Robotic-assisted Total Knee Arthroplasty Reduces Radiographic Outliers for Low-volume Total Knee Arthroplasty Surgeons.

Background: Most studies evaluating robotic-assisted total knee arthroplasty (RA TKA) analyzed the advantages offered to high-volume surgeons. This study aims to determine if RA TKA improves radiographic or clinical outcomes for low-volume, non-arthroplasty-trained surgeons. Methods: Radiographic and early clinical outcomes of 19 RA TKAs and 41 conventional TKAs, all performed by a single, non-arthroplasty-trained orthopaedic surgeon, were compared. Radiographic outliers were based on surgeon targets and defined as tibial posterior slope outside of 0°-5°, tibial tray varus outside of 0°-3°, and the presence of notching. Clinical outcomes included inpatient narcotic usage, length of stay, range of motion, and Patient-Reported Outcome Measurement Information System scores. Results: There was a significant decrease in tibial slope outliers (RA TKA 0% vs non-RA TKA 22%, P = .024) and notching incidence (RA TKA 0% vs non-RA TKA 19.5%, P = .044) in the RA group. Tibial tray varus/valgus outliers trended lower in the RA TKA group (10.0% vs 26.8%, P = .189). Length of stay was significantly shorter in RA patients (48.0 hours [standard deviation: 25.5] vs 67.7 hours [34.3], P = .038). RA patients trended toward lower in postoperative inpatient total mean morphine equivalents usage (79.9 [89.2] vs 140.1 [169.3], P = .142) and inpatient mean morphine equivalents usage per day (30.36 [26.9] vs 45.6 [36.7], P = .105). There was no significant difference in Patient-Reported Outcome Measurement Information System scores or range of motion at first and second postoperative follow-up within 3 months. Conclusions: RA TKA reduced the incidence of radiographic outliers when compared to conventional TKA for a low-volume arthroplasty surgeon.

Isolated Liner Exchange Versus All-Component Revision for Instability After Total Knee Arthroplasty.

BACKGROUND: Instability is a common cause for revision total knee arthroplasty (TKA). The risks and benefits of polyethylene liner exchange (LE) as compared to full metal component revision continue to be debated. The purpose of this study was to investigate the success rate and complication profiles of revision TKA for instability based on surgical procedure. METHODS: This was a retrospective study of patients undergoing revision TKA for instability from 2015 to 2019. Patients with prior revisions were excluded. 42 patients undergoing isolated polyethylene LE without an increase in constraint were compared with 48 patients undergoing full component revision revision (FCR) of both tibial and femoral components. The primary outcome was differences in rerevision for instability. Noninstability reoperations, 90-day readmissions, and lengths-of-stay were also compared. RESULTS: LEs had a 10.1% higher rerevision for instability rate that approached statistical significance (LE 14.3% versus FCR 4.2%, P = .092). Additionally, FCR had a 4.2% rate of aseptic loosening and a 4.2% rate of periprosthetic-joint-infection, whereas LE had none (P = .181). FCR also had a longer length-of-stay (FCR 3.0 ± 1.3 versus LE: 1.8 ± 0.9 days, P < .001). No differences were found in 90-day readmissions (LE 7.1% versus FCR 4.2%, P = .661). CONCLUSION: All component revision may have a higher success rate than isolated LE in addressing instability but is associated with higher rates of surgical complications. With appropriate patient selection and risk-benefit discussion, isolated LE may be a reasonable surgical option for TKA instability with a lower complication profile and length-of-stay.

Preoperative Depression Is Associated With Increased Short-term Complications But Equivalent Long-term Outcomes in Total Knee Arthroplasty.

Concomitant depression negatively impacts outcomes following total knee arthroplasty (TKA). Patient-Reported Outcomes Measurement Information System (PROMIS) surveys are validated measures that quantify depression, pain, and physical function. We hypothesized that higher preoperative PROMIS-depression scores would be associated with inferior outcomes following TKA. A total of 258 patients underwent primary TKA at a tertiary academic center between June 2018 and August 2020. PROMIS scores were collected preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. Patients with preoperative PROMIS depression scores of 55 or greater were considered PROMIS depressed (PD) and patients with scores less than 55 were considered not PROMIS depressed (ND). The primary outcomes were changes in PROMIS scores. Secondary outcomes included total and daily mean morphine milligram equivalents (MME) received during admission as well as 90-day hospital readmission and 2-year all-cause revision rates. There were 66 (25.58%) patients in the PD group and 192 (74.42%) in the ND group. Patients in the PD group had improved depression scores at all follow-up intervals (P<.001) and decreased pain scores at 1 year (P=.016). Both groups experienced similar changes in function scores at each follow-up interval. Patients in the PD group had higher total (P=.176) and daily (P=.433) mean MME use while admitted. Ninety-day hospital readmissions were higher in the PD group (P=.002). There were no differences in 2-year revision rates (P=.648). Preoperative PROMIS-depression scores of 55 or greater do not negatively impact postoperative function, depression, or pain, and patients with these scores have greater improvement in depression and pain at certain intervals. Patients in the PD group had higher readmission rates. [Orthopedics. 2024;47(1):40-45.].

Intra-Articular Corticosteroid Injections Into a Preexisting Total Knee Arthroplasty are Associated With Increased Risk of Periprosthetic Joint Infection and Revision.

Background: This study aims to determine the risks of periprosthetic joint infection (PJI) and revision associated with injecting a preexisting total knee arthroplasty (TKA) with intra-articular corticosteroids (IACSs). Methods: The PearlDiver database was used to identify patients who underwent elective, primary TKA between 2015 and 2019. Patients who received IACS injections into the ipsilateral knee within 1 year after their primary TKA were matched 2:1 on age, gender, and Charlson comorbidity index and compared to a no-injection control group. The incidence of PJI at 1 year postoperatively and revision at 2 years postoperatively were compared between groups. Results: A total of 27,059 patients were in the injection cohort and 54,116 patients in the control cohort. The overall PJI rate was 1.3% in the injection cohort and 0.8% in the control cohort (P < .001). The rate of PJI increased with the number of post-TKA IACS injections received: 1 injection (1.3%), 2 injections (1.4%), and >3 injections (1.8%) (P < .001 for all, compared to controls). The revision rate was 3.1% in the injection cohort and 1.3% in the control cohort (P < .001). Revision rates increased with the number of post-TKA IACS injections received: 1 injection (2.5%), 2 injections (4.2%), and >3 injections (7.3%) (P < .001 for all, compared to controls). Conclusions: IACS injections into a preexisting TKA are associated with an incremental increased risk of prosthetic joint infection and revision. Considering the potential deleterious impact of PJI and complexity of revision procedures, IACS injections into a preexisting TKA should be strongly discouraged.

Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters.

OBJECTIVE: To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN: Retrospective cohort study. SETTING: 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS: The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS: Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS: The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS: While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Higher Complication Rate in COVID-19 Recovered Patients Undergoing Primary Total Joint Arthroplasty.

BACKGROUND: There is limited data reviewing complication risks associated with total joint arthroplasty (TJA) after recovering from COVID-19. This study evaluated complications within 90 days of TJA in patients who had a COVID-19 diagnosis at varying intervals prior to surgery versus a non-COVID-19 cohort. METHODS: A large national database was used to identify patients diagnosed with COVID-19 in the six months prior to total hip arthroplasty (THA) or total knee arthroplasty. The incidence of complications within 90 days of surgery was recorded and compared to a COVID-19 negative control group matched 1:3 for age range in 5-year intervals, Charlson Comorbidity Index, and sex. There were 7,780 patients included in the study; 5,840 (75.1%) never diagnosed with COVID-19, 1,390 (17.9%) who had a COVID-19 diagnosis 0 to 3 months prior to surgery, and 550 (7.1%) who had a COVID-19 diagnosis 3 to 6 months prior to surgery. RESULTS: When compared to their COVID negative controls, patients who had a COVID-19 diagnosis 0 to 3 months prior to surgery had significantly higher rates of readmission (14.0 versus 11.1%, P = .001), pneumonia (2.2 versus 0.7%, P < .001), deep vein thrombosis (DVT) (3.3 versus 1.9%, P = .001), kidney failure (2.4 versus 1.4%, P = .006), and acute respiratory distress syndrome (1.4 versus 0.7%, P = .01). Patients who had a COVID-19 diagnosis 3 to 6 months prior to surgery had significantly higher rates of pneumonia (2.0 versus 0.7%, P = .002) and DVT (3.6 versus 1.9%, P = .005) when compared to their COVID negative controls. CONCLUSION: Patients diagnosed with COVID-19 within three months prior to TJA have an increased risk of 90-day postoperative complications. Risk for pneumonia and DVT remains elevated even when surgery was performed as far as 3 to 6 months after COVID-19 diagnosis.

Revision total knee arthroplasty for arthrofibrosis improves range of motion.

PURPOSE: Arthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis. METHODS: A retrospective study of 42 TKA's diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM. RESULTS: The patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient's pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively. CONCLUSION: Revision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM. LEVEL OF EVIDENCE: IV.

The presence of 3D printing in orthopedics: A clinical and material review.

The field of additive manufacturing, 3D printing (3DP), has experienced an exponential growth over the past four decades, in part due to increased accessibility. Developments including computer-aided design and manufacturing, incorporation of more versatile materials, and improved printing techniques/equipment have stimulated growth of 3DP technologies within various industries, but most specifically the medical field. Alternatives to metals including ceramics and polymers have been garnering popularity due to their resorbable properties and physiologic similarity to extracellular matrix. 3DP has the capacity to utilize an assortment of materials and printing techniques for a multitude of indications, each with their own associated benefits. Within the field of medicine, advances in medical imaging have facilitated the integration of 3DP. In particular, the field of orthopedics has been one of the earliest medical specialties to implement 3DP. Current indications include education for patients, providers, and trainees, in addition to surgical planning. Moreover, further possibilities within orthopedic surgery continue to be explored, including the development of patient-specific implants. This review aims to highlight the use of current 3DP technology and materials by the orthopedic community, and includes comments on current trends and future direction(s) within the field.

Is Psychiatric Illness Associated With Worse Outcomes Following Pilon Fracture?

Background: Patients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric comorbidities (PC) in patients with pilon fractures and clinical outcomes. Methods: A multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group. Results: There were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03). Conclusion: Patients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III.

First Carpometacarpal Joint Denervation: A Systematic Review.

PURPOSE: The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis. METHODS: A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing, intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint. RESULTS: Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications, the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection. CONCLUSIONS: The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability, but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Coccygectomy for refractory coccygodynia: a systematic review and meta-analysis.

PURPOSE: We sought to systematically assess and summarize the available literature on outcomes following coccygectomy for refractory coccygodynia. METHODS: PubMed, Scopus, and Cochrane Library databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data concerning patient demographics, validated patient reported outcome measures (PROMs) for pain relief, disability outcomes, complications, and reoperation rates were extracted and analyzed. RESULTS: A total of 21 studies (18 retrospective and 3 prospective) were included in the quantitative analysis. A total of 826 patients (females = 75%) received coccygectomy (720 total and 106 partial) for refractory coccygodynia. Trauma was reported as the most common etiology of coccygodynia (56%; n = 375), followed by idiopathic causes (33%; n = 221). The pooled mean difference (MD) in pain scores from baseline on a 0-10 scale was 5.03 (95% confidence interval [CI]: 4.35 to 6.86) at a 6-12 month follow-up (FU); 5.02 (95% CI: 3.47 to 6.57) at > 12-36 months FU; and 5.41 (95% CI: 4.33 to 6.48) at > 36 months FU. The MCID threshold for pain relief was surpassed at each follow-up. Oswestry Disability Index scores significantly improved postoperatively, with a pooled MD from baseline of - 23.49 (95% CI: - 31.51 to - 15.46), surpassing the MCID threshold. The pooled incidence of complications following coccygectomy was 8% (95% CI: 5% to 12%), the most frequent of which were surgical site infections and wound dehiscence. The pooled incidence of reoperations was 3% (95% CI: 1% to 5%). CONCLUSION: Coccygectomy represents a viable treatment option in patients with refractory coccygodynia.

Clean or Dirty? A Systematic Review of Splash Basin Use and Its Infectious Potential in Orthopaedic Surgery.

Background: Splash basins are used in orthopaedic surgery cases to wash and hold instrumentsintraoperatively. This systematic review aims to summarize information on contamination of splash basins intraoperatively. Methods: A systematic review was conducted using the following search terms: "splash basin" or "splash bucket." Two authors independently reviewed the literature. Studies were included if they reported on intraoperative splash basin contamination rates. Studies were excluded if they were not relevant to orthopaedic surgery, non-English articles, or repeat studies yielded by different online databases. Results: There were seven studies included in this review. The median contamination rate of sterile water or physiologic saline splash basins was 23.9% [range: 2%-74%]. The addition of surgical antiseptics to sterile water splash basins was associated with 0% contamination rates in two studies. The most frequent splash basin contaminants identified in bacterial culture were coagulase negative staphylococcus (50%) and staphylococcus aureus (10%). Conclusion: The splash basin appears to be a frequent source of contamination in the operating room. Many studies suggest abandoning splash basin use altogether, although the efficacy of alternative methods such as cleaning instruments with lap pads in avoiding contamination of the sterile field has not been studied. Further investigation into surgical teams' use of the splash basin and the contents of the splash basin as they relate to contamination rates may help advance our understanding of optimal use of this surgical tool. Shorter case durations and dilute surgical antiseptics in splash basins appear associated with lower splash basin contamination risk. Level of Evidence: V.

The association between number of intercostal nerves transferred and elbow flexion: a systematic review and pooled analysis.

OBJECTIVE: This pooled analysis evaluates the association between the number of nerves transferred and postoperative outcomes after intercostal nerve (ICN) nerve transfer for elbow flexion. METHODS: A systematic and pooled analysis of studies reporting individual patient demographics and outcomes after ICN-musculocutaneous nerve (MCN) transfer for traumatic brachial plexus injury was conducted. The primary outcome was the ability to attain an elbow flexion Medical Research Council (MRC) score of ≥4 at the final postoperative follow-up visit. RESULTS: Ten studies were included for a total of 128 patients. There were 43 patients who underwent two ICNT, 77 patients who underwent three ICNT, and 8 patients who underwent four ICNT. The three groups did not differ in ability to achieve MRC ≥ 4 (2ICNT 48.8%, 3ICNT 42.9%, 4ICNT 50.0%, p = 0.789). The number of ICNs transferred was not associated with MRC scores ≥4 on the multivariable analysis (OR: 0.55, p = 0.126). CONCLUSIONS: These results indicate that two ICN transfers may be as effective as three ICN and four ICN transfers and highlight the potential for nonsurgical factors to influence postoperative outcomes. Taken together, this pooled analysis leads us to question the utility of transferring >2 ICNs for MCN neurotization.

Scaphometacarpal Space and Postoperative Outcomes: A Systematic Review.

Background A common notion is that more complex techniques for treating trapeziometacarpal arthritis such as ligament reconstruction and tendon interposition (LRTI) better preserve the scaphometacarpal (SMC) space compared to a simple trapeziectomy and that this leads to superior functional outcomes. Purpose The purpose of this systematic review is to evaluate the relationship between scaphometacarpal space and objective outcomes such as grip and pinch strength as well as subjective patient-reported outcomes. Methods A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting SMC space and outcomes after surgery for carpometacarpal arthritis. The primary outcomes of these studies included any measure of postoperative scaphometacarpal space (trapezial height/trapezial index) as well as key pinch strength, grip strength, or lateral pinch strength. Studies that did not assess for association between SMC space and outcomes were excluded. Results Fourteen studies were included in this systematic review. Three (21.4%) studies found a statistically significant correlation between postoperative SMC space and postoperative pinch or grip strength. The correlation was weakly positive in one study (key pinch vs. scaphometacarpal space, r = 0.13), positive but unlisted in another (lateral pinch vs. trapezial ratio), and negative in the third study (key pinch vs. trapezial space ratio, r = -0.47). Conclusion Preservation of the SMC space postoperatively is not associated with postoperative outcomes. Further research is necessary to better characterize the importance of maintaining the SMC space in patients undergoing LRTI in order to substantiate claims by proponents of the procedure.

The extent of brachial plexus injury: an important factor in spinal accessory nerve to suprascapular nerve transfer outcomes.

Objective: The purpose of this study was to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer.Methods: A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting outcomes on patients undergoing SAN to SSN nerve transfer. Patients were excluded for the following reasons: age under 18, nerve transfer for reanimation of the shoulder other than SAN to SSN, and less than 12 months of follow-up postoperatively. Pooled analysis was performed, and primary outcomes were Medical Research Council (MRC) score and range of motion (ROM) for shoulder abduction and external rotation. Univariate logistic regression analysis was used to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after SAN to SSN transfer. A multivariate logistic regression analysis model including age, injury to surgery interval, and extent of injury as factors was also created.Results: Univariate logistic regression analysis showed greater extent of injury to be a predictor of poorer shoulder abduction outcomes (OR: 0.502; 95% CI: 0.260-0.971, p = 0.040). Multivariate logistic regression analysis confirmed this association (OR: 0.55; 95% CI: 0.236-0.877, p = 0.019). Extent of injury was not significantly associated with external rotation outcomes on univariate analysis (OR: 0.435; 95% CI: 0.095-1.995, p = 0.284) or multivariate analysis (OR: 0.445; 95% CI: 0.097-2.046, p = 0.298). Age and injury to surgery interval were not significantly associated with postoperative outcomes.Conclusions: More extensive brachial plexus injuries are associated with inferior outcomes after SAN to SSN transfer. A potential explanation for this finding includes lost contribution of muscles from the shoulder girdle that receive innervation from outside of the upper brachial plexus. The relationship between extent of injury and postoperative outcomes is important to recognize when determining and discussing operative intervention with patients.

Patellofemoral Arthroplasty: Short-Term Complications and Risk Factors.

There is a paucity of literature regarding the short-term readmission, reoperation, and complication rates of patellofemoral arthroplasty (PFA). The purpose of this study is to determine the incidence and risk factors of 30-day postoperative complications in patients undergoing PFA. A retrospective cohort study of subjects who underwent PFA from 2010 to 2015 was performed using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Perioperative outcomes and 30-day postoperative complications were ascertained, and patient demographics and comorbidities were analyzed using linear and binomial logistic regression analyses to determine risk factors for postoperative complications. Among the 1,069 patients identified in the NSQIP database, there was a 30-day readmission rate of 4.3% and a 30-day reoperation rate of 1.5%. The leading complications identified were bleeding requiring transfusion (11.7%), urinary tract infection (0.8%), and deep vein thrombosis (DVT) (0.8%). Younger age was a risk factor for superficial wound infection (p = 0.012). Older age was a significant risk factor for longer hospital stays, readmission, bleeding requiring transfusion, urinary tract infection, and pneumonia (p < 0.05 for all). Male sex was a risk factor for longer operation time and DVT (p = 0.001 and p = 0.017, respectively), while female sex was associated with greater incidence of bleeding requiring transfusion (p = 0.049). Elevated body mass index (BMI) was a risk factor for longer hospital stays, greater total operation time, and bleeding requiring transfusion (p < 0.001, p < 0.001, and p = 0.001, respectively). Nonwhite race was a significant risk factor for readmission (p = 0.008). This represents the largest study on early readmissions and the associated risk factors after PFA. PFA 30-day readmission and reoperation rates were <5%. Older age and elevated BMI were both identified as risk factors for adverse perioperative outcomes, including longer operation times, longer hospital stays, and bleeding requiring transfusion.

Is one nerve transfer enough? A systematic review and pooled analysis comparing ulnar fascicular nerve transfer and double ulnar and median fascicular nerve transfer for restoration of elbow flexion after traumatic brachial plexus injury.

OBJECTIVES: Double fascicular transfer is argued to result in improved elbow flexion compared to the traditional ulnar fascicular transfer because it reinnervates both the biceps and the brachialis. This study seeks to determine if double fascicular transfer should be preferred over ulnar fascicular transfer to restore elbow flexion in patients with upper trunk brachial plexus injuries (BPI) by analyzing the current database of literature on the topic. METHODS: A systematic review was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting Medical Research Council (MRC) scores on individual patients undergoing ulnar fascicular transfer and double fascicular transfer (ulnar and median nerve fascicle donors). Patients were excluded if: age < 18 years old and follow-up <12 months. Demographics obtained include age, sex, extent of injury (C5-C6/C5-C7), preoperative interval, procedure type, and follow-up time. Outcomes included absolute MRC score and ability to achieve MRC score ≥3 and ≥4. Univariate and multivariate regression analyses were completed to evaluate predictors of postoperative outcomes. RESULTS: Eighteen studies (176 patients) were included for pooled analysis. Patients that underwent double fascicular transfer had a higher percentage of patients attain a MRC score ≥ 4 compared to ulnar fascicular transfer subjects (83.0% vs. 63.3%, p = .013). Double fascicular transfer was a predictor of achieving high MRC scores (OR = 2.829, p = .015). Multivariate analysis showed that procedure type was the only near significant predictor of ability to obtain MRC ≥4 (OR: 2.338, p = .054). CONCLUSIONS: This analysis demonstrates that double fascicular transfer is associated with superior postoperative outcomes and should be performed for restoring elbow flexion.

Non-fibro-adipogenic pericytes from human embryonic stem cells attenuate degeneration of the chronically injured mouse muscle.

Massive tears of the rotator cuff (RC) are associated with chronic muscle degeneration due to fibrosis, fatty infiltration, and muscle atrophy. The microenvironment of diseased muscle often impairs efficient engraftment and regenerative activity of transplanted myogenic precursors. Accumulating myofibroblasts and fat cells disrupt the muscle stem cell niche and myogenic cell signaling and deposit excess disorganized connective tissue. Therefore, restoration of the damaged stromal niche with non-fibro-adipogenic cells is a prerequisite to successful repair of an injured RC. We generated from human embryonic stem cells (hES) a potentially novel subset of PDGFR-ß+CD146+CD34-CD56- pericytes that lack expression of the fibro-adipogenic cell marker PDGFR-α. Accordingly, the PDGFR-ß+PDGFR-α- phenotype typified non-fibro-adipogenic, non-myogenic, pericyte-like derivatives that maintained non-fibro-adipogenic properties when transplanted into chronically injured murine RCs. Although administered hES pericytes inhibited developing fibrosis at early and late stages of progressive muscle degeneration, transplanted PDGFR-ß+PDGFR-α+ human muscle-derived fibro-adipogenic progenitors contributed to adipogenesis and greater fibrosis. Additionally, transplanted hES pericytes substantially attenuated muscle atrophy at all tested injection time points after injury. Coinciding with this observation, conditioned medium from cultured hES pericytes rescued atrophic myotubes in vitro. These findings imply that non-fibro-adipogenic hES pericytes recapitulate the myogenic stromal niche and may be used to improve cell-based treatments for chronic muscle disorders.

The Effect of Total Knee Arthroplasty on Physical Activity and Body Mass Index: An Analysis of the Osteoarthritis Initiative Cohort.

INTRODUCTION: Preliminary analysis of accelerometry measurements has shown physical activity may not increase significantly after total knee arthroplasty (TKA). This study evaluates the effect of TKA on physical activity accelerometry measurements and body mass index (BMI). METHODS: Using the multicenter Osteoarthritis Initiative (OAI) database, a cohort of patients with physical activity level accelerometry measurements and BMI before and after TKA was identified. Physical activity levels and BMI were acquired at pre-TKA and post-TKA accelerometry visits 2 years apart. Survey scores pertaining to knee functionality and quality of life were also analyzed before and after knee surgery. Each patient included in the study had a unilateral TKA completed between these 2 accelerometry visits. Accelerometry measurements, BMI of the patients, and survey scores relating to knee functionality and pain relief from before and after TKA were compared using paired samples t tests. RESULTS: Twenty-three patients from the OAI database were identified for the paired analysis. They were evaluated at a mean postoperative follow-up of 15 months. There were no statistically significant differences between the post-TKA group and pre-TKA group for the accelerometry variables and BMI, though patients experienced a significant improvement in knee function and pain relief measures included in this analysis. DISCUSSION: Although TKA can successfully restore function and relieve pain, there remains no good evidence that neither physical activity nor BMI improve postoperatively. CONCLUSION: No significant differences in physical activity and BMI were observed after TKA in this study.

Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series.

OBJECTIVE: To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP). METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs. RESULTS: A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32-0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63-0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71-0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10-1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16-1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64-1.96), P < 0.001]. CONCLUSIONS: Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended. LEVEL OF EVIDENCE: Therapeutic Level III.