Fragility analysis and systematic review of patellar resurfacing versus non-patellar resurfacing in total knee arthroplasty.

Introduction: Fragility analysis is a method of further characterising the robustness of statistical outcomes. This study evaluates the statistical fragility of randomised controlled trials (RCTs) comparing patellar resurfacing versus non-patellar surfacing in total knee arthroplasty (TKA). Methods: PubMed, MEDLINE and EMBASE were searched for RCTs comparing outcomes in TKA based on patellar resurfacing. Fragility index (FI) and reverse FI (collectively, "FI") were calculated for dichotomous outcomes as the number of outcome reversals needed to change statistical significance. Fragility quotient (FQ) was calculated by dividing the FI by the sample size for that outcome. Median FI and FQ were calculated for each individual outcome and for the overall study. Subanalyses were performed to assess FI and FQ based on outcome type, statistical significance and loss to follow-up. Results: Twenty-one RCTs were included in the analysis, capturing 3910 subjects. The overall median FI was 5.0 (interquartile range, [IQR] 4.0-6.0), and the overall median FQ was 0.048 (IQR 0.022-0.065). The outcome of anterior knee pain has a median FI of 6.0 (IQR 4.0-6.0) and a median FQ of 0.057 (IQR 0.025-0.065). Only five (7%) outcomes were significant. The loss to follow-up was greater than the FI in 12 of 19 studies (63%) with available data. Conclusion: RCTs comparing patellar resurfacing in TKAs show significant statistical fragility; a few outcome reversals can alter findings. The majority of outcomes were nonsignificant, indicating that the choice to resurface the patella may not affect most clinical outcomes; however, clinical conclusions are limited by the statistical fragility of the analysed outcomes. Larger RCTs for this comparison are necessary, and we suggest adding FI and FQ to RCT reports with p values to improve the interpretability of results. Level of Evidence: Level II.

Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: (1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes. BACKGROUND: Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking. PATIENTS AND METHODS: We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity. RESULTS: A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists ( P < 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems. CONCLUSION: Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making. LEVEL OF EVIDENCE: Level III.

Perioperative Dexamethasone Does Not Reduce Postoperative Opioid Use Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To determine if dexamethasone administration reduced narcotic consumption during hospitalization and to evaluate if patients who received dexamethasone refilled fewer opioid prescriptions postoperatively. METHODS: All adult patients who underwent primary elective 1- to 4-level anterior cervical discectomy and fusion at a single center were retrospectively identified. Prescription opioid use was collected from governmental online prescription drug monitoring programs, and in-hospital opioid use was collected from each patient's medication administration record and recorded as morphine milligram equivalents (MMEs). Patients were categorized by whether or not intravenous dexamethasone was administered perioperatively. Dexamethasone protocols were considered high dose if weight-based dosing was >0.20 mg/kg and low dose if <0.20 mg/kg. Multivariable linear regression was conducted to assess the relationship between dexamethasone administration and MMEs prescribed at each time point while accounting for confounders. RESULTS: Of 249 included patients, 167 (67%) were administered dexamethasone. Patients in both groups used a similar quantity of opioids while hospitalized (no dexamethasone: 56.7 MMEs/day vs. dexamethasone: 39.4 MMEs/day, P = 0.350). Patients in both groups refilled a similar quantity of opioids in all postoperative time periods: 0-3 weeks (3.38 vs. 4.07 MMEs/day, P = 0.528), 3-6 weeks (0.36 vs. 0.75 MMEs/day, P = 0.198), 6-12 weeks (0.53 vs. 0.75 MMEs/day, P = 0.900), and 3 months to 1 year (0.28 vs. 0.43 MMEs/day, P = 0.531). On multivariable linear regression, dexamethasone was not associated with a reduction in opioid volume at any time point (all P > 0.05). CONCLUSIONS: Administration of perioperative dexamethasone does not reduce in-hospital or home opioid usage regardless of weight-based dose. Analgesia should not be the primary driver of dexamethasone administration for anterior cervical discectomy and fusion.