Presence of Cerebrospinal Fluid on Preoperative Imaging and the Associated Cervical Myelopathy Diagnosis and Outcome.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: The objective of this study is to determine whether the presence of cerebrospinal fluid is associated with the severity of degenerative cervical myelopathy or postoperative outcomes. SUMMARY OF BACKGROUND DATA: Degenerative cervical myelopathy (DCM) is a clinical diagnosis characterized as neurologic dysfunction. Preoperative imaging is used to determine the source of cord compression. In clinical practice, cerebrospinal fluid (CSF) around the cord is often used as an indicator to determine whether stenosis is relevant. It is unclear if the presence of CSF around the cord can serve as a metric for clinically relevant cord compression. METHODS: Patients undergoing single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy were identified from our institution's surgical database. Pre- and postoperative patient-reported health outcomes visual analog scale for neck pain (VAS-NP) and modified Japanese Orthopaedic Association (mJOA) were collected. The level of ACDF plus one level above and below were assessed for the presence of cerebrospinal fluid, as well as measuring the area of the spinal canal and spinal cord on preoperative magnetic resonance imaging. RESULTS: Two hundred forty-nine patients were included. Spearman correlation test comparing cord/canal ratios at the level of compression and preoperative mJOA shows a significant negative correlation (Rho = -0.206, P= 0.043). There was no significant correlation with postoperative change in mJOA scores (Rho = -0.002, P= 0.986). CONCLUSION: The presence of CSF around the cord was weakly correlated with the severity of myelopathy; however, it had no correlation with postoperative outcomes. The presence of CSF around the cord should not in isolation be used to rule in or rule out operative levels in cervical myelopathy.

Comparing outcomes in revision total hip arthroplasty in inpatient versus outpatient setting: a matched cohort analysis.

BACKGROUND: As the population ages, revision total hip arthroplasty (rTHA) is becoming more common. However, there is a paucity of literature regarding perioperative outcomes following inpatient versus outpatient rTHA. Our study aims to compare perioperative complications and readmission rates associated with rTHA in a large national cohort. METHODS: A retrospective, propensity-matched cohort study was conducted using the National Surgical Quality Improvement Program database from 2006 to 2020. Patients undergoing rTHA in the inpatient setting were propensity matched to patients receiving rTHA in the outpatient setting. Following 1:1 matching, multivariate analyses were performed to compare perioperative complications and readmission. RESULTS: A total of 207,102 patients were identified, including 181,164 outpatient primary THA, 25,466 inpatient rTHA, and 492 outpatient rTHA patients. Following propensity matching, outpatient primary THA versus outpatient rTHA had 210 patients and inpatient rTHA versus outpatient rTHA had 214 patients. Patients in the outpatient rTHA had a significantly higher operative time (132.4 ± 73.2 versus 90.9 ± 32.7, p < 0.001) and length of stay (1.6 ± 1.6 vs. 0.9 ± 1.0, p < 0.001) compared to outpatient primary THA. When comparing inpatient versus outpatient rTHA, the outpatient cohort had lower operative time (131.1 ± 70.9 vs. 145.4 ± 71.5, p = 0.038), total length of stay (1.7 ± 1.8 vs. 3.6 ± 4.1, p < 0.001), and bleeding complications (6% vs. 18%, p < 0.001). CONCLUSION: There were no difference in the odds of complications between outpatient primary and revision THA. Additionally, rTHA performed in an outpatient setting did not show any increase in immediate compared to inpatient settings. These findings suggest that rTHA can be safely performed on certain patients.

Comparison of sleep improvement in patients undergoing lumbar spine decompression.

OBJECTIVE: Degenerative spine conditions affect many people each year. These conditions have been shown to negatively impact pain, function, and patient quality of life (QOL), which often require surgical intervention. It is understood that sleep plays an important role in all of these factors. However, the relationship between sleep disruption and lumbar surgery is not well understood. The objective of this study was to use a large database to understand the relationship between sleep quality and lumbar spine surgery outcomes. METHODS: The surgical database of the authors' institute was used to identify all patients undergoing lumbar spine surgery for degenerative spine disease from January 1, 2012, through December 31, 2021. Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were collected, and only patients with both pre- and postoperative scores were included. Additional measures related to disability, pain, and depression were also obtained. Chart review was performed to collect patient demographics, health risk factors, and information related to sleep disturbances such as sleep medication usage and prior sleep condition diagnosis. RESULTS: The study had 674 patients who met the criteria. At 3, 6, and 12 months postoperatively, there was a significant decrease in sleep disruption scores (i.e., sleep improvement), although these decreases were not greater than the minimal clinically important difference (MCID). When stratified based on preoperative sleep quality, patients with poor preoperative scores (PROMIS sleep disruption > 63.04) showed a significant decrease in sleep disruption by 8.17 at 3 months, 7.99 at 6 months, and 7.21 at 12 months. All of these decreases were greater than the sleep disruption MCID of 6.5. Multivariate analysis showed high preoperative sleep disruption and improvement in PROMIS physical health were most associated with decreased postoperative sleep disruption at all postoperative time points. CONCLUSIONS: In patients with degenerative spine conditions, lumbar spine surgery offers improvement in sleep disruption for all patients. Those with poor preoperative sleep quality are more likely to see clinical improvement in their sleep disruption.

Photodynamic bone stabilization for traumatic and pathologic fractures: a systematic review of utilization, complications, and patient-reported outcomes.

INTRODUCTION: The photodynamic bone stabilization system (PBSS) was was developed in 2010, and in 2018 gained FDA approval in the United States. Given its relative novelty, our analysis sought to analyze the available literature exploring the indications, outcomes, and complications of the PBSS. METHODS: We performed a systematic review (PROSPERO registration of study protocol: CRD42022363065, October 8th, 2022). PubMed, EBSCOHost, and Google Scholar electronic databases were queried to identify articles evaluating PBSS in the treatment of pathologic or traumatic fractures between January 1 2010 and 15 October 2022. The quality of the included studies was assessed using the Methodological Index for Nonrandomized Studies tool. RESULTS: Our initial search yielded 326 publications, which were then screened for appropriate studies that aligned with the purpose of our review. A total of thirteen studies, comprising seven case series, four case reports, and two cohort studies. The total sample size of the included studies consisted of 345 patients, with 242 females (70%) and 103 males (30%). The implants were most commonly utilized in the humerus (41%), radius (12%), and metacarpal (12%). The most common complications were related to broken implants (5%) and dislocation (1%). Most studies reported complete fracture healing and return of full strength and range of motion. CONCLUSION: Despite being a relatively novel technology, PBSS appears to be a viable option for fracture stabilization. Most studies included in our analysis reported complete fracture healing and return of function with minimal complications.

Is Penicillin Allergy a Clinical Problem? A Systematic Review of Total Joint Arthroplasty Procedures With Implications for Patient Safety and Antibiotic Stewardship.

BACKGROUND: Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection. METHODS: PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection). RESULTS: All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients. CONCLUSIONS: Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Implant Selection Strategies for Total Joint Arthroplasty: The Effects on Cost Containment and Physician Autonomy.

BACKGROUND: With continued declines in reimbursement for total joint arthroplasty, health systems have explored implant cost containment measures to generate sustainable margins. This review evaluated how implementation of (1) implant price control programs, (2) vendor purchasing agreements, and (3) bundled payment models affected implant costs and physician autonomy in implant selection. METHODS: PubMed, EBSCOhost, and Google Scholar were searched to identify studies that evaluated the efficacy of total hip or total knee arthroplasty implant selection strategies. The review included publications between January 1, 2002, and October 17, 2022. The mean Methodological Index for Nonrandomized Studies score was 18.3 ± 1.8. RESULTS: A total of 13 studies (32,197 patients) were included. All studies implementing implant price capitation programs found decreased implant costs, ranging 2.2 to 26.1% and increased utilization of premium implants. Most studies found bundled payments models reduced total joint arthroplasty implant costs with greatest reduction being 28.9%. Additionally, while absolute single vendor agreements had higher implant costs, preferred single vendor agreements had reduced implant costs. When given price constraints, surgeons tended to select more premium implants. CONCLUSION: Alternative payment models that incorporated implant selection strategies saw reduced costs and surgeon utilization of premium implants. The study findings encourage further research on implant selection strategies, which must balance the goals of cost containment with physician autonomy and optimized patient care. LEVEL OF EVIDENCE: Level III.

Complications in Osteonecrosis Patients Following Total Knee Arthroplasty: A Propensity-Matched Cohort Study.

BACKGROUND: Several studies have demonstrated high complication rates in osteonecrosis (ON) patients undergoing total hip arthroplasty. However, there is a paucity of literature regarding outcomes of total knee arthroplasty (TKA) in ON patients. Our study aimed to assess preoperative risk factors associated with the development of ON and determine the incidence of postoperative complications up to one year following TKA. METHODS: A retrospective cohort study was conducted using a large national database. Patients who had a primary TKA and ON were isolated using Current Procedural Terminology code 27447 and ICD-10-CM code M87, respectively. A total of 185,045 patients were identified, including 181,151 patients who had a TKA and 3,894 patients who had a TKA and ON. After propensity matching, both groups each contained 3,758 patients. Intercohort comparisons of primary and secondary outcomes after propensity score matching were made using the odds ratio. A P value of < .01 was determined to be significant. RESULTS: The ON patients were found to have an increased risk for prosthetic joint infection, urinary tract infection, deep vein thrombosis, pulmonary embolism, wound dehiscence pneumonia, and the development of heterotopic ossification at different time points. Osteonecrosis patients had an increased risk of revision at the 1-year time point (odds ratio = 2.068, P < .0001). CONCLUSION: The ON patients had a higher risk of systemic and joint complications than non-ON patients. These complications suggest a more complicated management course for patients who have ON prior to and after TKA.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study.

BACKGROUND: Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized. QUESTIONS/PURPOSES: (1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states? METHODS: We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions. RESULTS: A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08). CONCLUSION: As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately. CLINICAL RELEVANCE: To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Readability of Online Patient Educational Materials in Pediatric Orthopaedics: A Systematic Review.

BACKGROUND: As most patients and their families utilize online education materials, ensuring that their readability is at or below the recommended reading level of sixth grade is imperative to enhance informed consent, patient involvement, and shared decision-making. We evaluated and compared the readability of online patient education materials (PEMs) about pediatric orthopaedics for academic-sponsored websites and search-engine result websites. METHODS: Following the PRISMA-P guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022352323, August 8, 2022). PubMed, EBSCOhost, Medline, and Google Scholar electronic databases were utilized to identify all studies evaluating the readability of pediatric orthopaedic online PEMs between January 1, 2000 and September 9, 2022. We included studies with full-text manuscripts in English addressing the readability of pediatric orthopaedic online patient education materials. We excluded general reviews, papers, case reports, duplicate studies between databases, grey literature, and publications in languages other than English. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) tool for cross-sectional studies. RESULTS: Our initial search yielded 196 candidate publications. Of these, 11 studies met inclusion criteria. These included a total of 893 PEMs assessed for readability between January 2001 to December 2021. The mean JBI score was 7.3±1.1. Each of the seven studies assessing PEMs from academic-sponsored sources reported mean readability scores of at least an eighth-grade level. Among the 5 studies assessing the readability of PEMs accessed through search engines, 3 studies reported ninth-grade reading level whereas the other 2 reported 10th-grade. Academic and search-engine website readability scores remained constant between 2001 and 2021. CONCLUSIONS: Our analysis showed poor readability scores for both academic-sponsored website PEMs and those accessed through search engines. In addition, the readability scores remained constant between 2001 and 2021, indicating that revisions to orthopaedic online PEMs are needed. Supplementation with visuals should be included to educate patients with lower health literacy. LEVEL OF EVIDENCE: III.

Interventions to Reduce Pediatric Anxiety During Orthopaedic Cast Room Procedures: A Systematic and Critical Analysis Review.

BACKGROUND: Cast room procedures can be a source of considerable distress for pediatric patients. High levels of anxiety can make it difficult to perform procedures effectively and may negatively affect the doctor-patient relationship. We sought to evaluate available interventions to reduce anxiety in pediatric patients undergoing orthopaedic cast room procedures. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022333001, May 28, 2022). PubMed, EBSCO host, MEDLINE, Cochrane, and Google Scholar electronic databases were used to identify all studies evaluating interventions to reduce pediatric anxiety during orthopaedic cast room procedures between January 1, 1975, and June 1, 2022. The quality of included studies was assessed using the Jadad scale. RESULTS: Our initial search yielded 1,490 publications, which were then screened for appropriate studies that aligned with the purpose of our review. Fourteen studies comprising 8 prospective cohort and 6 randomized controlled trials were included. The total sample size of included studies consisted of 1,158 patients with participant age ranging from 1 to 21 years. The interventions investigated included noise reduction headphones, musical therapy, inclusion of a certified child life specialist, casting shears, virtual reality, Bedside Entertainment and Relaxation Theater (BERT), children's and instructional videos, and video games. Most of the included interventions were effective at reducing anxiety during cast room procedures. However, there was variation in anxiety reduction across cast room procedure and treatment modality. CONCLUSION: The use of physical or technology-based distraction tools can play an important interventional role in improving patient satisfaction during cast room procedures. The majority were inexpensive, readily applicable to the clinical setting, and of negligible risk to the patient. LEVEL OF EVIDENCE: Level II. See Instructions for Authors for a complete description of levels of evidence.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures.

INTRODUCTION: Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS: The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R 2 values were calculated. RESULTS: A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION: Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.

Is prematurity a risk factor for developmental dysplasia of the hip? A systematic review and meta-analysis.

Developmental dysplasia of the hip (DDH) is the most common orthopedic disorder in newborns. Early recognition and diagnosis are critical to prevent long-term complications. While several risk factors have been established, the association between prematurity and DDH remains unclear. Our analysis sought to analyze the literature exploring the relationship between prematurity and DDH. Articles evaluating the relationship between prematurity and DDH published between 1 January 2000 and 1 February 2022 were queried, with 11 studies included for analysis. Overall, a total of 8720 patients were included. The gestational age ranged from 23 to 36 weeks for preterm and ≥37 weeks for term births. Seven studies agreed that gestational age did not have a significant impact on DDH. Pooled analysis of available data demonstrated no significant difference in DDH among preterm and term infants (OR, 1.11; 95% CI, 0.82-1.51; P = 0.49). Sub-group analysis of two studies reporting data on very preterm (≤32 weeks) and term infants revealed no significant difference in the occurrence of DDH (OR, 4.58; 95% CI, 0.09-244.78; P = 0.45). Four studies found early gestational age is associated with a significantly higher incidence of mature hips compared to late preterm or term babies. Similarly, pooled analysis demonstrated significantly lower Graf classification among preterm infants (OR, 0.13; 95% CI, 0.03-0.61; P = 0.009). Based on the current literature, our analysis found that prematurity is not strongly associated with DDH. Furthermore, early gestational age was associated with a significantly higher incidence of mature hips measured by Graf classification.

Pseudouridine synthase 7 is an opportunistic enzyme that binds and modifies substrates with diverse sequences and structures.

Pseudouridine (Ψ) is a ubiquitous RNA modification incorporated by pseudouridine synthase (Pus) enzymes into hundreds of noncoding and protein-coding RNA substrates. Here, we determined the contributions of substrate structure and protein sequence to binding and catalysis by pseudouridine synthase 7 (Pus7), one of the principal messenger RNA (mRNA) modifying enzymes. Pus7 is distinct among the eukaryotic Pus proteins because it modifies a wider variety of substrates and shares limited homology with other Pus family members. We solved the crystal structure of Saccharomyces cerevisiae Pus7, detailing the architecture of the eukaryotic-specific insertions thought to be responsible for the expanded substrate scope of Pus7. Additionally, we identified an insertion domain in the protein that fine-tunes Pus7 activity both in vitro and in cells. These data demonstrate that Pus7 preferentially binds substrates possessing the previously identified UGUAR (R = purine) consensus sequence and that RNA secondary structure is not a strong requirement for Pus7-binding. In contrast, the rate constants and extent of Ψ incorporation are more influenced by RNA structure, with Pus7 modifying UGUAR sequences in less-structured contexts more efficiently both in vitro and in cells. Although less-structured substrates were preferred, Pus7 fully modified every transfer RNA, mRNA, and nonnatural RNA containing the consensus recognition sequence that we tested. Our findings suggest that Pus7 is a promiscuous enzyme and lead us to propose that factors beyond inherent enzyme properties (e.g., enzyme localization, RNA structure, and competition with other RNA-binding proteins) largely dictate Pus7 substrate selection.