Lower Intraoperative and Immediate Postoperative Complications in Robotic Versus Conventional Primary Total Hip Arthroplasty: A Retrospective Cohort Analysis of Over 360,000 Patients.

PURPOSE: Although a trend of an improved alignment with robotic total hip arthroplasty (THA) over conventional methods has surfaced from recent series, it is unknown whether these results translate into meaningful enhancements in postoperative outcomes. To address this lack in the literature, we compared the perioperative morbidity and mortality with robotic and conventional THA in a large national cohort of 367,894 patients. We hypothesized that no significant differences would exist in the outcomes between the two groups. METHODS: Records were extracted from 2016-2019 from the National Inpatient Sample (NIS) database Healthcare Cost and Utilization Project which is the largest in-patient database in the United States. From 367,894 THAs, robotics were employed for 7,863 patients. The remaining 360,031 conventional THAs served as controls. The two groups were compared for demographics, admission, and hospital stay details including costs, and mortality and morbidity data including medical and surgical complications. Descriptive statistics were used for demographic data while analytical statistics including t-tests, chi-squared tests, Fischer exact test, and Pearson chi-squared tests were used for perioperative outcomes. Statistical significance was set at p<0.005. RESULTS: Demographic distributions between robotic and conventional THA groups displayed similar age and sex characteristics. Shorter mean lengths of stay (1.87 days) were seen in robotic THA versus conventional THA (2.33 days) while higher costs were noted for the former (mean $68,686.71 vs $66,840.39) (p<0.005). Low overall mortality (0.03% robotic, 0.09% conventional) was seen in both groups (p>0.005). Higher comparative incidences of anemia, acute renal failure, and pneumonia were seen in conventional THA (p<0.005) while no significant differences were noted for other complications including myocardial infarction, pulmonary embolism, deep vein thrombosis, and cardiac arrest (p>0.005). Among others, lower dislocation rates, mechanical complications, periprosthetic joint infection, and periprosthetic fractures were seen with robotic THA (p<0.005). Wound complications and superficial infection rates did not differ between the two groups (p>0.005). CONCLUSIONS: Evidence has emerged from our results to support more routine adaptation of the robotic option of performing a THA. These can be based on lower local, systemic, and mechanical complications as demonstrated by the present study. Further evaluation of these results in follow-up would help establish the foothold of robotic surgery in total hip replacement in the modern context.

The shifting trends in the epidemiology and risk factors of non-accidental fractures in children.

BACKGROUND: Fractures are a common presentation of non-accidental trauma (NAT) in the pediatric population. However, the presentation could be subtle, and a high degree of suspicion is needed not to miss NAT. OBJECTIVE: To analyze a comprehensive database, providing insights into the epidemiology of fractures associated with NAT. PARTICIPANTS AND SETTING: The TriNetX Research Network was utilized for this study, containing medical records from 55 healthcare organizations. TriNetX was queried for all visits in children under the age of 6 years from 2015 to 2022, resulting in a cohort of over 32 million. METHODS: All accidental and non-accidental fractures were extracted and analyzed to determine the incidence, fracture location, and demographics of NAT. Statistical analysis was done on a combination of Python and Epipy. RESULTS: Overall, 0.36 % of all pediatric patients had a diagnosis of NAT, and 4.93 % of fractures (34,038 out of 689,740 total fractures) were determined to be non-accidental. Skull and face fractures constituted 17.9 % of all NAT fractures, but rib/sternum fractures had an RR = 6.7 for NAT. Children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD) had a 9 times higher risk for non-accidental fractures. The number of non-accidental fractures significantly increased after 2019. CONCLUSIONS: The study findings suggest that nearly 1 out of all 20 fractures in children under age 6 are caused by NAT, and that rib/sternum fractures are most predictive of an inflicted nature. The study also showed a significant increase in the incidence of NAT, during and after the pandemic.

Rate and Risk Factors for Contralateral Slippage in Adolescents Treated for Slipped Capital Femoral Epiphysis: A Comprehensive Analysis of 3,528 Cases.

BACKGROUND: After a unilateral slipped capital femoral epiphysis (SCFE), the contralateral hip is at risk for a subsequent SCFE. However, further information with regard to risk factors involved in the development of contralateral SCFE must be investigated. The purpose of this study was to report the rate and risk factors for subsequent contralateral SCFE in adolescents treated for unilateral SCFE by exploring a mix of known and potential risk factors. METHODS: A case-control study utilizing aggregated multi-institutional electronic medical record data between January 2003 and March 2023 was conducted. Patients <18 years of age diagnosed with SCFE who underwent surgical management were included. Variables associated with contralateral SCFE were identified using multivariable logistic regression models that adjusted for patient characteristics and time of the surgical procedure, providing adjusted odds ratios (ORs). The false discovery rate was accounted for via the Benjamini-Hochberg method. RESULTS: In this study, 15.3% of patients developed contralateral SCFE at a mean (and standard error) of 296.53 ± 17.23 days and a median of 190 days following the initial SCFE. Increased thyrotropin (OR, 1.43 [95% confidence interval (CI), 1.04 to 1.97]; p = 0.022), diabetes mellitus (OR, 1.67 [95% CI, 1.22 to 2.49]; p = 0.005), severe obesity (OR, 1.81 [95% CI, 1.56 to 2.57]; p < 0.001), history of human growth hormone use (OR, 1.85 [95% CI, 1.10 to 3.38]; p = 0.032), low vitamin D (OR, 5.75 [95% CI, 2.23 to 13.83]; p < 0.001), younger age in boys (under 12 years of age: OR, 1.85 [95% CI, 1.37 to 2.43]; p < 0.001) and in girls (under 11 years of age: OR, 1.47 [95% CI, 1.05 to 2.02]; p = 0.026), and tobacco exposure (OR, 2.43 [95% CI, 1.49 to 3.87]; p < 0.001) were significantly associated with increased odds of developing contralateral SCFE. CONCLUSIONS: In the largest study on this topic, we identified the rate, odds, and risk factors associated with development of contralateral SCFE. We found younger age, hypothyroidism, severe obesity, low vitamin D, diabetes mellitus, and a history of human growth hormone use to be independent risk factors. Our findings can aid clinical decision-making in at-risk patients. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Effect of Human Growth Hormone Treatment on the Development of Slipped Capital Femoral Epiphysis: A Cohort Analysis With 6 Years of Follow-up.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is a common hip disorder in adolescents that can result in substantial complications, impacting the quality of life. Human Growth Hormone (HGH) administration may elevate the risk of SCFE, though the relationship remains unclear. Clarifying this association could enable better monitoring and earlier diagnosis of SCFE in patients receiving HGH. The aim of the study is to investigate the association between HGH administration and the incidence of SCFE. METHODS: This retrospective cohort study utilized data from the TriNetX research database from January 2003 to December 2022. The study included 2 cohorts: an HGH cohort including 36,791 patients aged below 18 years receiving HGH therapy and a control group consisting of patients who did not receive HGH therapy. A 1:1 propensity score matching technique was employed to ensure comparability between the HGH and no-HGH cohorts. The primary outcome measure was the development of SCFE identified by International Classification of Diseases codes. For comparative analysis, both risk ratios (RR) and hazard ratios were computed to evaluate the association between HGH therapy and the development of SCFE. RESULTS: The HGH cohort had an increased risk of SCFE compared with the no-HGH cohort (RR: 3.5, 95% CI: 2.073, 5.909, P <0.001) and had an increased hazard of developing SCFE (hazard ratio: 2.627, 95% CI: 1.555, 4.437, P <0.001). Patients with higher exposure to HGH (defined as >10 prescriptions) had an RR of 1.914 (95% CI: 1.160, 3.159, P =0.010) when compared with their counterparts with ≤10 prescriptions. CONCLUSIONS: In the largest study to date, HGH administration was associated with an elevated risk of SCFE in children in a dose-dependent manner. LEVEL OF EVIDENCE: Level III-therapeutic retrospective cohort study.

Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures.

BACKGROUND: Complex regional pain syndrome (CRPS) is a multifactorial condition that may affect patients who sustain a fracture in the upper and lower extremities. Prior investigations have formed a foundation for exploring a possible association between psychiatric disorders and the development of CRPS; however, current studies are conflicted regarding the existence and temporality of a relationship between psychiatric disorders and the potential development of CRPS. QUESTIONS/PURPOSES: (1) Are patients with preexisting anxiety and mood disorders (AMDs) at increased risk of receiving a diagnosis of CRPS after upper or lower extremity fractures? (2) Are patients with preexisting AMDs at increased risk of being diagnosed with CRPS after surgical fixation of their fracture? METHODS: A large, retrospective cohort study was conducted using the TriNetX electronic medical record platform, which contains data from more than 100 million patients. This platform gathers data from healthcare organizations in the United States and Europe and collects comprehensive data over time that includes temporality rather than simply the binary presence or absence of conditions. The cohort included 760,595 patients older than 18 years with upper or lower extremity fractures between 2003 and 2022. Included patients had a minimum 1-year follow-up. We defined AMDs as any diagnosis of anxiety, depressive episode or disorder, a manic episode, or bipolar disorder. Patients with polytrauma or concurrent upper and lower extremity fractures were excluded to reduce confounders. CRPS I diagnosis was identified via International Classification of Diseases, Tenth Edition codes. Propensity score matching was performed to balance cohorts based on age, gender, and race. Hazard ratios and Aalen-Johansen cumulative incidence curves for the diagnosis of CRPS were calculated for patients with and without AMD diagnoses before sustaining a fracture. A subanalysis was performed in which we examined individuals in the upper and lower extremity fracture cohorts who underwent surgical treatment. RESULTS: Patients with preexisting AMDs were at a higher risk of experiencing CRPS I than patients without AMDs were (upper extremity: HR 1.8 [95% CI 1.7 to 1.9]; p < 0.01, lower extremity: HR 2.2 [95% CI 2.0 to 2.3]; p < 0.01). Similarly, patients with preexisting AMDs were at higher risk of experiencing CRPS I after fracture fixation than patients without AMDs were (upper extremity: HR 1.3 [95% CI 1.2 to 1.5]; p < 0.01, lower extremity: HR 2.3 [95% CI 2.1 to 2.5]; p < 0.01). CONCLUSION: Awareness of the relationship between AMDs and CRPS I will direct future research about the development of this condition and associated neurologic changes. Additionally, surgeons can address AMDs perioperatively and arrange for the treatment of these AMDs with psychiatrists, neurologists, or social work, as appropriate. Accordingly, patients with AMDs should also be made aware of the inherent risk of CRPS I after an upper or lower extremity fracture to comprehensively educate and care for this at-risk patient population. LEVEL OF EVIDENCE: Level III, therapeutic study.

Emerging Strategies in Treating Corneal Alkali Burns: A Narrative Review.

Corneal alkali burns represent a complex and debilitating ocular injury, necessitating innovative strategies for effective management. This narrative medical review seeks to provide a comprehensive exploration of emerging approaches in the treatment of corneal alkali burns. The primary objectives of this review are multifaceted. First, we aim to unravel the intricate pathophysiology of corneal alkali burns, delving into the immediate and long-term consequences of alkali exposure on ocular tissues. Understanding the underlying mechanisms, including oxidative stress, inflammation, and neovascularization, is essential for the development of targeted therapeutic interventions. Second, we assess the efficacy of novel treatment modalities, encompassing pharmacological agents and surgical techniques, with a focus on their ability to mitigate corneal damage, facilitate tissue regeneration, and preserve visual function. By analyzing the latest clinical findings, we aim to identify promising avenues for improved patient outcomes. Temporal dynamics play a crucial role in the healing process, and thus our review investigates the progression of corneal lymphangiogenesis and the expression patterns of key growth factors, such as vascular endothelial growth factor-C (VEGF-C). These insights into the timing of corneal healing provide valuable guidance for tailoring therapeutic interventions to specific stages of injury. Finally, we delve into regenerative therapies, particularly the potential of mesenchymal stem cells (MSCs) and their secretome as anti-inflammatory and antiangiogenic agents. By summarizing the promising results from preclinical and clinical studies, we illuminate the prospects of regenerative approaches in corneal alkali burn management. This narrative review aspires to serve as an indispensable resource for clinicians, researchers, and healthcare professionals involved in the treatment of corneal alkali burns. By addressing these objectives, we aim to foster a deeper understanding of this challenging condition, facilitate the development of innovative strategies, and ultimately enhance patient outcomes in the realm of corneal health and vision preservation.

Duramesh registry study: short-term outcomes using mesh suture for abdominal wall closure.

Introduction: Sutures are flexible linear elements that join tissue and maintain their hold with a surgeon-created knot. Tension at the suture/tissue interface can cut the very tissues that sutures are designed to hold, leading to dehiscence and incisional hernia formation. A new suture design (Duramesh, Mesh Suture Inc., Chicago, IL) was approved for marketing by the United States Food and Drug Administration in September 2022. The multiple filaments of the mesh suture are designed to diffuse tension at the suture/tissue interface thereby limiting pull-through. The macroporosity and hollow core of the mesh suture encourage fibrovascular incorporation for a durable repair. We created the first registry and clinical report of patients undergoing mesh suture implantation to assess its real-world effectiveness. Methods: A patient registry was created based on institutional implant logs from January to August 2023 at an integrated health-care system. Operative reports were reviewed by the study team to verify use of "Duramesh" by dictation. Retrospective chart review was conducted to evaluate patient and surgical characteristics, follow-up, and short-term outcomes of interest. Results were analyzed using descriptive statistics and Chi-squared analysis with Microsoft Excel and GraphPad Prism. Results: Three hundred seventy-nine separate implantations by 56 surgeons across 12 (sub) specialties at a university hospital and two community hospitals were performed. Mesh suture was used for treatment of the abdominal wall in 314 cases. Follow-up averaged 80.8 ± 52.4 days. The most common abdominal wall indications were ventral hernia repair (N = 97), fascial closure (N = 93), abdominal donor site closure from autologous breast reconstruction (N = 51), and umbilical hernia repair (N = 41). Mesh suture was used in all Centers for Disease Control (CDC) wound classifications, including 92 CDC class 2 or 3 abdominal operations. There were 19 surgical site infections (6.1%) and 37 surgical site events (11.8%). Conclusions: Short-term registry data demonstrates the wide diversity of surgical disciplines and scenarios in which mesh suture has been used to date. The early adoption of mesh suture into practice highlights that consequences of suture pull-through influence operative decision making. As this is the first interim report of the Duramesh mesh suture registry, follow-up is too short for characterization of long-term durability of abdominal wall closures.