Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis

Background

Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources.

Purpose

To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated.

Results

Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient.

Conclusion

Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.

Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost-Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5-Year Analysis

PURPOSE

To assess the clinical utility of preoperative magnetic resonance imaging (MRI) and quantify the delay in surgical care for patients aged ≤40 years undergoing primary hip arthroscopy with history, physical examination, and radiographs concordant with femoroacetabular impingement syndrome (FAIS).

METHODS

From August 2015 to December 2020, 1,786 consecutive patients were reviewed from the practice of 1 fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of conservative management, or concomitant periacetabular osteotomy. After nonoperative treatment options were exhausted and a surgical plan was established, patients were stratified by those who presented with versus without MRI. Those without existing MRI received one, and any deviations from the surgical plan were noted. All preoperative MRIs were compared with office evaluation and intraoperative findings to assess agreement. Demographic data, Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, and time from office to MRI or arthroscopy were recorded.

RESULTS

Of the patients indicated by history, physical examination, and radiographs alone (70% female, body mass index 24.8 kg/m², age 25.9 years), 198 patients presented without MRI and 934 with MRI. None of the 198 had surgical plans altered after MRI. Patients in both groups had MRI findings demonstrating anterosuperior labral tears that were visualized and repaired intraoperatively. Mean time from office to arthroscopy for patients without MRI versus those with was 107.0 ± 67 and 85.0 ± 53 days, respectively (P < .001). Time to MRI was 22.8 days. No difference between groups was observed among the 85% of patients who surpassed the HOOS-Pain minimal clinically important difference (MCID).

CONCLUSION

Once indicated for surgery based on history, physical examination, and radiographs, preoperative MRI did not alter the surgical plan for patients aged ≤40 years with FAIS undergoing primary hip arthroscopy. Moreover, preoperative MRI delayed time to arthroscopy. The necessity of routine preoperative MRI in the young primary FAIS population should be challenged.

Meaningless Applications and Misguided Methodologies in Artificial Intelligence-Related Orthopaedic Research Propagates Hype Over Hope

There exists great hope and hype in the literature surrounding applications of artificial intelligence (AI) to orthopaedic surgery. Between 2018 and 2021, a total of 178 AI-related articles were published in orthopaedics. However, for every 2 original research papers that apply AI to orthopaedics, a commentary or review is published (30.3%). AI-related research in orthopaedics frequently fails to provide use cases that offer the uninitiated an opportunity to appraise the importance of AI by studying meaningful questions, evaluating unknown hypotheses, or analyzing quality data. The hype perpetuates a feed-forward cycle that relegates AI to a meaningless buzzword by rewarding those with nascent understanding and rudimentary technical knowhow into committing several basic errors: (1) inappropriately conflating vernacular ("AI/machine learning"), (2) repackaging registry data, (3) prematurely releasing internally validated algorithms, (4) overstating the "black box phenomenon" by failing to provide weighted analysis, (5) claiming to evaluate AI rather than the data itself, and (6) withholding full model architecture code. Relevant AI-specific guidelines are forthcoming, but forced application of the original Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis guidelines designed for regression analyses is irrelevant and misleading. To safeguard meaningful use, AI-related research efforts in orthopaedics should be (1) directed toward administrative support over clinical evaluation and management, (2) require the use of the advanced model, and (3) answer a question that was previously unknown, unanswered, or unquantifiable.

Triceps Tendon Rupture - A Novel Repair of an Uncommon Injury

Introduction

Triceps tendon rupture is a rare injury accounting for <1% of all tendon injuries with varying repair techniques described. We present this novel repair to supplement available literature and help optimize the clinical outcomes for affected patients. We report this technique because it is unique in that we augmented our surgical fixation with a subtle variation in the described technique by repairing the deep portion of the triceps tendon as a separate step, maximizing the recreation of the anatomic footprint of the triceps.

Case Report

The patient is a 70-year-old Caucasian male presenting with pain, swelling, and ecchymosis around the elbow after the episode of injury. He also complained of a painful popping sensation whenever he ranged the elbow and an inability to extend, with pain and weakness any time he attempted elbow extension. Radiographs reviewed at his initial visit revealed a small osseous fragment approximately 5 cm proximal to the olecranon tip. Subsequent MR imaging confirmed our suspicion, showing a complete tear of the triceps tendon with hematoma at its insertion site and tendon retraction approximately 3 cm proximally. With the diagnosis of triceps tendon rupture conformed, we took the patient for primary tendon repair using suture with bone bridge and suture anchor, using elements from described techniques. Our technique was unique in that we performed repair of the deep and superficial triceps attachments as separate steps, in an endeavor to improve the anatomic reconstruction of the footprint and biomechanical strength.

Conclusions

We combined findings from our review of the available literature with novel surgical techniques and suture design to maximize the patient outcome and minimize complications. The patient went on to have a very satisfactory functional recovery. We hope that this case report will complement the evidence-based care of these patients by orthopedic surgeons and lead to the best results possible.

Machine Learning and Artificial Intelligence: Definitions, Applications, and Future Directions

PURPOSE OF REVIEW

With the unprecedented advancement of data aggregation and deep learning algorithms, artificial intelligence (AI) and machine learning (ML) are poised to transform the practice of medicine. The field of orthopedics, in particular, is uniquely suited to harness the power of big data, and in doing so provide critical insight into elevating the many facets of care provided by orthopedic surgeons. The purpose of this review is to critically evaluate the recent and novel literature regarding ML in the field of orthopedics and to address its potential impact on the future of musculoskeletal care.

RECENT FINDINGS

Recent literature demonstrates that the incorporation of ML into orthopedics has the potential to elevate patient care through alternative patient-specific payment models, rapidly analyze imaging modalities, and remotely monitor patients. Just as the business of medicine was once considered outside the domain of the orthopedic surgeon, we report evidence that demonstrates these emerging applications of AI warrant ownership, leverage, and application by the orthopedic surgeon to better serve their patients and deliver optimal, value-based care.

Predicting Inpatient Payments Prior to Lower Extremity Arthroplasty Using Deep Learning: Which Model Architecture Is Best?

BACKGROUND

Recent advances in machine learning have given rise to deep learning, which uses hierarchical layers to build models, offering the ability to advance value-based healthcare by better predicting patient outcomes and costs of a given treatment. The purpose of this study is to compare the performance of 2 common deep learning models, traditional multilayer perceptron (MLP), and the newer dense neural network (DenseNet), in predicting outcomes for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) as a foundation for future musculoskeletal studies seeking to utilize machine learning.

METHODS

Using 295,605 patients undergoing primary THA and TKA from a New York State inpatient administrative database from 2009 to 2016, 2 neural network designs (MLP vs DenseNet) with different model regularization techniques (dropout, batch normalization, and DeCovLoss) were applied to compare model performance on predicting inpatient procedural cost using the area under the receiver operating characteristic curve (AUC). Models were implemented to identify high-cost surgical cases.

RESULTS

DenseNet performed similarly to or better than MLP across the different regularization techniques in predicting procedural costs of THA and TKA. Applying regularization to DenseNet resulted in a significantly higher AUC as compared to DenseNet alone (0.813 vs 0.792, P = .011). When regularization methods were applied to MLP, the AUC was significantly lower than without regularization (0.621 vs 0.791, P = 1.1 × 10^-15). When the optimal MLP and DenseNet models were compared in a head-to-head fashion, they performed similarly at cost prediction (P > .999).

CONCLUSION

This study establishes that in predicting costs of lower extremity arthroplasty, DenseNet models improve in performance with regularization, whereas simple neural network models perform significantly worse without regularization. In light of the resource-intensive nature of creating and testing deep learning models for orthopedic surgery, particularly for value-centric procedures such as arthroplasty, this study establishes a set of key technical features that resulted in better prediction of inpatient surgical costs. We demonstrated that regularization is critically important for neural networks in arthroplasty cost prediction and that future studies should utilize these deep learning techniques to predict arthroplasty costs.

LEVEL OF EVIDENCE

III.

Metastatic Malignant Thymoma to the Abdomen: A SEER Database Review and Assessment of Treatment Strategies

BACKGROUND

Thymoma is a neoplasm occurring in 0.15 of 100,000 persons/year. Abdominal metastases are rare. We report the incidence of malignant thymoma (MT) and suggest imaging and treatment options for cases of abdominal metastasis.

METHODS

A National Cancer Institute's Surveillance, Epidemiology and End Results database review was conducted to identify MT cases, followed by a literature review examining cases of metastases to the abdomen. Incidence rates were calculated, and symptoms, treatments, size and location of tumors, disease-free interval (DFI), and survival time were recorded.

RESULTS

From 1973 to 2008, a total of 1,588 MT cases were identified (45.4 cases/year), which were extrapolated to 2,724 over 60 years. Incidence has risen from 17 cases in 1973 to 90 cases in 2008, with a larger incidence in males than females (0.23 vs. 0.17 per 100,000). There were 25 cases of abdominal metastasis (0.92%), 13 of which were asymptomatic. There was a wide variety of DFI and survival noted amongst the case reports. Multiple treatment modalities were used.

CONCLUSIONS

The incidence of MT is on the rise with a male predominance. All patients should receive routine imaging to look for extrathoracic metastases as half will not have symptoms. All patients with abdominal metastases should be treated using a multimodal approach.

A novel solution for severe urinary incontinence in women with cystic fibrosis

BACKGROUND

To explore whether Tension-free Vaginal Tape offers a solution for women with cystic fibrosis who suffer from severe stress incontinence.

METHODS

Four adults with cystic fibrosis were formally assessed by gynaecological and urological specialists, prior to hospital admission for surgery.

RESULTS

The procedure was tolerated well by all patients. In three, leakage ceased completely. The fourth patient experienced considerable improvement in symptoms.

CONCLUSIONS

Tension-free Vaginal Tape is a safe, effective and worthwhile solution for stress incontinence in females with cystic fibrosis.

Behaviors of very preterm neonates as documented using NIDCAP observations

PURPOSE

The purpose of this study was to describe the range and frequency of behaviors in neonates 24-30 weeks postconceptional age (PCA) using the Newborn Individualized Developmental Care Assessment Program (NIDCAP).

DESIGN

A prospective design with convenience sampling was used.

SAMPLE

Starting 24-72 hours postnatally and continuing through 30 weeks PCA, 8,144 two-minute observations of 85 NIDCAP behaviors were collected and analyzed from 42 neonates born at 24-29 weeks gestation.

MAIN OUTCOME VARIABLE

The main outcome variables were the frequencies of the 85 neonatal behaviors measured by the NIDCAP. Frequencies were organized first by subsystem (autonomic, motor, or state) and were categorized further based on week of PCA. Comparisons of behavioral frequencies by number of weeks PCA were completed using correlation and regression analyses.

RESULTS

The most frequently observed behaviors were irregular respirations, pink color, postured flexion of the extremities, immature light sleep, and drowsiness. Least frequently observed behaviors consisted of burps, bowel movement, grunting, smooth motor movements, cooing, and speech movement. Regression analysis illustrated that the pattern of behavior was significantly similar week to week.

Common feeding problems in the intensive care nursery: maturation, organization, evaluation, and management strategies

This paper reviews current literature on feeding and swallowing of the premature and high-risk infant. If addresses issues of maturation and organization that affect feeding abilities. Evaluation issues including instrumental evaluations (e.g., cervical auscultation, modified barium swallow studies) are discussed. Finally, common problems seen in this population are described along with the wide range of management strategies to consider. Whenever intervening with this fragile population a team approach must be used; the individual needs and behavioral cues of the infant must be read, respected, and responded to, while ensuring that families play an integral part of the process.

Cognitive failure to thrive in high-risk infants: the importance of the psychosocial environment

We evaluated early social risk assessment as a predictor of cognitive development in high-risk infants. A social worker assessed social risk in 122 infants before discharge from a neonatal intensive care unit. Infants were evaluated at ages 12 and 36 months adjusted for prematurity. We found no difference in 12-month cognitive development among medical, neurologic, or social risk groups. However, from 12 to 36 months there was a significant decline in mean developmental quotient in the groups with social risk alone, neurologic and social risk, and medical and social risk, but not in the groups with medical or neurologic risks without social risk. Social risk assessment correctly predicted 36-month cognitive outcome in 71% of infants who had normal findings at 12 months. We conclude that neonatal social risk assessment can help identify infants at highest risk for cognitive retardation and is particularly important for infants who have medical or neurologic problems.

Genetic diversity at electrophoretic loci in the house fly, Musca domestica L

Vertical polyacrylamide gel electrophoresis was used to separate enzyme proteins at 73 putative loci in natural house fly populations sampled in central Iowa. Thirty-nine of the loci were polymorphic (53%). The mean effective number of alleles per polymorphic locus was 1.93 and 1.47 alleles among 68 scored loci. Observed and expected heterozygosities at 34 house fly loci were 0.1628 and 0.1834, respectively. No statistically significant differentiation was detected among nine central Iowa fly populations in 1989 or among nine Iowa and three Minnesota populations in 1990.