Metastatic epidural spinal cord compression from testicular yolk sac tumor: case report and literature review.

Background: Yolk sac tumor (YST), or endodermal sinus tumor, is classically associated with pediatric populations. Metastasis to the spine rarely occurs, usually involving the lower thoracic or lumbar vertebrae. The objective of this report is to present a rare case of YST metastasis to the lower cervical and upper thoracic vertebrae in an adult male. A case-based review of the literature on metastatic YSTs was also performed as an update to the relevant literature. Case Description: A 28-year-old male with a history of YST presented to our institution with urinary retention, increasing weakness in the upper extremities, and acute onset lower extremity weakness. Computed tomography (CT) and magnetic resonance imaging (MRI) scans confirmed evidence of metastasis from a known YST with symptomatic cord compression. The patient was treated with surgical excision via decompressive laminectomies with instrumentation as described, and histopathologic analysis of the specimen confirmed YST metastasis. His disease recurred one year after index surgery. He succumbed to his disease despite repeated debulking. Conclusions: Metastasis of YST is rare, but metastasis to lower cervical and upper thoracic vertebrae is possible. YSTs are usually treated via primary surgical resection. Systemic chemotherapy and radiation may prevent recurrence. However, individualized treatment is imperative for improved patient outcomes.

Impact of Extended Prophylactic Antibiotics on Risk of Prosthetic Joint Infection in Primary Total Hip Arthroplasty: A Matched Cohort Analysis.

BACKGROUND: Extended oral prophylactic antibiotics have been increasingly used in arthroplasty with the goal of reducing the risk of prosthetic joint infection (PJI). While a reduction in the rate of PJI has been noted with extended oral antibiotic regimens in high-risk patients, no large database study has assessed infection risk after primary total hip arthroplasty among well-balanced cohorts receiving and not receiving postoperative extended oral antibiotics. METHODS: A retrospective cohort study was conducted using a national database, TriNetX, to identify patients who underwent primary total hip arthroplasty. This cohort was stratified by oral antibiotic prescription within one day of procedure. A one-to-one propensity score matching based on age, sex, class of obesity, and medical comorbidities was conducted. Outcomes explored in this study were 90-day risk of PJI, superficial skin infection, deep skin infection, and all-cause revision. RESULTS: 90-day postoperative infection complications of PJI were higher in the group receiving antibiotics (hazard ratio: 1.83, P -value = 0.012). Other complications such as superficial skin infection, deep skin infection, and all-cause revision showed no statistically significant differences. CONCLUSION: This database analysis of 5,476 patients demonstrated no decrease in complications of PJI, superficial or deep skin infection, or revision at 90 days. Future randomized controlled trials are needed to evaluate the efficacy of extended oral antibiotics. LEVEL OF EVIDENCE: III.

Spinal Robotics in Single-Position Lateral Surgery: A Narrative Review of Key Concepts and Considerations.

Anterior column realignment via anterior, oblique, or lateral lumbar interbody fusion is increasingly recognized as a powerful mechanism for indirect decompression and sagittal realignment in flexible deformity. Single-position lateral surgery is a popular variation that places patients in the lateral decubitus position, allowing concomitant placement of lateral interbodies and posterior segmental instrumentation without the need for repositioning the patient. The addition of robotics to this technique can help to overcome ergonomic limitations of the placement of pedicle screws in the lateral decubitus position; however, its description in the literature is relatively lacking. In this review we aim to discuss the indications, advantages, and pitfalls of this approach.

Inadequate Spinal Anesthesia in Lumbar Spine Surgery Is Related to Volume of the Thecal Sac.

BACKGROUND: Spinal anesthesia (SA) is used in lumbar surgery, but initial adequate analgesia fails in some patients. In these cases, spinal redosing or conversion to general endotracheal anesthesia is required, both of which are detrimental to the patient experience and surgical workflow. METHODS: We reviewed cases of lumbar surgery performed under SA from 2017-2021. We identified 12 cases of inadequate first dose and then selected 36 random patients as controls. We used a measurement tool to approximate the volume of the dural sac for each patient using T2-weighted sagittal magnetic resonance imaging sequences. RESULTS: Patients who had an inadequate first dose of anesthesia had a significantly larger dural sac volume, 22.8 ± 7.9 cm3 in the inadequate dose group and 17.4 ± 4.7 cm3 in controls (P = 0.043). The inadequate dose group was significantly younger, 54.2 ± 8.8 years in failed first dose and 66.4 ± 11.9 years in controls (P = 0.001). The groups did not differ by surgical procedure (P = 0.238), level (P = 0.353), American Society of Anesthesia score (P = 0.546), or comorbidities. CONCLUSIONS: We found that age, larger height, and dural sac volume are risk factors for an inadequate first dose of SA. The availability of spinal magnetic resonance imaging in patients undergoing spine surgery allows the preoperative measurement of their thecal sac size. In the future, these data may be used to personalize spinal anesthesia dosing on the basis of individual anatomic variables and potentially reduce the incidence of failed spinal anesthesia in spine surgery.

Ventricular Migration of Vitreous Silicone Oil Masquerading as a Ruptured Colloid Cyst.

The ventricular migration of vitreous silicone oil (SiO) is rare and can easily be mistaken for intraventricular hemorrhage or a ruptured colloid cyst. We report here the case of an adult male who was misdiagnosed with a ruptured colloid cyst and was subsequently found to have ventricular migration of vitreous SiO. A 57-year-old male presented unresponsive following a respiratory arrest and underwent a head computed tomography (CT) scan that demonstrated multiple ovoid hyperdensities in the ventricular system, which was concerning for a ruptured colloid cyst. He was transferred to our institution for neurosurgical evaluation. Magnetic resonance imaging (MRI) was performed and demonstrated widespread abnormal diffusion restriction throughout the cortex and basal ganglia, consistent with anoxic brain injury secondary to hypoxic respiratory arrest. The MRI also demonstrated an abnormal signal in areas corresponding with the previously identified intraventricular lesions, which did not layer posteriorly. Given that the MRI sequence signals of the lesions in the ventricular system matched perfectly with the signals of the somewhat deflated SiO within the globe, these multiple ovoid lesions on imaging were most consistent with the migration of SiO from the vitreous body of the right globe into the ventricular system. This case demonstrates a diagnostic error that can occur in emergent settings because of the broad differential diagnosis for cerebral ventricular hyperdensities. A ruptured colloid cyst was considered the reason for transfer, with the anticipation of neurosurgical intervention, but further imaging demonstrated that this was an incidental finding in this patient who presented in extremis. Awareness of this rare clinical condition can prevent overutilization of resources and unnecessary interventions.

Brachioradial Pruritus Caused by Cervical Disc Herniation Precipitated by Trauma Treated with Anterior Cervical Discectomy and Fusion: Report of Two Cases and Review of the Literature.

Brachioradial pruritis (BRP) is a rare form of dermatomal pruritis that appears to be caused both by cervical radiculopathy and exposure to ultraviolet-light, although the exact pathophysiology for the manifestation of these symptoms remains to be determined. A diagnosis of BRP is typically confirmed with the "ice-pack" test and evidence of cervical spine pathology using magnetic resonance imaging. Treatment options consist of application of ice, reduction in sun exposure, and topical capsaicin, antiepileptics, or tricyclic antidepressants. Patients with refractory symptoms and cervical spine pathology may be candidates for surgical decompression, particularly at the C5 and C6 levels. However, there are currently no established guidelines to treat BRP, or surgical procedures that have shown to be superior. Here, we report two cases of cervical disc herniations after traumatic events that presented as BRP. Both cases were successfully treated with anterior cervical discectomy and fusion with complete resolution of symptoms.

Preoperative Robotics Planning Facilitates Complex Construct Design in Robot-Assisted Minimally Invasive Adult Spinal Deformity Surgery-A Preliminary Experience.

(1) Background: The correction of adult spinal deformity (ASD) can require long, complex constructs with multiple rods which traverse important biomechanical levels to achieve multi-pelvic fixation. Minimally invasive (MIS) placement of these constructs has historically been difficult. Advanced technologies such as spinal robotics platforms can facilitate the design and placement of these constructs and further enable these surgical approaches in MIS deformity surgery. (2) Methods: A retrospective study was performed on a series of ASD patients undergoing MIS deformity correction with ≥eight fusion levels to the lower thoracic spine with preoperative robotic construct planning and robot-assisted pedicle screw placement. (3) Results: There were 12 patients (10 female, mean age 68.6 years) with a diagnosis of either degenerative scoliosis (8 patients) or sagittal imbalance (4 patients). All underwent preoperative robotic planning to assist in MIS robot-assisted percutaneous or transfascial placement of pedicle and iliac screws with multiple-rod constructs. Mean operative values per patient were 9.9 levels instrumented (range 8-11), 3.9 interbody cages (range 2-6), 3.3 iliac fixation points (range 2-4), 3.3 rods (range 2-4), 18.7 screws (range 13-24), estimated blood loss 254 cc (range 150-350 cc), and operative time 347 min (range 242-442 min). All patients showed improvement in radiographic sagittal, and, if applicable, coronal parameters. Mean length of stay was 5.8 days with no ICU admissions. Ten patients ambulated on POD 1 or 2. Of 224 screws placed minimally invasively, four breaches were identified on intraoperative CT and repositioned (three lateral, one medial) for a robot-assisted screw accuracy of 98.2%. (4) Conclusions: Minimally invasive long-segment fixation for adult spinal deformity surgery has historically been considered laborious and technically intensive. Preoperative robotics planning facilitates the design and placement of even complex multi-rod multi-pelvic fixation for MIS deformity surgery.

Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA). METHODS: A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n = 120) or GA (n = 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test. RESULTS: Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P = 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001). CONCLUSIONS: SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.

Minimally Invasive L4-5 Oblique Lumbar Interbody Fusion With Robot-Assisted Single-Position Posterior Fixation: 2-Dimensional Operative Video.

We present here a 58-year-old female patient with L4-5 spondylolisthesis, who underwent a minimally invasive L4-5 oblique lumbar interbody fusion (OLIF) with robot-assisted bilateral posterior instrumented fixation in a single lateral position (Mazor X Stealth Edition, Medtronic). There has been interest in detailed video-based descriptions of single-position surgery with lateral approach interbody fusions, either in the prone or lateral decubitus position.1-6 Particularly, the addition of robotics has been shown to help increase overall operating efficiency in the lateral position with reduced case times even with the increased up-front robot setup time.7,8 The OLIF, also known as an anterior-to-psoas approach, allows for single-position posterior fixation and can be very effective at L4-5 where the anatomy of the iliac crest or lumbar plexus does not preclude this surgical corridor the way it could in the transpsoas lateral lumbar interbody fusion. Clinical outcomes between these 2 lateral approaches have been shown to be very good,9 and OLIF has reduced blood loss while still restoring alignment parameters compared with anterior lumbar interbody fusion, with better fusion and reduced subsidence compared with transforaminal lumbar interbody fusion.10,11 To our knowledge, this is the first video demonstrating a view of the OLIF approach through a high-definition retractor-based camera (MaxView Camera, Viseon Inc). There is no identifying patient information in this video. The participants and any identifiable individuals consented to publication of his/her image, and the patient consented to the procedure.

The Relationship of Spinal Anesthesia Dosing Based on Thecal Sac Area to Anesthetic Failure in Lumbar Surgery.

BACKGROUND AND OBJECTIVES: Greater thecal sac volumes are associated with an increased risk of spinal anesthesia (SA) failure. The thecal sac cross-sectional area accurately predicts thecal sac volume. The thecal sac area may be used to adjust the dose and prevent anesthetic failure. We aim to assess the rate of SA failure in a prospective cohort of lumbar surgery patients who receive an individualized dose of bupivacaine based on preoperative measurement of their thecal sac area. METHODS: A total of 80 patients prospectively received lumbar spine surgery under SA at a single academic center (2022-2023). Before surgery, the cross-sectional area of the thecal sac was measured at the planned level of SA injection using T2-weighted MRI. Patients with an area <175 mm2, equal to or between 175 and 225 mm2, and >225 mm2 received an SA injection of 15, 20, or 25 mg of 0.5% isobaric bupivacaine, respectively. Instances of anesthetic failure and adverse outcomes were noted. Incidence of SA failure was compared with a retrospectively obtained control cohort of 250 patients (2019-2022) who received the standard 15 mg of bupivacaine. RESULTS: No patients in the individualized dose cohort experienced failure of SA compared with 14 patients (5.6%) who experienced failure in the control cohort (P = .0259). The average thecal sac area was 187.49 mm2, and a total 28 patients received 15 mg of bupivacaine, 42 patients received 20 mg of bupivacaine, and 10 patients received 25 mg of bupivacaine. None of the patients experienced any adverse outcomes associated with SA. Patients in the individualized dose cohort and control cohort were comparable and had a similar distribution of lumbar procedures and comorbidities. CONCLUSION: Adjusting the dose of SA according to thecal sac area significantly reduces the rate of SA failure in patients undergoing lumbar spine surgery.

Extended Prophylactic Antibiotics for Primary and Aseptic Revision Total Joint Arthroplasty: A Meta-Analysis.

BACKGROUND: There is growing interest in extended antibiotic prophylaxis (EAP) following total joint arthroplasty (TJA); however, the benefit of EAP remains controversial. For this investigation, both oral and intravenous antibiotic protocols were included in the EAP group. METHODS: The Cochrane Database of Systematic Reviews, Cochrane Register of Controlled Trials, PubMed, MEDLINE, Web of Science, Ovid Embase, Elton B. Stephens CO, and Cumulative Index to Nursing and Allied Health Literature were queried for literature comparing outcomes of primary and aseptic revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients who were treated with either ≤24 hours of postoperative antibiotic prophylaxis (standard of care [SoC]) or >24 hours of EAP. The primary outcome was periprosthetic joint infection (PJI). A pooled relative-risk random-effects Mantel-Haenszel model was implemented to compare cohorts. RESULTS: There were 18 studies with a total of 19,153 patients included. There was considerable variation in antibiotic prophylaxis protocols with first-generation cephalosporins being the most commonly implemented antibiotic for both groups. Patients treated with EAP were 35% less likely to develop PJI relative to the SoC (P = .0004). When examining primary TJA, patients treated with EAP were 39% and 40% less likely to develop a PJI for TJA (P = .0008) and THA (P = .02), respectively. There was no significant difference for primary TKA (P = .17). When examining aseptic revision TJA, EAP led to a 36% and 47% reduction in the probability of a PJI for aseptic revision TJA (P = .007) and aseptic revision TKA (P = .008), respectively; there was no observed benefit for aseptic revision THA (P = .36). CONCLUSIONS: This meta-analysis demonstrated that patients treated with EAP were less likely to develop a PJI relative to those treated with the SoC for all TJA, primary TJA, primary THA, aseptic revision TJA, and aseptic revision TKA. There was no significant difference observed between EAP and SoC for primary TKA or aseptic revision THA.

Chat Generative Pretrained Transformer (ChatGPT) and Bard: Artificial Intelligence Does not yet Provide Clinically Supported Answers for Hip and Knee Osteoarthritis.

BACKGROUND: Advancements in artificial intelligence (AI) have led to the creation of large language models (LLMs), such as Chat Generative Pretrained Transformer (ChatGPT) and Bard, that analyze online resources to synthesize responses to user queries. Despite their popularity, the accuracy of LLM responses to medical questions remains unknown. This study aimed to compare the responses of ChatGPT and Bard regarding treatments for hip and knee osteoarthritis with the American Academy of Orthopaedic Surgeons (AAOS) Evidence-Based Clinical Practice Guidelines (CPGs) recommendations. METHODS: Both ChatGPT (Open AI) and Bard (Google) were queried regarding 20 treatments (10 for hip and 10 for knee osteoarthritis) from the AAOS CPGs. Responses were classified by 2 reviewers as being in "Concordance," "Discordance," or "No Concordance" with AAOS CPGs. A Cohen's Kappa coefficient was used to assess inter-rater reliability, and Chi-squared analyses were used to compare responses between LLMs. RESULTS: Overall, ChatGPT and Bard provided responses that were concordant with the AAOS CPGs for 16 (80%) and 12 (60%) treatments, respectively. Notably, ChatGPT and Bard encouraged the use of non-recommended treatments in 30% and 60% of queries, respectively. There were no differences in performance when evaluating by joint or by recommended versus non-recommended treatments. Studies were referenced in 6 (30%) of the Bard responses and none (0%) of the ChatGPT responses. Of the 6 Bard responses, studies could only be identified for 1 (16.7%). Of the remaining, 2 (33.3%) responses cited studies in journals that did not exist, 2 (33.3%) cited studies that could not be found with the information given, and 1 (16.7%) provided links to unrelated studies. CONCLUSIONS: Both ChatGPT and Bard do not consistently provide responses that align with the AAOS CPGs. Consequently, physicians and patients should temper expectations on the guidance AI platforms can currently provide.

Spinal anesthesia in elective lumbar spinal surgery.

Spinal anesthesia (SA) is gaining recognition as a safe and efficacious regional alternative to general anesthesia for elective lumbar surgery. However, unfamiliarity with management issues related to its use has limited the adoption of awake spine surgery, despite its benefits. Few centers in the United States routinely offer SA for elective lumbar surgery, and a comprehensive workflow to standardize SA for lumbar surgery is lacking. In this article, we examine recent literature on the use of SA in lumbar surgery, review the experience of our institution with SA in lumbar surgery, and provide a cohesive outline to streamline the implementation of SA from the perspective of the anesthesiologist. We review the critical features of SA in contemporary lumbar surgery, including selection of patients, methods of SA, intraoperative sedation, and management of several important technical considerations. We aimed to flatten the learning curve to improve the availability and accessibility of the technique for eligible patients.

Single position L5-S1 lateral ALIF with simultaneous robotic posterior fixation is safe and improves regional alignment and lordosis distribution index.

PURPOSE: Minimally invasive single position lateral ALIF at L5-S1 with simultaneous robot-assisted posterior fixation has technical and anatomic considerations that need further description. METHODS: This is a retrospective case series of single position lateral ALIF at L5-S1 with robotic assisted fixation. End points included radiographic parameters, lordosis distribution index (LDI), complications, pedicle screw accuracy, and inpatient metrics. RESULTS: There were 17 patients with mean age of 60.5 years. Eight patients underwent interbody fusion at L5-S1, five patients at L4-S1, two patients at L3-S1, and one patient at L2-S1 in single lateral position. Operative times for 1-level and 2-level cases were 193 min and 278 min, respectively. Mean EBL was 71 cc. Mean improvements in L5-S1 segmental lordosis were 11.7 ± 4.0°, L1-S1 lordosis of 4.8 ± 6.4°, sagittal vertical axis of - 0.1 ± 1.7 cm°, pelvic tilt of - 3.1 ± 5.9°, and pelvic incidence lumbar-lordosis mismatch of - 4.6 ± 6.4°. Six patients corrected into a normal LDI (50-80%) and no patients became imbalanced over a mean follow-up period of 14.4 months. Of 100 screws placed in lateral position with robotic assistance, there were three total breaches (two lateral grade 3, one medial grade 2) for a screw accuracy of 97.0%. There were no neurologic, vascular, bowel, or ureteral injuries, and no implant failure or reoperation. CONCLUSION: Single position lateral ALIF at L5-S1 with simultaneous robotic placement of pedicle screws by a second surgeon is a safe and effective technique that improves global alignment and lordosis distribution index.

Intraoperative Triggered Electromyography for Pedicle Screw Placement Under Spinal Anesthesia: A Preliminary Report.

BACKGROUND: Triggered electromyography (tEMG) is an intraoperative neuromonitoring technique used to assess pedicle screw placement during instrumented fusion procedures. Although spinal anesthesia is a safe alternative to general anesthesia in patients undergoing lumbar fusion, its use may potentially block conduction of triggered action potentials or may require higher threshold currents to elicit myotomal responses when using tEMG. Given the broad utilization of tEMG for confirmation of pedicle screw placement, adoption of spinal anesthesia may be hindered by limited studies of its use alongside tEMG. OBJECTIVE: To investigate whether spinal anesthesia affects the efficacy of tEMG, we compare the baseline spinal nerve thresholds during lumbar fusion procedures under general vs spinal anesthesia. METHODS: Twenty-three consecutive patients (12 general and 11 spinal) undergoing single-level transforaminal lumbar interbody fusion were included in the study. Baseline nerve threshold was determined through direct stimulation of the spinal nerve using tEMG. RESULTS: Baseline spinal nerve threshold did not differ between the general and spinal anesthesia cohorts (3.25 ± 1.14 vs 3.64 ± 2.16 mA, respectively; P = .949). General and spinal anesthesia cohorts did not differ by age, body mass index, American Society of Anesthesiologists score status, or surgical indication. CONCLUSION: We report that tEMG for pedicle screw placement can be safely and effectively used in procedures under spinal anesthesia. The baseline nerve threshold required to illicit a myotomal response did not differ between patients under general or spinal anesthesia. This preliminary finding suggests that spinal anesthetic blockade does not contraindicate the use of tEMG for neuromonitoring during pedicle screw placement.

Periprocedural Polypharmacy in Lumbar Fusions Performed Under Spinal Anesthesia Compared With General Anesthesia.

BACKGROUND: Spinal anesthesia (SA) is a safe and effective alternative to general endotracheal anesthesia (GEA) for lumbar surgery. Foremost among the reasons to avoid GEA is the desire to minimize postoperative cognitive dysfunction (POCD). Although POCD is a complex and multifactorial entity, the risk of its development has been associated with anesthetic modality and perioperative polypharmacy, among others. OBJECTIVE: To determine whether SA reduced polypharmacy compared with GEA in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: Demographic and procedural data of 424 consecutive TLIF patients were extracted retrospectively. Patients undergoing single-level TLIF through GEA (n = 186) or SA (n = 238) were enrolled into our database. Perioperative medications, excluding antibiotic prophylaxis and local anesthetics, were classified into various categories. RESULTS: Patients in the SA cohort received a mean of 4.5 medications vs a mean of 10.5 medications in the GEA cohort ( P < .0001). This reduction in perioperative medications remained significant after a multivariate analysis to control for confounders ( P < .001 for all variables). The use of vasopressors was significantly reduced in the SA cohort ( P < .001), which coincided with a significant reduction in hypotensive episodes ( P < .001). Patients undergoing TLIF through GEA had 3.6 times greater odds of experiencing a hypotensive episode intraoperatively (odds ratio = 3.62, 95% CI [2.38-5.49]). CONCLUSION: Spinal anesthesia is associated with a significant decrease in perioperative medications and may confer superior intraoperative hemodynamic stability, which lowers pressor requirements. The decrease of perioperative medications may be an important contribution in reducing the incidence of POCD in patients undergoing TLIFs, although this requires further study.

Do Patients with Paget's Disease Have Worse Outcomes following Primary Total Knee Arthroplasty?

Well-powered studies evaluating the effects of Paget's disease on patient outcomes following primary total knee arthroplasty (TKA) are limited. The objective of this study was to determine whether Paget's disease patients undergoing primary TKA have higher rates of complications. A query of an administrative database was performed identifying Paget's disease patients undergoing primary TKA as the study cohort. Patients who did not have Paget's disease served as a matching cohort. Study group patients were matched in a 1:5 ratio by age, sex, and comorbidities. The query yielded 34,284 patients in the study (n = 5,714) and matched (n = 28,570) cohorts. Outcomes analyzed included length of stay (LOS), costs of care, 90-day medical and surgical complications, and 2-year implant-related complications. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of complications. Paget's disease patients undergoing primary TKA were found to have significantly longer in-hospital LOS (4 vs. 3 days, p < 0.0001). Study group patients incurred significantly higher 90-day episode-of-care costs ($15,124.55 vs. $14,610.01, p < 0.0001). Additionally, Paget's disease patients were found to have higher incidences and odds of medical/surgical (25.93 vs. 13.58%; OR: 1.64, p < 0.0001) and implant-related complications (8.97 vs. 5.02%; OR: 1.71, p < 0.0001). Specifically, Paget's disease patients were more likely to have periprosthetic fractures, mechanical loosening, and revision TKAs (p < 0.0001). This study demonstrated that Paget's disease was associated with longer in-hospital LOS, increased costs, and higher rates of complications. The study can be utilized by physicians to adequately educate patients with Paget's disease concerning potential complications following their primary TKA.

Midterm Results of Contemporary Uncemented Total Hip Arthroplasty in Patients 45 Years or Younger.

Total hip arthroplasty (THA) in young patients has varying results, and some reports show inferior results when compared with those of older patients. This study evaluated the outcomes of contemporary uncemented THA in patients 45 years or younger. This was a retrospective review from 2003 to 2015 at an academic institution. Three hundred one uncemented THAs in 232 patients 45 years or younger were evaluated. All patients had a minimum follow-up of 5 years. Ninety-day complications, survivorship free of revision, and dislocations were evaluated. Mean age was 35.7 years, 43.1% of patients were women, and mean follow-up was 9.3 years. Ninety-day complications included 26 emergency department visits, 11 readmissions, 3 revisions, and 3 dislocations. The rate of 10-year survivorship free of revision was 85.5%, and the rate of 10-year survivorship free of aseptic revision was 87.7%. Excluding metal-on-metal (MOM) THAs, 10-year aseptic survivorship was 93.3%. The most common reasons for revision were adverse local tissue reaction after MOM THA (16 hips) and periprosthetic joint infection (6 hips). In a multivariable logistic regression model, sickle cell disease (SCD) and conversion THA were associated with 90-day readmissions. Both MOM THA and SCD were associated with revision (P<.05). Patients who are 45 years or younger undergoing THA (excluding MOM articulation) had a rate of 10-year survival free of aseptic revision of 93.3%. At 9.3 years' mean follow-up, THA in young patients was associated with low revision rates with acceptable risk of prosthetic joint infection and dislocation. Patients with SCD are at increased risk for early readmission and revision at latest follow-up. [Orthopedics. 2023;46(1):e45-e51.].

Body Mass Index and American Society of Anesthesiologists Score Predict Perioperative Delays in Different Phases for Total Hip Arthroplasty.

Perioperative efficiency has become increasingly important with cost constraints and expanding indications for total hip arthroplasty (THA). We chose to analyze body mass index (BMI) and American Society of Anesthesiologists (ASA) score, in predicting perioperative efficiency. We retrospectively reviewed the institutional database for primary THAs from July 2015 to January 2018. Patient demographics and perioperative times lines were collected. A multivariable model was utilized to evaluate BMI (< 30, ≥ 30) and ASA (< 3, ≥ 3) for all outcomes. A total of 2,934 patients were included with mean age 62.0 (12.2) years, and 1,599 (54.5%) were female. A BMI ≥ 30 was associated with prolonged operative time (p < 0.001) while an ASA ≥ 3 was predictive of post-anesthesia care unit time (p < 0.001), physical therapy hours (p < 0.001), and length of stay (p < 0.001). Both BMI (p = 0.004) and ASA (p < 0.001) were associated with skilled nursing/rehabilitation dispositions. While BMI predicts prolonged operative time, ASA predicts perioperative delays for anesthesia, nursing, and physical therapy. (Journal of Surgical Orthopaedic Advances 32(3):169-172, 2023).