Orthopedic One

Background:The diagnostic accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) for detecting labral tears is well established in femoroacetabular impingement but remains unclear in dysplastic hips undergoing hip arthroscopy (HA) combined with periacetabular osteotomy (PAO).Purpose:To determine the sensitivity and specificity of MRI and MRA in identifying labral tears in patients with dysplasia undergoing HA combined with PAO.Study Design:Cohort study (diagnosis); Level of evidence, 3.Methods:A retrospective, real-world study was conducted at a single tertiary hip preservation center. Patients included in the analysis had undergone primary HA and PAO with available radiologist interpretation for labral assessment. Diagnostic accuracy of MRI and MRA for detecting labral tears was assessed using arthroscopic findings as the reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR−) were calculated.Results:A total of 122 patients (mean age, 22.3 years; SD, 5.6; 90% women) were included. Radiographic measurements showed a mean lateral center-edge angle of 22.91° (SD, 6.52), an acetabular index of 8.87° (SD, 5.27), and a Tönnis grade of 0.09 (SD, 0.35). Both MRI and MRA demonstrated low sensitivity (55% and 54.1%, respectively) and low specificity (38.5% and 45.5%, respectively). The PPV was moderate (67.3% for MRI; 71.4% for MRA), and the NPV was low (27% for MRI; 31.3% for MRA). LR+ and LR− values of MRI and MRA were close to 1.Conclusion:This study highlights the limited diagnostic accuracy of MRI and MRA for identifying labral tears in patients with hip dysplasia undergoing combined HA and PAO. Operative decisions regarding labral treatment at the time of PAO should not be based solely on preoperative imaging.

This study aimed to evaluate and compare the pregnancy outcomes in ovulatory frozen embryo transfer (FET) cycles, with or without an ovulation trigger, against non-ovulatory FET cycles. The goal was to identify whether utilizing the natural ovulatory process, either spontaneous or medically induced, yields better clinical outcomes rather than relying entirely on hormone replacement therapy for endometrial preparation, focusing on pregnancy rates, ongoing clinical pregnancies, and early pregnancy losses. This was a single-centre retrospective cohort analysis. A total of 1490 first-time FET cycles were analyzed. Patients undergoing a first FET cycle with a single vitrified and warmed blastocyst for transfer were stratified based on their FET preparation cycle for comparison. Patients were grouped into non-ovulatory FET cycles (group A, n = 1061), ovulatory FET cycles with ovulation trigger (group B, n = 328), and ovulatory FET cycles without trigger (group C, n = 101). The primary outcomes assessed were pregnancy rates (determined by positive beta-human chorionic gonadotropin) and ongoing pregnancy rates (based on detecting a fetal heartbeat at 7 weeks). Secondary outcomes included miscarriage rates. Statistical significance was evaluated using analysis of variance and χ2 tests (P < 0.05). Pregnancy rates were comparable between all groups, with 50.3% in group A, 54.9% in group B, and 52.5% in group C (P = 0.35). Ovulatory cycles (groups B and C) showed significantly higher ongoing pregnancy rates compared to non-ovulatory cycles (P = 0.02). The miscarriage rate was higher in group A (17.0%) compared to group B (8.9%) and group C (11.3%), though this difference did not reach statistical significance (P = 0.07). Ovulatory FET cycles, whether triggered or not, result in significantly higher ongoing pregnancy rates and lower miscarriage rates compared to non-ovulatory cycles. These findings support the preservation of the natural ovulatory process, either through spontaneous or induced ovulation, as a key factor in improving clinical outcomes in assisted reproductive technologies. The study highlights the potential advantages of modified natural cycles over artificial cycles that rely solely on exogenous hormone supplementation.

The aim of this study was to determine independent risk factors for vertebral compression fracture (VCF) following stereotactic body radiation therapy (SBRT) in metastatic spine disease. Patients treated with SBRT for spinal metastasis at a single tertiary care center between 2008 and 2019 were retrospectively identified. Patients with CT scans obtained within 1 year of SBRT completion were included. Variables collected included demographics, Spine Instability Neoplastic Score (SINS), primary tumor pathology, Weinstein-Boriani-Biagini (WBB) classification, chemoradiation treatment details, and bone quality as assessed by Hounsfield units (HUs) on CT. HUs were measured for the medullary bone of the metastatic level, the tumor, and the vertebral bodies cephalad and caudal to the metastasis. Multivariable logistic regression was used to identify predictors of post-SBRT pathological fracture. A total of 292 patients (mean age 66 years) with 392 unique lesions were included. The most common pathologies were prostate (n = 193), kidney/renal cell (n = 46), and lung (n = 33). The most common tumor levels were thoracic (n = 206 lesions) and lumbar (n = 128 lesions). SBRT was generally delivered in 1-3 fractions with doses ranging from 16 to 24 Gy in 1 fraction and 24-36 Gy in 3 fractions. Of the 392 lesions, 73 suffered VCF: 21 (29%) with < 25% height loss, 15 (21%) with 25%-40% height loss, and 37 (51%) with > 40% height loss. On univariate analysis, patients with VCF had lower average HUs (156 ± 52 vs 202 ± 89, p < 0.001), more WBB sectors involved (3 ± 2 vs 3 ± 1, p < 0.001), higher SINSs (8 ± 3 vs 6 ± 2, p < 0.001), were more commonly female (33% vs 22%, p = 0.05), and more commonly had nonprostate pathology (67% vs 47%, p = 0.003). VCF rates were similar between moderate (< 20 Gy in 1 fraction, < 30 Gy in 3 or 5 fractions) and high-dose (> 20 Gy in 1 fraction, > 30 Gy in 3 or 5 fractions) radiation schema (15% VCF vs 16% no VCF, respectively; p = 0.99). On multivariable logistic regression, independently significant predictors of VCF were HUs ≤ 229 (OR 6, p < 0.001), affected levels ≥ 3 WBB segments (OR 3, p < 0.001), and an SINS ≥ 8 (OR 2, p = 0.02). Low pre-radiation HUs, involvement of more WBB sectors, and a higher SINS were independent predictors of VCF following SBRT for metastatic spine disease.

Abstract Introduction: MRI interpretation has been utilized by surgeons and payors to determine the necessity for labral repair. Some PAO surgeons have stated that hip arthroscopy (HA) is unnecessary for PAO patients and others have reported that approximately 10% of patients undergoing PAO would require HA for labral fixation based on the MRI. Purpose was to determine the sensitivity and specificity of MRI for labral tear in patients undergoing HA+PAO. Hypothesis was that MRI would show low sensitivity and specificity for labral tear decision-making. Methods: IRB approval was obtained. Inclusion all patients undergoing HA+PAO with MRI radiologist interpretation undergoing primary HA + PAO. Exclusion any revision patients. MRIs were from a referral base encompassing a four-state area and read by MSK radiologist. Time from MRI to surgery in months was recorded. Presence of a tear was defined arthroscopically, and treatment was based on surgeons’ discretion at time of HA. HA + PAO technique was post-less and previously published. Power analysis performed 90 patients were needed to detect a significance P&amp;lt;0.05 for tear. Welch’s t-test was used for non-categorical and Fisher’s exact for categorical data. Linear regression model utilized for factors associated with identifying labral tear. Results: 167 patients met inclusion, 91% female. LCEA 19± 3, all Tonnis 0-1. Mean age 22.8 yrs, and time to surgery 8.3 months from MRI. 148 had definitive MRI reads of tear 98 (56%) or no tear 50 (28.6%), and 19 (10.8%) of patients were read as indeterminate. At time of HA of the positive tear MRI 68 (69.4 %) had a tear and 43 (63.3%) were repaired. In the negative MRI group for labral tear, 33 (66%) had a tear and 19 (58%) were repaired. The sensitivity of MRI for labral tear was 67.3% and specificity 36.2%. A subgroup of 39 patients had definitive MRA reads the SN of 70 and SP of 75. MRA nor plain MRI were predictive of labral tear. Regression analysis showed no association with MRI/MRA/radiologist/time between scan and surgeon to identify a labral tear. Conclusion: MRI and MRA has low sensitivity and specificity for labral tear for patients with DDH undergoing HA+PAO. There is no predictive was to determine presence of tear on imaging. MRI alone should not be considered reliable for sole decision making for the presence of a tear nor operative decisions to repair or not repair the labrum at the time of PAO.

Giant cell tumors of bone are locally aggressive, frequently harbor H3F3A p.G34W mutations, and rarely undergo malignant transformation. The pathogenesis of malignant transformation remains incompletely characterized. Herein, we present 28 malignant giant cell tumors of bone from 14 males and 14 females, aged 16 to 65 (median 39) years. Primary sites included long bones (n=20), pelvis (n=3), vertebrae (n=2), and rarely rib, phalanx, and cuneiform (n=1 each). Sixteen (62%) of 26 tumors with available history represented malignant transformation or recurrence of conventional giant cell tumors of bone, at intervals of 1.3 to 35 (median 7.3) years before malignant transformation. Eight of 15 patients with available treatment history received denosumab before a diagnosis of malignancy. Ten (38%) of 26 tumors with available history likely arose de novo, including 7 with conventional areas and 3 H3F3A -mutant sarcomas lacking conventional giant cell tumor of bone. Of 28 malignant giant cell tumors of bone, 18 (64%) and 10 (36%) harbored osteoblastic and chondroblastic elements, respectively. Among 23 tumors with available genetic testing or surrogate immunohistochemistry, 17 (74%) were p.G34W-mutant, whereas other tumors carried H3F3A p.G34L (n=2), p.G34V (n=2), and p.G34R (n=1) alterations; 1 tumor harbored H3F3B p.K116E and p.R117S in cis. Seven (70%) of 10 malignant giant cell tumors of bone showed complex copy number alterations by single nucleotide polymorphism (SNP) array, DNA next-generation sequencing (NGS), and/or karyotype analysis. In contrast, complex chromosomal alterations were lacking in 32 conventional giant cell tumors of bone tested (24 by karyotype, 7 by SNP array, 1 by DNA NGS), 3 atypical giant cell tumors of bone with isolated marked nuclear atypia (2 by karyotype, 1 by SNP array) and 3 metastasizing conventional giant cell tumors of bone (2 by DNA NGS, 1 by karyotype). Clinical follow-up was available for 20 patients (71%), and one additional patient had metastases at presentation. Overall, 14 of 21 patients (67%) developed metastases, and 10 of 20 patients with follow-up (50%) died of disease at 2 months to 9.6 years (median 7mo). Most patients were treated with chemotherapy; 1 patient (PD-L1 TPS >95%) was treated with pembrolizumab, with complete clinical response of metastatic disease at 2.5 years. In conclusion, malignant giant cell tumors of bone typically arise from long bones, harbor osteosarcomatous and/or chondrosarcomatous differentiation, and show significant risk for distant metastasis and demise. Our data suggest that copy number analysis may be useful in distinguishing malignant giant cell tumors of bone from their conventional, atypical, and metastasizing conventional counterparts.

Magnesium sulfate is commonly used intraoperatively to reduce postoperative pain in spinal surgery patients, but its effects when administered postoperatively are not well established. This study specifically aimed to assess the effect of magnesium sulfate on a postoperative basis on the incidence of postoperative pain in lumbar spinal surgery patients. This systematic review focuses on assessing the practicality of postoperative magnesium sulfate in the mitigation of pain after lumbar surgery. A comprehensive search was conducted across multiple databases, focusing on studies published between January 2000 and December 2023. The findings emphasize the significant role of magnesium in postoperative analgesia for adult patients undergoing lumbar spinal surgeries, with various administration routes explored, such as infusion, intravenous, or intramuscular. All in all, magnesium sulfate shows potential as an analgesic additive in lumbar surgery, aiding in postoperative pain reduction and decreased opioid use. However, its efficacy assessment is hindered by external variables. Standardized research is crucial to establish its optimal clinical applications and address knowledge gaps.

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The study aimed to evaluate the effectiveness of deep subgluteal block (DSGB) for pain relief after posterolateral-approached total hip replacement. The cadaver study and observational case series assessed the spread and outcomes of ultrasound-guided DSGB. Results showed low postoperative pain scores, minimal opioid requirements, and no complications related to DSGB. Anatomical dissection revealed effective spread of the injected substance. These findings suggest that DSGB could be a promising regional analgesic technique for postoperative pain management after posterolateral-approached total hip replacement.

The meniscus of the knee serves as a crucial load-bearing structure, and its damage can significantly impact weight distribution. In addressing focal meniscal defects, segmental meniscal allograft transplantation (SMALT) emerges as an innovative solution. Here, we detail a case involving a young, active female who underwent SMALT augmented with osteochondral allograft transplantation (OCA) and bone marrow aspirate concentration (BMAC). The patient, a 40-year-old former Division I volleyball player, previously underwent arthroscopic procedures and presented with knee pain alongside complex lateral meniscus tear evident in magnetic resonance imaging (MRI) findings. Initial arthroscopy revealed multiple tears, including segmental deficiency at the posterior horn-body junction and a horizontal cleavage tear. Despite failed attempts at repair due to the meniscal gap, a second-stage lateral SMALT was performed, with the allograft soaked in the patient's BMAC, supplemented with OCA to the lateral femoral condyle. Rehabilitation protocols tailored to both SMALT and OCA were implemented. This represents the first documented instance of lateral SMALT, extending the scope of viable solutions for segmental meniscal deficiencies, and marking a significant milestone in orthopedic practice.