Chronic Supraspinatus Tendonitis Pain: An Integrative Approach for Treatment with Cross-Fiber Massage, Electroacupuncture, Far-Infrared Heat, and Photobiomodulation.

Objective: More than 70 million Americans suffer from chronic pain; many cases are related to sports injuries. This type of injury often involves soft tissues (muscles, tendons, and ligaments). Direct-force injury (e.g., impact trauma) and indirect-force injury (e.g., repetitive motion) are normally the cause of strained muscles, sprained ligaments, and tendonitis. The standard of acute care is RICE [rest, ice, compression, and elevation] plus anti-inflammatory medication. While this regimen often relieves acute pain, the consequence of the long-term use is chronic pain due to un-remodeled scar-tissue formation. The goal of this article is to show how a combination of integrative modalities can be used to relieve the pain caused by such injuries and their sequelae. Materials and Methods: This article focuses on a combination of clinical modalities that integrate osteopathic cross-fiber massage, microcurrent electroacupuncture, far-infrared heat, and photobiomodulation to break up the scar tissue and reactivate the body's intrinsic repair mechanism. Chronic shoulder pain, associated with supraspinatus tendonitis is used here, to illustrate this integrative treatment in an acupuncture clinic setting. Results: This method heals chronic pain from an injury with clinic visits, twice per week, for 3-5 weeks. Conclusions: More clinical and research studies are recommended to validate this approach for this condition and other soft-tissue traumata.

Outcomes of Hip Arthroscopy in the Medicare Patient: A Growing Population.

Background: Although the results of hip arthroscopy in the elderly have been inferior to the results in younger patients, there have recently been some encouraging reports in carefully selected series of older patients. The purpose of this study was to identify the utilization of hip arthroscopy in the Medicare population and to determine the rate and timing of revision arthroscopy and/or total hip arthroplasty (THA) with the goal of identifying risk factors for secondary procedures based on patient demographics, comorbidities and the diagnosis at the time of arthroscopy. Methods: The Medicare Standard Analytic Files were reviewed from 2005-2014 for all patients undergoing hip arthroscopy allowing for minimum 2 year follow-up (100% sample). Patients were tracked through the dataset for the occurrence of an ipsilateral THA or revision hip arthroscopy. Rates and timing of the subsequent procedures were then determined within 6 month intervals. Patients less than 65 years old were excluded. Multivariate logistic regression analysis was performed to determine the impact of patient age, sex, obesity or a diagnosis of hip osteoarthritis on need for revision procedures. Results: 3,320 Medicare patients had a hip arthroscopy during 2005-2014 (0.3% compared to THA). 73 patients (2.2%) underwent reoperation during the follow-up period. Two-thirds (n = 46) of all revision procedures occurred within one year of primary hip arthroscopy. A pre-operative diagnosis of hip osteoarthritis significantly increased the odds of reoperation (OR = 5.3). (Conclusion: Relatively few numbers of Medicare patients underwent hip arthroscopy during the time interval evaluated (0.3% when compared to THA utilization). 2.2% underwent a subsequent revision arthroscopy or THA with many occurring soon after the procedure and for the diagnosis of hip OA demonstrating the need to better define indications in this population. This study should provide baseline utilization and outcome trends for future studies.Level of Evidence: IV.

Reversal of warfarin-coagulopathy: How to improve plasma transfusion practice in a community hospital setting?

BACKGROUND: Plasma is often given inappropriately to reverse warfarin-induced coagulopathy, wasting health-care resources and exposing the patients to transfusion-associated risks. AIMS: The clinical practice at our institution was evaluated in order to reduce the number of unnecessary plasma transfusions. MATERIALS AND METHODS: Retrospective audit of plasma transfusions was done (July 2014 to June 2015). DESIGN: To improve the clinical practice, a two-prong strategy was implemented: (1) in-service was given to clinicians on the warfarin-reversal guidelines and (2) for a 30-day period, plasma orders were placed on the approval list of the Transfusion Medicine Service. RESULTS: Of the 729 units of plasma, 189 (26% of total) were given for the reversal of warfarin-induced coagulopathy. The medical charts of these patients were reviewed: 46 units of plasma (~25%) were given inappropriately (e.g., patients with minimally elevated international normalized ratio, no evidence of bleeding, and no surgery within 24 h). To check the effectiveness of our intervention, two audits of plasma transfusions were done. During the first audit (January 1-February 29, 2016), 24 patients received plasma to reverse warfarin-coagulopathy. Medical chart review revealed that the vast majority of plasma orders (96.66%) followed the guidelines. A second audit was carried out a year later (January 1-March 31, 2017): during this 3-month period, 47 patients were transfused with plasma for warfarin reversal with a 94% adherence to the guidelines. CONCLUSION: We conclude that plasma transfusion practices may be improved by a combination of education and active enforcement of warfarin reversal guidelines.

Ganglion Cyst as a Rare Complication of Hip Arthroscopy Resolved With THA: A Case Report.

Background: A rare complication of hip arthroscopy is the development of a ganglion cyst. These cysts can affect structures surrounding the hip joint. In some cases, the femoral artery may be involved, leading to claudication or a pulsatile mass that can resemble an aneurysm. Case Description: We present the case of a 62 year-old male who complains of 3 months of right hip pain. Workup reveals a degenerative labrum with cam impingement. After a discussion of various treatment options, the patient elected for arthroscopy to correct the impingement. An anterior capsulotomy was created to establish access to the joint. Cam decompression was indicated to address the impingement. The patient developed a recurring ganglion cyst following the procedure that was not permanently prevented with cyst aspiration. Total hip arthroplasty with ganglion cyst decompression resolved the ganglion cyst and resolved the hip pain. Conclusions: This is the first case report that describes the development of a ganglion cyst following hip arthroscopy. Arthroplasty and ganglion cyst decompression in the presence of degenerative joint disease presents a viable treatment option for these cysts. Additionally, this case suggests interportal capsulotomy closure may prevent ganglion cyst development and should be considered when performing hip arthroscopy.

Preoperative Opioid Use and Its Association With Early Revision of Total Knee Arthroplasty.

BACKGROUND: Few studies have evaluated the impact of preoperative opioid use on risk of subsequent revision following primary total knee arthroplasty (TKA). The purpose of this study was to determine whether preoperative opioid use is associated with an increased risk of early revision TKA. METHODS: The Humana administrative claims database was queried to identify patients who underwent unilateral TKA during the years 2007-2015. Patients were tracked for the occurrence of an ipsilateral revision procedure within 2 years. Preoperative opioid use was defined as having an opioid prescription filled within the 3 months before TKA. Age, sex, diabetes, obesity, chronic kidney disease, and anxiety/depression were also analyzed. Univariate and multivariate analyses were performed. RESULTS: A total of 35,894 primary TKA patients were identified and 1.2% (n = 413) had a revision TKA procedure within 2 years. 29.2% of patients filled an opioid prescription within the 3 months before TKA. Preoperative opioid users were significantly more likely to undergo early TKA revision (1.6% vs 1.0%, P < .001). Preoperative opioid use (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.25-1.88; P < .001), younger age (OR, 2.46; 95% CI, 1.43-3.95; P < .001), obesity (OR, 1.25; 95% CI, 1.01-1.56; P = .04), and smoking (OR, 1.66; 95% CI, 1.22-2.22; P < .001) were associated with early revision TKA. CONCLUSION: This study identified preoperative opioid use as being independently associated with a greater risk for an early revision TKA. Younger age, obesity, and smoking were also associated with elevated risk. These findings support efforts to reduce inappropriate opioid prescribing.

Does Preoperative Opioid Use Increase the Risk of Early Revision Total Hip Arthroplasty?

BACKGROUND: The purpose of this study is to evaluate the impact of preoperative opioid use on the risk of subsequent revison after primary total hip arthroplasty (THA). METHODS: The Humana database was queried for unilateral THA between 2007-2015. Patients were tracked for the occurrence of an ipsilateral revision THA for 2 years. Factors analyzed included preoperative opioid use (defined as a history of opioid prescription filled within 3 months preceding primary THA), age, sex, diabetes, anxiety/depression, chronic kidney disease, and obesity (body mass index > 30 kg/m2). Multivariate logistic regression analysis was used to determine odds ratios. RESULTS: A total of 17,695 primary THA patients were analyzed and 0.88% (n = 155) underwent revision THA within 2 years. Preoperative opioid use occurred in 36.7% of all. Females comprised 58.7% of the total cohort and 80% were >50 years. Preoperative opioid users were significantly more likely to undergo early THA revision (1.2% vs 0.7%, P < .001). Other patient factors that significantly increased the risk of early THA revision included obesity (1.3% vs 0.8%, P = .03) and a preoperative diagnosis of anxiety/depression (1.9% vs 0.8%, P = .006). CONCLUSION: Opioid use within 3 months preceding THA independently predicts an increased risk of early revision. Additionally, independent predictors of early revision include obesity and a diagnosis of anxiety/depression. Factors such as these will need to be considered in risk adjustment models when assessing quality of care or implementing bundled payment initiatives. Further research is needed to evaluate whether discontinuing opioids before surgery mitigates this risk.

Recent Trends in Blood Utilization After Revision Hip and Knee Arthroplasty.

BACKGROUND: Blood transfusion guidelines in elective surgery have been implemented over the last decade to minimize risk and cost related to transfusion without sacrificing patient outcomes. Blood utilization in primary total hip (THA) and total knee arthroplasty (TKA) has been extensively studied but there is a paucity of studies evaluating utilization in revision THA and TKA. The purpose of this study is to evaluate current trends in transfusion following revision THA and TKA. METHODS: The Humana dataset was reviewed for transfusion trends from 2007 to 2015 for patients undergoing revision THA and TKA. Subgroup analysis was performed to evaluate the impact of age, gender, geographic location, and obesity. RESULTS: In total, 9176 and 12,493 revision THA and TKA patients were analyzed with transfusion rates of 19.2% and 11.9%, respectively. Allogeneic packed red blood cells were most commonly transfused (90% and 92%, respectively). Transfusion rates decreased significantly from 24.7% to 10.3% and 15.9% to 4.5%, respectively, over the years 2007-2015. Women had higher transfusion rates (odds ratio [OR] THA:TKA 1.24:1.23), while obesity was associated with lower transfusion rates after revision THA (OR 0.88). Transfusion rates were higher in 2-component revisions compared to primary (OR THA:TKA 1.24:1.24), while 1-component revisions had lower transfusion rates than primary procedures (OR THA:TKA 0.79:0.25). CONCLUSION: Transfusion rates after revision THA and TKA have fallen substantially since 2007. In 2016, only 10% and 4% of revision THA and TKA, respectively, required transfusion. The study should provide benchmark data for surgeons to use as comparison to the blood utilization following revision joint replacement at their institutions.

Are Trends in Total Hip Arthroplasty Bearing Surface Continuing to Change? 2007-2015 Usage in a Large Database Cohort.

BACKGROUND: Bearing surface issues related to trunnionosis or metal-on-metal (MoM) articulations have likely impacted recent trends in bearing surface choice. The purpose of this study is to evaluate trends in total hip arthroplasty (THA) bearing surface use, including 2015 data, with respect to the date of operation and patient demographics. METHODS: The Humana dataset was reviewed from 2007 through 2015 to analyze bearing surface usage in primary THA. Four bearing surface types were identified by International Classification of Disease, 10th Revision codes and trended throughout the years: metal-on-polyethylene (MoP), ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), and MoM. Prevalence was analyzed as a function of age and sex. RESULTS: Of the 28,504 primary THA procedures, the most commonly used bearing was MoP (46.1%), followed by CoP (33.2%), MoM (17.1%), and ceramic-on-ceramic (3.6%). The use of CoP bearings significantly increased from 6.4% in 2007 to 52.0% in 2015, while MoM bearings decreased during this period. MoP bearings decreased over 2012-2015 (P < .001). CoP usage decreased with age, while MoP bearings increased with a transition occurring at 65-69 years of age. Women were more likely to receive MoP bearings (odds ratio [OR] 1.2), while men were more likely to receive MoM and CoP bearings (OR 1.1). Multivariate logistic regression showed age to be an independent predictor of bearing surface choice with patients 65 and older more likely to receive MoP bearings (OR 3.2). CONCLUSION: Bearing surface choice in primary THA has changed tremendously from 2007 to 2015. MoM bearing use has decreased as a result of adverse effects. Age continues to remain a significant factor in bearing surface choice.

The John N. Insall Award: Do Intraarticular Injections Increase the Risk of Infection After TKA?

BACKGROUND: Infection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size. QUESTIONS/PURPOSES: The purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection. METHODS: The Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups. RESULTS: The proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively. CONCLUSIONS: Injection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection. LEVEL OF EVIDENCE: Level III, therapeutic study.

Topography of microglial activation in sensory- and affect-related brain regions in chronic pain.

Microglial activation in the spinal cord plays a central role in the development and maintenance of chronic pain after a peripheral nerve injury (PNI). There has not yet been a thorough assessment of microglial activation in brain regions associated with pain and reward. To this end, this study uses a mouse model of neuropathic pain in which the left sciatic nerve of male C57Bl/6J mice is loosely constricted (chronic constriction injury) to assess microglial activation in several brain regions 2 weeks after injury, a time point at which pain hypersensitivity is well established. We found significant microglial activation in brain regions associated with sensory pain transmission and affect, including the thalamus, sensory cortex, and amygdala. Activation was consistently most robust in brain regions contralateral to the side of injury. Brain regions not directly involved in either sensory or affective dimensions of pain, such as the motor cortex, did not display microglial activation. This study confirms that PNI induces microglial activation in regions involved with both sensory and affective components of pain. © 2016 Wiley Periodicals, Inc.

Recent Trends in Blood Utilization After Primary Hip and Knee Arthroplasty.

BACKGROUND: Blood conservation strategies have evolved greatly over the last 5 years. There is a paucity of large blood utilization studies of total hip arthroplasty (THA) and total knee arthroplasty (TKA) that include recently performed surgery. The purpose of this study was to use a large database to evaluate trends in blood transfusion after THA and TKA, including 2015 data. METHODS: The Humana data set was reviewed from 2007 to the third quarter of 2015 for all patients undergoing primary THA and TKA. Rates and type of postoperative blood transfusion were trended through the years of the data set. Further subgroup analysis was performed to evaluate the impact of patients' age, gender, geographic location, and obesity on the incidence of blood transfusion using standard statistical techniques. RESULTS: In total, 69,350 THA patients and 139,804 TKA patients were analyzed. Overall transfusion rate was 18.2% and 12.7% after TKA and THA, respectively. The most common type of blood transfused was allogeneic packed red blood cells (88% of all transfusions) followed by perioperative collected autologous blood (12% of all transfusions). There were no transfusions of preoperatively collected autologous blood. Transfusion rates decreased significantly from 21.3%-8.7% and 17.3%-4.4% for THA and TKA, respectively, over the years 2007-2015 (P < .001). CONCLUSION: Rates of blood transfusion after primary THA and TKA have fallen precipitously since 2010 and are now down to 9% and 4% for THA and TKA, respectively. Blood management strategies instituted over the last 5 years have had a large impact on transfusion rates after joint arthroplasty.

Two- to 4-Year Followup of a Short Stem THA Construct: Excellent Fixation, Thigh Pain a Concern.

BACKGROUND: Short stem cementless femoral components were developed to aid insertion through smaller incisions, preserve metaphyseal bone, and potentially decrease or limit the incidence of thigh pain. Despite some clinical success, the senior author (DDG) believed a higher percentage of his patients who had received a cementless short stem design were experiencing thigh pain, which, coupled with concerns about bone ingrowth fixation, motivated the review of this case series. QUESTIONS/PURPOSES: (1) What is the proportion of patients treated with a short stem cementless THA femoral component that develop thigh pain and what are the hip scores of this population? (2) What are the radiographic results, specifically with respect to bone ingrowth fixation and stress shielding, of this design? (3) Are there particular patient or procedural factors that are associated with thigh pain with this short stem design? METHODS: Two hundred sixty-one primary THAs were performed in 238 patients by one surgeon between November 2010 and August 2012. During this time period, all patients undergoing primary THA by this surgeon received the same cementless short titanium taper stem. Seven patients (eight hips) died and five patients (five hips) were lost to followup, leaving 226 patients (248 hips) with a mean followup of 3 years (range, 2-5 years). Patients rated their thigh pain during activity or rest at final followup on a 10-point visual analog scale. Harris hip scores (HHS) were obtained at every clinic appointment. Thigh pain was evaluated at the final followup or by contacting the patient by phone. Radiographs were evaluated for bone-implant fixation, bone remodeling, and osteolysis. An attempt was made to correlate thigh pain with patient demographics, implant specifications, or radiographic findings. RESULTS: Seventy-six percent of hips (180 of 238) had no thigh pain, 16% of hips (37 of 238) had mild thigh pain, and 9% (21 of 238) had moderate or severe thigh pain. Preoperatively, mean HHS was 47 (SD, 16) and at last followup, mean HHS was 88 (SD, 13). There were two femoral revisions, one for severe thigh pain and the other for infection. All but two components demonstrated bone ingrowth fixation (99%). Femoral stress shielding was mild in 64% of hips (135 of 212), moderate in 0.5% (one of 212), and severe in no hips. There is an inverse linear relationship between age and severity of thigh pain (r = -0.196; p < 0.0024). CONCLUSIONS: Although reliable fixation was achieved and good HHS were attained, the frequency and severity of thigh pain with this short cementless stem were concerning. The surgeon has subsequently abandoned this short stem design and returned to a conventional length stem. Future study direction might investigate the biomechanical grounds for the thigh pain associated with this stem design. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Minimum 10-Year Follow-Up of Cementless Total Hip Arthroplasty Using a Contemporary Triple-Tapered Titanium Stem.

BACKGROUND: There is extensive variation in design and insertion technique of cementless tapered femoral stems. The purpose of our study was to evaluate a consecutive series of contemporary tapered cementless femoral stems inserted with a ream-and-broach technique at a minimum 10-year follow-up in patients undergoing total hip arthroplasty (THA). METHODS: One hundred consecutive THAs (88 patients) performed by a single surgeon were followed for a minimum of 10 years. Hips were evaluated clinically for revision status, Western Ontario and McMaster Universities Osteoarthritis Index, 36-item Short Form Health Survey, Harris Hip Score, and University of California, Los Angeles, and Tegner Activity Scores. Radiographic evaluation included assessment for loosening, osteolysis, and stress shielding. Kaplan-Meier survivorship analysis included end points for revision and radiographic evidence of femoral component loosening. RESULTS: At minimum 10-year follow-up, 66 patients (74 hips) were living, 20 patients (24 hips) were deceased, and 2 patients (2 hips) were lost to follow-up. Four hips required reoperation, but no femoral components were revised for aseptic loosening. One femoral component (1%) was revised due to a postoperative periprosthetic fracture. Radiographic evaluation demonstrated bone ingrowth of all stems without evidence of component loosening and 1 case of severe stress shielding. Kaplan-Meier survivorship at 10 years was 100% for the end points of femoral revision for loosening or femoral radiographic loosening. CONCLUSION: This contemporary, cementless titanium-tapered femoral component inserted with ream-and-broach technique demonstrated excellent results in terms of outcomes and clinical durability as well as osteointegration on radiographs at minimum 10-year follow-up. This study corroborates, with level 2 and level 3 data, level 1 data reported in national registries.