Predictors and trajectories of chronic postoperative pain following hip preservation surgery

Abstract Factors contributing to chronic postoperative pain (CPOP) are poorly defined in young people and developmental considerations are poorly understood. With over 5 million children undergoing surgery yearly and 25% of adults referred to chronic pain clinics identifying surgery as the antecedent, there is a need to elucidate factors that contribute to CPOP in surgical patients. The present study includes patients undergoing hip preservation surgery at a children’s hospital. The HOOS and SF-12 Health Survey were administered to 614 pre-surgical patients with 421 patients completing follow-up (6-months, 1-year and 2-years post-surgery). Pain, quality of life, and functioning across time were examined for each group within the population. A three trajectory model (low pain, pain improvement and high pain) emerged indicating three categories of treatment responders. Pain trajectory groups did not differ significantly on gender, pre-surgical age, BMI, prior hip surgery, surgical type, joint congruence or Tönnis grade. The groups differed significantly from each other on pre-surgical pain, pain chronicity, quality of life and functioning. Those in the high pain and pain improvement groups endorsed having pre-surgical depression at significantly higher rates and lower pre-surgical quality of life compared to those in the low pain group (P < 0.01). Those in the high pain group reported significantly worse pre-surgical functioning compared to those in the pain improvement (P < 0.0001) and low pain groups (P < 0.0001).The results demonstrate the need for preoperative screening prior to hip preservation surgery, as there may be a subset of patients who are predisposed to chronic pain independent of hip health

The alpha angle as a predictor of contralateral slipped capital femoral epiphysis

Purpose Contralateral hip involvement in slipped capital femoral epiphysis (SCFE) is common. Femoral head−neck asphericity, as measured by an elevated alpha angle, has not previously been assessed with respect to SCFE risk. Our aim was to assess the utility of the alpha angle in predicting contralateral SCFE. Methods: We retrospectively reviewed 168 patients (94 males) managed surgically for unilateral SCFE between 2001 and 2013 who had a minimum of 18 months follow-up. The alpha angle, the posterior sloping angle (PSA), and the modified Oxford score were recorded for every patient at the time of initial SCFE presentation. Follow-up clinical records and radiographs were assessed to determine the presence of absence of contralateral SCFE. Results: Forty-five patients (27 %) developed a contralateral SCFE. Patients who developed a contralateral SCFE had a significantly higher alpha angle (51° vs 45°, p 0.10) between patients who developed a contralateral SCFE and those who did not. Using a proposed alpha angle of 50.5° as a threshold for prophylactic fixation, 26 (58 %) of the 45 cases of contralateral SCFE in our study would have been prevented and 18 (15 %) of 123 patients would have undergone fixation unnecessarily. Conclusions: We found the alpha angle to positively correlate with contralateral SCFE risk. Patients with significantly elevated alpha angles may be at greater risk of contralateral SCFE and benefit from further investigation or prophylactic hip fixation

Patient-reported outcomes of periacetabular osteotomy from the prospective ANCHOR cohort study

BACKGROUND: Current literature describing the periacetabular osteotomy (PAO) is mostly limited to retrospective case series. Larger, prospective cohort studies are needed to provide better clinical evidence regarding this procedure. The goals of the current study were to (1) report minimum 2-year patient-reported outcomes (pain, hip function, activity, overall health, and quality of life), (2) investigate preoperative clinical and disease characteristics as predictors of clinical outcomes, and (3) report the rate of early failures and reoperations in patients undergoing contemporary PAO surgery. METHODS: A large, prospective, multicenter cohort of PAO procedures was established, and outcomes at a minimum of 2 years were analyzed. A total of 391 hips were included for analysis (79% of the patients were female, and the average patient age was 25.4 years). Patient-reported outcomes, conversion to total hip replacement, reoperations, and major complications were documented. Variables with a p value of ≤0.10 in the univariate linear regressions were included in the multivariate linear regression. The backward stepwise selection method was used to determine the final risk factors of clinical outcomes. RESULTS: Clinical outcome analysis demonstrated major clinically important improvements in pain, function, quality of life, overall health, and activity level. Increasing age and a body mass index status of overweight or obese were predictive of improved results for certain outcome metrics. Male sex and mild acetabular dysplasia were predictive of lesser improvements in certain outcome measures. Three (0.8%) of the hips underwent early conversion to total hip arthroplasty, 12 (3%) required reoperation, and 26 (7%) experienced a major complication. CONCLUSIONS: This large, prospective cohort study demonstrated the clinical success of contemporary PAO surgery for the treatment of symptomatic acetabular dysplasia. Patient and disease characteristics demonstrated predictive value that should be considered in surgical decision-making. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence

The Demise of Islet Allotransplantation in the US: A Call for an Urgent Regulatory Update The ISLETS FOR US Collaborative

Islet allotransplantation in the United States (US) is facing an imminent demise. Despite nearly three decades of progress in the field, an archaic regulatory framework has stymied US clinical practice. Current regulations do not reflect the state-of-the-art in clinical or technical practices. In the US, islets are considered biologic drugs and more than minimally manipulated human cell and tissue products (HCT/Ps). Across the world, human islets are appropriately defined as minimally manipulated tissue which has led to islet transplantation becoming a standard-of-care procedure for patients with type 1 diabetes mellitus and problematic hypoglycemia. As a result of the outdated US regulations, only eleven patients underwent allo-ITx in the US between 2011-2016 and all in the setting of a clinical trial. Herein, we describe the current regulations pertaining to islet transplantation in the United States. We explore the progress which has been made in the field and demonstrate why the regulatory framework must be updated to both, better reflect our current clinical practice and to deal with upcoming challenges. We propose specific updates to current regulations which are required for the renaissance of ethical, safe, effective, and affordable allo-ITx in the United States

The Glasgow Outcome Scale -- 40 years of application and refinement

The Glasgow Outcome Scale (GOS) was first published in 1975 by Bryan Jennett and Michael Bond. With over 4,000 citations to the original paper, it is the most highly cited outcome measure in studies of brain injury and the second most-cited paper in clinical neurosurgery. The original GOS and the subsequently developed extended GOS (GOSE) are recommended by several national bodies as the outcome measure for major trauma and for head injury. The enduring appeal of the GOS is linked to its simplicity, short administration time, reliability and validity, stability, flexibility of administration (face-to-face, over the telephone and by post), cost-free availability and ease of access. These benefits apply to other derivatives of the scale, including the Glasgow Outcome at Discharge Scale (GODS) and the GOS paediatric revision. The GOS was devised to provide an overview of outcome and to focus on social recovery. Since the initial development of the GOS, there has been an increasing focus on the multidimensional nature of outcome after head injury. This Review charts the development of the GOS, its refinement and usage over the past 40 years, and considers its current and future roles in developing an understanding of brain injury

The demise of islet allotransplantation in the United States: A call for an urgent regulatory update

Islet allotransplantation in the United States (US) is facing an imminent demise. Despite nearly three decades of progress in the field, an archaic regulatory framework has stymied US clinical practice. Current regulations do not reflect the state-of-the-art in clinical or technical practices. In the US, islets are considered biologic drugs and “more than minimally manipulated” human cell and tissue products (HCT/Ps). In contrast, across the world, human islets are appropriately defined as “minimally manipulated tissue” and not regulated as a drug, which has led to islet allotransplantation (allo-ITx) becoming a standard-of-care procedure for selected patients with type 1 diabetes mellitus. This regulatory distinction impedes patient access to islets for transplantation in the US. As a result only 11 patients underwent allo-ITx in the US between 2016 and 2019, and all as investigational procedures in the settings of a clinical trials. Herein, we describe the current regulations pertaining to islet transplantation in the United States. We explore the progress which has been made in the field and demonstrate why the regulatory framework must be updated to both better reflect our current clinical practice and to deal with upcoming challenges. We propose specific updates to current regulations which are required for the renaissance of ethical, safe, effective, and affordable allo-ITx in the United States