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Raji Y, Smith KL, Megerian M, Maheshwer B, Sattar A, Chen RE, Gillespie RJ. Same-Day Discharge vs. Inpatient Total Shoulder Arthroplasty: An Age Stratified Comparison of Postoperative Outcomes and Hospital Charges. J Shoulder Elbow Surg 2024:S1058-2746(24)00242-8. [PMID: 38604401 DOI: 10.1016/j.jse.2024.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND As the number of total shoulder arthroplasty (TSA) procedures increases, there is a growing interest in improving patient outcomes, limiting costs, and optimizing efficiency. One approach has been to transition these surgeries to an outpatient setting. Therefore, the purpose of this study was to conduct an age-stratified analysis comparing the 90-day postoperative outcomes of primary TSA in the same-day discharge (SDD) and inpatient (IP) settings with a specific focus on the super-elderly. METHODS This retrospective study included all patients who underwent primary anatomic or reverse TSA between January 2018 and December 2021 in ambulatory and inpatient settings. The outcome measures included LOS, complications, hospital charges, ED utilization, readmissions, and reoperations within 90-days following TSA. Patients with LOS ≤8 hours were considered as SDD, and those with LOS >8 hours were considered as IP. P <0.05 was considered statistically significant. RESULTS There were 121 and 174 procedures performed in SDD and IP settings, respectively. There were no differences in comorbidity indices between the SDD and IP groups (ASA score P=0.12, ECI P=0.067). The SDD cohort was younger than the IP group (SDD 67.0 years vs. 73.0 IP years, P<0.001), and the SDD group higher rate of intraoperative tranexamic acid use (P=0.015) and lower estimated blood loss (P=0.009). There were no differences in 90-day overall minor (P=0.20) and major complications (P=1.00), ED utilization (P=0.63), readmission (P=0.25) or reoperation (P =0.51) between the SDD and IP groups. When stratified by age, there were no differences in overall major (P=0.80) and minor (P=0.36) complications among the groups. However, the LOS was directly correlated with increasing age (LOS=8.4 hours in ≥65 to < 75-year cohort vs. LOS=25.9 hours in ≥80-year cohort; P<0.001). There were no differences in hospital charges between SDD and IP primary TSA in all 3 age groups (P=0.82). CONCLUSION SDD TSA has a shorter LOS without increasing postoperative major and minor complications, ED encounters, readmissions, or reoperations. Older age was not associated with an increase in the complication profile or hospital charges even in the SDD setting, although it was associated with increased LOS in the IP group. These results suggest that TSA can be safely performed expeditiously in an outpatient setting. LEVEL OF EVIDENCE Level III; Retrospective Comparative Study.
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Affiliation(s)
- Yazdan Raji
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Kira L Smith
- Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Mark Megerian
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Bhargavi Maheshwer
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Abdus Sattar
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raymond E Chen
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert J Gillespie
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Maheshwer B, Halkiadakis P, Ina JG, Bafus BT, Lee A. Demographics and Outcomes of Glenohumeral Dislocations in Individuals With Elevated Body Mass Index. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00013. [PMID: 38603558 PMCID: PMC11003501 DOI: 10.5435/jaaosglobal-d-24-00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION No specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The purpose of this study was to describe shoulder dislocations in patients with body mass index (BMI) greater than 40. METHODS A retrospective review was conducted to identify patients aged 18 years and older with a BMI ≥40 who presented with a shoulder dislocation in a single institution from 2000 to 2020. Dislocation patterns, associated injuries, treatment modalities, and associated complications were recorded. RESULTS A significant increase was noted in the number of patients with BMI greater than 40 presenting per year (r2 = -0.831, P < 0.01) over the past 20 years. A significant increase was noted in the average BMI per year in this population (r2 = 0.504, P = 0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode. Ten patients had a Bankart lesion that was associated with an elevated BMI (P = 0.04). Nine patients (11.7%) sustained an associated neurologic injury (no association with BMI). CONCLUSIONS Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations.
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Affiliation(s)
- Bhargavi Maheshwer
- From the University Hospitals Cleveland Medical Center (Dr. Maheshwer, and Dr. Ina); the Case Western Reserve University School of Medicine (Ms. Halkiadakis); the Veterans Affairs Medical Center (Dr. Bafus); and the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus, and Dr. Lee)
| | - Penelope Halkiadakis
- From the University Hospitals Cleveland Medical Center (Dr. Maheshwer, and Dr. Ina); the Case Western Reserve University School of Medicine (Ms. Halkiadakis); the Veterans Affairs Medical Center (Dr. Bafus); and the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus, and Dr. Lee)
| | - Jason G. Ina
- From the University Hospitals Cleveland Medical Center (Dr. Maheshwer, and Dr. Ina); the Case Western Reserve University School of Medicine (Ms. Halkiadakis); the Veterans Affairs Medical Center (Dr. Bafus); and the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus, and Dr. Lee)
| | - Blaine T. Bafus
- From the University Hospitals Cleveland Medical Center (Dr. Maheshwer, and Dr. Ina); the Case Western Reserve University School of Medicine (Ms. Halkiadakis); the Veterans Affairs Medical Center (Dr. Bafus); and the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus, and Dr. Lee)
| | - Adrienne Lee
- From the University Hospitals Cleveland Medical Center (Dr. Maheshwer, and Dr. Ina); the Case Western Reserve University School of Medicine (Ms. Halkiadakis); the Veterans Affairs Medical Center (Dr. Bafus); and the MetroHealth Medical Center, Cleveland, OH (Dr. Bafus, and Dr. Lee)
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Huddleston HP, Mehta N, Lavoie-Gagne OZ, Maheshwer B, Fu MC, Cole BJ, Verma NN, Forsythe B, Yanke AB. Patient-reported outcomes measurement information system depression psychometrically underperforms compared to legacy measures and is poorly associated with postoperative functional outcomes in shoulder arthroplasty patients. Shoulder Elbow 2023; 15:626-633. [PMID: 37981972 PMCID: PMC10656966 DOI: 10.1177/17585732221137555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/18/2022] [Indexed: 11/21/2023]
Abstract
Background The purpose of this study was to investigate the associations between each mental health patient-reported outcome measure with postoperative functional outcomes following shoulder arthroplasty, and to compare psychometric properties of patient-reported outcomes measurement information system depression to the legacy (VR-12 Mental) patient-reported outcome measure. Methods Patients who underwent primary shoulder arthroplasty from July 2018 to February 2019 were retrospectively reviewed. Patient-reported outcomes measurement information system depression and VR-12 Mental were administered preoperatively; American Shoulder and Elbow Surgeons and Single Assessment Numeric Evaluation were administered at 6-month and 1-year postoperatively. Rasch partial credit modeling analysis was used to compare psychometric properties of legacy versus patient-reported outcomes measurement information system instruments in assessing mental health. Results Ninety-three patients who underwent total shoulder arthroplasty (n = 52), reverse total shoulder arthroplasty (n = 39), or hemiarthroplasty (n = 2) were included. Preoperative VR-12 Mental scores were moderately associated with American Shoulder and Elbow Surgeons at 6-months (coefficient: 0.52, P = 0.026) and 1-year (coefficient: 0.65, P = 0.002), while preoperative patient-reported outcomes measurement information system depression scores were not. Patient-reported outcomes measurement information system depression demonstrated significant floor effects (16%); VR-12 Mental demonstrated minimal floor and ceiling effects (1.1% for both). VR-12 Mental demonstrated broader coverage of mental outlook on Rasch modeling than patient-reported outcomes measurement information system depression and had adequate model fit after one round of reiterative item elimination. Discussion Patient-reported outcomes measurement information system depression was poorly associated with postoperative American Shoulder and Elbow Surgeons scores, demonstrated significant floor effects, and had limited coverage of mental health on Rasch modeling with reiterative elimination. Level of Evidence IV.
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Affiliation(s)
| | - Nabil Mehta
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | | | - Bhargavi Maheshwer
- Department of Orthopedic Surgery, Case Western Reserve University, Cleveland, OH, USA
| | | | - Brian J Cole
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Brian Forsythe
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
| | - Adam B Yanke
- Department of Orthopedics, Rush University Medical Center, Chicago, IL, USA
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Maheshwer B, Paliobeis A, Halkiadakis P, Konda S, Calcei JG, Voos JE. Anterior Cruciate Ligament Tears in the Adolescent Population: Injury Demographics and Risk of Reinjury Among High School Athletes. J Pediatr Orthop 2023; 43:591-597. [PMID: 37728131 DOI: 10.1097/bpo.0000000000002505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND The incidence of anterior cruciate ligament (ACL) injuries is increasing among the adolescent population with a peak occurring in the high school age range. PURPOSE To characterize recent epidemiologic trends of ACL injuries, ACL reconstruction (ACLR), and retear rates in high school adolescents based on age, participating sport, and mechanism of injury. STUDY DESIGN Retrospective case series. METHODS A prospectively maintained institutional database was retrospectively reviewed for all patients 18 or younger who underwent primary ACLR between 2015 and 2020. Odds ratios were calculated for baseline patient characteristics and their association with risk of retear. Multivariate regression analysis was also performed to identify the relationship between retear and specific categorical variables. RESULTS A total of 482 patients were included, with a mean follow-up time of 13.0 ± 11.8 months. Patients were an average age of 16.1 ± 1.3 years old (range: 13 to 18 y). Initial presentation of ACL injuries in high school athletes often occurred at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. One hundred three patients (21.6%) completed at least 2 or more years of follow-up after ACLR. Of these patients, 38.8% received a bone-tendon-bone (BTB) autograft, 36.9% hamstring autograft, 14.6% quadriceps tendon autograft, and 3.9% received hamstring allograft or other graft (eg, tibialis anterior and BTB allograft), respectively. There were 25 ipsilateral ACL retears that occurred in the patient cohort (5.2%). Thirteen (52%) of retears were females. Football and soccer were the most common sports played by patients with a retear of the ipsilateral knee (31.8% and 27.3%, respectively). Patients who were 13 to 14 or 18 years old ( P = 0.009 and 0.035, respectively) or who received a tibialis anterior/BTB allograft ( P = 0.002) were found to have increased risk of ACL retear compared with other age groups. When evaluating by sex, female soccer players had a greater risk of retear compared with male soccer players ( P = 0.007). When adjusting for multiple variables, (including age, sex, body mass index, primary reconstruction graft choice, sport, and length of follow-up), the odds of ipsilateral retear in patients who received hamstring autograft ( P = 0.02), sustained a contralateral ACL tear ( P = 0 .04), or a contact injury ( P = 0.01) were increased. CONCLUSION Initial presentation of ACL injuries in high school athletes often occurs at 16 years old regardless of the sport played. Based on age, high school freshmen and seniors are found to have an increased risk of ACL retear. However, the overall rate of ACL retear in high school athletes of all ages is low. Patients who underwent ACLR with hamstring tendon autograft had a greater risk of retear compared with other graft types. Female soccer players also had a greater risk of ACL retear. High school athletes must take caution when in the early high school years (underclassman) and more senior years (upperclassman), as susceptibility for ACL retears is elevated. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Bhargavi Maheshwer
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - Andrew Paliobeis
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - Penelope Halkiadakis
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - Sreenivas Konda
- Department of Epidemiology and Biostatistics, University of Illinois, Chicago School of Public Health, Chicago, IL
| | - Jacob G Calcei
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; and
| | - James E Voos
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH; and
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Figueras JH, Chan D, Maheshwer B, Erwin J, Thomson C, Dixon T, Grawe BM, Thompson AR. Development of an Orthopedic Surgery Anatomy Curricular Model for Fourth Year Medical Students Using a Modified Delphi Method. J Surg Educ 2023; 80:1403-1411. [PMID: 37598058 DOI: 10.1016/j.jsurg.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 03/24/2023] [Accepted: 07/01/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE The purpose of this study was to develop anatomy-focused learning outcomes that can be used to design a fourth-year elective for students matriculating into orthopedic surgery residencies. DESIGN A series of proposed learning outcomes (N=72) was developed using the ACGME Orthopedic Milestones 2.0 as a framework. In 2021, these were converted into a survey asking participants to rate the importance of each outcome on a 5-point Likert scale. The modified Delphi Method was used to refine the list of outcomes until group consensus was achieved. The consensus was defined using a conservative 3-tier approach. SETTING Eighteen academic centers with an associated orthopedic surgery residency. PARTICIPANTS Twenty-six orthopedic surgeons (ranging from 1 to 42 years in practice). RESULTS Of the 72 learning outcomes from the first-round survey, 25 met consensus criteria. Of the 62 learning outcomes from the second-round survey, 45 met consensus criteria. All learning outcomes that met consensus criteria after the second-round survey were stratified into low-yield (n = 8), intermediate-yield (n = 34), and high-yield (n = 28) categories. CONCLUSION Using a modified Delphi Method, this study elicited feedback from experts in the field of orthopedic surgery to develop a framework for a fourth-year elective focused on anatomical concepts important for students applying to residencies in orthopedic surgery. The product of this process affords a great deal of flexibility when utilizing the results of this study in institution-specific curricular development.
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Affiliation(s)
- Jorge H Figueras
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Dorothy Chan
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bhargavi Maheshwer
- Case Western Reserve/University Hospitals Cleveland Medical Center Orthopedic Surgery, Cleveland, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jace Erwin
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cameron Thomson
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Tonya Dixon
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Brian M Grawe
- Department of Orthopedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Andrew R Thompson
- Case Western Reserve/University Hospitals Cleveland Medical Center Orthopedic Surgery, Cleveland, Ohio; Department of Medical Education, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Yao B, Ko J, Maheshwer B, Dumaine AM, Nguyen CV, Liu RW. Assessment and Validation of Anterior Humeral Line for Diagnosing Supracondylar Humerus Fractures in the Pediatric Population. J Pediatr Orthop 2023; 43:555-559. [PMID: 37522477 DOI: 10.1097/bpo.0000000000002477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Pediatric supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in radiographic projection are common due to child discomfort and could lead to changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish whether rotational variations in elbow rotation leads to significant changes in AHL position and whether drawing the AHL based on the distal humerus versus shaft is more tolerant to rotation. METHODS Fifty children with nonoperative supracondylar humerus fractures were identified with sub optimally positioned injury and well positioned follow-up lateral radiographs. The proportion of the bone anterior to the intersection of the AHL and the capitellum was measured using the humeral shaft versus distal humerus to guide position of the AHL. This process was repeated on ten pediatric humerus dry cadaveric specimens which were imaged in 5-degree rotational increments along the axis of the humeral shaft from -20 to +20 degrees. RESULTS AHL position correlated poorly when measured on rotated lateral radiographs of clinical patients versus non-rotated lateral radiographs when using the distal humerus as a guide (intraclass correlation coefficient 0.14), compared with when using the humeral shaft as a guide (intraclass correlation coefficient 0.81). When assessing the pediatric humerus dry cadavers between the 2 techniques, there was greater statistically significant variation in rotated positions compared with the neutral position in the distal humerus AHL measurement approach compared with the humeral shaft AHL measurement approach, with the mean AHL within the central third of the capitellum for more rotational positions when using the shaft compared with the distal humerus. CONCLUSIONS With rotated lateral elbow radiographs in supracondylar humerus fractures, utilizing the humeral shaft provides more consistent AHL measurements than utilizing the distal humerus, and thus drawing the line starting at the shaft of the humerus is recommended for surgical decision making.
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Affiliation(s)
- Benjamin Yao
- Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Bronx
| | - Justine Ko
- Department of Emergency Medicine, Weill Cornell Medical College, New York, NY
| | - Bhargavi Maheshwer
- Department of Orthopedic Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Anne M Dumaine
- Department of Orthopedic Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Cynthia V Nguyen
- Shriners Hospital for Children Southern California, Pascadena, CA
| | - Raymond W Liu
- Department of Orthopedic Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
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Perry AK, Knapik DM, Maheshwer B, Polce EM, Hodakowski AJ, Jackson G, Gursoy S, Chahla J. Lateral meniscus posterior root repair in the setting of anterior cruciate ligament reconstruction restores joint mechanics to the intact state and improves clinical function: a systematic review of biomechanical and clinical outcomes. Knee Surg Sports Traumatol Arthrosc 2023; 31:4474-4484. [PMID: 37516986 DOI: 10.1007/s00167-023-07461-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/17/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To perform a systematic review of biomechanical and clinical outcomes following lateral meniscus posterior root (LMPR) repair with concomitant anterior cruciate ligament reconstruction (ACLR). METHODS A literature search was performed systematically using PubMed, Embase, and Medline databases in April 2022. The search included the following terms combined with Boolean operators: 'Meniscus repairs', 'Meniscal Repair', 'Posterior Horn', 'Root', 'Radial'. Inclusion criteria consisted of level I-IV human clinical and biomechanical studies reporting biomechanical data and/or outcomes following LMPR repair in the setting of ACLR. RESULTS Three biomechanical studies, all utilizing a transtibial pullout technique, were identified, all of which reported significant improvement in joint contact pressures and mechanics and 3/4 of which reported significant improvement in anterior or rotational stability with LMPR repair. Five clinical studies, consisting of 146 patients (mean age 28.5 ± 1.1 years) undergoing LMPR repair, were identified with an average follow-up of 19.1 months (range 6.2-46 months). Across all clinical studies, Lysholm and International Knee Documentation Committee (IKDC) scores were found to improve postoperatively, with 3/4 reporting significant improvement in Lysholm (all, p ≤ 0.001) scores and 3/5 reporting significant improvement in IKDC scores when compared to preoperative values (all, p ≥ 0.004). Meniscal extrusion decreased significantly following repair in 2/4 studies (all, p ≤ 0.001). CONCLUSIONS Biomechanically, transtibial pullout repair of the LMPR restored joint contact pressures and joint mechanics to intact levels when performed with concomitant ACLR. Clinically, LMPR repair with concurrent ACLR resulted in improved Lysholm and IKDC scores. These findings enable surgeons to determine optimal treatment plans and discuss realistic outcomes with patients when encountering LMPR injuries. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Allison K Perry
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA.
| | - Derrick M Knapik
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Bhargavi Maheshwer
- University of Cincinnati College of Medicine, Cincinnati, OH, 45219, USA
| | - Evan M Polce
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53726, USA
| | - Alexander J Hodakowski
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Garrett Jackson
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL, 60612, USA.
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Culbert AA, Ren BO, Maheshwer B, Curtis A, Ajayakumar J, Gilmore A, Hardesty C, Mistovich RJ, Son-Hing J, Liu RW, Glotzbecker MP. Disparities in Pediatric Orthopedic Surgery Care During the COVID-19 Pandemic Pre-vaccine and Post-Vaccine Availability. J Pediatr Orthop 2023; 43:529-535. [PMID: 37442779 PMCID: PMC10627400 DOI: 10.1097/bpo.0000000000002469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
BACKGROUND The COVID-19 pandemic has led to significant disruptions in medical care, resulting in an estimated 40% of US adults avoiding care. However, the return to baseline health care utilization following COVID-19 restrictions within the pediatric orthopedic population remains unexplored. We sought to analyze the visit volume and demographics of pediatric orthopedic patients at 3 timepoints: prepandemic (2019), pandemic (2020), and pandemic post-vaccine availability (2021), to determine the impact of COVID-19 restrictions on our single-center, multisite institution. METHODS We performed a retrospective cohort study of 6318 patients seeking treatment at our institution from May through August in 2019, 2020, and 2021. Patient age, sex, address, encounter date, and ICD-10 codes were obtained. Diagnoses were classified into fractures and dislocations, non-fracture-related trauma, sports, elective, and other categories. Geospatial analysis comparing incidence and geospatial distribution of diagnoses across the time periods was performed and compared with the Centers for Disease Control (CDC) social vulnerability index (SVI). RESULTS The total number of pediatric orthopedic visits decreased by 22.2% during the pandemic ( P <0.001) and remained 11.6% lower post-vaccine availability compared with prepandemic numbers ( P <0.001). There was no significant difference in age ( P =0.097) or sex ( P =0.248) of the patients across all 3 timepoints; however, patients seen during the pandemic were more often White race (67.7% vs. 59.3%, P <0.001). Post-vaccine availability, trauma visits increased by 18.2% ( P <0.001) and total fractures remained 13.4% lower than prepandemic volume ( P <0.001). Sports volume decreased during the pandemic but returned to prepandemic volume in the post-vaccine availability period ( P =0.298). Elective visits did not recover to prepandemic volume and remained 13.0% lower compared with baseline ( P <0.001). Geospatial analysis of patient distribution illustrated neighborhood trends in access to care during the COVID-19 pandemic, with fewer patients from high SVI and low socioeconomic status neighborhoods seeking fracture care during the pandemic than prepandemic. Post-vaccine availability, fracture population distribution resembled prepandemic levels, suggesting a return to baseline health care utilization. CONCLUSION Pediatric orthopedic surgery visit volume broadly decreased during the COVID-19 pandemic and did not return to prepandemic levels. All categories increased in the post-vaccine availability time point except elective visits. Geospatial analysis revealed that neighborhoods with a high social vulnerability index (SVI) were associated with decreased fracture visits during the pandemic, whereas low SVI neighborhoods did not experience as much of a decline. Future research is needed to study these neighborhood trends and more completely characterize factors preventing equitable access to care in the pediatric orthopedic population. LEVEL OF EVIDENCE Retrospective Study, Level III.
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Affiliation(s)
- August A. Culbert
- Cleveland Clinic Lerner College of Medicine
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Bryan O. Ren
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, MI
| | - Bhargavi Maheshwer
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Andrew Curtis
- Department of Population and Quantitative Health Sciences, Case Western Reserve University
| | | | - Allison Gilmore
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Christina Hardesty
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - R. Justin Mistovich
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Jochen Son-Hing
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Raymond W. Liu
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Michael P. Glotzbecker
- Division of Pediatric Orthopedic Surgery, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
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Folkman MJ, Ren BO, Maheshwer B, Klyce WB, Mistovich RJ. Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation. J Pediatr Orthop 2023; 43:e446-e450. [PMID: 37072917 DOI: 10.1097/bpo.0000000000002412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Pediatric forearm fractures are common injuries and can sometimes require surgical treatment. Few studies have evaluated the long-term outcomes of pediatric forearm fracture plating. We evaluated long-term functional outcomes and satisfaction in children with forearm fractures treated with plate fixation. METHODS We performed a single-institution case series at a pediatric level 1 trauma center. Inclusion criteria were: patients with radius and/or ulna diaphyseal fractures, index surgery at 18 years of age or younger, plate fixation, and a minimum of 2 years follow-up. We surveyed patients with the QuickDASH outcome measure and supplemented this with functional outcomes and satisfaction questions. Demographics and surgery characteristics were obtained from the electronic medical record. RESULTS A total of 41 patients met the eligibility criteria, of whom 17 completed the survey with a mean follow-up of 7.2 ± 1.4 years. The mean age at index surgery was 13.1 ± 3.6 years (range, 4 to 17), with 65% males. All patients reported at least one symptom, with aching (41%) and pain (35%) occurring most frequently. There were 2 complications (12%), including one infection and one compartment syndrome treated with fasciotomy. Hardware removal occurred in 29% of patients. There were no refractures. The mean QuickDASH score was 7.7 ± 11.9, with an occupation module score of 1.6 ± 3.9 and a sports/performing arts module score of 12.0 ± 19.7. The mean surgery satisfaction was 92% and scar satisfaction was 75%. All patients returned to prior activities and 88% reported a return to their preoperative baseline level of function. CONCLUSIONS Plate fixation for pediatric forearm fractures achieves osseous union but not without the potential for long-term sequelae. All patients reported residual symptoms 7 years later. Scar satisfaction and return to baseline function were imperfect. Patient education for long-term outcomes of surgery is essential, especially in the transition to adulthood. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Matthew J Folkman
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University
- The University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Bryan O Ren
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Bhargavi Maheshwer
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center
| | - Walter B Klyce
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center
| | - R Justin Mistovich
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, Case Western Reserve University
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center
- Division of Orthopaedic Surgery, MetroHealth System, Cleveland
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10
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Dasari SP, Hevesi M, Mameri E, Ferrer-Rivero R, Fortier LM, Jackson GR, Warrier AA, Maheshwer B, Jawanda H, Khan ZA, Kerzner B, Browning RB, Gursoy S, Chahla J. Patient-specific instrumentation for medial opening wedge high tibial osteotomies in the management of medial compartment osteoarthritis yields high accuracy and low complication rates: A systematic review. J ISAKOS 2023; 8:163-176. [PMID: 36931505 DOI: 10.1016/j.jisako.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 01/15/2023] [Accepted: 02/25/2023] [Indexed: 03/17/2023]
Abstract
IMPORTANCE There has been growing interest in the use of patient-specific instrumentation (PSI) to maximise accuracy and minimise the risk of major complications for medial opening-wedge high tibial osteotomies (MOW-HTOs). Numerous studies have reported the efficacy and safety of implementing this technology into clinical practice, yet no systematic review summarising the clinical literature on PSI for MOW-HTOs has been performed to date. AIM The aim of this investigation was to perform a systematic review summarising the evidence surrounding the use of PSI for MOW-HTOs in the management of medial compartment osteoarthritis. EVIDENCE REVIEW PubMed, Scopus, and the Cochrane Library were queried in October 2021 for studies that used PSI for MOW-HTOs when managing medial compartment knee osteoarthritis. Primary outcomes included accuracy in coronal plane correction (mechanical medial proximal tibial angle), sagittal plane correction (posterior tibial slope), and mechanical axis correction (hip-knee-ankle angle [HKA], mechanical femorotibial angle, and weight-bearing line). Accuracy was defined as error between post-operative measurements relative to the planned pre-operative correction. A secondary outcome was the incidence of major complications. FINDINGS This review included eight different techniques among the 14 included studies. There was a weighted mean error of 0.5° (range: 0.1°-1.3°) for the mechanical medial proximal tibial angle, 0.6° (range: 0.3°-2.7°) for the posterior tibial slope, and 0.8° (range: 0.1°-1.0°) for the hip-knee-ankle angle. Four studies compared the correctional error of the mechanical axis between conventional techniques and PSI techniques. The comparative difference between the two techniques favoured the use of PSI for MOW-HTOs (standardised mean difference = 0.52; 95% confidence interval, 0.16 to 0.87; p = 0.004). Among the 14 studies evaluated, four studies explicitly reported no major complications, while five studies reported a non-zero incidence of major complications. Among these nine studies, the weighted mean major complication rate was 7.1% (range: 0.0-13.0%). CONCLUSIONS AND RELEVANCE The findings of this present systematic review suggest that the use of PSI for MOW-HTOs leads to high accuracy relative to the planned corrections in the coronal plane, sagittal plane, and mechanical axis. Furthermore, these findings would suggest there is a low risk of major complications when implementing PSI for MOW-HTOs. LEVEL OF EVIDENCE Systematic review; IV.
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Affiliation(s)
- Suhas P Dasari
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Mario Hevesi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Enzo Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Robert Ferrer-Rivero
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Luc M Fortier
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Alec A Warrier
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Bhargavi Maheshwer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Zeeshan A Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Benjamin Kerzner
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Robert B Browning
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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11
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Haase L, Maheshwer B, Boes K, Ina J, Haase D, Napora J, Ochenjele G. Patients With Simple Posterior Hip Dislocations Have Higher Rates of Hip Dysplasia and Borderline Dysplasia. J Orthop Trauma 2023; 37:195-199. [PMID: 36730006 DOI: 10.1097/bot.0000000000002536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if patients suffering simple, posterior hip dislocations are more likely to display dysplastic characteristics of their acetabulum as compared with those suffering fracture dislocations. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Eighty-six patients suffering posterior, native hip dislocations over a 5-year period. MAIN OUTCOME MEASUREMENT The primary outcome was measurement of the lateral center edge angle (LCEA), acetabular index (AI), acetabular version, and femoro-epiphyseal acetabular roof (FEAR) index. RESULTS Eighteen patients (20.9%) sustained simple dislocations, whereas 68 patients (79.1%) suffered fracture dislocations. Patients with simple dislocations had decreased LCEA (25.7 vs. 34.3; P < 0.001), increased AI (7.4 vs. 5.8; P = 0.019), and decreased acetabular anteversion (14.02 vs. 18.45; P = 0.011). Additionally, patients with simple dislocations had higher rates of dysplasia and borderline dysplasia (61.1% vs. 7.3%; P < 0.001). Patients with fracture dislocations had higher rates of concomitant injuries (60.9% vs. 29.4%; P = 0.039) and higher injury severity scores (8.1 vs. 12.3; P = 0.022). CONCLUSION Patients who sustain simple hip dislocations are more likely to have undercoverage of the femoral head by the acetabulum as compared with patients suffering fracture dislocations. In addition, the simple dislocation group had a lower ISS and fewer concomitant injuries, which likely relates to a lower energy required for dislocation in the setting of lesser bony constraint. Surgeons treating these complicated injuries should consider measurements of LCE and AI when counseling patients on treatment strategies. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas Haase
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
| | - Bhargavi Maheshwer
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
| | - Kirsten Boes
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
| | - Jason Ina
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
| | - Douglas Haase
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Joshua Napora
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
| | - George Ochenjele
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH; and
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12
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Perry AK, Maheshwer B, DeFroda SF, Hevesi M, Gursoy S, Chahla J, Yanke A. Patellar Instability. JBJS Rev 2022; 10:01874474-202211000-00008. [PMID: 36441831 DOI: 10.2106/jbjs.rvw.22.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
➢ Certain anatomic factors, such as patella alta, increased tibial tubercle-trochlear groove distance, rotational deformity, and trochlear dysplasia, are associated with an increased risk of recurrent patellar instability. ➢ The presence of a preoperative J-sign is predictive of recurrent instability after operative management. ➢ Isolated medial patellofemoral ligament reconstruction may be considered on an individualized basis, considering whether the patient has anatomic abnormalities such as valgus malalignment, trochlear dysplasia, or patella alta in addition to the patient activity level. ➢ More complex operative management (bony or cartilaginous procedures) should be considered in patients with recurrent instability, malalignment, and certain anatomic factors.
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Affiliation(s)
- Allison K Perry
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | | | - Steven F DeFroda
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Mario Hevesi
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Adam Yanke
- Division of Sports Medicine, Midwest Orthopaedics at Rush University, Chicago, Illinois
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13
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Maheshwer B, Polce EM, Parvaresh KC, Paul K, Yanke AB, Forsythe B, Bush-Joseph CA, Bach BR, Cole BJ, Verma NN, Kogan M, Chahla J. Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients. J Pediatr Orthop 2022; 42:e641-e648. [PMID: 35297390 DOI: 10.1097/bpo.0000000000002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE Level IV: case series.
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Affiliation(s)
- Bhargavi Maheshwer
- University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, OH
| | - Evan M Polce
- University of Wisconsin College of Medicine, Madison, WI
| | | | - Katlynn Paul
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Adam B Yanke
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Monica Kogan
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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14
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Dasari SP, Fortier LM, Maheshwer B, Hevesi M, Gursoy S, Chahla J. Use of 3D-Printed Patient Specific Guides in Osteotomies around the Knee. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Perry AK, Lavoie-Gagne O, Knapik DM, Maheshwer B, Hodakowski A, Gursoy S, LaPrade RF, Chahla J. Examining the Efficacy of Medial Meniscus Posterior Root Repair: A Meta-analysis and Systematic Review of Biomechanical and Clinical Outcomes. Am J Sports Med 2022:3635465221077271. [PMID: 35384728 DOI: 10.1177/03635465221077271] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Medial meniscus posterior root (MMPR) injuries accelerate the progression of osteoarthritis. While partial meniscectomy was once considered the gold standard for treatment, meniscus root repair has become increasingly utilized with reported improvements in clinical and biomechanical outcomes. PURPOSE To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical and radiographic outcomes after MMPR repair. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 4. METHODS The PubMed, Embase, and Cochrane databases were queried in August 2021 for studies reporting biomechanical, clinical, and radiographic outcomes after MMPR repair. Biomechanical studies were assessed for main results and conclusions. Data including study characteristics, cohort demographics, and outcomes were extracted. Included clinical studies were analyzed with a random-effects meta-analysis of proportions for binary outcomes or continuous outcomes for mean differences between preoperative and postoperative time points. Subgroup analysis for studies reporting repair outcomes with concomitant high tibial osteotomy (HTO) was performed where appropriate. RESULTS A total of 13 biomechanical studies were identified and reported an overall improvement in mean and peak contact pressures after MMPR repair. There were 24 clinical studies, consisting of 876 patients (877 knees), identified, with 3 studies (106 knees) reporting outcomes with concomitant HTO. The mean patient age was 57.1 years (range, 23-74 years), with a mean follow-up of 27.7 months (range, 2-64 months). Overall, clinical outcomes (Lysholm, Hospital for Special Surgery, International Knee Documentation Committee, visual analog scale for pain, Tegner, and Knee injury and Osteoarthritis Outcome Score scores) were noted to improve postoperatively compared with preoperatively, with improved Lysholm scores in patients undergoing concomitant HTO versus MMPR repair alone. Meniscal extrusion was not significantly improved after MMPR repair compared with preoperative measurements. The progression in Kellgren-Lawrence grades from grade 0 to grades 1 to 3 occurred in 5.9% (21/354) of patients after repair, with no patients progressing from grades 1 to 3 to grade 4. CONCLUSION MMPR repair generally improved biomechanical outcomes and led to improved patient-reported outcomes with greater improvements noted in patients undergoing concomitant HTO. Repair did not significantly improve meniscal extrusion, while only 5.9% of patients were noted to progress to low-grade osteoarthritis. The high level of heterogeneity in the included biomechanical and clinical investigations emphasizes the need for more well-designed studies that evaluate outcomes after MMPR repair.
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Affiliation(s)
- Allison K Perry
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Ophelie Lavoie-Gagne
- Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Derrick M Knapik
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Hodakowski
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jorge Chahla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
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16
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Polce EM, Vadhera AS, Williams BT, Maheshwer B, O’Donnell R, Yanke AB, Forsythe B, Cole BJ, Chahla J. Preoperative Symptom Duration Does Not Affect Clinical Outcomes after High Tibial Osteotomy at a Minimum of 2-Year Follow-Up. J ISAKOS 2022; 7:60-65. [DOI: 10.1016/j.jisako.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/05/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
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17
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Maheshwer B, Parvaresh KC, Williams BT, Polce EM, Schloss D, Chahla J. Posterolateral Corner Reconstruction. JBJS Essent Surg Tech 2022; 12:ST-D-20-00047. [DOI: 10.2106/jbjs.st.20.00047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Perry AK, McCormick JR, Knapik DM, Maheshwer B, Gursoy S, Kogan M, Chahla J. Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery. Arthrosc Sports Med Rehabil 2021; 3:e1905-e1912. [PMID: 34977647 PMCID: PMC8689250 DOI: 10.1016/j.asmr.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/11/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair. Methods A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported. Results Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, “always” counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills. Conclusions While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal. Clinical Relevance ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.
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Affiliation(s)
| | | | | | | | | | | | - Jorge Chahla
- Address correspondence to Jorge Chahla, M.D., Ph.D., Rush University Medical Center, Department of Orthopedic Surgery, 1611 W Harrison St., Suite 201, Chicago, IL 60612.
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19
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Maheshwer B, Wong SE, Polce EM, Paul K, Forsythe B, Bush-Joseph C, Bach BR, Yanke AB, Cole BJ, Verma NN, Chahla J. Establishing the Minimal Clinically Important Difference and Patient-Acceptable Symptomatic State After Arthroscopic Meniscal Repair and Associated Variables for Achievement. Arthroscopy 2021; 37:3479-3486. [PMID: 33964390 DOI: 10.1016/j.arthro.2021.04.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To establish the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) after arthroscopic meniscal repair and identify the factors associated with achieving these outcomes. METHODS This is a retrospective study with prospectively collected data. Patient-reported outcome measures (PROMs) were collected from April 2017 to March 2020. All patients who underwent arthroscopic meniscal repair and completed both preoperative and postoperative PROMs were included in the analysis. MCID and PASS were calculated via half the standard deviation of the delta PRO change from baseline (for International Knee Documentation Committee Score [IKDC]) and via anchor-based methodology (Knee Injury and Osteoarthritis Outcome Score [KOOS] subscales). RESULTS Sixty patients were included in the final analysis. The established MCID threshold values were 10.9 for IKDC, 12.3 for KOOS Symptoms, 11.8 for KOOS Pain, 11.4 for KOOS Activities of Daily Living (ADL), 16.7 for KOOS Sport, and 16.9 for KOOS Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 69.0 for IKDC, 75.0 for KOOS Symptoms, 80.6 for KOOS Pain, 92.7 for KOOS ADL, 80.0 for KOOS Sport, and 56.3 for KOOS QoL. Higher preoperative PRO scores were associated with lower likelihood of achieving MCID. Concomitant ligament procedures were associated with a higher likelihood of achieving PASS. Tears to both menisci were associated with decreased likelihood of achieving MCID and PASS for IKDC. Horizontal tears were associated with decreased likelihood of achieving PASS for IKDC and KOOS. Complex tears were associated with decreased likelihood of achieving MCID for KOOS. CONCLUSION Clinically meaningful outcomes such as MCID and PASS were established for meniscal repair surgery using selected PROMs for IKDC and KOOS subscales. Variables more likely to be associated with achieving these outcomes include lower preoperative PRO score and concomitant ligament procedure, whereas higher preoperative PRO score, tearing of both medial and lateral menisci, and horizontal and complex tear classifications were associated with decreased likelihood of achieving these outcomes. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
| | - Stephanie E Wong
- University of California San Francisco Medical Center, San Francisco, CA, U.S.A
| | - Evan M Polce
- University of Wisconsin College of Medicine, Madison, WI, U.S.A
| | | | - Brian Forsythe
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Charles Bush-Joseph
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Bernard R Bach
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Adam B Yanke
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Brian J Cole
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Nikhil N Verma
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, U.S.A..
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20
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Maheshwer B, Drager J, John NS, Williams BT, LaPrade RF, Chahla J. Incidence of Intraoperative and Postoperative Complications After Posterolateral Corner Reconstruction or Repair: A Systematic Review of the Current Literature. Am J Sports Med 2021; 49:3443-3452. [PMID: 33502894 DOI: 10.1177/0363546520981697] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Posterolateral corner (PLC) injuries of the knee are being increasingly recognized and treated in current orthopaedic practice. While there are numerous systematic reviews evaluating the management and outcomes after PLC injuries, there are limited data investigating complications after PLC reconstruction or repair. PURPOSE To systematically review the literature to determine the incidence of postoperative complications after the surgical treatment of PLC injury. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), Embase (2008-2019), and MEDLINE (2008-2019) were queried for literature reporting on PLC reconstruction or repair, with or without concomitant ligamentous or meniscal surgery. Data including type of surgery performed, concomitant procedures, and follow-up time were extracted. Complications recorded included intra- and postoperative complications. RESULTS After the intra- and postoperative complication data of 60 studies (1747 cases) were combined, surgical management of PLC injuries was associated with an intraoperative complication rate of 0.34% (range, 0%-2.8%) and a postoperative complication rate of 20% (range, 0%-51.2%). The most common postoperative complication was arthrofibrosis (range, 0%-20%). The overall infection rate was 1.3% (range, 0%-10%). Four cases of postoperative common peroneal nerve palsy were reported. Failure of reconstruction or repair was reported in 164 (9.4%) of all cases examined (range, 0%-37.1%). CONCLUSION Although the intraoperative rate of complications during PLC reconstructions is low, postoperative complications rates of 20% can be expected, including arthrofibrosis, infection, and neurovascular injury. PLC structures repaired or reconstructed failed in 9.4% of the cases.
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Affiliation(s)
| | - Justin Drager
- Tufts University Medical Center, Boston, Massachusetts, USA
| | - Nalin S John
- University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | | | - Jorge Chahla
- Rush University Medical Center, Chicago, Illinois, USA
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Gowd AK, Liu JN, Maheshwer B, Garcia GH, Beck EC, Cohen MS, Nicholson GP, Cole BJ, Verma NN. Return to sport and weightlifting analysis following distal biceps tendon repair. J Shoulder Elbow Surg 2021; 30:2097-2104. [PMID: 33667641 DOI: 10.1016/j.jse.2021.01.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/16/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Rupture of the distal biceps tendon is an increasingly frequent injury sustained predominantly by middle-aged men. Despite the prevalence of sport in this age group, little is known regarding return to sport outcomes following surgery. METHODS Patients undergoing distal biceps tendon repair (DBR) between January 2015 and January 2017 were contacted electronically via e-mail and via telephone to administer a previously validated and standard return to sport survey. Patients self-reported preinjury and current level of sport and activity as well as preinjury and current level of select weightlifts. RESULTS A total of 77 of 124 patients were available for follow-up (62.1%). Of these patients, 61 endorsed preoperative sport and were included for analysis. Average follow-up was 38.7 ± 6.7 months. The mean age at surgery was 47.5 ± 8.8 years, and the mean body mass index was 30.3 ± 5.1. The dominant side was affected in 25 of 61 cases. Of the 61 included patients, 57 (93.4%) were able to return to sport at any level (lower, same, or higher intensity than preinjury activity level). Forty of the patients (65.6%) were able to return to sport at same or higher intensity. Mean time to return to sport was 6.0 ± 2.8 months. Days from injury to surgery (odds ratio [OR] 0.999, 95% confidence interval [CI] 0.998-0.999), suture anchor fixation in comparison to suture button (OR 0.602, 95% CI 0.427-0.850), and dominant-side surgery (OR 0.749, 95% CI 0.582-0.963) were associated with a decreased likelihood to return to sport at same or higher level of duty. Single-sided incision in comparison to double (OR 5.209, 95% CI 1.239-20.903) and dominant-side surgery (OR 6.370, 95% CI 1.639-24.762) were associated with increased duration to return to sport. CONCLUSION Distal biceps tendon rupture is a significant injury; however, patients can expect high levels of return to sport following DBR with some residual impairment compared with baseline. It is important to counsel patients on their expectations while taking into account the results of this study: that there will be a small but appreciable decrease in strength compared with preinjury levels.
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Affiliation(s)
- Anirudh K Gowd
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Joseph N Liu
- Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | | | - Edward C Beck
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Mark S Cohen
- Rush University Medical Center, Chicago, IL, USA
| | | | - Brian J Cole
- Rush University Medical Center, Chicago, IL, USA
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Maheshwer B, Knapik DM, Polce EM, Verma NN, LaPrade RF, Chahla J. Contribution of Multimodal Analgesia to Postoperative Pain Outcomes Immediately After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Level 1 Randomized Clinical Trials. Am J Sports Med 2021; 49:3132-3144. [PMID: 33411564 DOI: 10.1177/0363546520980429] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe pain in the immediate postoperative period. The optimal individual preemptive or intraoperative anesthetic modality on postoperative pain control is not well-known. PURPOSE To systematically review and perform a meta-analysis comparing postoperative pain scores (visual analog scale [VAS]), opioid consumption, and incidence of complications during the first 24 hours after primary ACLR in patients receiving spinal anesthetic, adjunct regional nerve blocks, or local analgesics. STUDY DESIGN Systematic review and meta-analysis. METHODS PubMed, Embase, MEDLINE, Biosis Previews, SPORTDiscus, Ovid, PEDRO, and the Cochrane Library databases were systematically searched from inception to March 2020 for human studies, using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Inclusion criteria consisted of (1) level 1 studies reporting on the use of spinal anesthesia, adjunct regional anesthesia (femoral nerve block [FNB] or adductor canal block [ACB]), or local analgesia in patients undergoing primary ACLR and (2) studies reporting on patient-reported VAS, opioid consumption, and incidence of complications related to anesthesia within the first 24 hours after surgery. Non-level 1 studies, studies utilizing a combination of anesthetic modalities, and those not reporting outcomes during the first 24 hours were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine postoperative pain, opioid use, and complications based on anesthetic modality at multiple time points (0-4, 4-8, 8-12, 12-24 hours). RESULTS A total of 263 studies were screened, of which 27 level 1 studies (n = 16 regional blocks; n = 12 local; n = 4 spinal) met the inclusion criteria and were included in the meta-analysis. VAS scores were significantly lower in patients receiving a regional block as compared with spinal anesthesia 8 to 12 hours after surgery (P < .01), patients receiving an FNB versus ACB at 12 to 24 hours (P < .01), and those treated with a continuous FNB rather than single-shot regional blocks (FNB, ACB) at 12 to 24 hours (P < .01). No significant difference in VAS was appreciated when spinal, regional, and local anesthesia groups were compared. CONCLUSION Based on evidence from level 1 studies, pain control after primary ACLR based on VAS was significantly improved at 8 to 12 hours in patients receiving regional anesthesia as compared with spinal anesthesia. Pain scores were significantly lower at 12 to 24 hours in patients receiving FNB versus ACB and those treated with continuous FNB rather than single-shot regional anesthetic.
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Affiliation(s)
| | | | - Evan M Polce
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA
| | | | - Jorge Chahla
- Midwest Orthopaedics at Rush University, Chicago, Illinois, USA
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Swarup I, Maheshwer B, Orr S, Kehoe C, Zhang Y, Dodwell E. Intermediate-Term Outcomes Following Operative and Nonoperative Management of Midshaft Clavicle Fractures in Children and Adolescents: Internal Fixation May Improve Outcomes. JB JS Open Access 2021; 6:JBJSOA-D-20-00036. [PMID: 33748645 PMCID: PMC7963509 DOI: 10.2106/jbjs.oa.20.00036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Although multiple prospective comparative studies exist for adults with midshaft clavicle fractures, few comparative studies exist in older children and adolescents. This study compares intermediate-term functional, pain, radiographic, and complication outcomes in children and adolescents with midshaft clavicle fractures treated operatively or nonoperatively.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital Oakland, Oakland, California
| | | | - Steven Orr
- NYU Langone Orthopedic Hospital, New York, NY
| | | | - Yi Zhang
- Hospital for Special Surgery, New York, NY
| | - Emily Dodwell
- Hospital for Special Surgery, New York, NY.,New York Presbyterian-Weill Cornell Medical Center, New York, NY
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Maheshwer B, Polce EM, Paul K, Williams BT, Wolfson TS, Yanke A, Verma NN, Cole BJ, Chahla J. Regenerative Potential of Mesenchymal Stem Cells for the Treatment of Knee Osteoarthritis and Chondral Defects: A Systematic Review and Meta-analysis. Arthroscopy 2021; 37:362-378. [PMID: 32497658 DOI: 10.1016/j.arthro.2020.05.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/21/2020] [Accepted: 05/17/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis evaluating the effects of mesenchymal stem cells (MSCs) on cartilage regeneration and patient-reported pain and function. METHODS A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a PRISMA checklist. The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) were queried in July 2019 for literature reporting use of stem cells to treat knee osteoarthritis or chondral defects. Data describing administered treatment, subject population, injection type, duration of follow-up, pain and functional outcomes, and radiographic and magnetic resonance imaging findings were extracted. Risk of bias was assessed using the Downs and Black scale. Meta-analyses adjusted for random effects were performed, calculating pooled effect sizes in terms of patient-reported pain and function, cartilage quality, and cartilage volume. RESULTS Twenty-five studies with 439 subjects were identified. There was no significant difference in pain improvement between MSC treatment and controls (pooled standardized mean difference [SMD] = 0.23, P = .30). However, MSC treatment was significantly favored for functional improvement (SMD = 0.66, P < .001). There was improvement in cartilage volume after MSC treatment (SMD = 0.84, P < .001). Regarding cartilage quality, meta-analysis resulted in a small, nonsignificant effect size of 0.37 (95%, -0.03 to 0.77, P = .07). There was risk for potential bias among included studies, with 17 (68%) receiving either a grade of "poor" or "fair." CONCLUSIONS The pooled SMD from meta-analyses showed statistically significant effects of MSC on self-reported physical function but not self-reported pain. MSCs provided functional benefit only in patients who underwent concomitant surgery. However, this must be interpreted with caution, as there was substantial variability in MSC composition and mode of delivery. MSC treatment provided significant improvement in cartilage volume but not cartilage quality. Preliminary data regarding therapeutic properties of MSC treatment suggest significant heterogeneity in the current literature, and risk of bias is not negligible. LEVEL OF EVIDENCE II, Systematic Review and Meta-analysis.
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Affiliation(s)
- Bhargavi Maheshwer
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Evan M Polce
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Katlynn Paul
- Loyola University Chicago, Chicago, Illinois, U.S.A
| | - Brady T Williams
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Theodore S Wolfson
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Adam Yanke
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University, Medical Center, Chicago, Illinois, U.S.A..
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Garcia FL, Williams BT, Maheshwer B, Bedi A, Wong IH, Martin HD, Nho SJ, Chahla J. Pain management practice patterns after hip arthroscopy: an international survey. J Hip Preserv Surg 2020; 7:537-546. [PMID: 33948210 PMCID: PMC8081420 DOI: 10.1093/jhps/hnaa050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/16/2022] Open
Abstract
Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons’ responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.
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Affiliation(s)
- Flávio L Garcia
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA.,Department of Orthopaedic Surgery, Instituto Brasil de Tecnologias da Saúde, Rio de Janeiro, RJ, Brazil, Rua Visconde de Pirajá, 407 Rio de Janeiro, RJ, 22410-003, Brazil.,Department of Orthopaedics and Anesthesiology, Ribeirão Preto Medical School of the University of São Paulo, Ribeirão Preto, Avenida Bandeirantes, 3900 Ribeirão Preto, SP, 14049-900, Brazil
| | - Brady T Williams
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Bhargavi Maheshwer
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, 1500 E Medical Center Drive Ann Arbor, MI, 48109, USA
| | - Ivan H Wong
- Department of Surgery, Dalhousie University, Halifax, 6299 South St Halifax, NS, B3H 4R2, Nova Scotia, Canada
| | - Hal D Martin
- Hip Preservation, aylor University Medical Center, 411 N Washington Ave, Suite 7300 Dallas, TX, 75246, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W Harrison St, Chicago, IL, 60612, USA
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Williams BT, Vadhera A, Maheshwer B, Polce EM, Salata MJ, Mather RC, Nho SJ, Chahla J. Is There a Role for Ultrasound in Hip Arthroscopy? A Systematic Review. Arthrosc Sports Med Rehabil 2020; 2:e655-e660. [PMID: 33135007 PMCID: PMC7588635 DOI: 10.1016/j.asmr.2020.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The purpose of this study is to identify and summarize the current utility of intraoperative ultrasound (US) during hip arthroscopy. Methods A systematic database query of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, EMBASE, PubMed (1980 to 2019), and Ovid MEDLINE (1980 to 2019) was performed. After article identification, descriptions of the surgical procedure, use of intraoperative US, procedural complications, and conclusions from each article were recorded and summarized. Results Five studies met inclusion criteria, all of which were surgical techniques or technical notes. Four of the 5 studies described US used for placement of arthroscopic portals, and 1 described the use of an intraarticular US catheter for the assessment of an osteochondritis dissecans (OCD) lesion. Of the 4 studies using US for portal placement, 3 were performed supine and 1 was performed in the lateral decubitus position. All studies recognized the need for additional US training or the required assistance of a radiologist to incorporate US into a surgical practice. Conclusion Descriptions of intraoperative US during hip arthroscopy are limited in the literature. However, existing technique reports demonstrate the feasibility of US for both portal placement with superficial probes and limited evaluation of cartilage using intraarticular US catheters. Level of Evidence V, systematic review.
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Affiliation(s)
- Brady T. Williams
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Amar Vadhera
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bhargavi Maheshwer
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Evan M. Polce
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Michael J. Salata
- Department of Orthopedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Richard C. Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, U.S.A
| | - Shane J. Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
- Address correspondence to Jorge Chahla, MD, PhD, Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612, U.S.A.
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Bessa FS, Williams BT, Polce EM, Maheshwer B, Williams JC, Nho SJ, Chahla J. No Differences in Hip Joint Space Measurements Between Weightbearing or Supine Anteroposterior Pelvic Radiographs. Arthroscopy 2020; 36:2843-2848. [PMID: 32735940 DOI: 10.1016/j.arthro.2020.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To to assess whether there are any significant differences in hip joint space width (JSW) between weight-bearing versus supine pelvic radiographs. METHODS Standing and supine anteroposterior pelvic radiographs of 86 patients (146 hips) were included. Sample size was sufficiently powered to assess for equivalence between standing and supine films for JSW measurements made at the medial, lateral, and central aspects of the sourcil line. Measurements were made by 2 independent reviewers blinded to patient positioning. Each reviewer repeated a subset of the measurements to assess intra-rater reproducibility. Mean differences in joint space measurements between standing and supine radiographs were reported for each point of the sourcil. Intraclass correlation coefficients (ICCs) for inter and intra-rater reliability were also calculated. RESULTS There were no significant differences between JSW measurements made on standing and supine pelvic radiographs (P = .468). Furthermore, equivalence testing demonstrated statistical equivalence between standing and supine JSW measurements made based on an equivalence threshold of ±0.5 mm. Inter-rater reliability demonstrated good agreement with an overall ICC of 0.775 (95% confidence interval [CI] 0.734-0.809). Intra-rater reliability also demonstrated good agreement with ICCs of 0.84 (95% CI 0.758-0.889) and 0.798 (95% CI 0.721-0.851) for the 2 reviewers, respectively. CONCLUSIONS JSW measurements on standing and supine pelvic radiographs were not significantly different, and their inter-rater agreement and intra-rater reproducibility demonstrated good reliability and repeatability. Therefore, either may be used to assess JSW, including measurements that may impact treatment decisions for hip arthroscopy. LEVEL OF EVIDENCE Level III; retrospective comparative study.
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Affiliation(s)
- Felipe S Bessa
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Instituto Brasil de Tecnologias da Saúde (IBTS), Rio de Janeiro, Brazil
| | - Brady T Williams
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Evan M Polce
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Bhargavi Maheshwer
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joel C Williams
- Hip Preservation and Orthopedic Trauma, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Beletsky A, Lu Y, Nwachukwu BU, Polce E, Maheshwer B, Chahla J, Forsythe B, Cole BJ, Verma NN. Preoperative psychometric properties of visual analog scale asessments for function, pain, and strength compared with legacy upper extremity outcome measures in glenohumeral osteoarthritis. JSES Int 2020; 4:443-448. [PMID: 32939466 PMCID: PMC7478988 DOI: 10.1016/j.jseint.2020.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Patient-reported outcome measures (PROMs) are increasingly being used in orthopedic surgery; however, there is significant variability and burden associated with their administration. The visual analog scale (VAS) may represent an efficient, single-question method to establish functional baselines in a domain-specific manner for glenohumeral arthritis. Methods Single-question VAS measures assessing function, strength, and pain as a percentage of normal were administered alongside legacy PROMs in patients with primary glenohumeral arthritis in a preoperative setting between October 2015 and March 2017. PROM performance was assessed using Spearman correlation coefficients. Both absolute and relative floor and ceiling effects were examined. Results A total of 70 patients (age 66.09 ± 9.84 years, body mass index 28.8 ± 9.77, 57.1% male, 54.2% right-sided) were included. The VAS Pain instrument (r = 0.45-0.64) outperformed the VAS Function (r = 0.23-0.62) and VAS Strength (r = 0.21-0.65) in correlation to preoperative PROMs. The performance of VAS Pain was comparable to American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES; r = 0.47-0.84). None of the VAS instruments in our study demonstrated preoperative floor effects (7.1%-8.6%) or ceiling effects (0.0%-4.3%). The most efficient instruments were Single-Assessment Numerical Evaluation (SANE; 0.87 ± 0.41 minutes), Patient-Reported Outcome Measurement Information System Upper Extremity Computer Adaptive Test (PROMIS UE CAT; 1.27 ± 1.30 minutes), and the triad of VAS measures (1.51 ± 1.61 minutes). Conclusion VAS Pain outperformed VAS Strength and Function relative to legacy PROMs, while performing comparable to ASES. None of the VAS measures were susceptible to significant floor or ceiling effects preoperatively. The VAS instruments along with SANE and PROMIS UE were the most time-efficient measures. VAS instruments may have a role in establishing preoperative baselines in those with glenohumeral arthritis in a simple, efficient, and adoptable manner.
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Affiliation(s)
- Alexander Beletsky
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Yining Lu
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Benedict U Nwachukwu
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Evan Polce
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Bhargavi Maheshwer
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Brian Forsythe
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Brian J Cole
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
| | - Nikhil N Verma
- Division of Sports Medicine, Department of Orthopedics, Midwest Orthopedics at Rush, Rush University, Chicago, IL, USA
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Cui TX, Maheshwer B, Hong JY, Goldsmith AM, Bentley JK, Popova AP. Hyperoxic Exposure of Immature Mice Increases the Inflammatory Response to Subsequent Rhinovirus Infection: Association with Danger Signals. J Immunol 2016; 196:4692-705. [PMID: 27183577 DOI: 10.4049/jimmunol.1501116] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 04/04/2016] [Indexed: 11/19/2022]
Abstract
Infants with a history of prematurity and bronchopulmonary dysplasia have a high risk of asthma and viral-induced exacerbations later in life. We hypothesized that hyperoxic exposure, a predisposing factor to bronchopulmonary dysplasia, modulates the innate immune response, producing an exaggerated proinflammatory reaction to viral infection. Two- to 3-d-old C57BL/6J mice were exposed to air or 75% oxygen for 14 d. Mice were infected intranasally with rhinovirus (RV) immediately after O2 exposure. Lung mRNA and protein expression, histology, dendritic cells (DCs), and airway responsiveness were assessed 1-12 d postinfection. Tracheal aspirates from premature human infants were collected for mRNA detection. Hyperoxia increased lung IL-12 expression, which persisted up to 12 d postexposure. Hyperoxia-exposed RV-infected mice showed further increases in IL-12 and increased expression of IFN-γ, TNF-α, CCL2, CCL3, and CCL4, as well as increased airway inflammation and responsiveness. In RV-infected, air-exposed mice, the response was not significant. Induced IL-12 expression in hyperoxia-exposed, RV-infected mice was associated with increased IL-12-producing CD103(+) lung DCs. Hyperoxia also increased expression of Clec9a, a CD103(+) DC-specific damaged cell-recognition molecule. Hyperoxia increased levels of ATP metabolites and expression of adenosine receptor A1, further evidence of cell damage and related signaling. In human preterm infants, tracheal aspirate Clec9a expression positively correlated with the level of prematurity. Hyperoxic exposure increases the activation of CD103(+), Clec9a(+) DCs, leading to increased inflammation and airway hyperresponsiveness upon RV infection. In premature infants, danger signal-induced DC activation may promote proinflammatory airway responses, thereby increasing respiratory morbidity.
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Affiliation(s)
- Tracy X Cui
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Bhargavi Maheshwer
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Jun Y Hong
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Adam M Goldsmith
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - J Kelley Bentley
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
| | - Antonia P Popova
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI 48109
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