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Safety and early results of Subchondroplasty® for the treatment of bone marrow lesions in osteoarthritis: a systematic review

Nairn, Leah N; Subramaniam, Maegha; Ekhtiari, Seper; Axelrod, Daniel E; Grant, John A; Khan, Moin
PURPOSE/OBJECTIVE:Subchondroplasty® is a novel minimally invasive procedure for painful subchondral bone marrow lesions (BMLs). The aim of this systematic review was to characterize the clinical outcomes of the Subchondroplasty® procedure, a novel minimally invasive procedure for the treatment of BMLs. The hypothesis tested was that patients experience improvements in pain and functional outcomes following the Subchondroplasty® procedure. METHODS:MEDLINE, Embase, Web of Science, and were searched from database inception to search date (June 10, 2020) for all clinical studies which discussed Subchondroplasty®. Two reviewers independently screened 45 unique results and 17 studies were included in the final analysis. Data were collected regarding patient demographics, indications, pain, functional scores, conversion to TKA, and complications of the procedure. RESULTS:All but one study were level IV evidence; the mean MINORS score was 9 ± 2. There were 756 patients included, 45.1% were female, and the mean age was 54 years (range 20-85). Thirteen studies investigated the effect Subchondroplasty® to the knee, while four studied the impact on the foot and ankle. Median length of follow-up was 12 months. The most common indication for Subchondroplasty® was joint pain with corresponding BML. Major contraindications to Subchondroplasty® included severe OA, joint instability, and malalignment. Mean pain score on visual analogue scale (VAS) prior to Subchondroplasty® was 7.8 ± 0.6, but decreased to 3.4 ± 0.7 postoperatively. All studies investigating functional scores reported improvement following Subchondroplasty® (IKDC 31.7 ± 1.9-54.0 ± 4.2 and KOOS 38.1 ± 0.6-70.0 ± 4.1). There were consistently high levels of patient satisfaction; 87 ± 8% of patients would be willing to undergo the procedure again. Seven cases of complications were reported, most seriously osteomyelitis and avascular necrosis. Conversion to knee arthroplasty ranged from 12.5 to 30% with length of follow-up ranging from 10 months to 7 years. CONCLUSIONS:Existing low-quality studies show Subchondroplasty® to benefit patients with BMLs through reduction in pain and improvement in function, along with a high degree of satisfaction following the procedure. The low short-to-medium term conversion rate to arthroplasty suggests that Subchondroplasty® may play a role in delaying more invasive and expensive procedures in patients with BMLs. Subchondroplasty® is a novel procedure that has promising initial findings, but requires further high-quality, comparative studies with long-term follow-up to better understand the outcomes of the procedure and impact clinical practice recommendations. LEVEL OF EVIDENCE/METHODS:Systematic Review of Level III and IV Studies, Level IV.
PMID: 32990774
ISSN: 1433-7347
CID: 5035812

Beach Chair Versus Lateral Decubitus Position: Differences in Suture Anchor Position and Number During Arthroscopic Anterior Shoulder Stabilization

Baron, Jacqueline E; Duchman, Kyle R; Hettrich, Carolyn M; Glass, Natalie A; Ortiz, Shannon F; Baumgarten, Keith M; Bishop, Julie Y; Bollier, Matthew J; Bravman, Jonathan T; Brophy, Robert H; Carpenter, James E; Cox, Charles L; Feeley, Brian T; Frank, Rachel M; Grant, John A; Jones, Grant L; Kuhn, John E; Lansdown, Drew A; Benjamin Ma, C; Marx, Robert G; McCarty, Eric C; Miller, Bruce S; Neviaser, Andres S; Seidl, Adam J; Smith, Matthew V; Wright, Rick W; Zhang, Alan L; Wolf, Brian R
BACKGROUND:Arthroscopic shoulder capsulolabral repair using glenoid-based suture anchor fixation provides consistently favorable outcomes for patients with anterior glenohumeral instability. To optimize outcomes, inferior anchor position, especially at the 6-o'clock position, has been emphasized. Proponents of both the beach-chair (BC) and lateral decubitus (LD) positions advocate that this anchor location can be consistently achieved in both positions. HYPOTHESIS:Patient positioning would be associated with the surgeon-reported labral tear length, total number of anchors used, number of anchors in the inferior glenoid, and placement of an anchor at the 6-o'clock position. STUDY DESIGN:Cross-sectional study; Level of evidence, 3. METHODS:test [normal distributions], Wilcoxon rank sum test [nonnormal distributions], and chi-square test [categorical]) were assessed. RESULTS:< .001). CONCLUSION:Surgeons utilizing the LD position for arthroscopic capsulolabral repair in patients with anterior shoulder instability more frequently placed anchors in the inferior glenoid and at the 6-o'clock position. Additionally, surgeon-reported labral tear length was longer when utilizing the LD position. These results suggest that patient positioning may influence the total number of anchors used, the number of anchors used in the inferior glenoid, and the frequency of anchor placement at the 6 o'clock position during arthroscopic capsulolabral repair for anterior shoulder instability. How these findings affect clinical outcomes warrants further study. REGISTRATION:NCT02075775 ( identifier).
PMID: 34019439
ISSN: 1552-3365
CID: 5035852

Comparing the Efficacy of Kneeling Stress Radiographs and Weighted Gravity Stress Radiographs to Assess PCL Insufficiency: Response [Comment]

Grant, John A; Martin, Ryan; Holliday, Charles L
PMID: 34190649
ISSN: 1552-3365
CID: 5035862

Male Sex, Western Ontario Shoulder Instability Index Score, and Sport as Predictors of Large Labral Tears of the Shoulder: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study

Cronin, Kevin J; Magnuson, Justin A; Wolf, Brian R; Hawk, Gregory S; Thompson, Katherine L; Jacobs, Cale A; Hettrich, Carolyn M; Bishop, Julie Y; Bollier, Matthew J; Baumgarten, Keith M; Bravman, Jonathan T; Brophy, Robert H; Cox, Charles L; Feeley, Brian T; Frank, Rachel M; Grant, John A; Jones, Grant L; Kuhn, John E; Ma, C Benjamin; Marx, Robert G; McCarty, Eric C; Miller, Bruce S; Neviaser, Andrew S; Seidl, Adam J; Smith, Matthew V; Wright, Rick W; Zhang, Alan L
PURPOSE:To identify factors predictive of a large labral tear at the time of shoulder instability surgery. METHODS:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients undergoing open or arthroscopic shoulder instability surgery for a labral tear were evaluated. Patients with >270° tears were defined as having large labral tears. To build a predictive logistic regression model for large tears, the Feasible Solutions Algorithm was used to add significant interaction effects. RESULTS:After applying exclusion criteria, 1235 patients were available for analysis. There were 222 females (18.0%) and 1013 males (82.0%) in the cohort, with an average age of 24.7 years (range 12 to 66). The prevalence of large tears was 4.6% (n = 57), with the average tear size being 141.9°. Males accounted for significantly more of the large tears seen in the cohort (94.7%, P = .01). Racquet sports (P = .01), swimming (P = .02), softball (P = .05), skiing (P = .04), and golf (P = .04) were all associated with large labral tears, as was a higher Western Ontario Shoulder Instability Index (WOSI; P = .01). Age, race, history of dislocation, and injury during sport were not associated with having a larger tear. Using our predictive logistic regression model for large tears, patients with a larger body mass index (BMI) who played contact sports were also more likely to have large tears (P = .007). CONCLUSIONS:Multiple factors were identified as being associated with large labral tears at the time of surgery, including male sex, preoperative WOSI score, and participation in certain sports including racquet sports, softball, skiing, swimming, and golf. LEVEL OF EVIDENCE:I, prognostic study.
PMID: 33460709
ISSN: 1526-3231
CID: 5035832

Effect of a brief scenario-tailored educational program on parents' risk knowledge, perceptions, and decisions to administer prescribed opioids: a randomized controlled trial

Voepel-Lewis, Terri; Malviya, Shobha; Grant, John A; Dwyer, Sarah; Becher, Asif; Schwartz, Jacob H; Tait, Alan R
ABSTRACT:This randomized, controlled trial evaluated whether a brief educational program (ie, Scenario-Tailored Opioid Messaging Program [STOMP]) would improve parental opioid risk knowledge, perceptions, and analgesic efficacy; ensure safe opioid use decisions; and impact prescription opioid use after surgery. Parent-child dyads (n = 604) who were prescribed an opioid for short-term use were randomized to routine instruction (Control) or routine plus STOMP administered preoperatively. Baseline and follow-up surveys assessed parents' awareness and perceived seriousness of adverse opioid effects, and their analgesic efficacy. Parents' decisions to give an opioid in hypothetical scenarios and total opioid doses they gave to children at home were assessed at follow-up. Scenario-Tailored Opioid Messaging Program parents gained enhanced perceptions of opioid-related risks over time, whereas Controls did not; however, risk perceptions did not differ between groups except for addiction risk. Scenario-Tailored Opioid Messaging Program parents exhibited marginally greater self-efficacy compared to Controls (mean difference vs controls = 0.58 [95% confidence interval 0.08-1.09], P = 0.023). Scenario-Tailored Opioid Messaging Program parents had a 53% lower odds of giving an opioid in an excessive sedation scenario (odds ratio 0.47 [95% confidence interval 0.28-0.78], P = 0.003), but otherwise made similar scenario-based opioid decisions. Scenario-Tailored Opioid Messaging Program was not associated with total opioid doses administered at home. Instead, parents' analgesic efficacy and pain-relief preferences explained 7%, whereas child and surgical factors explained 22% of the variance in opioid doses. Scenario-tailored education enhanced parents' opioid risk knowledge, perceptions, and scenario-based decision-making. Although this may inform later situation-specific decision-making, our research did not demonstrate an impact on total opioid dosing, which was primarily driven by surgical and child-related factors.
PMID: 33009245
ISSN: 1872-6623
CID: 5035822

Comparing the Efficacy of Kneeling Stress Radiographs and Weighted Gravity Stress Radiographs to Assess Posterior Cruciate Ligament Insufficiency

Holliday, Charles L; Martin, Ryan; Grant, John A
BACKGROUND:Kneeling posterior cruciate ligament (PCL) stress radiographs are commonly used to evaluate PCL laxity. Patients, however, report significant pain, and the method's reproducibility may be challenged due to its dependence on patient body weight distribution to produce posterior tibial displacement. Weighted gravity stress radiography may offer better reproducibility and comfort than the kneeling technique, but its efficacy has not been studied. HYPOTHESIS:Weighted gravity PCL stress radiographs will be more comfortable and produce similar measurements of side-to-side difference in posterior tibial displacement when compared with the kneeling technique. STUDY DESIGN:Cohort study (diagnosis); Level of evidence, 3. METHODS:tests were used to compare the side-to-side difference, pain score, and time to complete the radiographs. RESULTS:< .0001). Of the patients, 88% preferred the weighted gravity method. CONCLUSION:Weighted gravity stress radiographs produce similar side-to-side differences in posterior tibial translation compared with the kneeling stress technique, but do not rely on patient weightbearing and provide significantly better patient comfort. Clinicians should therefore consider the use of weighted gravity stress radiographs in clinical practice to minimize the pain associated with stress radiography while allowing for accurate decision making.
PMID: 33599526
ISSN: 1552-3365
CID: 5035842

Does the Symmetry of Patellar Morphology Matter When Matching Osteochondral Allografts for Osteochondral Defects Involving the Central Ridge of the Patella?

Patel, Karan; Salka, Nabeel S; Ramme, Austin; Scott, Jaron C; Grant, John A
OBJECTIVE:The purpose of this study was to determine if differences in Wiberg classification play a role in the ability of donor patellar osteochondral allografts to match the native patellar surface when treating osteochondral defects of the patellar apex. DESIGN/METHODS:Twenty (10 Wiberg I and 10 Wiberg II/III) human patellae were designated as the recipient. Each recipient was size-matched to both a Wiberg I and a Wiberg II/III patellar donor. A 16-mm circular osteochondral "defect" was created on the central ridge of the recipient patella. The randomly ordered donor Wiberg I or Wiberg II/III plug was harvested from a homologous location and transplanted into the recipient. The recipient was then nano-CT (computed tomography) scanned, digitally reconstructed, registered to the initial nano-CT scan of the recipient patella, and processed to determine root mean squared circumferential step-off heights as well as surface height deviation. The process was then repeated for the other allograft plug. RESULTS:= 0.68). CONCLUSIONS:For osteochondral allograft sizes up to 16 mm there appears to be no advantage to match donor and recipient patellar morphology. Further study is warranted to evaluate defects requiring larger graft sizes.
PMID: 32819146
ISSN: 1947-6043
CID: 5035802

Risk Factors for Intra-articular Bone and Cartilage Lesions in Patients Undergoing Surgical Treatment for Posterior Instability

Lansdown, Drew A; Cvetanovich, Gregory L; Zhang, Alan L; Feeley, Brian T; Wolf, Brian R; Hettrich, Carolyn M; Baumgarten, Keith M; Bishop, Julie Y; Bollier, Matthew J; Bravman, Jonathan T; Brophy, Robert H; Cox, Charles L; Frank, Rachel M; Grant, John A; Jones, Grant L; Kuhn, John E; Marx, Robert G; McCarty, Eric C; Miller, Bruce S; Ortiz, Shannon F; Smith, Matthew V; Wright, Rick W; Ma, C Benjamin
BACKGROUND:Patients with posterior shoulder instability may have bone and cartilage lesions (BCLs) in addition to capsulolabral injuries, although the risk factors for these intra-articular lesions are unclear. HYPOTHESIS:We hypothesized that patients with posterior instability who had a greater number of instability events would have a higher rate of BCLs compared with patients who had fewer instability episodes. STUDY DESIGN:Cross-sectional study; Level of evidence, 3. METHODS:< .05. RESULTS:= .011). CONCLUSION:Bone and cartilage lesions are seen significantly more frequently with increasing patient age and in patients with 2 to 5 instability events. Early surgical stabilization for posterior instability may be considered to potentially limit the extent of associated intra-articular injury. The group of patients with more than 5 instability events may represent a different pathological condition, as this group showed a decrease in the likelihood of cartilage injury, although not bony injury.
PMID: 32150443
ISSN: 1552-3365
CID: 5035792

The Prevalence and Clinical Implications of Comorbid Back Pain in Shoulder Instability: A Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability Cohort Study

Cronin, Kevin J; Wolf, Brian R; Magnuson, Justin A; Jacobs, Cale A; Ortiz, Shannon; Bishop, Julie Y; Bollier, Matthew J; Baumgarten, Keith M; Bravman, Jonathan T; Brophy, Robert H; Cox, Charles L; Feeley, Brian T; Grant, John A; Jones, Grant L; Kuhn, John E; Benjamin Ma, C; Marx, Robert G; McCarty, Eric C; Miller, Bruce S; Seidl, Adam J; Smith, Matthew V; Wright, Rick W; Zhang, Alan L; Hettrich, Carolyn M
Background/UNASSIGNED:Understanding predictors of pain is critical, as recent literature shows that comorbid back pain is an independent risk factor for worse functional and patient-reported outcomes (PROs) as well as increased opioid dependence after total joint arthroplasty. Purpose/Hypothesis/UNASSIGNED:The purpose of this study was to evaluate whether comorbid back pain would be predictive of pain or self-reported instability symptoms at the time of stabilization surgery. We hypothesized that comorbid back pain will correlate with increased pain at the time of surgery as well as with worse scores on shoulder-related PRO measures. Study Design/UNASSIGNED:Cross-sectional study; Level of evidence, 3. Methods/UNASSIGNED:As part of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Instability cohort, patients consented to participate in pre- and intraoperative data collection. Demographic characteristics, injury history, preoperative PRO scores, and radiologic and intraoperative findings were recorded for patients undergoing surgical shoulder stabilization. Patients were also asked, whether they had any back pain. Results/UNASSIGNED:< .01). Conclusion/UNASSIGNED:Despite having similar physical findings, patients with comorbid back pain had more severe preoperative pain and self-reported symptoms of instability as well as more frequent depression and lower mental health scores. The combination of disproportionate shoulder pain, comorbid back pain and mental health conditions, and inferior preoperative expectations may affect not only the patient's preoperative state but also postoperative pain control and/or postoperative outcomes.
PMID: 32110679
ISSN: 2325-9671
CID: 5035782

Measuring markers of aging and knee osteoarthritis gait using inertial measurement units

Hafer, Jocelyn F; Provenzano, Seraphina G; Kern, Kathy L; Agresta, Cristine E; Grant, John A; Zernicke, Ronald F
Differences in gait with age or knee osteoarthritis have been demonstrated in laboratory studies using optical motion capture (MoCap). While MoCap is accurate and reliable, it is impractical for assessment outside the laboratory. Inertial measurement units (IMUs) may be useful in these situations. Before IMUs are used as a surrogate for MoCap, methods that are reliable, repeatable, and that calculate metrics at similar accuracy to MoCap must be demonstrated. The purpose of this study was to compare spatiotemporal gait parameters and knee range of motion calculated via MoCap to IMU-derived variables and to compare the ability of these tools to discriminate between groups. MoCap and IMU data were collected from young, older, and adults with knee osteoarthritis during overground walking at three self-selected speeds. Walking velocity, stride length, cadence, percent of gait cycle in stance, and sagittal knee range of motion were calculated and compared between tools (MoCap and IMU), between participant groups, and across speed. There were no significant differences between MoCap and IMU outcomes, and root mean square error between tools was ≤0.05 m/s for walking velocity, ≤0.07 m for stride length, ≤0.5 strides/min for cadence, ≤5% for percent of gait cycle in stance, and ≤1.5° for knee range of motion. No interactions were present, suggesting that MoCap and IMU calculated metrics similarly across groups and speeds. These results demonstrate IMUs can accurately calculate spatiotemporal variables and knee range of motion during gait in young and older, asymptomatic and knee osteoarthritis cohorts.
PMID: 31916999
ISSN: 1873-2380
CID: 5035762