Arthroplasty/Joint Replacement

SEATTLE—It was previously believed that children and adolescents with anterior cruciate ligament (ACL) injuries should wait until skeletal maturity to have their knee injuries surgically corrected; however, this is no longer the case, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine.

“In reviewing records of young patients who received ACL reconstructions, our data showed higher rates and severity of secondary meniscus injuries when surgery is delayed,” said study author Allen F. Anderson, MD, from the Tennessee Orthopaedic Alliance in Nashville, Tennessee.

Dr. Anderson’s findings suggest that early reconstruction is preferable to nonoperative treatment because increased time from injury to surgery may be associated with a higher rate of meniscal and articular cartilage injury.

In the study 135 consecutive patients, ages 8 to 16 years, (mean age, 13.8) with ACL tears were evaluated from 2000 and 2012. The time from surgery was divided into three groups based on timing—acute (< 6 weeks), subacute (6 weeks to 3 months), and chronic (> 3 months). The type and grade of lateral and medial meniscus tears was documented according to the ISAKOS Meniscal Documentation Criteria and chondral injury location and grade was documented according to ICRS Criteria.

A total of 112 meniscal tears (70 lateral, 42 medial) were found in the study cohort. Sixty two patients were treated acutely, 37 subacute, and 36 chronic. Eighty percent of the patients ages 8 to 12 years had a meniscal tear and 84% of patients ages 13 to 16 years had a meniscal tear. Multivariant logistic regression revealed the risk factors for lateral meniscus tears were younger age (P = .007) and increased time to surgery (P = .008).

Study findings also conclude:

• The odds ratio of lateral meniscus tears for patients who had a single episode of instability was 3.1.

• For time to surgery, the odds ratio was 1 for acute reconstruction, 2.6 for subacute, and 2.59 for reconstruction of chronic injuries.

• The odds ratio for increased grade of tear was 3.3 for a giving-way episode and 6.5 for increased time to surgery.

• For medial meniscus tears, the risk factors were: older age (P = .001), increasing time to surgery (P =.007), return to sports (P = .044), and instability episodes (P = .001).

• Risk factors for increasing grade of medial meniscus tears were: time to surgery, return to sports, and any instability episode (P = < .001 for all).

“These data provide evidence that initial nonoperative treatment of ACL tears in this age group carries a high risk of additional meniscal and chondral injury, which may result in long-term knee injury,” Dr. Anderson concluded.

SEATTLE—It was previously believed that children and adolescents with anterior cruciate ligament (ACL) injuries should wait until skeletal maturity to have their knee injuries surgically corrected; however, this is no longer the case, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine.

“In reviewing records of young patients who received ACL reconstructions, our data showed higher rates and severity of secondary meniscus injuries when surgery is delayed,” said study author Allen F. Anderson, MD, from the Tennessee Orthopaedic Alliance in Nashville, Tennessee.

Dr. Anderson’s findings suggest that early reconstruction is preferable to nonoperative treatment because increased time from injury to surgery may be associated with a higher rate of meniscal and articular cartilage injury.

In the study 135 consecutive patients, ages 8 to 16 years, (mean age, 13.8) with ACL tears were evaluated from 2000 and 2012. The time from surgery was divided into three groups based on timing—acute (< 6 weeks), subacute (6 weeks to 3 months), and chronic (> 3 months). The type and grade of lateral and medial meniscus tears was documented according to the ISAKOS Meniscal Documentation Criteria and chondral injury location and grade was documented according to ICRS Criteria.

A total of 112 meniscal tears (70 lateral, 42 medial) were found in the study cohort. Sixty two patients were treated acutely, 37 subacute, and 36 chronic. Eighty percent of the patients ages 8 to 12 years had a meniscal tear and 84% of patients ages 13 to 16 years had a meniscal tear. Multivariant logistic regression revealed the risk factors for lateral meniscus tears were younger age (P = .007) and increased time to surgery (P = .008).

Study findings also conclude:

• The odds ratio of lateral meniscus tears for patients who had a single episode of instability was 3.1.

• For time to surgery, the odds ratio was 1 for acute reconstruction, 2.6 for subacute, and 2.59 for reconstruction of chronic injuries.

• The odds ratio for increased grade of tear was 3.3 for a giving-way episode and 6.5 for increased time to surgery.

• For medial meniscus tears, the risk factors were: older age (P = .001), increasing time to surgery (P =.007), return to sports (P = .044), and instability episodes (P = .001).

• Risk factors for increasing grade of medial meniscus tears were: time to surgery, return to sports, and any instability episode (P = < .001 for all).

“These data provide evidence that initial nonoperative treatment of ACL tears in this age group carries a high risk of additional meniscal and chondral injury, which may result in long-term knee injury,” Dr. Anderson concluded.

SEATTLE—It was previously believed that children and adolescents with anterior cruciate ligament (ACL) injuries should wait until skeletal maturity to have their knee injuries surgically corrected; however, this is no longer the case, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine.

“In reviewing records of young patients who received ACL reconstructions, our data showed higher rates and severity of secondary meniscus injuries when surgery is delayed,” said study author Allen F. Anderson, MD, from the Tennessee Orthopaedic Alliance in Nashville, Tennessee.

Dr. Anderson’s findings suggest that early reconstruction is preferable to nonoperative treatment because increased time from injury to surgery may be associated with a higher rate of meniscal and articular cartilage injury.

In the study 135 consecutive patients, ages 8 to 16 years, (mean age, 13.8) with ACL tears were evaluated from 2000 and 2012. The time from surgery was divided into three groups based on timing—acute (< 6 weeks), subacute (6 weeks to 3 months), and chronic (> 3 months). The type and grade of lateral and medial meniscus tears was documented according to the ISAKOS Meniscal Documentation Criteria and chondral injury location and grade was documented according to ICRS Criteria.

A total of 112 meniscal tears (70 lateral, 42 medial) were found in the study cohort. Sixty two patients were treated acutely, 37 subacute, and 36 chronic. Eighty percent of the patients ages 8 to 12 years had a meniscal tear and 84% of patients ages 13 to 16 years had a meniscal tear. Multivariant logistic regression revealed the risk factors for lateral meniscus tears were younger age (P = .007) and increased time to surgery (P = .008).

Study findings also conclude:

• The odds ratio of lateral meniscus tears for patients who had a single episode of instability was 3.1.

• For time to surgery, the odds ratio was 1 for acute reconstruction, 2.6 for subacute, and 2.59 for reconstruction of chronic injuries.

• The odds ratio for increased grade of tear was 3.3 for a giving-way episode and 6.5 for increased time to surgery.

• For medial meniscus tears, the risk factors were: older age (P = .001), increasing time to surgery (P =.007), return to sports (P = .044), and instability episodes (P = .001).

• Risk factors for increasing grade of medial meniscus tears were: time to surgery, return to sports, and any instability episode (P = < .001 for all).

“These data provide evidence that initial nonoperative treatment of ACL tears in this age group carries a high risk of additional meniscal and chondral injury, which may result in long-term knee injury,” Dr. Anderson concluded.

SEATTLE— Eighty-seven percent of Major League Baseball (MLB) pitchers who underwent ulnar collateral ligament (UCL) reconstructive surgery returned to the Major League level of sport, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine. However, the study also documented a decline in pitching performance after undergoing reconstructive surgery. Entering the Major Leagues at a younger age also increased a player’s risk for requiring surgery.

A tremendous amount of stress is placed on the elbow while pitching a baseball. Due to these stresses, MLB pitchers are at increased risk for UCL injuries. Robert A. Keller, MD, of Henry Ford Hospital in Detroit, Michigan, and colleagues, reviewed the statistics for 168 MLB pitchers, who threw at least 1 season at the Major League level and underwent UCL reconstruction. Statistical data, including earned run average (ERA), walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared for the 3 years before and 3 years after undergoing UCL reconstruction. “Having athletic trainers and team physicians closely look at when players pitching performance stats start to decrease may allow for steps to be taken with a pitcher before a surgery is needed,” said Dr. Keller.

Of the 87% of pitchers that returned to the Major League level after undergoing UCL reconstruction, a statistically significant decline in their ERA (P = 0.001), WHIP (P = 0.011), and innings pitched (P = 0.026) was seen compared to pre-reconstruction performance. Reconstructed pitchers also had a statistically decline in their pitching performance in the season before their surgery (ERA P = 0.014, WHIP P = 0.036, innings pitched P < 0.001, win percentage P = 0.004). Approximately 60% of pitchers requiring UCL reconstruction had surgery within the first 5 years of being in the Major Leagues. Validated by a multivariable generalized estimating equation model that examined risk factors, arm stress from earlier Major League experience contributed to injury. In addition, players who entered the MLB at an earlier age also appeared to have a greater risk for surgery.

“Our results suggest that UCL reconstructive surgery does a tremendous job in allowing players to return to their same level of sport but it also describes a decline in pitching performance after undergoing reconstruction,” said Dr. Keller. “Our study also further highlights the need for kids not to overuse their arms early in their pitching careers.”

SEATTLE— Eighty-seven percent of Major League Baseball (MLB) pitchers who underwent ulnar collateral ligament (UCL) reconstructive surgery returned to the Major League level of sport, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine. However, the study also documented a decline in pitching performance after undergoing reconstructive surgery. Entering the Major Leagues at a younger age also increased a player’s risk for requiring surgery.

A tremendous amount of stress is placed on the elbow while pitching a baseball. Due to these stresses, MLB pitchers are at increased risk for UCL injuries. Robert A. Keller, MD, of Henry Ford Hospital in Detroit, Michigan, and colleagues, reviewed the statistics for 168 MLB pitchers, who threw at least 1 season at the Major League level and underwent UCL reconstruction. Statistical data, including earned run average (ERA), walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared for the 3 years before and 3 years after undergoing UCL reconstruction. “Having athletic trainers and team physicians closely look at when players pitching performance stats start to decrease may allow for steps to be taken with a pitcher before a surgery is needed,” said Dr. Keller.

Of the 87% of pitchers that returned to the Major League level after undergoing UCL reconstruction, a statistically significant decline in their ERA (P = 0.001), WHIP (P = 0.011), and innings pitched (P = 0.026) was seen compared to pre-reconstruction performance. Reconstructed pitchers also had a statistically decline in their pitching performance in the season before their surgery (ERA P = 0.014, WHIP P = 0.036, innings pitched P < 0.001, win percentage P = 0.004). Approximately 60% of pitchers requiring UCL reconstruction had surgery within the first 5 years of being in the Major Leagues. Validated by a multivariable generalized estimating equation model that examined risk factors, arm stress from earlier Major League experience contributed to injury. In addition, players who entered the MLB at an earlier age also appeared to have a greater risk for surgery.

“Our results suggest that UCL reconstructive surgery does a tremendous job in allowing players to return to their same level of sport but it also describes a decline in pitching performance after undergoing reconstruction,” said Dr. Keller. “Our study also further highlights the need for kids not to overuse their arms early in their pitching careers.”

SEATTLE— Eighty-seven percent of Major League Baseball (MLB) pitchers who underwent ulnar collateral ligament (UCL) reconstructive surgery returned to the Major League level of sport, according to a study presented at the 2014 Annual Meeting of the American Orthopaedic Society for Sports Medicine. However, the study also documented a decline in pitching performance after undergoing reconstructive surgery. Entering the Major Leagues at a younger age also increased a player’s risk for requiring surgery.

A tremendous amount of stress is placed on the elbow while pitching a baseball. Due to these stresses, MLB pitchers are at increased risk for UCL injuries. Robert A. Keller, MD, of Henry Ford Hospital in Detroit, Michigan, and colleagues, reviewed the statistics for 168 MLB pitchers, who threw at least 1 season at the Major League level and underwent UCL reconstruction. Statistical data, including earned run average (ERA), walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared for the 3 years before and 3 years after undergoing UCL reconstruction. “Having athletic trainers and team physicians closely look at when players pitching performance stats start to decrease may allow for steps to be taken with a pitcher before a surgery is needed,” said Dr. Keller.

Of the 87% of pitchers that returned to the Major League level after undergoing UCL reconstruction, a statistically significant decline in their ERA (P = 0.001), WHIP (P = 0.011), and innings pitched (P = 0.026) was seen compared to pre-reconstruction performance. Reconstructed pitchers also had a statistically decline in their pitching performance in the season before their surgery (ERA P = 0.014, WHIP P = 0.036, innings pitched P < 0.001, win percentage P = 0.004). Approximately 60% of pitchers requiring UCL reconstruction had surgery within the first 5 years of being in the Major Leagues. Validated by a multivariable generalized estimating equation model that examined risk factors, arm stress from earlier Major League experience contributed to injury. In addition, players who entered the MLB at an earlier age also appeared to have a greater risk for surgery.

“Our results suggest that UCL reconstructive surgery does a tremendous job in allowing players to return to their same level of sport but it also describes a decline in pitching performance after undergoing reconstruction,” said Dr. Keller. “Our study also further highlights the need for kids not to overuse their arms early in their pitching careers.”

There is a direct link between the number of total knee replacement surgeries and obesity, according to a study published online ahead of print June 4 in the Journal of Bone and Joint Surgery. Lead study author Peter B. Derman, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery in New York, and colleagues reported that the number of total knee replacement surgeries more than tripled between 1993 and 2009, while the number of total hip replacements doubled in the same time period.

“We observed that growth of knee replacement volumes was far outpacing that of hip replacements and were curious as to the origins of this trend,” said Dr. Derman. He and his research colleagues found that an increase in the prevalence of overweight and obesity in the US accounted for 95% of the higher demand for knee replacements, with younger patients affected to a greater degree.

The researchers compiled longitudinal data on total hip arthroplasty and total knee arthroplasty volume, length of hospital stay, and in-hospital mortality from the Nationwide Inpatient Sample. They then calculated reimbursement using information available in the Federal Register and Centers for Medicare and Medicaid databases. Trends in body mass index (BMI) were determined from Behavioral Risk Factor Surveillance System findings and the size of the surgical workforce was based on membership data from the American Academy of Orthopaedic Surgeons.

Among the study’s findings:

• Growth in total knee arthroplasty volume far outpaced that of total hip arthroplasty among those patients with a BMI of 25 kg/m² or above, but not for those with a BMI of less than 25 kg/m².

• In 1993, surgeons performed 1.16 total knee replacements for every total hip replacement, but this ratio grew to 1.60 by the year 2009.

• Patients ages 18 to 64 years experienced a more rapid rise in obesity, compared to patients older than 65 years.

• From 1997 to 2009, the share of patient’s ages 18 to 64 years undergoing total knee replacement rose 56% compared to 35% for total hip replacement.

• Surgeon per-case reimbursement for total knee replacement fell from approximately $3000 in 1995 to $1560 in 2009. Surgeon fees for total hip replacement dropped from $2840 to $1460 in the same time period.

• As the data represent an approximate 48% drop in fees for both procedures, surgeons do not appear to be performing more total knee replacements over total hip replacements due to higher reimbursement.

• Hospital reimbursement, length of hospital stay, and in-hospital mortality pertaining to total knee replacement and total hip replacement also declined between 1995 and 2009.

Commenting on the study findings, Dr. Derman said, “Because excess body weight appears to be more damaging to the knee than to the hip, the increasing prevalence of overweight and obesity may explain the growing demand for knee replacements over hip replacements. If rates of overweight and obesity continue to climb, we should expect further acceleration in the number of knee replacements performed annually in the United States with a more modest increase in hip replacement volumes.”

There is a direct link between the number of total knee replacement surgeries and obesity, according to a study published online ahead of print June 4 in the Journal of Bone and Joint Surgery. Lead study author Peter B. Derman, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery in New York, and colleagues reported that the number of total knee replacement surgeries more than tripled between 1993 and 2009, while the number of total hip replacements doubled in the same time period.

“We observed that growth of knee replacement volumes was far outpacing that of hip replacements and were curious as to the origins of this trend,” said Dr. Derman. He and his research colleagues found that an increase in the prevalence of overweight and obesity in the US accounted for 95% of the higher demand for knee replacements, with younger patients affected to a greater degree.

The researchers compiled longitudinal data on total hip arthroplasty and total knee arthroplasty volume, length of hospital stay, and in-hospital mortality from the Nationwide Inpatient Sample. They then calculated reimbursement using information available in the Federal Register and Centers for Medicare and Medicaid databases. Trends in body mass index (BMI) were determined from Behavioral Risk Factor Surveillance System findings and the size of the surgical workforce was based on membership data from the American Academy of Orthopaedic Surgeons.

Among the study’s findings:

• Growth in total knee arthroplasty volume far outpaced that of total hip arthroplasty among those patients with a BMI of 25 kg/m² or above, but not for those with a BMI of less than 25 kg/m².

• In 1993, surgeons performed 1.16 total knee replacements for every total hip replacement, but this ratio grew to 1.60 by the year 2009.

• Patients ages 18 to 64 years experienced a more rapid rise in obesity, compared to patients older than 65 years.

• From 1997 to 2009, the share of patient’s ages 18 to 64 years undergoing total knee replacement rose 56% compared to 35% for total hip replacement.

• Surgeon per-case reimbursement for total knee replacement fell from approximately $3000 in 1995 to $1560 in 2009. Surgeon fees for total hip replacement dropped from $2840 to $1460 in the same time period.

• As the data represent an approximate 48% drop in fees for both procedures, surgeons do not appear to be performing more total knee replacements over total hip replacements due to higher reimbursement.

• Hospital reimbursement, length of hospital stay, and in-hospital mortality pertaining to total knee replacement and total hip replacement also declined between 1995 and 2009.

Commenting on the study findings, Dr. Derman said, “Because excess body weight appears to be more damaging to the knee than to the hip, the increasing prevalence of overweight and obesity may explain the growing demand for knee replacements over hip replacements. If rates of overweight and obesity continue to climb, we should expect further acceleration in the number of knee replacements performed annually in the United States with a more modest increase in hip replacement volumes.”

There is a direct link between the number of total knee replacement surgeries and obesity, according to a study published online ahead of print June 4 in the Journal of Bone and Joint Surgery. Lead study author Peter B. Derman, MD, MBA, an orthopedic surgery resident at the Hospital for Special Surgery in New York, and colleagues reported that the number of total knee replacement surgeries more than tripled between 1993 and 2009, while the number of total hip replacements doubled in the same time period.

“We observed that growth of knee replacement volumes was far outpacing that of hip replacements and were curious as to the origins of this trend,” said Dr. Derman. He and his research colleagues found that an increase in the prevalence of overweight and obesity in the US accounted for 95% of the higher demand for knee replacements, with younger patients affected to a greater degree.

The researchers compiled longitudinal data on total hip arthroplasty and total knee arthroplasty volume, length of hospital stay, and in-hospital mortality from the Nationwide Inpatient Sample. They then calculated reimbursement using information available in the Federal Register and Centers for Medicare and Medicaid databases. Trends in body mass index (BMI) were determined from Behavioral Risk Factor Surveillance System findings and the size of the surgical workforce was based on membership data from the American Academy of Orthopaedic Surgeons.

Among the study’s findings:

• Growth in total knee arthroplasty volume far outpaced that of total hip arthroplasty among those patients with a BMI of 25 kg/m² or above, but not for those with a BMI of less than 25 kg/m².

• In 1993, surgeons performed 1.16 total knee replacements for every total hip replacement, but this ratio grew to 1.60 by the year 2009.

• Patients ages 18 to 64 years experienced a more rapid rise in obesity, compared to patients older than 65 years.

• From 1997 to 2009, the share of patient’s ages 18 to 64 years undergoing total knee replacement rose 56% compared to 35% for total hip replacement.

• Surgeon per-case reimbursement for total knee replacement fell from approximately $3000 in 1995 to $1560 in 2009. Surgeon fees for total hip replacement dropped from $2840 to $1460 in the same time period.

• As the data represent an approximate 48% drop in fees for both procedures, surgeons do not appear to be performing more total knee replacements over total hip replacements due to higher reimbursement.

• Hospital reimbursement, length of hospital stay, and in-hospital mortality pertaining to total knee replacement and total hip replacement also declined between 1995 and 2009.

Commenting on the study findings, Dr. Derman said, “Because excess body weight appears to be more damaging to the knee than to the hip, the increasing prevalence of overweight and obesity may explain the growing demand for knee replacements over hip replacements. If rates of overweight and obesity continue to climb, we should expect further acceleration in the number of knee replacements performed annually in the United States with a more modest increase in hip replacement volumes.”