Factors Associated With COVID-19 Vaccine Hesitancy in Rheumatology Outpatients in New York City.

OBJECTIVE: The aim of this study was to measure COVID-19 vaccine hesitancy among rheumatology outpatients from an early COVID-19 "hotspot" during the initial period of vaccine availability. METHODS: In March 2021, a Web-based survey was sent to 7505 adults seen at a Rheumatology Division in New York City. We evaluated characteristics associated with 3 categories of COVID-19 vaccination status: declined, undecided, and willing/already received. We used multinomial logistic regression models to calculate relative risk ratios assessing predictors of vaccination status. RESULTS: Among 2384 (32%) respondents (80% female, 87% White, 59% with systemic rheumatic disease), 2240 (94.0%) were willing/already received COVID-19 vaccination, 88 (3.7%) were undecided, and 56 (2.3%) declined. Compared with those willing/already vaccinated, those declining or undecided were younger, more likely identified as Black or Hispanic/Latinx, and had lower household income and educational attainment. Immunosuppressive medication use did not differ among groups. After multivariable adjustment, every 1-year increase in age was associated with a 0.96 lower relative risk of declining or being undecided versus willing/already vaccinated. Respondents identifying as Black versus White had a higher relative risk ratio of being undecided (4.29 [95% confidence interval, 1.96-9.36]), as did those identifying as Hispanic/Latinx versus non-Hispanic/non-Latinx (2.81 [95% confidence interval, 1.29-6.09]). Those declining vaccination were least likely to believe in general vaccine importance or the safety and efficacy of the COVID-19 vaccine. CONCLUSIONS: Among rheumatology patients in New York City with and without systemic rheumatic disease, COVID-19 vaccine uptake was high after its initial availability. Sociodemographic but not medication-related factors were associated with vaccine hesitancy; these findings can inform future rheumatology vaccination programs.

Black Patients are More Likely to Undergo Early Revision Total Knee Arthroplasty in a Matched Cohort Regardless of Surgeon Experience.

BACKGROUND: Black patients are at an increased risk of aseptic revision total knee arthroplasty (TKA) when compared to White patients. The goal of this study was to determine whether racial disparities in revision TKA risk are related to surgeon characteristics. METHODS: This was an observational cohort study. We used inpatient administrative data to identify Black patients who underwent unilateral primary TKA in New York State. There were 21,948 Black patients who were matched 1:1 to White patients on age, sex, ethnicity, and insurance type. The primary outcome was aseptic revision TKA within 2 years of primary TKA. We calculated annual surgeon TKA volume and identified surgeon characteristics such as training in North America, board certification, and years of experience. RESULTS: Black patients had a higher odds of aseptic revision TKA (odds ratio (OR) 1.32, 95% CI 1.12-1.54, P < .001) and were disproportionately cared for by low volume surgeons (≤12 TKA/year). The relationship between low volume surgeons and risk of aseptic revision was not statistically significant (OR 1.24, 95% CI 0.72-2.11, P = .436). The adjusted odds ratio (aOR) for aseptic revision TKA in Black versus White patients varied across surgeon/hospital TKA volume category pairs, with the greatest aOR when TKA were performed by the highest volume surgeons at the highest volume hospitals (aOR 2.8, 95% CI 0.98- 8.09, P = .055). CONCLUSION: Black patients were more likely to undergo aseptic TKA revision than matched White patients. This disparity was not explained by surgeon characteristics.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study.

INTRODUCTION: Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS: 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS: A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION: In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

Clinical Characteristics and Fracture Patterns Among Postmenopausal Women with Isolated Osteoporosis at the Forearm.

Patients found to have isolated osteoporosis at the 1/3 radius (1/3RO) represent a therapeutic dilemma. It is unknown whether 1/3RO is associated with an increased risk of fragility fractures, and is therefore unclear whether these patients should be treated similarly to those with osteoporosis at central sites. This retrospective study investigated the clinical significance of 1/3RO by comparing medical history, fracture prevalence, areal BMD, and Trabecular Bone Score in postmenopausal women with 1/3RO (n = 107) to age-matched women with osteoporosis at the hip and/or spine (PMO, n = 214), and to controls without osteoporosis at any site (n = 214). We then compared the clinical and densitometric characteristics among women with 1/3RO according to fracture history. The mean age of the 535 women included in the study was 71 ± 8 yr. Women with 1/3RO had BMD in the osteopenic range at all other sites (mean spine T-score = -1.0, total hip = -1.4, femoral neck = -1.7). Women with 1/3RO reported similar calcium and vitamin D intake, prevalence of primary hyperparathyroidism, chronic kidney disease, and other comorbidities compared to the other groups. The prevalence of an osteoporotic fracture of the spine, hip, wrist, or humerus tended to be higher among women with PMO compared to 1/3RO or controls (PMO: 31%, 1/3RO: 21%, Controls: 23%, p = 0.07). Among women with 1/3RO, fracture prevalence was related to older age. No other clinical characteristic distinguished women with and without fracture. Neither BMD at other sites nor TBS differed according to fracture history. Among postmenopausal women with 1/3RO, those who are older are at an increased risk of fracture, even when T-scores at other sites are well above the osteoporosis threshold. Additional research is needed to confirm our results, and to assess whether treatment should be considered to reduce fracture risk in older women with 1/3RO.

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty.

BACKGROUND: Patient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA. RESULTS: In total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001). CONCLUSION: We found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.

FANCM and FAAP24 maintain genome stability via cooperative as well as unique functions.

The DNA remodeling enzyme FANCM and its DNA-binding partner, FAAP24, constitute a complex involved in the activation of Fanconi anemia (FA) DNA damage response mechanism, but neither gene has distinct patient mutants. In this study, we created isogenic models for both FANCM and FAAP24 and investigated their integrated functions in DNA damage response. We found that FANCM and FAAP24 coordinately facilitate FA pathway activation and suppress sister chromatid exchange. Importantly, we show that FANCM and FAAP24 possess nonoverlapping functions such that FAAP24 promotes ATR-mediated checkpoint activation particularly in response to DNA crosslinking agents, whereas FANCM participates in recombination-independent interstrand crosslink repair by facilitating recruitment of lesion incision activities, which requires its translocase activity. Our data suggest that FANCM and FAAP24 play multiple, while not fully epistatic, roles in maintaining genomic integrity.

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve.

BACKGROUND: Proponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA). METHODS: A total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year. RESULTS: Intraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02). CONCLUSION: This comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.

Therapeutic effect of prolonged testosterone pretreatment in women with poor ovarian response: A randomized control trial.

PURPOSE: This study compared the therapeutic effects of transdermal testosterone gel (TTG) application at 4 and 6 weeks before controlled ovarian hyperstimulation (COH) in women with poor ovarian response (POR). METHODS: In this randomized control trial, infertile women with POR who underwent in vitro fertilization (IVF) were recruited and randomly classified into 4 week (n = 42) and 6 week (n = 38) TTG treatment groups and control group (n = 42). The primary outcome was total number of retrieved mature oocytes. The secondary outcomes were the biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate. RESULTS: No significant differences were observed in the number of oocytes retrieved, mature oocytes and embryos between all groups. Human chorionic gonadotropin (hCG) positive, clinical, and ongoing pregnancy rates were significantly higher in the TTG pretreatment groups than in the control group but no differences were observed between the 4- and 6 week groups. CONCLUSIONS: Applying TTG in infertile women with POR may ameliorate the outcomes of IVF. The extended application of TTG to 6 weeks did not improve the response to ovarian stimulation regarding the number of retrieved oocytes nor pregnancy outcomes compared to the 4 week pretreatment.

The tomato I gene for Fusarium wilt resistance encodes an atypical leucine-rich repeat receptor-like protein whose function is nevertheless dependent on SOBIR1 and SERK3/BAK1.

We have identified the tomato I gene for resistance to the Fusarium wilt fungus Fusarium oxysporum f. sp. lycopersici (Fol) and show that it encodes a membrane-anchored leucine-rich repeat receptor-like protein (LRR-RLP). Unlike most other LRR-RLP genes involved in plant defence, the I gene is not a member of a gene cluster and contains introns in its coding sequence. The I gene encodes a loopout domain larger than those in most other LRR-RLPs, with a distinct composition rich in serine and threonine residues. The I protein also lacks a basic cytosolic domain. Instead, this domain is rich in aromatic residues that could form a second transmembrane domain. The I protein recognises the Fol Avr1 effector protein, but, unlike many other LRR-RLPs, recognition specificity is determined in the C-terminal half of the protein by polymorphic amino acid residues in the LRRs just preceding the loopout domain and in the loopout domain itself. Despite these differences, we show that I/Avr1-dependent necrosis in Nicotiana benthamiana depends on the LRR receptor-like kinases (RLKs) SERK3/BAK1 and SOBIR1. Sequence comparisons revealed that the I protein and other LRR-RLPs involved in plant defence all carry residues in their last LRR and C-terminal LRR capping domain that are conserved with SERK3/BAK1-interacting residues in the same relative positions in the LRR-RLKs BRI1 and PSKR1. Tyrosine mutations of two of these conserved residues, Q922 and T925, abolished I/Avr1-dependent necrosis in N. benthamiana, consistent with similar mutations in BRI1 and PSKR1 preventing their interaction with SERK3/BAK1.

Bariatric Surgery Improves Outcomes After Lower Extremity Arthroplasty in the Morbidly Obese: A Propensity Score-Matched Analysis of a New York Statewide Database.

BACKGROUND: The purpose of this study was to compare risks for revision and short-term complications after total joint arthroplasty (TJA) in matched cohorts of morbidly obese patients, receiving and not receiving prior bariatric surgery. METHODS: Patients undergoing elective TJA between 1997 and 2011 were identified in a New York Statewide database, analyzing total knee arthroplasty (TKA) and total hip arthroplasty (THA) separately. Propensity scores were used to match morbidly obese patients receiving and not receiving bariatric surgery prior to TJA. Cox proportional hazard modeling assessed revision risk. Logistic regression evaluated odds for complications. RESULTS: For TKA, 2636 bariatric surgery patients were matched to 2636 morbidly obese patients. For THA, 792 bariatric surgery patients were matched to 792 morbidly obese patients. Matching balanced all covariates. Bariatric surgery reduced co-morbidities prior to TJA (TKA P < .0001; THA P < .005). Risks for in-hospital complications were lower for THA and TKA patients receiving prior bariatric surgery (odds ratio [OR] 0.25, P < .001; and OR = 0.69, P = .021, respectively). Risks for 90-day complications were lower for TKA (OR 0.61, P = .002). Revision risks were not different for either THA (P = .634) or TKA (P = .431), nor was THA dislocation risk (P = 1.000). CONCLUSION: After accounting for relevant selection biases, bariatric surgery prior to TJA was associated with reduced co-morbidity burden at the time of TJA and with reduced post-TJA complications. However, bariatric surgery did not reduce the risk for revision surgery for either TKA or THA.

Risk of Ischemic Stroke After Perioperative Atrial Fibrillation in Total Knee and Hip Arthroplasty Patients.

BACKGROUND: To determine if new-onset perioperative atrial fibrillation during arthroplasty represents a benign response to intraoperative cardiac stress or is a risk factor for stroke, we evaluated the subsequent risk of ischemic stroke in patients with new-onset atrial fibrillation occurring during primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Discharge data of all adult patients undergoing primary TKA or THA from 1997 to 2013 were queried via the New York Statewide Planning and Research Cooperative System database to find patients with new-onset perioperative atrial fibrillation. These patients were then followed up over time to determine their risk of ischemic stroke. RESULTS: Of the 312,636 TKA and 215,610 THA unique patient admissions, 3646 (0.7%) had a diagnosis of new-onset perioperative atrial fibrillation. The cohort of patients with this finding was 58.9% female with an average age of 73.6 years and higher prevalence of vascular risk factors. Adjusting for validated stroke risk factors, the risk of ischemic stroke within 1 year after THA or TKA in patients with new-onset atrial fibrillation was 2.7 times higher than in those without a history of atrial fibrillation (odds ratio: 2.7, 95% confidence interval: 1.5-4.8). Hospital length of stay and charges for patients with new-onset atrial fibrillation were also greater than patients with either a prior diagnosis or no diagnosis of atrial fibrillation. CONCLUSION: New-onset atrial fibrillation during TKA and THA may indicate risk of ischemic stroke following surgery that should warrant medical follow-up and may increase hospital length of stay and charges.

Recruitment of fanconi anemia and breast cancer proteins to DNA damage sites is differentially governed by replication.

Fanconi anemia (FA) is characterized by cellular hypersensitivity to DNA crosslinking agents, but how the Fanconi pathway protects cells from DNA crosslinks and whether FA proteins act directly on crosslinks remain unclear. We developed a chromatin-IP-based strategy termed eChIP and detected association of multiple FA proteins with DNA crosslinks in vivo. Interdependence analyses revealed that crosslink-specific enrichment of various FA proteins is controlled by distinct mechanisms. BRCA-related FA proteins (BRCA2, FANCJ/BACH1, and FANCN/PALB2), but not FA core and I/D2 complexes, require replication for their crosslink association. FANCD2, but not FANCJ and FANCN, requires the FA core complex for its recruitment. FA core complex requires nucleotide excision repair proteins XPA and XPC for its association. Consistent with the distinct recruitment mechanism, recombination-independent crosslink repair was inversely affected in cells deficient of FANC-core versus BRCA-related FA proteins. Thus, FA proteins participate in distinct DNA damage response mechanisms governed by DNA replication status.

Perioperative Morbidity of Same-Day and Staged Bilateral Total Hip Arthroplasty.

BACKGROUND: Management strategies for bilateral hip degenerative disease include same-day or staged bilateral total hip arthroplasty (THA), but information on outcomes remains sparse. We sought to describe in-hospital complications and blood transfusion rates after same-day and staged bilateral THAs at different time intervals and to assess risk factors for these events. METHODS: We retrospectively reviewed administrative data for 3785 patients treated with same-day bilateral (n = 1946; group A) and staged bilateral THA within (1) 0-3 months apart (n = 328; group B); (2) 3-6 months apart (n = 703; group C); and (3) 6-12 months apart (n = 808; group D), between 1999 and 2014. We recorded demographics, the Charlson-Deyo comorbidity index and in-hospital local and systemic (minor and major) complications. Complication and blood transfusion rates among groups were compared. A logistic regression model was developed to identify risk factors for major complications. RESULTS: Local complications were rare. Minor complications were less frequent in group A (P < .001). Major complications were more frequent in group D (P = .012). Group A had higher overall (P < .001) and allogeneic blood transfusion rates (P < .001) compared with the staged groups. Staged procedures within 6-12 months apart vs same-day bilateral THA, older age, Charlson-Deyo index ≥2 vs 0, and earlier vs recent admission year were associated with higher adjusted odds for major complications. CONCLUSION: Same-day bilateral THA in a high-volume joint replacement center may be a safe option for younger and healthier patients, given the relatively low incidence of adverse events reported in this study.

Magnetic Resonance Imaging Evidence of Postoperative Cyst Formation Does Not Appear to Affect Clinical Outcomes After Autologous Osteochondral Transplantation of the Talus.

PURPOSE: To identify potential cysts using magnetic resonance imaging (MRI) after autologous osteochondral transplantation (AOT) for osteochondral lesions of the talus (OLTs) as well as to determine the effect of cysts on short-term clinical outcomes. METHODS: Eighty-nine MRI scans of 37 patients who had AOT for an OLT were evaluated. Radiographic variables examined included cyst presence, cyst location, bone edema, and cartilage integrity. Patient clinical variables recorded and examined for association with the presence of a cyst included gender, age, preoperative lesion size, size and number of osteochondral graft used, symptoms reported, and pre- and postoperative Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) scores measured at final follow-up. RESULTS: Twenty-four patients (64.8%) had MRI evidence of cystic change after AOT for an OLT at a mean MRI follow-up time of 15 months after surgery (range 2-54). Patients with presence of a cyst after surgery were older (mean age, 42.7 years) than those without cysts (mean age, 32.7 years) (P = .041), and among patients with a cyst, older patients more often had involvement of the subchondral plate (57.3 v 36.7 years) (P < .001). No other variables associated with cyst formation had statistical significance. Mean patient FAOS scores increased from 50 (±19) preoperatively to 87 (±8) postoperatively. Mean SF-12 scores increased from 52 (±18) preoperatively to 85 (±6) postoperatively. Patients not identified as having a cyst had lower SF-12 (P = .028) and FAOS (P = .032) preoperative scores and more improvement in SF-12 (P = .006) and FAOS (P = .016) scores than patients with cysts. CONCLUSIONS: Postoperative cyst formation on MRI was found to be a common occurrence after AOT for OLT. Although increasing age was related to increased cyst prevalence, the clinical impact of cyst formation was not found to be significant at short-term follow-up. Continued long-term longitudinal follow-up of postoperative cysts is needed. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Autologous Osteochondral Transplantation for Osteochondral Lesions of the Talus: Does Previous Bone Marrow Stimulation Negatively Affect Clinical Outcome?

PURPOSE: To determine if functional outcomes and magnetic resonance imaging (MRI) outcomes were significantly different between patients receiving primary autologous osteochondral transplantation (AOT) and patients receiving secondary AOT surgery after failed microfracture. METHODS: A group of 76 patients enrolled into the Foot and Ankle Service between 2006 and 2012 was retrospectively analyzed. Patient-reported outcomes were evaluated in 76 patients using the Foot and Ankle Outcome Score (FAOS). Superficial and deep tissues at the repaired defect site, as well as the adjacent normal cartilage, were analyzed using quantitative T2 mapping MRI. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) allowed for morphological evaluation of the repair tissue. The mean clinical follow-up time was 51 ± 23 months (range, 12 to 97 months), and the mean MRI follow-up time was 26 months (range, 24 to 36 months). RESULTS: Twenty-two patients received primary AOT and 54 received secondary AOT after failed microfracture. Patient characteristics between groups were similar with regard to age, gender, lesion size, and follow-up time. The mean postoperative FAOS was 10 points higher in the primary AOT group (83.2 ± 17.0) compared with the secondary AOT group (72.4 ± 19.4) (P = .01). Regression analysis showed that secondary AOT patients preoperative to postoperative change in FAOS was 9 points lower than in primary AOT patients after adjustment for age, preoperative FAOS, and lesion size (P = .045). The mean MOCART score, superficial T2 and deep T2 values, and the difference between normal and repair cartilage T2 values were not significantly different between groups. Lesion size was negatively correlated with MOCART scores (ρ = -0.2, P = .04), but positively correlated with difference in T2 values between repair and adjacent normal cartilage in the superficial layer (ρ = 0.3, P = .045). CONCLUSIONS: Primary AOT shows better functional outcomes compared with secondary AOT after failed microfracture in patients with similar characteristics and lesion size. No significant differences in T2 mapping relaxation times and MOCART scores were identified. LEVEL OF EVIDENCE: Level III, case control study.

Arthroscopic Bone Marrow Stimulation and Concentrated Bone Marrow Aspirate for Osteochondral Lesions of the Talus: A Case-Control Study of Functional and Magnetic Resonance Observation of Cartilage Repair Tissue Outcomes.

PURPOSE: This study compares retrospective functional and magnetic resonance imaging (MRI) outcomes after arthroscopic bone marrow stimulation (BMS) with and without concentrated bone marrow aspirate (cBMA) as a biological adjunct to the surgical treatment of osteochondral lesions (OCLs) of the talus. METHODS: Twenty-two patients who underwent arthroscopic BMS with cBMA (cBMA/BMS group) for an osteochondral lesion (OCL) of the talus and 12 patients who underwent arthroscopic BMS (BMS alone) for an OCL of the talus were retrospectively reviewed. The Foot and Ankle Outcome Score (FAOS) pain subscale and Short Form 12 general health questionnaire physical component summary score (SF-12 PCS) provided patient-reported outcome scores pre- and postoperatively. MRI scans were assessed postoperatively using the magnetic resonance observation of cartilage repair tissue (MOCART) score. All patients had postoperative MRI performed at the 2-year postoperative visit, and quantitative T2 mapping relaxation time values were assessed in a subset of the cBMA/BMS group. RESULTS: The mean FAOS and SF-12 PCS scores improved significantly pre- to post-operatively (P < .01) at a mean follow-up of 48.3 months (range, 34 to 82 months) for the cBMA/BMS group and 77.3 months (range, 46 to 100 months) for the BMS-alone group. The MOCART score in the cBMA/BMS group was significantly higher than that in the BMS-alone group (P = .023). Superficial and deep T2 relaxation values in cBMA/BMS patients were higher in repair tissue compared with measurements in adjacent native articular cartilage (P = .030 and P < .001, respectively). CONCLUSIONS: BMS is an effective treatment strategy for treatment of OCLs of the talus and results in good medium-term functional outcomes. Arthroscopic BMS with cBMA also results in similar functional outcomes and improved border repair tissue integration, with less evidence of fissuring and fibrillation on MRI.

Perioperative morbidity and mortality of same-admission staged bilateral TKA.

BACKGROUND: Controversy continues regarding the optimal timing of surgery for patients with symptomatic bilateral degenerative knee arthritis who are not considered eligible for same-day bilateral TKA (BTKA). QUESTIONS/PURPOSES: We compared (1) 30-day mortality; (2) rates of in-hospital complications; and (3) blood transfusion rates between patients undergoing same-admission staged BTKA and patients undergoing BTKA staged within 1 year in a highly specialized center where specific guidelines have been implemented for same-day BTKA patient selection. METHODS: We analyzed institutional data for 149 patients undergoing same-admission staged and 1557 patients undergoing staged BTKA diagnosed with bilateral knee idiopathic osteoarthritis from 1998 to 2011. Although patients in both groups presented with bilateral knee disease, same-admission staged patients had more medical comorbidities and did not qualify for same-day BTKA. Specifically, patients with coronary artery disease with inducible ischemia, congestive heart failure, advanced chronic obstructive pulmonary disease, uncontrolled diabetes, peripheral vascular disease, renal failure, morbid obesity, history of venous thromboembolism, or those who were older than 75 years were not considered eligible for same-day BTKA. Patient demographics and Deyo comorbidity index were tabulated. The groups were similar in age, but same-admission staged patients were more likely to be male and had a higher overall comorbidity burden. The complications were categorized into systemic (medical) and local (orthopaedic). Furthermore, the systemic complications were subcategorized into major (required complex surgical or medical intervention or were deemed life-threatening) and minor (necessitated additional observation or required medical treatment), depending on their severity. Regression models were conducted to examine the association between surgery type and development of complications. RESULTS: There was no difference in 30-day mortality between the groups (0% versus 0.06%; p=0.754). There was no difference in the local complication rates (0.7% versus 0.8%; p=1.000). However, multivariable regression analysis adjusting for age, sex, and Deyo comorbidity index showed that same-admission staged patients were three and two times more likely than staged to develop a minor (odds ratio [OR], 3.02; 95% confidence interval [CI], 1.25-3.25; p=0.004) and major (OR, 2.02; 95% CI, 2.09-4.37; p<0.001) complication, respectively. The same-admission group experienced more acute postoperative anemia (11% versus 3%; p<0.001) and blood transfusions (93% versus 54%; p<0.001). CONCLUSIONS: These results suggest that patients who are not appropriate candidates for same-day BTKA as a result of increased overall comorbidity burden may be better served by undergoing staged BTKA within 1 year rather than same-admission staged because of the associated higher perioperative morbidity observed in the same-admission BTKA group. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Secondary ossification centers in the development of the medial malleolus.

BACKGROUND: Accessory ossicles of the medial malleolus have been reported, however, these have not been linked to a pattern of development and are considered anomalies. Here, we describe a pattern of ossification of the medial malleolus in children including a secondary ossification center. METHODS: Twenty anteroposterior (AP) and mortise x-rays of each sex and age from 4 to 12 were randomly selected from skeletally immature patients identified at our institution. X-rays were excluded if there was a cast or splint, fracture, hardware, or obvious tibial deformity. Each x-ray was evaluated and categorized to a 4-part stage of development. These stages were then applied to randomly selected AP hip to ankle films from the same age groups. RESULTS: Four distinct stages of medial malleolus ossification were identified on ankle x-rays. Stage 1 consists of the widening of the epiphysis that did not reach the medial border of the metaphysis. In stage 2, the epiphysis had widened medially to the level of the metaphysis, however, had not extended distally to the level of the dome of the talus. In stage 3, the proximal portion of the medial malleolus has ossified distal to the dome of the talus with ossification centers at this level identified. Stage 4 consisted of a completely fused ossification center extending distally to a mature medial malleolus. The stages were reconfirmed on AP standing hip to ankle to have a similar distribution, secondary ossification centers were more common in females aged 6 to -9 and males aged 8 to 11 years. CONCLUSIONS: The medial malleolus develops in predictable stages which may involve a secondary ossification center in the final stages of development. These findings were initially described on AP and mortise views, then confirmed on AP hip to ankle radiographs were evaluated to exclude potentially confounding ankle pain. These secondary ossification centers were seen at similar ages on both ankle and hip to ankle x-rays. LEVEL OF EVIDENCE: Level III.

Hypovitaminosis D is a predictor of aromatase inhibitor musculoskeletal symptoms.

The aromatase inhibitor (AI)-associated musculoskeletal (MSK) pain symptoms are often debilitating and limit compliance with this important hormonal breast cancer therapy. The etiology of this syndrome is unknown. Hypovitaminosis D has been suggested as a possible risk factor for the development of MSK symptoms in women starting AIs. The objective of this substudy was to define the prevalence of low 25(OH)D in this population, to assess risk of low levels on developing pain and to define a target therapeutic goal for 25(OH)D in this population. This analysis was part of a 6-month prospective cohort study examining the MSK side effects of adjuvant AI therapy in postmenopausal women. Patients were evaluated by a rheumatologist with a joint examination, had 25(OH)D levels measured and completed quality of life questionnaires at baseline, 3 and 6 months. Symptomatic patients were defined as those that self-reported new or worsening MSK symptoms. Of 52 patients, 28 (54%) were symptomatic, and two (3.8%) stopped AIs due to MSK ailments. Thirteen patients had objective evidence of tendonitis on rheumatologic examination. Thirty-three percent of all subjects had baseline 25(OH)D levels <40 ng/mL, 19.2% had levels <30 ng/mL and 5.8% had levels <20 ng/mL. Symptomatic patients were more likely to have had baseline levels below 40 ng/mL, compared with asymptomatic patients (46.4% versus 16.7%, p = 0.037). In multivariate regression analyses, levels <40 ng/mL were associated with developing objective tenosynovitis (p = 0.033) but not with developing nonspecific myalgias. Our findings suggest hypovitaminosis D may be contributing to the AI-associated MSK pain syndrome and in particular to the development of tendonitis. Repletion to 25(OH)D levels >40 ng/mL is advisable. Further research should be carried out on identifying additional modifiable risk factors for this syndrome.

Epidemiology of multiligament knee reconstruction.

BACKGROUND: The multiple-ligament-injured knee represents a special challenge, being an uncommon injury that is both severe and complicated to treat. Many studies have evaluated patients treated for this injury, but most are limited in their scope. The evaluation of this injury and its treatment using an administrative database might provide a different perspective. QUESTIONS/PURPOSES: Using a large administrative database, we determined (1) the number of multiligament knee reconstructions in New York State, (2) the rate of 90-day hospital readmission, and (3) the frequency of subsequent knee surgery. We examined the rates of these outcomes as a function of diagnosis, admission type, discharge status, comorbidity burden, and patient demographic factors. METHODS: We used the New York Department of Health Statewide Planning and Research Cooperative System (SPARCS), a database with information on patient characteristics, diagnoses, and treatments, to identify patients who underwent a multiligament procedure in a nonfederal facility from 1997 to 2005 using ICD-9-CM and Current Procedural Terminology codes. SPARCS collects data from all nonfederal acute care facilities, with an estimated reporting completeness of almost 99% for the years in this study. We evaluated data on patient age, sex, admission type, discharge status, and comorbidity burden (using Elixhauser comorbidities) and developed a multivariable logistic regression model to assess the influence of confounding variables. RESULTS: We identified 1032 patients in this database who underwent multiligament knee reconstruction in New York State from 1997 to 2005. The frequency of readmission within 90 days was 4.8% (n = 49). Readmission was more likely for patients who underwent inpatient multiligament reconstruction (odds ratio [OR] = 2.3; 95% CI: 1.2-4.4; p = 0.014), had a diagnosis of dislocation (OR = 2.2; 95% CI: 1.2-3.9; p = 0.011), or had various Elixhauser comorbidities, including chronic lung disease (OR = 6.4; 95% CI: 1.5-27.2; p = 0.013), fluid and electrolyte disorders (OR = 19.7; 95% CI: 2.5-155.7; p = 0.005), and anemia deficiency (OR = 5.6; 95% CI: 1.05-29.4; p = 0.044). Two hundred eighty-seven patients (28%) underwent subsequent knee surgery between their index procedure and 2006. Subsequent surgery was more likely for patients who underwent inpatient multiligament reconstruction (OR = 1.4; 95% CI: 1.1-1.9; p = 0.011) or were readmitted within 90 days of the index surgery (OR = 4.2; 95% CI: 2.3-7.6; p < 0.001). CONCLUSIONS: Our findings have the potential to aid clinicians in identifying their patients with multiligament reconstruction at highest risk for 90-day readmission and subsequent knee surgery. Future research, particularly large prospective studies evaluating surgical approaches and timing, will be critical in advancing the treatment of multiligament knee injuries. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.