A new total knee arthroplasty (TKA) implant design provides surgeons with the option for intra-operative conversion from standard implants to an intermediate level of constraint. This is done using the same cutting blocks and guides, resulting in minimal added surgical time and effort. While ease of use and increased stability make this an attractive tool, this mid-level constraing (MLC) system does have drawbacks including increased expense and the addition of potentially unnecessary constraint. We sought to quantify our usage of this new technology and to determine the variables that dictate the decision to convert to MLC implants.

Background

Osteochondral injuries of the elbow are limiting and affect the ability of pediatric and adolescent athletes to participate in sports.

Purpose

To report short- and midterm outcomes on athletes undergoing microfracture or fragment fixation of osteochondral elbow lesions and evaluate the effects thereof on sporting activity.

Study design

Case series; Level of evidence, 4.

Methods

This was a retrospective study analyzing patients who underwent surgical treatment via microfracture or fragment fixation for osteochondral elbow lesions. Patients were treated at a single institution by a single surgeon between 2012 and 2019. Diagnosis was confirmed with magnetic resonance imaging, and patients were indicated for surgery after having persistent symptoms despite trialing rest, immobilization, and/or activity restriction for at least 3 months. Demographic data including sports of choice were collected preoperatively. Imaging and intraoperative findings were documented, and any complications were noted. Range of motion (ROM) was compared pre- to postoperatively. Return-to-sport evaluation included the ability to play the preoperative sport of choice.

Results

In total, 23 patients (25 elbows) were included with a mean follow-up of 23.5 months (range, 6-60.3 months) and a mean age of 13.8 years. Of 25 lesions, 20 (80%) were on the athlete's dominant side. There was significant improvement from pre- to postoperative ROM, including extension (mean ± SD, 6.4° ± 5.3° to 0.04° ± 0.2°; P < .00001), flexion (129.2° ± 10.6° to 138.6° ± 4.4°; P = .00013), and arc of ROM (122.6° ± 13.2° to 138.6° ± 4.4°; P < .00001). Mean lesion size was 81.9 ± 59.3 mm² (range, 15-225 mm²). All elbows demonstrated radiographic healing postoperatively. Mean time to release to sport was 4.48 ± 1.38 months (range, 2.5-8 months). Six (26.1%) patients changed or stopped their preoperative sporting activity, including 2 of 4 gymnasts and 4 of 11 baseball players.

Conclusion

Arthroscopic technique with lesion debridement and microfracture or fixation appears safe and results in radiographic healing; however, with these techniques, there remains a high rate of inability to return to sport in patients involved in higher-demand upper extremity activity, such as baseball and gymnastics. Further treatment strategies, including cartilage restoration procedures, may be warranted in this population.

Background

Indications and techniques for limb lengthening procedures have evolved over the past two decades. Although there are several case series reporting on the complications and efficacy of these techniques, limited data are available on length of stay and hospital readmission rates after these procedures.

Questions/purposes

(1) What is the median length of stay after lower limb lengthening procedures, and is variability in patient demographics, preoperative diagnosis, and surgical technique associated with length of stay? (2) What is the 1-year readmission rate after lower limb lengthening procedures? (3) Is variability in patient demographics, preoperative diagnosis, and surgical technique associated with varying rates of hospital readmission?

Methods

Patients who underwent femoral or tibial lengthening from 2005 to 2015 in seven states were identified using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. These databases include a large, diverse group of patients across a wide range of hospitals and socioeconomic backgrounds with inclusion of patients regardless of payer. Between 2005 and 2015, there were 3979 inpatient admissions that were identified as involving femoral and/or tibial lengthening procedures based on ICD-9 procedure codes; of those, 2% (97 of 3979) of the inpatient admissions were excluded from analysis because they had ICD-9 procedure codes for primary or revision hip or knee arthroplasty, and 10% (394 of 3979) of the inpatient admissions were excluded because they involved repeated admissions of patients with previous hospitalization data within the database. This yielded 3488 patients for analysis. The median (interquartile range) age of patients was 18 years (12 to 41), and 42% (1481 of 3488) of patients were women. A total of 49% (1705 of 3469) of patients were children (younger than 18 years), 19% (675 of 3469) were young adults (18 to 34 years), 24% (817 of 3469) were adults (35 to 59 years), and 8% (272 of 3469) were seniors (60 years and older). Length of stay and rates of readmission at 1 year after the lengthening procedure were calculated. Univariate analysis was performed to examine associations between age, race, payment method, underlying diagnosis, bone lengthened, and lengthening technique with length of stay and readmission rate. Factors found to be significantly associated with the outcome variables (p < 0.05) were further examined with a multivariate analyses.

Results

Included patients had a median (IQR) length of hospital stay of 3 days (2 to 4). Given the poor explanatory power of the multivariate model for length of stay (R 2 = 0.03), no meaningful correlations could be drawn between age, race, underlying diagnosis, lengthening technique, and length of stay. The overall 1-year readmission rate was 35% (1237 of 3488). There were higher readmission rates among adult patients compared with pediatric patients (odds ratio 1.78 [95% confidence interval 1.46 to 2.18]; p < 0.001), patients with government insurance compared with commercial insurance (OR 1.28 [95% CI 1.05 to 1.54]; p = 0.01), and patients undergoing lengthening via external fixation (OR 1.61 [95% CI 1.29 to 2.02]; p < 0.001) or hybrid fixation (OR 1.81 [95% CI 1.38 to 2.37]; p < 0.001) compared with lengthening with internal fixation only.

Conclusion

When counseling patients who may be candidates for limb lengthening, providers should inform individual patients and their caretakers on the anticipated length of hospital stay and likelihood of hospital readmission based on our findings. Adult patients, those with government insurance, and patients undergoing hybrid or external fixator limb lengthening procedures should be advised that they are at greater risk for hospital readmission. The relationship of specific patient-related factors (such as severity of deformity or associated comorbidities) and treatment-related variables (such as amount of lengthening, compliance with physical therapy, or surgeon's experience) with clinical outcomes after lower limb lengthening and the burden of care associated with hospital readmission needs further study.

Level of evidence

Level III, therapeutic study.

AIM: Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. MATERIALS AND METHODS: Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. RESULTS: There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. CONCLUSION: There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. CLINICAL SIGNIFICANCE: Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis. HOW TO CITE THIS ARTICLE: Mittal A, Allahabadi S, Jayaram R, et al. Trends and Practices in Limb Lengthening: An 11-year US Database Study. Strategies Trauma Limb Reconstr 2023;18(1):21-31.

Purpose

To compare hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) techniques including adult-type/anatomic, transphyseal, and transphyseal techniques by (1) ACL graft tear, (2) contralateral ACL tear, and (3) all-cause ipsilateral reoperation.

Methods

A retrospective, single-surgeon review was performed including all ACLR with hamstring autograft in pediatric and adolescent patients from 2011 to 2019. Minimum 2-year follow-up was required for patients unless a tear or reoperation was sustained before that time point. Data collected included demographics and baseline surgical variables, type of reconstruction, sporting activity, and deviations from rehabilitation protocols. Comparisons were made among hamstring autograft reconstruction groups (adult-type/anatomic, transphyseal, and partial transphyseal) for primary outcomes of graft tear, contralateral ACL tears, and all-cause ipsilateral knee reoperations, including hardware removal. Secondary surgeries performed with different surgeons were noted.

Results

In total, 214 patients of age 15.2 ± 2.0 years with 4.1 ± 1.7-year follow-up were included. Overall graft tear rate was 11.7% (11.0% adult-type vs 19.1% transphyseal vs 5.6% partial transphyseal; P = .18). On univariate analyses, all-cause ipsilateral reoperation did not differ by technique (21.3% vs 31.0% vs 33.3%; P = .20), and neither did contralateral ACL tear (8.1% vs 9.5% vs 0%; P = .17). 21.7% of ipsilateral revision ACLRs (all adult-type) and 16.7% of patients with any reoperations had subsequent procedures performed with a different surgeon.

Conclusions

The graft tear rates in primary hamstring autograft ACLRs in the adolescent population did not significantly differ by technique (11.0% vs 19.1% vs 5.6% in adult-type, transphyseal, and partial transphyseal reconstructions, respectively). Furthermore, contralateral ACL tears (8.1% vs 9.5% vs 0%) and all-cause (including > 1/4 hardware removal) ipsilateral knee reoperations (21.3% vs 31.0% vs 33.3%) did not statistically differ. Higher powered studies may detect statistical significance in the observed differences in this study.

Level of evidence

Level IV, therapeutic case series.