopic procedures have about an 8% to 13% rate of revision in short-term follow-up.17
Labral tears occur with trauma and certain sports
In addition to FAI, causes of labral tears include dysplasia, instability, trauma, and degeneration, as well as sports that require repetitive hip flexion and/or pivoting, such as hockey, soccer, and football.22,23
Patients with labral tears typically present with anterior hip pain radiating to the groin, worsening with twisting motions, running, walking, and sitting for prolonged periods. Clicking or catching may occur, as well. Patients may exhibit what one researcher called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.4 The work-up for labral tears includes radiographs and, often, MRA, which is nearly 100% specific.24
Treatment. Conservative treatment, which may include activity modification or rest and ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy, is often effective for labral tears; when such measures fail, surgical intervention is indicated. A systematic review found a 67% satisfaction rate after 3.5 years in patients who had undergone labral debridement, and complete resolution of mechanical symptoms in nearly 50%.25 Another study showed similar results for hip arthroscopy, with symptom relief continuing for 4.8 years after surgery, on average, and 84% of patients able to return to their previous level of activity.26
The long-term results of labral debridement are unknown, however, and the possibility of an association between this procedure and the development of arthritis remains. Most specialists prefer anatomic repair to restore normal hip kinematics and, potentially, long-term hip function,27,28 but structural abnormalities must also be addressed to prevent failure of the repair or recurrent tears.
Iliopsoas tendonitis: You know the snap
Often referred to as internal snapping of the hip or internal coxa saltans, iliopsoas tendonitis/bursitis can be a recalcitrant cause of anterior hip pain. Snapping of the iliopsoas leading to bursitis or tendonitis can occur at the iliopectineal eminence, the femoral head, or the lesser trochanter.29 Runners and ballet dancers are often affected.30,31
Snapping in itself is not an indication of pathology, but chronicity of symptoms is. Patients with relatively acute symptoms typically have only bursitis, while a longer duration of symptoms leads to tendonitis or tendinopathy.32
Treatment. First-line therapy is nonoperative, and includes activity modification, rest, ice, NSAIDs, and physical therapy. Advise patients to refrain from activities causing pain, and to apply ice to the affected every 20 minutes (with a 20- to 30-minute off period) for one to 2 hours. Physical therapy focuses on stretching the iliopsoas and rectus femoris muscles and strengthening the hamstring muscles to relieve the stress on the anterior pelvis. If such treatment is unsuccessful, ultrasound can be used to guide a therapeutic injection of cortisone.33 If this fails to bring relief, fractional lengthening of the iliopsoas tendon can be performed to eliminate snapping and relieve pain.34
Muscular strains/avulsion fractures: Sports and age play a role
Although strains can affect any of the anterior muscles around the hip, in active individuals the adductors are most commonly affected. Skeletally immature patients are an exception: apophyseal fractures at the origin of the sartorius and rectus femoris muscles are more common than muscular strains in this patient population.
Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required—eg, football, hockey, and soccer35—and generally are able to tell you exactly what they were doing when the injury occurred. Physical examination can reveal focal findings, with swelling and tenderness confined to the anteromedial aspect of the hip along the adductor muscle group. MRI can help differentiate the site of true pathology.36
Treatment of adductor strains is nonoperative, with rest, ice, and activity modification until the tendon heals. In the rare case in which complete tendon avulsion is found, surgical reattachment is needed.
Apophyseal fracture in skeletally immature patients typically occurs during participation in a sport that requires rapid acceleration and deceleration with the hip in an extended position. In such patients, stretching the affected muscle should reproduce the pain. Radiographs are diagnostic and will often show minimal displacement of the apophysis. Treatment is almost always nonoperative. Surgical intervention is rarely needed, and only indicated with displacement >2 cm.37
Athletic pubalgia: A challenging Dx
Also referred to as sports hernia, athletic pubalgia is an enigmatic cause of anterior hip pain in athletes. Diagnosis can be especially challenging, and patients may have lingering symptoms for years before the cause is discovered.38 A sports hernia, unlike other hernias, does not involve a bulge of tissue protruding through one body part into another. In contrast, a sports hernia occurs when the oblique abdominal muscles strain or completely tear away from the pubis. A recent systematic review found that the underlying etiology involves posterior inguinal wall weakening, which can be a result of poorly balanced hip adductor and abdominal muscle activation.39
Patients with sports hernia will often present with anterior hip and/or groin pain, especially with hip extension, twisting, and turning. In addition, patients can have pain in the lower abdomen and, in males, in the testicles. Physical examination will usually show pubic point tenderness, which is exacerbated by resisted hip adduction.40 MRI and ultrasound are extremely helpful in diagnosing and forming a treatment plan.39
The initial treatment of choice for sports hernias is nonoperative, and the first step is always activity modification or temporary avoidance of symptom-producing activities. Additional modalities include NSAIDs, ice, and physical therapy to strengthen the surrounding muscles. Surgical intervention, if needed, may be done laparoscopically or via an open approach with direct repair.40,41
Less common causes to consider
While the conditions detailed here account for most anterior hip etiologies, there are other less common causes to consider. One such cause is osteitis pubis, an umbrella term for conditions that affect the area surrounding the symphysis pubis. Patients with osteitis pubis present with pain over the anterior aspect of the pelvis that is worse with sit-ups, rising from a chair, or any activity where contraction of the rectus muscles occurs.29 Tenderness is found directly over and just lateral to the pubic symphysis. Radiographs are frequently negative, but occasionally chronic degenerative changes at the symphysis are present in addition to symphyseal narrowing. Additional imaging is often necessary for diagnosis.
Neuropathies. When history, physical examination, and imaging studies have ruled out other causes, neuropathies (ilioinguinal, genitofemoral, and obturator) should be considered, particularly in patients with vague, radiating anterior hip and/or groin pain.42 In pediatric patients, Legg-Calve-Perthes disease and slipped capital femoral epiphysis are possibilities, as well.
Getting patients back on track
Rehabilitation after hip injury resulting in anterior hip pain will be determined by the site, type, and mechanism of injury, as well as the severity. Restrictions in weight bearing and the use of an assistive device may be needed to prevent excessive stress on bone and supporting soft-tissue structures in the early stages of healing. Physical therapy, as needed, should initially focus on early controlled ROM of the hip joint to prevent both intra- and extra-articular adhesions and excessive scar tissue formation.2
For patients who undergo surgery, much of the focus will be on strengthening the supporting musculature—the hip abductor group, anterior and posterior thigh musculature, and core stabilizing muscles. Neuromuscular training may be needed to promote normal biomechanics and minimize compensatory movement patterns. For athletes, cardiovascular training and a return-to-play program should be implemented, as well.2,43,44
CASE Mr. Q was diagnosed with right hip pain due to a labral tear secondary to a cam femoral acetabular impingement. Given that he had failed nonoperative treatment and had long-standing pain, we recommended surgery for this patient. He underwent right hip arthroscopic labral repair, acetabular rim trimming, acetabular microfracture, femoral osteochondroplasty with capsular plication. At 12-month follow-up, he was doing well, with resolution of the presurgical pain and return to all athletic activities.
CORRESPONDENCE Rachel M. Frank, MD, Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612; rmfrank3@gmail.com
• Consider both musculoskeletal and nonmusculoskeletal causes in patients with vague complaints of hip and groin pain. B
• Use imaging studies to confirm a hip pain diagnosis. B
• Refer patients who fail to respond to nonsurgical treatment to a sports medicine specialist or an orthopedic surgeon. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Hip pain is a common complaint, and commonly misunderstood. Although the pain can be associated with a broad spectrum of conditions, the presentation is often vague and nonspecific.
Thus, hip pain and injury are frequently attributed, often incorrectly, to a “hip pointer”—a contusion of soft tissues against the iliac crest. It’s not unusual for patients who receive this diagnosis to be treated conservatively for prolonged periods, leading some previously active individuals to abandon their favorite sport or self-impose limits on the activities they engage in.1
But it doesn’t have to be this way.
Minimally invasive hip arthroscopy and advances in imaging, instrumentation, and devices have made it easier to identify and address underlying pathology associated with hip pain, helping patients return to their previous level of activity more rapidly.2,3 And, while many conditions associated with hip pain can be treated conservatively, family physicians—whom patients often go to first—should not hesitate to provide a referral when more aggressive treatment or diagnostic confirmation is needed.
We created this guide with family physicians in mind. Our focus here is primarily on anterior hip pain—the most common presentation—in active, or athletic, patients.
When did the pain begin? Where does it hurt?
Before performing a physical examination, find out as much as possible about the onset of pain and when and under what circumstances it occurs. (A review of hip anatomy is provided here.) Did it begin suddenly, after an acute injury or a particular physical maneuver? Or is the pain insidious, as was the case with one of our patients?
Osseous morphology of the hip includes the anterior superior iliac spine, the origin of the sartorius muscle and the ilioinguinal ligament. The anterior inferior iliac spine attaches to the rectus femoris, a major hip flexor and knee extender. The adductors of the hip originate in the anterior pelvic region.
The inguinal canal contains the ilioinguinal nerve, which is responsible for radiation of pain to the anterior hip. The hip joint itself is a spheroid comprising the femoral head and acetabulum, with most of the articular hip innervated by the femoral or obturator nerves.
Most intra-articular conditions radiate to the anterior groin or hip, although there are cases in which the pain is referred to either the lateral aspect of the hip or the buttocks. The iliopsoas muscle is the major hip flexor, and crosses under the ilioinguinal ligament to insert on the lesser tuberosity after crossing over the anterior capsule of the hip. A large bursa surrounds it, helping the tendon glide smoothly over the hip.
CASE Mack Q, a 27-year-old man with an 8-month history of right hip pain, sought care at our medical center for an achy pain in his right groin; he also described an occasional “clicking and popping sensation” in his groin but denied any trauma. The pain worsened with prolonged sitting and certain activities, such as squatting, twisting, and putting on shoes and socks. Our patient had stopped playing soccer because it hurt too much. He had tried physical therapy, oral anti-inflammatories, and a corticosteroid injection, with little relief.
Start with a gait assessment
The physical examination should begin with a gait assessment. Consider the patient’s ability to bear weight and his or her foot angle.
An individual with a stress fracture will have difficulty bearing weight on the affected side, resulting in a limp, or antalgic gait. A patient with femoral acetabular impingement (FAI) will often exhibit greater external rotation of the foot on the affected side compared with the other foot. And a patient with weakened abductor muscles, typically because of severe osteoarthritis, will exhibit the Trendelenburg sign—a pelvic tilt when the weight is shifted to the affected extremity.
Although most individuals with hip pain will not have an obvious gait abnormality, any patient who walks with a limp or needs crutches requires an immediate referral to an orthopedic surgeon.
Include these elements in the physical exam
Examine the hip with the patient sitting on the side of the exam table. Assess range of motion (ROM), comparing the range of flexion, extension, and internal/external rotation on the affected and unaffected sides. Include the following maneuvers:
Impingement testing. In patients with FAI and osteoarthritis, impingement testing—encompassing Flexion, ADDuction, and Internal Rotation (FADDIR)—will elicit pain. The maneuver can be tested starting at 45° of hip flexion, increasing to approximately 120°. Pain with <45° of hip flexion indicates that the impingement is severe.
Such testing can also reveal labral tears, which may be caused by FAI or other structural abnormalities. In a patient with anterior labral tears, FADDIR will produce groin pain; posterior labral tears will produce pain when the patient is sitting with legs hanging off the exam table and the contralateral leg is brought to the chest and the affected limb fully extended.
In patients with hip pain and bursitis, applying downward pressure will elicit a snapping sound as the iliopsoas snaps over the iliopectineal eminence or femoral head. Flexion, ABduction, and External Rotation (FABER) can also be used to diagnose iliopsoas tendonitis: The test is positive if it elicits pain in the affected extremity or in the sacroiliac joint on the opposite side.
Log roll. A painful response to this test, which involves internally and externally rotating the affected hip while it is relaxed and the knee fully extended, is an indication of synovitis of the hip caused by intra-articular pathology. To test hip stability, externally rotate the leg while it is extended. If the hip is stable, the leg will return to a neutral position; microinstability of the hip is likely if the leg remains in the rotated position.
Muscular strength testing. To assess for tendinopathy in the hip area, the patient should be in a seated position and contract the internal and external rotators and the adductor muscles while you apply resistance. To test abductor strength, have the patient assume a lateral position and hold and abduct the leg on the affected side while you apply resistance.
Hip flexion strength should be tested with the patient in both supine and seated positions. A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in the supine position vs the seated position; the opposite is true for a patient with iliopsoas tendonitis. (See “Did you know…? Hip pain facts and findings” on for additional diagnostic tips.)
- A patient with quadriceps tendonitis will have much greater pain with resisted hip flexion in a supine position vs a seated position. The opposite is true for a patient with iliopsoas tendonitis.
- Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest. Initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.”
- Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but magnetic resonance imaging is useful for evaluating earlier clinical presentations.
- Patients with labral tears often exhibit what has been called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.
- Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required, such as football, hockey, and soccer, and are generally able to tell you exactly what they were doing when the injury occurred.
- Unlike other hernias, a sports hernia (athletic pubalgia) does not involve a bulge of tissue protruding through one part of the body into another. Instead, it occurs when the oblique abdominal muscles strain or completely tear away from the pubis.
Perform a neurologic evaluation to rule out a back condition that might radiate pain into the anterior hip; ask the patient to do a sit-up while you apply resistance to test for abdominal wall pathology, as well.
Hip palpation. This aspect of the physical exam is important regardless of the cause of the pain but especially crucial for pediatric and adolescent patients, whose anterior hip pain may be related to apophyseal injury. Palpate the superior iliac spine (and over the inferior iliac spine in thin patients) to determine if the sartorius or rectus femoris has been injured. The area just lateral to the symphysis will be tender to palpation in patients with osteitis pubis.
Refer or treat? Here’s what to consider
While the history and physical should provide ample information for a differential diagnosis, imaging studies are generally required for confirmation. Clinical assessment— including physical exam, imaging, and intra-articular injection—of patients with hip pain is up to 98% accurate in identifying hip abnormalities, with arthroscopy as the gold standard.4
CASE On physical examination, Mr. Q had right hip extension to 0°, flexion to 110°, external rotation to 50°, and internal rotation to neutral; he also had positive impingement and subspine impingement tests, a painful arc of motion from 12 to 4 o’clock, tenderness over the hip adductor, and pain with resisted hip adduction. He did not walk with a limp.
Diagnostic studies included plain radiographs, which demonstrated that the joint space was well preserved. We identified subtle anatomical abnormalities on the femoral head-neck junction, known as a cam deformity. Magnetic resonance imaging (MRI) revealed an anterior superior labral tear with cartilage delamination.
Stress fractures affect runners, military recruits
In addition to long-distance runners who have recently increased the frequency, duration, or intensity of training,5,6 military recruits have a higher incidence of stress fractures due to the rapid onset of intensive training. Stress fractures can also occur in patients who do not have a history of intense activity but have metabolically weakened bone, in some cases as a result of an eating disorder.7
Patients with femoral neck stress fractures typically present with activity-related anterior groin pain that is relieved by rest; initially, they may be only mildly affected, but the condition worsens in those who continue to “work through the pain.” By the time such individuals seek treatment, they almost always have pain with weight bearing and an antalgic gait.
Symptoms consistent with a femoral neck stress fracture can be further evaluated with plain radiographs. However, x-rays are often negative for up to 4 weeks after the onset of pain.8 In cases in which radiographs are negative but the physical exam is suggestive of a stress fracture, MRI—which can detect an abnormality within a day or 2 of injury8,9—should be used to confirm the diagnosis (FIGURE 1).
FIGURE 1
MRI reveals a femoral neck stress fracture
Treatment. A complete femoral neck fracture portends impending displacement and requires emergent evaluation by an orthopedist, and superior neck changes, also known as tension-sided stress fractures, require urgent treatment with percutaneous screw fixation.9 However, compression-sided, or inferior, stress fractures can be treated with restricted weight bearing and activity modification. Gradual resumption of activity is allowed only after the patient has been asymptomatic for 6 weeks; recurrent pain indicates residual stress reaction, and signals that activities should be abated.
Osteonecrosis has many causes
Necrosis of the femoral head is a debilitating and progressive condition primarily affecting patients between the ages of 20 and 50 years.10 It has multiple (and diverse) causes, including trauma, steroids, alcohol, smoking, lupus, sickle cell anemia, and coagulopathies, as well as scuba diving. But about 20% of cases have no apparent cause.11,12
Patients with osteonecrosis of the hip typically present with groin pain, often described as a deep, intermittent ache that interferes with activities of daily living. Exam findings depend on the stage of presentation. Early on, pain will occur only with extreme ROM; in advanced cases, ROM is restricted and pain occurs even with limited motion.
Femoral head collapse due to loss of the structural integrity of the subchondral bone—which occurs in 80% of cases12—is thought to be caused by decreased blood flow. Plain radiography can confirm a diagnosis of osteonecrosis in patients with advanced disease, but MRI is useful for evaluating patients with earlier clinical presentations.
Treatment of osteonecrosis is dictated by the stage of the disease, but remains controversial because no intervention has been shown to prevent progression in all cases.12 All patients should be referred to a specialist. Those without collapse or cartilage damage can be treated surgically with core decompression, possibly with additional vascularized bone grafting,13,14 while those with more advanced disease typically require a total hip replacement at a relatively young age. Results for total hip replacement in patients with osteonecrosis are thought to be inferior to hip replacement in patients with osteoarthritis, although comparison is difficult because of the differences in age and activity levels in these 2 groups.15,16
Femoral acetabular impingement can occur on the cam or pincer side
FAI pathology can exist on either the femoral (cam) or acetabular (pincer) side,17 or both.18 In pure cam impingement, the anterior femoral neck loses its normal concave anatomy and develops a “bump,” which impinges on the anterosuperior labrum during hip flexion, causing labral tears and delamination of the adjacent cartilage.
Pure pincer impingement arises from a prominent acetabular rim, causing overcoverage of the femoral head. Acetabular labral tears result from the repetitive impaction with flexion and internal rotation.
Patients report an insidious onset of groin pain that is exacerbated by flexion-type sports, such as hockey, football, and golf,19 as well as activities of daily living. In patients with cartilage damage, even walking can be painful. Physical examination of patients with FAI reveals findings that are similar to those of patients with acetabular labral tears. Abnormally large cam lesions or acetabular overcoverage will result in restriction of hip ROM, especially internal rotation and flexion due to a mechanical block.
Radiographs (FIGURE 2) are essential to diagnose FAI and to distinguish this condition from an isolated labral tear.20 Cam impingement will be best demonstrated on a cross-table lateral radiograph, which shows an asphericity of the femoral head/neck junction anteriorly, while pincer impingement will show overcoverage of the femoral head on an AP radiograph. MRI or magnetic resonance arthrography (MRA) is frequently obtained to see whether any cartilage deterioration has occurred. Computed tomography, which can provide a 3-dimensional reproduction of the hip morphology, is often used for preoperative planning when surgical intervention is required.
FIGURE 2
Femoral acetabular impingement with a prominent pincer lesion
Treatment. Surgical intervention is often needed to correct or remove the abnormal anatomy, and both arthroscopic and open surgery are recommended.20 Both methods include osteoplasty at the femoral head/neck junction and/or the acetabular rim to allow the proximal femur to articulate with the acetabulum without injury to the labrum with flexion and internal rotation.21
Results of both open and arthroscopic osteoplasty of the femur and acetabulum are still preliminary, with only a few studies reporting mid-term results. Open surgery typically has longer recovery and rehabilitation, but advocates emphasize the improved ability to contour the femur or acetabulum. Both open and arthroscopic procedures have about an 8% to 13% rate of revision in short-term follow-up.17
Labral tears occur with trauma and certain sports
In addition to FAI, causes of labral tears include dysplasia, instability, trauma, and degeneration, as well as sports that require repetitive hip flexion and/or pivoting, such as hockey, soccer, and football.22,23
Patients with labral tears typically present with anterior hip pain radiating to the groin, worsening with twisting motions, running, walking, and sitting for prolonged periods. Clicking or catching may occur, as well. Patients may exhibit what one researcher called the “c-sign”—so named for the shape patients make with their hand as they grip their hip just above the greater trochanter to indicate where it hurts.4 The work-up for labral tears includes radiographs and, often, MRA, which is nearly 100% specific.24
Treatment. Conservative treatment, which may include activity modification or rest and ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy, is often effective for labral tears; when such measures fail, surgical intervention is indicated. A systematic review found a 67% satisfaction rate after 3.5 years in patients who had undergone labral debridement, and complete resolution of mechanical symptoms in nearly 50%.25 Another study showed similar results for hip arthroscopy, with symptom relief continuing for 4.8 years after surgery, on average, and 84% of patients able to return to their previous level of activity.26
The long-term results of labral debridement are unknown, however, and the possibility of an association between this procedure and the development of arthritis remains. Most specialists prefer anatomic repair to restore normal hip kinematics and, potentially, long-term hip function,27,28 but structural abnormalities must also be addressed to prevent failure of the repair or recurrent tears.
Iliopsoas tendonitis: You know the snap
Often referred to as internal snapping of the hip or internal coxa saltans, iliopsoas tendonitis/bursitis can be a recalcitrant cause of anterior hip pain. Snapping of the iliopsoas leading to bursitis or tendonitis can occur at the iliopectineal eminence, the femoral head, or the lesser trochanter.29 Runners and ballet dancers are often affected.30,31
Snapping in itself is not an indication of pathology, but chronicity of symptoms is. Patients with relatively acute symptoms typically have only bursitis, while a longer duration of symptoms leads to tendonitis or tendinopathy.32
Treatment. First-line therapy is nonoperative, and includes activity modification, rest, ice, NSAIDs, and physical therapy. Advise patients to refrain from activities causing pain, and to apply ice to the affected every 20 minutes (with a 20- to 30-minute off period) for one to 2 hours. Physical therapy focuses on stretching the iliopsoas and rectus femoris muscles and strengthening the hamstring muscles to relieve the stress on the anterior pelvis. If such treatment is unsuccessful, ultrasound can be used to guide a therapeutic injection of cortisone.33 If this fails to bring relief, fractional lengthening of the iliopsoas tendon can be performed to eliminate snapping and relieve pain.34
Muscular strains/avulsion fractures: Sports and age play a role
Although strains can affect any of the anterior muscles around the hip, in active individuals the adductors are most commonly affected. Skeletally immature patients are an exception: apophyseal fractures at the origin of the sartorius and rectus femoris muscles are more common than muscular strains in this patient population.
Athletes who experience adductor strains often play sports in which kicking or frequent changes in direction are required—eg, football, hockey, and soccer35—and generally are able to tell you exactly what they were doing when the injury occurred. Physical examination can reveal focal findings, with swelling and tenderness confined to the anteromedial aspect of the hip along the adductor muscle group. MRI can help differentiate the site of true pathology.36
Treatment of adductor strains is nonoperative, with rest, ice, and activity modification until the tendon heals. In the rare case in which complete tendon avulsion is found, surgical reattachment is needed.
Apophyseal fracture in skeletally immature patients typically occurs during participation in a sport that requires rapid acceleration and deceleration with the hip in an extended position. In such patients, stretching the affected muscle should reproduce the pain. Radiographs are diagnostic and will often show minimal displacement of the apophysis. Treatment is almost always nonoperative. Surgical intervention is rarely needed, and only indicated with displacement >2 cm.37
Athletic pubalgia: A challenging Dx
Also referred to as sports hernia, athletic pubalgia is an enigmatic cause of anterior hip pain in athletes. Diagnosis can be especially challenging, and patients may have lingering symptoms for years before the cause is discovered.38 A sports hernia, unlike other hernias, does not involve a bulge of tissue protruding through one body part into another. In contrast, a sports hernia occurs when the oblique abdominal muscles strain or completely tear away from the pubis. A recent systematic review found that the underlying etiology involves posterior inguinal wall weakening, which can be a result of poorly balanced hip adductor and abdominal muscle activation.39
Patients with sports hernia will often present with anterior hip and/or groin pain, especially with hip extension, twisting, and turning. In addition, patients can have pain in the lower abdomen and, in males, in the testicles. Physical examination will usually show pubic point tenderness, which is exacerbated by resisted hip adduction.40 MRI and ultrasound are extremely helpful in diagnosing and forming a treatment plan.39
The initial treatment of choice for sports hernias is nonoperative, and the first step is always activity modification or temporary avoidance of symptom-producing activities. Additional modalities include NSAIDs, ice, and physical therapy to strengthen the surrounding muscles. Surgical intervention, if needed, may be done laparoscopically or via an open approach with direct repair.40,41
Less common causes to consider
While the conditions detailed here account for most anterior hip etiologies, there are other less common causes to consider. One such cause is osteitis pubis, an umbrella term for conditions that affect the area surrounding the symphysis pubis. Patients with osteitis pubis present with pain over the anterior aspect of the pelvis that is worse with sit-ups, rising from a chair, or any activity where contraction of the rectus muscles occurs.29 Tenderness is found directly over and just lateral to the pubic symphysis. Radiographs are frequently negative, but occasionally chronic degenerative changes at the symphysis are present in addition to symphyseal narrowing. Additional imaging is often necessary for diagnosis.
Neuropathies. When history, physical examination, and imaging studies have ruled out other causes, neuropathies (ilioinguinal, genitofemoral, and obturator) should be considered, particularly in patients with vague, radiating anterior hip and/or groin pain.42 In pediatric patients, Legg-Calve-Perthes disease and slipped capital femoral epiphysis are possibilities, as well.
Getting patients back on track
Rehabilitation after hip injury resulting in anterior hip pain will be determined by the site, type, and mechanism of injury, as well as the severity. Restrictions in weight bearing and the use of an assistive device may be needed to prevent excessive stress on bone and supporting soft-tissue structures in the early stages of healing. Physical therapy, as needed, should initially focus on early controlled ROM of the hip joint to prevent both intra- and extra-articular adhesions and excessive scar tissue formation.2
For patients who undergo surgery, much of the focus will be on strengthening the supporting musculature—the hip abductor group, anterior and posterior thigh musculature, and core stabilizing muscles. Neuromuscular training may be needed to promote normal biomechanics and minimize compensatory movement patterns. For athletes, cardiovascular training and a return-to-play program should be implemented, as well.2,43,44
CASE Mr. Q was diagnosed with right hip pain due to a labral tear secondary to a cam femoral acetabular impingement. Given that he had failed nonoperative treatment and had long-standing pain, we recommended surgery for this patient. He underwent right hip arthroscopic labral repair, acetabular rim trimming, acetabular microfracture, femoral osteochondroplasty with capsular plication. At 12-month follow-up, he was doing well, with resolution of the presurgical pain and return to all athletic activities.
CORRESPONDENCE Rachel M. Frank, MD, Department of Orthopedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612; rmfrank3@gmail.com
1. Margo K, Drezner J, Motzkin D. Evaluation and management of hip pain: an algorithmic approach. J Fam Pract. 2003;52:607-617.
2. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res. 2009;467:616-622.
3. Enseki KR, Martin RL, Draovitch P, et al. The hip joint: arthroscopic procedures and postoperative rehabilitation J Orthop Sports Phys Ther. 2006;36:516-525.
4. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004;32:1668-1674.
5. Fredericson M, Jennings F, Beaulieu C, et al. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17:309-325.
6. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15:46-58.
7. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6:391-396.
8. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25:53-62, viii.
9. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. 1997;5:293-302.
10. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77:459-474.
11. Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res. 1999;(367):172-180.
12. Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999;7:250-261.
13. Smith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am. 1995;77:674-680.
14. Fairbank AC, Bhatia D, Jinnah RH, et al. Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br. 1995;77:42-49.
15. Chandler HP, Reineck FT, Wixson RL, et al. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63:1426-1434.
16. Wei SY, Klimkiewicz JJ, Lai M, et al. Revision total hip arthroplasty in patients with avascular necrosis. Orthopedics. 1999;22:747-757.
17. Bedi A, Chen N, Robertson W, et al. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008;24:1135-1145.
18. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy. 2006;22:95-106.
19. Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement in 45 professional athletes: Knee Surg Sports Traumatol Arthrosc. 2007;15:908-914.
20. Sierra RJ, Trousdale RT, Ganz R, et al. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop Surg. 2008;16:689-703.
21. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2009;468:741-746.
22. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88:1448-1457.
23. Bare AA, Guanche CA. Hip impingement: the role of arthroscopy. Orthopedics. 2005;28:266-273.
24. Toomayan GA, Holman WR, Major NM, et al. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol. 2006;186:449-453.
25. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
26. Kamath AF, Componovo R, Baldwin K, et al. Hip arthroscopy for labral tears: review of clinical outcomes with 4.8-year mean follow-up. Am J Sports Med. 2009;37:1721-1727.
27. Larson CM, Giveans MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25:369-376.
28. Larson CM, Guanche CA, Kelly BT, et al. Advanced techniques in hip arthroscopy. Instr Course Lect. 2009;58:423-436.
29. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24:1407-1421.
30. Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247-252.
31. Winston P, Awan R, Cassidy JD, et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.
32. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip. Skeletal Radiol. 2006;35:565-571.
33. Adler RS, Buly R, Ambrose R, et al. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005;185:940-943.
34. Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. Am J Sports Med. 2008;36:2363-2371.
35. Maffey L, Emery C. What are the risk factors for groin strain injury in sport? Sports Med. 2007;37:881-894.
36. Verrall GM, Slavotinek JP, Fon GT, et al. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007;35:467-474.
37. Pointinger H, Munk P, Poeschl GP. Avulsion fracture of the anterior superior iliac spine following apophysitis. Br J Sports Med. 2003;37:361-362.
38. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J Orthop Sports Phys Ther. 2008;38:63-70.
39. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008;42:954-964.
40. Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: definition and surgical treatment. Ann Plast Surg. 2005;55:393-396.
41. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521-533.
42. Petchprapa CN, Rosenberg ZS, Sconfienza LM, et al. MR imaging of entrapment neuropathies of the lower extremity. Part I. Radiographs. 2010;30:983-1000.
43. Voight M, Robinson K, Gill L, et al. Postoperative guidelines for hip arthroscopy in the active population. Sports Health. 2010;2:222-230.
44. Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25:337-357.
1. Margo K, Drezner J, Motzkin D. Evaluation and management of hip pain: an algorithmic approach. J Fam Pract. 2003;52:607-617.
2. Leunig M, Beaule PE, Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res. 2009;467:616-622.
3. Enseki KR, Martin RL, Draovitch P, et al. The hip joint: arthroscopic procedures and postoperative rehabilitation J Orthop Sports Phys Ther. 2006;36:516-525.
4. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med. 2004;32:1668-1674.
5. Fredericson M, Jennings F, Beaulieu C, et al. Stress fractures in athletes. Top Magn Reson Imaging. 2006;17:309-325.
6. Matheson GO, Clement DB, McKenzie DC, et al. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15:46-58.
7. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6:391-396.
8. Sofka CM. Imaging of stress fractures. Clin Sports Med. 2006;25:53-62, viii.
9. Shin AY, Gillingham BL. Fatigue fractures of the femoral neck in athletes. J Am Acad Orthop Surg. 1997;5:293-302.
10. Mont MA, Hungerford DS. Non-traumatic avascular necrosis of the femoral head. J Bone Joint Surg Am. 1995;77:459-474.
11. Lavernia CJ, Sierra RJ, Gomez-Marin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res. 1999;(367):172-180.
12. Lavernia CJ, Sierra RJ, Grieco FR. Osteonecrosis of the femoral head. J Am Acad Orthop Surg. 1999;7:250-261.
13. Smith SW, Fehring TK, Griffin WL, Beaver WB. Core decompression of the osteonecrotic femoral head. J Bone Joint Surg Am. 1995;77:674-680.
14. Fairbank AC, Bhatia D, Jinnah RH, et al. Long-term results of core decompression for ischaemic necrosis of the femoral head. J Bone Joint Surg Br. 1995;77:42-49.
15. Chandler HP, Reineck FT, Wixson RL, et al. Total hip replacement in patients younger than thirty years old. A five-year follow-up study. J Bone Joint Surg Am. 1981;63:1426-1434.
16. Wei SY, Klimkiewicz JJ, Lai M, et al. Revision total hip arthroplasty in patients with avascular necrosis. Orthopedics. 1999;22:747-757.
17. Bedi A, Chen N, Robertson W, et al. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008;24:1135-1145.
18. Guanche CA, Bare AA. Arthroscopic treatment of femoroacetabular impingement. Arthroscopy. 2006;22:95-106.
19. Philippon M, Schenker M, Briggs K, et al. Femoroacetabular impingement in 45 professional athletes: Knee Surg Sports Traumatol Arthrosc. 2007;15:908-914.
20. Sierra RJ, Trousdale RT, Ganz R, et al. Hip disease in the young, active patient: evaluation and nonarthroplasty surgical options. J Am Acad Orthop Surg. 2008;16:689-703.
21. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2009;468:741-746.
22. Burnett RS, Della Rocca GJ, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88:1448-1457.
23. Bare AA, Guanche CA. Hip impingement: the role of arthroscopy. Orthopedics. 2005;28:266-273.
24. Toomayan GA, Holman WR, Major NM, et al. Sensitivity of MR arthrography in the evaluation of acetabular labral tears. AJR Am J Roentgenol. 2006;186:449-453.
25. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88-92.
26. Kamath AF, Componovo R, Baldwin K, et al. Hip arthroscopy for labral tears: review of clinical outcomes with 4.8-year mean follow-up. Am J Sports Med. 2009;37:1721-1727.
27. Larson CM, Giveans MR. Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement. Arthroscopy. 2009;25:369-376.
28. Larson CM, Guanche CA, Kelly BT, et al. Advanced techniques in hip arthroscopy. Instr Course Lect. 2009;58:423-436.
29. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24:1407-1421.
30. Holmich P. Long-standing groin pain in sportspeople falls into three primary patterns, a “clinical entity” approach: a prospective study of 207 patients. Br J Sports Med. 2007;41:247-252.
31. Winston P, Awan R, Cassidy JD, et al. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med. 2007;35:118-126.
32. Blankenbaker DG, De Smet AA, Keene JS. Sonography of the iliopsoas tendon and injection of the iliopsoas bursa for diagnosis and management of the painful snapping hip. Skeletal Radiol. 2006;35:565-571.
33. Adler RS, Buly R, Ambrose R, et al. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005;185:940-943.
34. Anderson SA, Keene JS. Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes. Am J Sports Med. 2008;36:2363-2371.
35. Maffey L, Emery C. What are the risk factors for groin strain injury in sport? Sports Med. 2007;37:881-894.
36. Verrall GM, Slavotinek JP, Fon GT, et al. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007;35:467-474.
37. Pointinger H, Munk P, Poeschl GP. Avulsion fracture of the anterior superior iliac spine following apophysitis. Br J Sports Med. 2003;37:361-362.
38. Unverzagt CA, Schuemann T, Mathisen J. Differential diagnosis of a sports hernia in a high-school athlete. J Orthop Sports Phys Ther. 2008;38:63-70.
39. Caudill P, Nyland J, Smith C, et al. Sports hernias: a systematic literature review. Br J Sports Med. 2008;42:954-964.
40. Ahumada LA, Ashruf S, Espinosa-de-los-Monteros A, et al. Athletic pubalgia: definition and surgical treatment. Ann Plast Surg. 2005;55:393-396.
41. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521-533.
42. Petchprapa CN, Rosenberg ZS, Sconfienza LM, et al. MR imaging of entrapment neuropathies of the lower extremity. Part I. Radiographs. 2010;30:983-1000.
43. Voight M, Robinson K, Gill L, et al. Postoperative guidelines for hip arthroscopy in the active population. Sports Health. 2010;2:222-230.
44. Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip arthroscopy. Clin Sports Med. 2006;25:337-357.