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Comrie R, Pfeil AN, Huerta P, Lautenshlager K, Hryc CF, Ihekweazu UN. The 22-Modifier in Total Hip and Knee Arthroplasty: A Comprehensive Analysis. J Arthroplasty 2024; 39:1640-1644.e3. [PMID: 38311299 DOI: 10.1016/j.arth.2024.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/24/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND The 22-modifier requests additional compensation for increased case complexity. Unfortunately, there is little to guide physicians on the application, which may increase successful reimbursement. We sought to evaluate various factors affecting reimbursement of the 22-modifier in primary total joint arthroplasty (TJA) and report which factors contributed to successful utilization. METHODS In this retrospective study, all cases from a single practice where the 22-modifier was added to Current Procedural Terminology codes: 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty) from October 2018 to March 2022 were evaluated. Out of the 6,869 total cases performed, 816 22-modifier cases were identified (11.9%). Operative reports, demographics, insurance type, billing information, and clinical records were assessed. T-tests were used to determine statistical significance. RESULTS Of the 816 cases, 221 (27.1%) were successfully reimbursed. Cases justified 22-modifier application with obesity, anatomic variations, or intraoperative factors. Some cases lacked justification, or operative reports were not submitted. Reimbursement was successful for 27.6% of obesity cases, 29.7% of intraoperative complications, and 35.7% of anatomic variations. There was a significantly higher likelihood of Medicare reimbursement than third-party payers or Medicaid (69.6 versus 20.5 and 6.9%) (P < .0001). Additionally, Medicare was more likely to reimburse for obesity (76.6 versus 20.0, and 5.2%), anatomic variations (77.3 versus 22.0%), and intraoperative factors (66.6 versus 21.1, and 1.7%). CONCLUSIONS Reimbursement for 22-modifier cases in TJA is unlikely. Obesity was cited for most 22-modifier justifications, but anatomic variation justification was successfully reimbursed most often. Medicare was most likely to reimburse compared to third-party payers or Medicaid. These findings should be considered when applying a 22-modifier to TJA procedures.
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Affiliation(s)
- Robert Comrie
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
| | - Allyson N Pfeil
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
| | - Pito Huerta
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
| | - Kurt Lautenshlager
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
| | - Corey F Hryc
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
| | - Ugonna N Ihekweazu
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, Texas
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Testa EJ, Callanan TC, Albright JA, Quinn M, O'Donnell R, Daniels AH, Arcand M. Decreased prevalence of new-onset adhesive capsulitis in patients prescribed angiotensin receptor blockers. J Shoulder Elbow Surg 2024:S1058-2746(24)00237-4. [PMID: 38599458 DOI: 10.1016/j.jse.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) are commonly prescribed antihypertensive agents that have well-known antifibrotic properties. The purpose of this study was to examine the association between ARB use and the rates of new-onset adhesive capsulitis as well as adhesive capsulitis requiring operative treatment. METHODS Using a large national insurance database, a randomly generated cohort of patients with at least 3 continuous months of ARB use between January 2010 and December 2019 (n = 1,000,000) was compared to a separate randomly generated cohort without ARB use (n = 3,000,000). Rates of newly diagnosed adhesive capsulitis and associated manipulation under anesthesia (MUA) and/or arthroscopic capsulotomy were calculated over a 1- and 2-year period following the completion of at least 3 continuous months of ARB therapy. Rates were compared using multivariable logistic regression to control for demographics and comorbidities. Both unadjusted and adjusted odds ratios and 95% confidence intervals were calculated and reported for each comparison. Statistical significance was set at P <.05. RESULTS The mean age in the ARB cohort was 61.8 years (standard deviation [SD] = 10.0), whereas in the control cohort, it was 54.8 years (SD = 12.3) (P < .001). The ARB cohort had significantly lower rates of newly diagnosed adhesive capsulitis compared with the control cohort at both 1 year (0.15% vs. 0.55%, P < .001) and 2 years (0.3% vs. 0.78%, P < .001). Similar findings were observed for the arthroscopic capsular release/MUA cohort associated with adhesive capsulitis. After adjusting for confounding factors, the lower rates of adhesive capsulitis and arthroscopic capsular release/MUA associated with adhesive capsulitis in the ARB cohort remained statistically significant (P < .001). CONCLUSION Patients prescribed ARBs experienced a decreased rate of newly diagnosed adhesive capsulitis, as well as adhesive capsulitis requiring surgical intervention when compared to a control cohort. These findings suggest a potential protective effect of ARBs against the development of adhesive capsulitis. Further investigations are warranted to elucidate the underlying mechanisms and establish a causal relationship.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
| | - Tucker C Callanan
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - J Alex Albright
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Matthew Quinn
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Ryan O'Donnell
- Department of Orthopaedic Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Michel Arcand
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Cardenas J, Pfeil AN, Fertitta DK, Comrie R, Rospigliosi D, Shumareva M, Vidal E, Hryc CF, Ihekweazu UN. Orthopedic Hardware Type Impacts Case Complexity in Conversion Total Hip Arthroplasty Surgery. Arthroplast Today 2024; 26:101317. [PMID: 38415066 PMCID: PMC10897850 DOI: 10.1016/j.artd.2024.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/15/2023] [Accepted: 01/21/2024] [Indexed: 02/29/2024] Open
Abstract
Background Conversion total hip arthroplasty (THA) includes a variety of operations and prior implants. The implant present before conversion may influence the outcome and complexity of the procedure. The group hypothesized that conversion arthroplasty for patients with intramedullary nails (IMNs) is more complex from a surgical and resource utilization perspective than for those with screw fixation. Methods THA conversion cases were reviewed retrospectively from 2012 to 2020 from 6 surgeons across 3 institutions. The included cohort had 106 patients with fixation in the proximal femur for prior traumatic events. Demographics, operative data, outcomes, and implant information were collected from the medical record. The conversion THA group was categorized by preoperative fixation type: closed reduction and percutaneous pinning/screw fixation (CRPP) or IMN. Results No age or body mass index differences were observed between the cohorts. Prior to conversion THA, IMN patients had undergone more surgeries than CRPP (P < .05). Perioperatively, the IMN cohort sustained increased blood loss (P < .001), had longer surgeries (P < .0001), had longer length of hospital stays (P < .01), necessitated trochanteric plates more often (P < .05), were readmitted more (P < .05), and required additional follow-up surgery (P < .01) than the CRPP cohort. Conclusions Conversion THA of a prior IMN implant is associated with worse perioperative outcomes than conversion of a CRPP construct. Surgeons, health systems, and payors should consider these differences when caring for these distinct groups of patients.
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Affiliation(s)
- Justin Cardenas
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Allyson N Pfeil
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Davin K Fertitta
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Robert Comrie
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Delia Rospigliosi
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mariya Shumareva
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Emily Vidal
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Corey F Hryc
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Ugonna N Ihekweazu
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
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Sheplay KA, Sheplay AW. Posterior femoral cutaneous nerve impingement post marathon: A case report. Pain Pract 2023; 23:970-973. [PMID: 37051935 DOI: 10.1111/papr.13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 01/18/2023] [Accepted: 03/24/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION Posterior femoral cutaneous nerve (PFCN) neuropathy is an uncommon, potentially under-recognized cause of low back, buttock, perineal, and posterior and lateral thigh pain and numbness. Most PFCN injuries are caused by intramuscular injections; however, this is the first reported case of a PFCN injury of hamstring pathology due to tendonitis caused by long-distance running. CASE REPORT A middle-aged man presented with right lower buttock pain, which started 2 weeks after running a marathon. The pain was located medial and superior to the ischia tuberosity and extended distally to the right scrotum with no testicular pain. The pain progressed such that he was unable to sit down for over a year. An initial MRI showed right hamstring tendonitis. Consults with sports medicine and hip orthopedics provided no clear diagnosis. He failed to improve with NSAIDs, physical therapy, massage, PRP injection, two Ganglion of Impar Nerve blocks, and trial of Pregabalin. The diagnosis was confirmed with temporary relief following a PFCN block. He was then advised to have the nerve resected because of the failure of nonsurgical treatment. DISCUSSION After excluding the more common etiologies of buttock pain and sitting intolerance, practitioners should consider the rarer condition of the impingement of the PFCN in runners.
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Affiliation(s)
- Kirk A Sheplay
- Ascension Providence Southfield GME, Southfield, Michigan, USA
| | - Anthony W Sheplay
- Pain & Spine Medicine Center of the Central Coast, Templeton, California, USA
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Bi AS, Papalia AG, Romeo PV, Schoof LH, Kwon YW, Rokito AS, Zuckerman JD, Virk MS. Effect of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers on need for operative intervention for idiopathic adhesive capsulitis. JSES Int 2023; 7:793-798. [PMID: 37719830 PMCID: PMC10499842 DOI: 10.1016/j.jseint.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background The exact pathogenesis of idiopathic adhesive capsulitis (IAC) is not fully understood, but an inflammatory profibrotic cascade, largely mediated by transforming growth factor-beta 1 (TGF- β1) has been implicated. Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACE-Is) both decrease the activity of TGF-β1. The aim of this study was to determine the impact of ACE-Is or ARBs use on the need for operative intervention in IAC. Methods This was a retrospective cohort study of patients from a single institutional database with IAC, divided into two cohorts, with and without ACE-I and/or ARB use as the primary exposure and a minimum 2-year follow-up. The primary outcome measured was the incidence of operative intervention including manipulation under anesthesia (MUA) and arthroscopic capsular release (ACR). Additional multivariable logistic regression analysis was performed to evaluate associations between ACE-I/ARB use and likelihood of undergoing an operative procedure. Results A total of 17,645 patients met inclusion criteria, with 5424 patients in the ACE-I/ARB cohort and 12,221 in the non-ACE-I/ARB cohort. Overall, 422 (2.4%) patients underwent surgical treatment, 378 (2.1%) ACR, and 74 (0.4%) MUA. There was no significant difference between cohorts in the frequency of surgical procedures or time to procedure since diagnosis. There were no significant differences between individual ACE-Is or ARBs, although Losartan was found to have a trend of decreased rate of intervention (31.7% vs. 36.8%, P = .209) when compared to patients not on losartan that did not reach statistical significance. Patient factors predictive of undergoing MUA/ACR were diabetes (P = .013), obesity (P < .001), and male sex (P < .001). Increasing patient age reduces the likelihood of undergoing operative intervention, with patients aged 50-70 years (P = .022) and age >70 years (P < .001) demonstrating reduced odds as compared to patients aged <30 years. Conclusion Patients with IAC have an overall low (2.4%) rate of requiring surgical intervention. While the antifibrotic mechanism of ACE inhibitors and ARBs did not significantly affect the rate of requiring surgical intervention, male gender, obesity, younger age, and diabetes, all increased the risk for operative intervention. Losartan, specifically, may have a disease modifying effect on IAC that should be investigated with larger controlled trials.
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Affiliation(s)
- Andrew S. Bi
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Aidan G. Papalia
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Paul V. Romeo
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Lauren H. Schoof
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Young W. Kwon
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Andrew S. Rokito
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Joseph D. Zuckerman
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
| | - Mandeep S. Virk
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, NY, USA
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Bi AS, Li ZI, Triana J, Fisher ND, Morgan AM, Garra S, Gonzalez-Lomas G, Campbell KA, Jazrawi LM. Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors Have No Significant Relationship With Postoperative Arthrofibrosis After Shoulder Arthroscopy. Arthrosc Sports Med Rehabil 2023; 5:100748. [PMID: 37645401 PMCID: PMC10461208 DOI: 10.1016/j.asmr.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/23/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To determine the effect of perioperative angiotensin II receptor blocker (ARB) or angiotensin-converting enzyme inhibitors (ACEi) on postoperative arthrofibrosis, as defined by requiring manipulation under anesthesia (MUA) or new diagnosis of adhesive capsulitis (AC) following arthroscopic shoulder procedures. Methods Patients were retrospectively identified using Current Procedural Terminology surgical billing codes to identify patients who underwent any shoulder arthroscopic procedure at a single urban academic institution from 2012 to 2020 with a minimum 2-year follow-up. Patients were excluded if <30 years old at time of surgery, as these patients rarely use ARB and ACEi medications, or if they had pre-existing AC. Demographics, active medication prescriptions at the time of surgery, and medical comorbidities were recorded. Multivariable logistic regression was performed to determine the effect of ARB/ACEi on subsequent MUA or AC by 90 days, 1 year, and 2 years. Results In total, 5,559 patients were included in the final analysis. A majority of the cohort (53.4%) underwent arthroscopic surgery between the ages of 50 to 69 years. Most patients were male (61.8%) and without obesity (67.3%). In total, 18.9% and 15.0% were taking an ARB or ACEi medication perioperatively, respectively. Within 2 years' postoperatively, 51 patients (0.9%) underwent subsequent ipsilateral MUA, and 174 patients (3.1%) developed AC. Patients taking ARBs had a 17.5% rate of postoperative arthrofibrosis within 2-years compared with 19.1% in those not on ARBs, although this difference was not significant (P = .58). Likewise, no significant difference was found between those taking ACEi versus not (15.0% vs 15.0%, P = .99). Individual generic ARB/ACEi subgroup analysis did not demonstrate any significant associations with rate of postoperative arthrofibrosis (P > .05). Conclusions ARBs or ACEi did not significantly affect the rate of postoperative arthrofibrosis following shoulder arthroscopy, however female sex, diabetes mellitus, and Black/African American race were associated with an increased rate of necessitating MUA or developing AC within 2 years postoperatively. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Andrew S. Bi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Zachary I. Li
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Jairo Triana
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Nina D. Fisher
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Allison M. Morgan
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Sharif Garra
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Guillem Gonzalez-Lomas
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Kirk A. Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
| | - Laith M. Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, U.S.A
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Abstract
Fibrosis is a common and debilitating pathological process that affects many organ systems and contributes to connective tissue disorders in orthopaedics. Tendons heal after acute and chronic injury through a process of fibrovascular scar tissue formation, and soft tissue joint capsules can be affected after traumatic joint injury, leading to arthrofibrosis. Although the precise underlying mechanisms are still being elucidated, fibrosis is thought to be a consequence of dysregulated immune and cytokine signaling that leads to myofibroblast activation and proliferation and subsequent excessive collagen deposition. Current treatments for connective tissue fibrosis include physical therapy and surgery, but there are no therapies that directly target the underlying cellular and molecular mechanisms of fibrosis. Many pharmacological agents have been used to successfully target fibrosis in other tissues and organ systems and thus are a promising treatment option to fill this gap. However, limited evidence is available to guide the use of these agents in musculoskeletal connective tissues. This article provides an overview of pharmacological therapies that have potential to treat connective tissue fibrosis in patients with musculoskeletal conditions, along with the current supporting evidence and future uses of each therapy.
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Affiliation(s)
- Nathaniel P Disser
- Hospital for Special Surgery, New York, New York, USA
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jonathan S Yu
- Hospital for Special Surgery, New York, New York, USA
- Weill Cornell Medicine, New York, New York, USA
| | - Vincent J H Yao
- Hospital for Special Surgery, New York, New York, USA
- Sophie Davis Biomedical Education Program at CUNY School of Medicine, New York, New York, USA
| | - Scott A Rodeo
- Hospital for Special Surgery, New York, New York, USA
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Melugin HP, Comfort SM, Shelton TS, Day HK, Ruzbarsky JJ, Dornan GJ, Philippon MJ. The revision hip arthroscopy complex: capsular deficiency, labral deficiency, femoral over-resection and adhesions can result in good survivorship with revision hip arthroscopy. J Hip Preserv Surg 2023; 10:197-203. [PMID: 38162272 PMCID: PMC10757422 DOI: 10.1093/jhps/hnad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 06/18/2023] [Accepted: 08/16/2023] [Indexed: 01/03/2024] Open
Abstract
To evaluate the patient-reported outcomes (PROs) and survivorship of combined arthroscopic hip labral reconstruction/augmentation, capsular reconstruction, femoral neck remplissage and lysis of adhesions. Patients ≥18 years old who underwent this combination of procedures during revision hip arthroscopy and were eligible for minimum 2-year follow-up were identified. PRO scores including Hip Outcome Score (HOS)-Activities of Daily Living scale, HOS-Sports scale, modified Harris Hip Score, Short Form 12, and Western Ontario & McMaster Universities Osteoarthritis Index, patient satisfaction and failure rates were analyzed. Seven patients (5 females and 2 males) with average age of 45.0 ± 5.2 (range: 40-54 years) met inclusion criteria. Patients had a median of 1 (range: 1-3) prior hip surgery at an outside institution. All patients had previously undergone femoral osteoplasty, and 85% (6/7) of patients had a labral repair performed. Four patients had no capsule closure performed in their prior procedures. Six patients were available for minimum 2-year follow-up. Two patients converted to total hip arthroplasty: one patient with four prior hip arthroscopies and the other had advanced osteoarthritis with outerbridge grade 3/4 defects requiring microfracture. Mean patient satisfaction was 7 (range: 2-9). At mean follow-up of 3 years, most patients who underwent the combination of labral reconstruction, capsular reconstruction, femoral neck remplissage and lysis of adhesions during revision hip arthroscopy demonstrated improved PROs. This salvage procedure has the potential to restore hip function in patients who have failed an initial hip arthroscopy procedure. In patients with these pathologies present and concomitant joint space narrowing, a total hip arthroplasty may be a more appropriate salvage option.
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Affiliation(s)
- Heath P Melugin
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
- Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, 181 W Meadow Dr, Ste 400, Vail, CO 81657, USA
| | - Spencer M Comfort
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
| | - Trevor S Shelton
- Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, 181 W Meadow Dr, Ste 400, Vail, CO 81657, USA
| | - Hannah K Day
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
| | - Joseph J Ruzbarsky
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
- Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, 181 W Meadow Dr, Ste 400, Vail, CO 81657, USA
| | - Grant J Dornan
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
| | - Marc J Philippon
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, USA
- Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, 181 W Meadow Dr, Ste 400, Vail, CO 81657, USA
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Leo H, Shelton T, Bradley H. Criteria-Based Rehabilitation Following Revision Hip Arthroscopy: A Clinical Commentary. Int J Sports Phys Ther 2023; 18:477-492. [PMID: 37020439 PMCID: PMC10069339 DOI: 10.26603/001c.71355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/15/2023] [Indexed: 04/04/2023] Open
Abstract
Hip revision arthroscopy is becoming an increasingly popular surgery for those with unsatisfactory outcomes following primary hip arthroscopy. With the relatively uncommon but potentially increased difficulty of rehabilitation from this surgery, a lack of established research regarding rehabilitative programs remains. Therefore, the purpose of this clinical commentary is to propose a criterion-based progression that considers the intricacies present following a hip revision arthroscopy from early rehabilitation through return to sport. Criteria are presented clearly to promote objective progression through rehabilitation as opposed to relying on time since surgery as revision surgeries do not always follow traditional tissue healing time-frames. This criterion based progression promotes range of motion (ROM), strength, gait, neuromuscular control, load introduction and gradual return to play. Level of Evidence 5.
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Ruzbarsky JJ, Comfort SM, Martin MD, Briggs KK, Philippon MJ. Outcomes for Treatment of Capsulolabral Adhesions With a Capsular Spacer During Revision Hip Arthroscopy. Am J Sports Med 2023; 51:487-493. [PMID: 36661250 DOI: 10.1177/03635465221145704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The presence of adhesions is a common source of pain and dysfunction after hip arthroscopic surgery and an indication for revision surgery. The placement of a capsular spacer in the capsulolabral recess after lysis of adhesions has been developed to treat and prevent the recurrence of adhesions. PURPOSE To evaluate patient-reported outcomes (PROs) and survivorship at a minimum of 2 years after revision hip arthroscopic surgery with capsular spacer placement for capsular adhesions. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between January 2013 and June 2018, a total of 95 patients (99 hips) aged ≥18 years underwent revision hip arthroscopic surgery for the treatment of capsular adhesions with the placement of a capsular spacer. Overall, 53 patients (56 hips) met the inclusion criteria and had a minimum 2-year follow-up, forming the cohort of this study. Exclusion criteria included confounding metabolic bone diseases (eg, Legg-Calve-Perthes disease, Marfan syndrome), labral deficiency, or advanced osteoarthritis (Tönnis grade 2 or 3). Preoperative and postoperative outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sport-Specific Subscale [HOS-SSS], 12-Item Short Form Health Survey [SF-12], and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were collected and compared in addition to the revision rate, conversion to total hip arthroplasty, and patient satisfaction. RESULTS The mean age of the cohort was 32 ± 11 years, with 32 female hips (57%) and a median number of previous hip arthroscopic procedures of 1 (range, 1-5). The arthroplasty- and revision-free survivorship rate at 2 years was 91%. Overall, 5 patients (6 hips; 11%) underwent revision surgery at a mean of 2.4 ± 1.4 years after capsular spacer placement, with symptomatic capsular defects being the most common finding. There were 4 patients (7%) who converted to total hip arthroplasty. For hips not requiring subsequent surgery (n = 46), there was a significant improvement in outcome scores except for the SF-12 Mental Component Summary, with rates of achieving the minimal clinically important difference of 70%, 70%, and 65% for the mHHS, HOS-ADL, and HOS-SSS, respectively. CONCLUSION Capsular spacers, as part of a systematic approach including lysis of adhesions with early and consistent postoperative physical therapy including circumduction exercises, resulted in improved PROs as well as high arthroplasty- and revision-free survivorship (91%) at a minimum 2-year follow-up. Capsular spacers should be considered in revision hip arthroscopic procedures when an adequate labral volume remains but adhesions continue to be a concern.
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Affiliation(s)
- Joseph J Ruzbarsky
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
| | | | | | - Karen K Briggs
- Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, USA.,The Steadman Clinic, Vail, Colorado, USA
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Sriwatananukulkit O, Desclaux S, Tawonsawatruk T, Srikuea R, Himakhun W, Likitnukul S, Hemstapat R. Effectiveness of losartan on infrapatellar fat pad/synovial fibrosis and pain behavior in the monoiodoacetate-induced rat model of osteoarthritis pain. Biomed Pharmacother 2023; 158:114121. [PMID: 36516695 DOI: 10.1016/j.biopha.2022.114121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Infrapatellar fat pad (IFP)/ synovial fibrosis is closely associated with the clinical symptoms of joint pain and stiffness, which contribute to locomotor restriction in osteoarthritis (OA) patients. Hence, this study was designed to gain insight on whether losartan, a selective angiotensin II type 1 receptor (AT1R) antagonist, has therapeutic benefit to reverse IFP/synovial fibrosis and secondarily to attenuate pain behavior. In male Wistar rats with monoiodoacetic acid (MIA)-induced IFP/synovial fibrosis, a possible role for increased AT1R expression in the pathogenesis of IFP/synovial fibrosis was assessed over an 8-week period. Pain behavior comprised static weight bearing and von Frey paw withdrawal thresholds (PWTs), which were assessed once or twice weekly, respectively. Groups of MIA-rats received oral losartan (30-mg/kg; n = 8 or 100-mg/kg; n = 9) or vehicle (n = 9) for 28-days according to a prevention protocol. Animals were euthanized on day 28 and various tissues (IFP/synovium, cartilage and lumbar dorsal root ganglia (DRGs)) were collected for histological, immunohistochemical and western blot analyses. Administration of once-daily losartan for 28-days dose-dependently attenuated the development of static weight bearing. This was accompanied by reduced IFP/synovial fibrosis and suppression of TGF-β1 expression. Chronic treatment of MIA-rats with losartan had an anti-fibrotic effect and it attenuated pain behavior in this animal model.
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Affiliation(s)
- Orada Sriwatananukulkit
- Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand.
| | - Scarlett Desclaux
- Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand.
| | | | - Ratchakrit Srikuea
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand.
| | - Wanwisa Himakhun
- Department of Pathology and Forensic Medicine, Faculty of Medicine, Thammasat University, Pathumthani 12120, Thailand.
| | - Sutharinee Likitnukul
- Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand.
| | - Ruedee Hemstapat
- Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok 10400, Thailand.
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12
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Hutchinson ID, Rodeo SA. The Current Role of Biologics for Meniscus Injury and Treatment. Curr Rev Musculoskelet Med 2022; 15:456-464. [PMID: 35881326 PMCID: PMC9789233 DOI: 10.1007/s12178-022-09778-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW There is little doubt that the consensus has changed to favor preservation of meniscal function where possible. Accordingly, the indications for meniscal repair strategies have been refocused on the long-term interest of knee joint health. The development and refinements in surgical technique have been complemented by biological augmentation strategies to address intrinsic challenges in healing capacity of meniscal tissue, with variable effects. RECENT FINDINGS A contemporary approach to meniscal healing includes adequate surgical fixation, meniscal and synovial tissue stimulation, and management of the intraarticular milieu. Overall, evidence supporting the use of autogenous or allogeneic cell sources remains limited. The use of FDA-approved medications to effect biologically favorable mechanisms during meniscal healing holds promise. Development and characterization of biologics continue to advance with translational research focused on specific growth factors, cell and tissue behaviors in meniscal healing, and joint homeostasis. Although significant strides have been made in laboratory and pre-clinical studies, translation to clinical application remains challenging. Finally, expert consensus and standardization of nomenclature related to orthobiologics for meniscal preservation will be important for the advancement of this field.
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Affiliation(s)
- Ian D. Hutchinson
- grid.239915.50000 0001 2285 8823Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,grid.239915.50000 0001 2285 8823Laboratory for Tissue Engineering, Regeneration & Repair, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Scott A. Rodeo
- grid.239915.50000 0001 2285 8823Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,grid.239915.50000 0001 2285 8823Laboratory for Tissue Engineering, Regeneration & Repair, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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13
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Ruzbarsky JJ, Seiter MN, Comfort SM, Soares RW, Briggs KK, Philippon MJ. Arthroscopic Hip Capsular Reconstruction Using Iliotibial Band Allograft as a Salvage Option for Unrepairable Capsular Defects Demonstrates Good Survivorship and Improved Patient-Reported Outcomes. Arthroscopy 2022; 38:2219-2226. [PMID: 34990758 DOI: 10.1016/j.arthro.2021.12.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe patient outcomes 3 to 5 years after arthroscopic hip capsule reconstruction. METHODS Between January 2007 and December 2016, patients aged 18 to 50 years who underwent arthroscopic hip capsular reconstruction using an Iliotibial band allograft by the senior author and had minimum of 3-year follow-up were identified. Patients were excluded if they had previous open hip surgery, advanced osteoarthritis (Tönnis grade >2), significant acetabular dysplasia (lateral center edge angle <20°), avascular necrosis, or Legg-Calve-Perthes disease. Outcome scores including the Hip Outcome Score (HOS)-Activities of Daily Living scale, modified Harris Hip Score, HOS-Sports scale, SF-12, and Western Ontario & McMaster Universities Osteoarthritis Index were compared in addition to failure rate, revision rate, and patient satisfaction rate with the outcome (range, 1-10). All patients were assessed by the senior author pre- and postoperatively. RESULTS Thirty-nine patients met the inclusion criteria. The mean age of the cohort was 32 ± 10 years, with 6 male and 33 female patients. The average number of previous hip arthroscopy surgeries was 2 ± 1. Six patients (15%) converted to total hip arthroplasty at an average of 2.1 years (range 7 months to 6 years) following capsular reconstruction. Four patients required revision hip arthroscopy after the arthroscopic capsular reconstruction. All arthroscopic revisions occurred in female patients with the primary intraoperative finding of capsulolabral adhesions at the time of revision. At mean follow-up of 4.3 years (range 3-6.8 years), the 29 patients who did not require subsequent surgery had significant improvements from preoperatively to postoperatively in HOS-Activities of Daily Living and HOS-Sport with 90% reaching minimal clinically important difference. All other scores showed significant improvement. Survival for patients not requiring total hip arthroplasty was 86% at 3 years, with a mean survival of 5.7 years (95% confidence interval 4.97-6.4). CONCLUSIONS Arthroscopic hip capsular reconstruction with iliotibial band allograft is a successful treatment option for patients with symptomatic capsular defects, demonstrating improved patient-reported outcomes maintained at mean follow-up time of 4 years. This technique offers restoration of the anatomic structure and function of the capsular ligaments to improve pain and instability. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Joseph J Ruzbarsky
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | - Max N Seiter
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | | | - Rui W Soares
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Karen K Briggs
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A.; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A..
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14
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David MA, Reiter AJ, Dunham CL, Castile RM, Abraham JA, Iannucci LE, Shah ID, Havlioglu N, Chamberlain AM, Lake SP. Pleiotropic Effects of Simvastatin and Losartan in Preclinical Models of Post-Traumatic Elbow Contracture. Front Bioeng Biotechnol 2022; 10:803403. [PMID: 35265595 PMCID: PMC8899197 DOI: 10.3389/fbioe.2022.803403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/04/2022] [Indexed: 02/02/2023] Open
Abstract
Elbow trauma can lead to post-traumatic joint contracture (PTJC), which is characterized by loss of motion associated with capsule/ligament fibrosis and cartilage damage. Unfortunately, current therapies are often unsuccessful or cause complications. This study aimed to determine the effects of prophylactically administered simvastatin (SV) and losartan (LS) in two preclinical models of elbow PTJC: an in vivo elbow-specific rat injury model and an in vitro collagen gel contraction assay. The in vivo elbow rat (n = 3-10/group) injury model evaluated the effects of orally administered SV and LS at two dosing strategies [i.e., low dose/high frequency/short duration (D1) vs. high dose/low frequency/long duration (D2)] on post-mortem elbow range of motion (via biomechanical testing) as well as capsule fibrosis and cartilage damage (via histopathology). The in vitro gel contraction assay coupled with live/dead staining (n = 3-19/group) evaluated the effects of SV and LS at various concentrations (i.e., 1, 10, 100 µM) and durations (i.e., continuous, short, or delayed) on the contractibility and viability of fibroblasts/myofibroblasts [i.e., NIH3T3 fibroblasts with endogenous transforming growth factor-beta 1 (TGFβ1)]. In vivo, no drug strategy prevented elbow contracture biomechanically. Histologically, only SV-D2 modestly reduced capsule fibrosis but maintained elevated cellularity and tissue hypertrophy, and both SV strategies lessened cartilage damage. SV modest benefits were localized to the anterior region, not the posterior, of the joint. Neither LS strategy had meaningful benefits in capsule nor cartilage. In vitro, irrespective of the presence of TGFβ1, SV (≥10 μM) prevented gel contraction partly by decreasing cell viability (100 μM). In contrast, LS did not prevent gel contraction or affect cell viability. This study demonstrates that SV, but not LS, might be suitable prophylactic drug therapy in two preclinical models of elbow PTJC. Results provide initial insight to guide future preclinical studies aimed at preventing or mitigating elbow PTJC.
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Affiliation(s)
- Michael A. David
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States
| | - Alex J. Reiter
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States
| | - Chelsey L. Dunham
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Ryan M. Castile
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States
| | - James A. Abraham
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States
| | - Leanne E. Iannucci
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States
| | - Ishani D. Shah
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States
| | - Necat Havlioglu
- Department of Pathology, John Cochran VA Medical Center, St. Louis, MO, United States
| | - Aaron M. Chamberlain
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Spencer P. Lake
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, MO, United States,Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO, United States,Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, United States,*Correspondence: Spencer P. Lake,
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15
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Capsulolabral Adhesions After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement: Strategies During Rehabilitation and Return to Sport to Reduce the Risk of Revision. Arthrosc Sports Med Rehabil 2022; 4:e255-e262. [PMID: 35141559 PMCID: PMC8811550 DOI: 10.1016/j.asmr.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/30/2021] [Indexed: 11/23/2022] Open
Abstract
This article will review various strategies such as passive range of motion modalities, active range of motion movements, and pharmacological interventions for the prevention of adhesion formation after hip arthroscopy. Capsulolabral adhesions are a common cause of revision hip arthroscopy for which treatment methods are still evolving. Efforts to prevent and limit their formation postoperatively, including adjuncts such as losartan, as well as the use of consistent passive and active, multiplanar movements, both therapist and continuous passive motion machine assisted, should be considered.
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16
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Mucke HAM. Drug Repurposing Patent Applications July-September 2021. Assay Drug Dev Technol 2021. [PMID: 34936476 DOI: 10.1089/adt.2021.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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17
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Meheux CJ, Hirase T, Dong D, Clyburn TA, Harris JD. Author Reply to "How Complex Is the Complex Innervation of the Coxal Capsular Complex?". Arthroscopy 2021; 37:2024-2026. [PMID: 34225994 DOI: 10.1016/j.arthro.2021.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/21/2021] [Indexed: 02/02/2023]
Affiliation(s)
- Carlos J Meheux
- Houston Methodist Hospital, Orthopedics and Sports Medicine, Houston, Texas, U.S.A
| | - Takashi Hirase
- Houston Methodist Hospital, Orthopedics and Sports Medicine, Houston, Texas, U.S.A
| | - David Dong
- Houston Methodist Hospital, Orthopedics and Sports Medicine, Houston, Texas, U.S.A
| | - Terry A Clyburn
- Houston Methodist Hospital, Orthopedics and Sports Medicine, Houston, Texas, U.S.A
| | - Joshua D Harris
- Houston Methodist Hospital, Orthopedics and Sports Medicine, Houston, Texas, U.S.A
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18
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Thompson RG, Bradley K, Lourie GM. Ulnar nerve dysfunction at the elbow after platelet-rich plasma treatment for partial ulnar collateral ligament injuries. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:41-44. [PMID: 37588639 PMCID: PMC10426667 DOI: 10.1016/j.xrrt.2020.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Platelet-rich plasma (PRP) has been used for the treatment of partial ulnar collateral ligament (UCL) tears of the elbow in throwing athletes. Very few studies have focused on the complication profile of PRP in this application.The purpose of this study was to discuss the complication of ulnar nerve fibrosis and resulting cubital tunnel syndrome after a PRP injection for a partial UCL injury. Methods A retrospective review of 3 high-level baseball players who underwent a PRP injection for treatment of their partial UCL injury was completed. All 3 were noted to have an asymptomatic subluxing ulnar nerve at time of presentation. Their postinjection course is discussed, and the complication of cubital tunnel syndrome highlighted. Results All 3 players developed cubital tunnel syndrome with significant fibrosis surrounding their ulnar nerve. Conclusion PRP injections for the treatment of partial UCL injuries of the elbow may place some patients at risk of developing postinjection cubital tunnel syndrome from increased fibrosis around the ulnar nerve. This complication may be more likely to develop in patients who present with a subluxing ulnar nerve.
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Affiliation(s)
- Robert G. Thompson
- Wellstar Atlanta Medical Center, Department of Orthopedic Surgery, Atlanta, GA, USA
| | - Kendall Bradley
- Duke University, Department of Orthopedic Surgery, Durham, NC, USA
| | - Gary M. Lourie
- Wellstar Atlanta Medical Center, Department of Orthopedic Surgery, Atlanta, GA, USA
- The Hand & Upper Extremity Center of Georgia, Atlanta, GA, USA
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19
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Yosef B, Zhou Y, Mouschouris K, Poteracki J, Soker S, Criswell T. N-Acetyl-L-Cysteine Reduces Fibrosis and Improves Muscle Function After Acute Compartment Syndrome Injury. Mil Med 2020; 185:25-34. [PMID: 32074330 DOI: 10.1093/milmed/usz232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Upon injury, skeletal muscle undergoes a multiphase process beginning with degeneration of the damaged tissue, which is accompanied by inflammation and finally regeneration. One consequence of an injured microenvironment is excessive production of reactive oxygen species, which results in attenuated regeneration and recovery of function ultimately leading to fibrosis and disability. The objective of this research was to test the potential of the antioxidant, N-Acetyl-L-Cysteine (NAC), as a mediator of reactive oxygen species damage that results from traumatic muscle injury in order to support repair and regeneration of wounded muscle tissue and improve function recovery. MATERIALS AND METHODS Adult female Lewis rats were subjected to compartment syndrome injury as previously published by our group. Rats received intramuscular injections of NAC or vehicle at 24, 48, and 72 hours postinjury. Muscle function, tissue fibrosis, and the expression of myogenic and angiogenic markers were measured. RESULTS Muscle function was significantly improved, and tissue fibrosis was significantly decreased in NAC-treated muscles. CONCLUSIONS These results suggest that NAC treatment of skeletal muscle after injury may be a viable option for the prevention of long-term fibrosis and scar formation, facilitating recovery of muscle function.
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Affiliation(s)
- Benyam Yosef
- Department of Cardiac Surgery, Brigham and Young Women's Hospital, 75 Francis St., Boston, MA 02115
| | - Yu Zhou
- Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157
| | - Kathryn Mouschouris
- Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157
| | - James Poteracki
- Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157
| | - Shay Soker
- Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157
| | - Tracy Criswell
- Department of Cardiac Surgery, Brigham and Young Women's Hospital, 75 Francis St., Boston, MA 02115.,Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Health, Medical Center Blvd, Winston-Salem, NC 27157
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20
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Philippon MJ, Arner JW, Crawford MD, Bolia IK, Briggs KK. Acetabular Labral Reconstruction with Iliotibial Band Autograft: Outcome and Survivorship at a Minimum 10-Year Follow-up. J Bone Joint Surg Am 2020; 102:1581-1587. [PMID: 32675477 DOI: 10.2106/jbjs.19.01499] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Labral reconstruction has been shown to result in improved patient-reported outcomes (PROs) at mid-term follow-up in patients with a deficient labrum. The purpose of this study was to determine survivorship and PROs at a minimum 10-year follow-up. METHODS A retrospective evaluation of a prospectively collected single-surgeon database included 91 hips (89 patients) that underwent arthroscopic labral reconstruction with iliotibial band autograft between 2006 and 2008. The primary PRO was the Hip Outcome Score (HOS)-activities of daily living (ADL). The modified Harris hip score (mHHS), HOS-sports, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and patient satisfaction (on a scale of 1 to 10) were also collected at a 10-year minimum follow-up. Survivorship analysis curves were evaluated. RESULTS Eighty-two hips were evaluated at a 10-year minimum follow-up. Overall survivorship, with revision hip arthroscopy or total hip arthroplasty (THA) as the end point, was 70% at 5 years and 61% at 10 years, and the mean survival time was 9 years (95% confidence interval = 7.6 to 10 years). For the patients who did not undergo subsequent surgery, on average the mHHS increased from 60 preoperatively to 82 at the 10-year follow-up (p = 0.001), the HOS-ADL improved from 69 to 90 (p = 0.004), the HOS-sports improved from 43 to 76 (p = 0.001), and the median patient satisfaction was 10 of 10. Eighty percent of the patients achieved the minimal clinically important difference (MCID) in the HOS-ADL, and 87% obtained a patient acceptable symptom state (PASS). CONCLUSIONS Following arthroscopic labral reconstruction with iliotibial band autograft, 9% of the hips underwent revision arthroscopy and 27% underwent THA. At 10 years, the survival rate, with revision hip arthroscopy or THA as the end point, was 61%; however, for those with >2 mm of joint space, the current indication for labral reconstruction, the 10-year survival rate was 90%. Excellent PROs and patient satisfaction were reported by those who did not require revision or THA. With appropriate patient selection and prevention of postoperative adhesions, labral reconstruction results in excellent outcomes and high patient satisfaction that is sustained at a minimum 10-year follow-up. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marc J Philippon
- The Steadman Clinic (M.J.P. and J.W.A.), Steadman Philippon Research Institute (M.J.P., J.W.A., and K.K.B.), Vail, Colorado
| | - Justin W Arner
- The Steadman Clinic (M.J.P. and J.W.A.), Steadman Philippon Research Institute (M.J.P., J.W.A., and K.K.B.), Vail, Colorado
| | | | - Ioanna K Bolia
- Department of Orthopaedics, University of Southern California, Los Angeles, California
| | - Karen K Briggs
- The Steadman Clinic (M.J.P. and J.W.A.), Steadman Philippon Research Institute (M.J.P., J.W.A., and K.K.B.), Vail, Colorado
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21
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Oberlohr V, Lengel H, Hambright WS, Whitney KE, Evans TA, Huard J. Biologics for Skeletal Muscle Healing: The Role of Senescence and Platelet-Based Treatment Modalities. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150754] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Utsunomiya H, Gao X, Deng Z, Cheng H, Nakama G, Scibetta AC, Ravuri SK, Goldman JL, Lowe WR, Rodkey WG, Alliston T, Philippon MJ, Huard J. Biologically Regulated Marrow Stimulation by Blocking TGF-β1 With Losartan Oral Administration Results in Hyaline-like Cartilage Repair: A Rabbit Osteochondral Defect Model. Am J Sports Med 2020; 48:974-984. [PMID: 32027515 DOI: 10.1177/0363546519898681] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Microfracture or bone marrow stimulation (BMS) is often the first choice for clinical treatment of cartilage injuries; however, fibrocartilage, not pure hyaline cartilage, has been reported because of the development of fibrosis in the repair tissue. Transforming growth factor β1 (TGF-β1), which can promote fibrosis, can be inhibited by losartan and potentially be used to reduce fibrocartilage. HYPOTHESIS Blocking TGF-β1 would improve cartilage healing in a rabbit knee BMS model via decreasing the amount of fibrocartilage and increasing hyaline-like cartilage formation. STUDY DESIGN Controlled laboratory study. METHODS An osteochondral defect was made in the patellar groove of 48 New Zealand White rabbits. The rabbits were divided into 3 groups: a defect group (defect only), a BMS group (osteochondral defect + BMS), and a BMS + losartan group (osteochondral defect + BMS + losartan). For the rabbits in the BMS + losartan group, losartan was administrated orally from the day after surgery through the day of euthanasia. Rabbits were sacrificed 6 or 12 weeks postoperatively. Macroscopic appearance, microcomputed tomography, histological assessment, and TGF-β1 signaling pathway were evaluated at 6 and 12 weeks postoperatively. RESULTS The macroscopic assessment of the repair revealed that the BMS + losartan group was superior to the other groups tested. Microcomputed tomography showed superior healing of the bony defect in the BMS + losartan group in comparison with the other groups. Histologically, fibrosis in the repair tissue of the BMS + losartan group was significantly reduced when compared with the other groups. Results obtained with the modified O'Driscoll International Cartilage Repair Society grading system yielded significantly superior scores in the BMS + losartan group as compared with both the defect group and the BMS group (F value: 15.8, P < .001, P = .012, respectively). TGF-β1 signaling and TGF-β-activated kinase 1 of the BMS + losartan group were significantly suppressed in the synovial tissues. CONCLUSION By blocking TGF-β1 with losartan, the repair cartilage tissue after BMS was superior to the other groups and consisted primarily of hyaline cartilage. These results should be easily translated to the clinic because losartan is a Food and Drug Administration-approved drug and it can be combined with the BMS technique for optimal repair of chondral defects. CLINICAL RELEVANCE Biologically regulated marrow stimulation by blocking TGF-β1 (oral intake of losartan) provides superior repair via decreasing fibrocartilage formation and resulting in hyaline-like cartilage as compared with outcomes from BMS only.
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Affiliation(s)
- Hajime Utsunomiya
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Xueqin Gao
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Zhenhan Deng
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Haizi Cheng
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Gilberto Nakama
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Alex C Scibetta
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Sudheer K Ravuri
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Julia L Goldman
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Walter R Lowe
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - William G Rodkey
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Tamara Alliston
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Marc J Philippon
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Johnny Huard
- Investigation performed at Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
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23
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Abstract
PURPOSE OF REVIEW With the rapid growth of hip arthroscopy over the past decade, new treatment paradigms as well as recognition of new disease states have sprung forth. The ability to perform complex arthroscopic procedures of the hip such as labral augmentation and reconstruction is essential for hip arthroscopists in the revision setting, with patient selection and indications for various labral treatments the key driver for improved short- and mid-term clinical outcomes. RECENT FINDINGS Current techniques have been developed to address disease states where the labrum is either unstable, torn, deficient, or otherwise incompetent. Many early reports focused on the description of these techniques with new literature reporting short- and mid-term outcomes. A few of these have demonstrated improved outcomes with a contemporary arthroscopy with emphasis on capsule preservation and repair. Studies have demonstrated that labral repair has improved outcomes over labral debridement, with results of labral reconstruction in a revision approaching those of labral repair. In addition, newer reports have shown significantly improved outcomes and survivorship with capsule repair and therefore should be included in every hip arthroscopy.
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Affiliation(s)
- Dustin Woyski
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC, 27705, USA.
| | - Richard Chad Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC, 27705, USA
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