Improved functional status in patients undergoing cement and rebar reconstruction with total hip arthroplasty for uncontained metastatic tumors of the acetabulum.

BACKGROUND AND OBJECTIVE: Metastatic cancer of the acetabulum can produce marked pain and disability for patients. Several reconstruction techniques for such lesions have been described, with variable outcomes. The purpose of this study was to determine functional outcomes and complication rate for patients undergoing cement rebar reconstruction using posterior column screws with total hip arthroplasty for large, uncontained lesions of the acetabulum. METHODS: Twenty-two consecutive patients who underwent cement rebar reconstruction with posterior column screws and total hip arthroplasty for metastatic tumors of the acetabulum between 2014 and 2017 were identified. All cases were reviewed for patient demographics, surgical parameters, implant survival, complications, and functional status following these procedures. RESULTS: There was a significant increase in the proportion of patients able to ambulate post-surgery (95.5%) compared with presurgery (22.7%) (p < 0.001). Mean musculoskeletal tumor society score postoperatively was 17.9 (60%). Average operative time was 174 min and average estimated blood loss was 689 mL. Seven patients required an intraoperative or postoperative blood transfusion. Three patients had postoperative complications (14%), two of whom required revision (9%). CONCLUSION: Reconstruction using cement rebar with posterior column screws and total hip arthroplasty is a safe, reproducible approach that may greatly improve functional outcomes with a low rate of intraoperative or postoperative complications.

Is There Value in Radiology Reads for Pediatric Supracondylar Fractures in the Outpatient Clinic?

BACKGROUND: Increased health care costs have driven assessment of value of common practices. The Joint Commission mandates the dual interpretation of musculoskeletal radiographs by radiologists and orthopedic surgeons in hospital-based clinic settings. However, the value of this practice has come under question. The purpose of this study was to investigate whether radiologist interpretations change orthopedists' management during follow-up of pediatric supracondylar humerus fractures. METHODS: A retrospective review was performed of pediatric elbow fractures at a single institution from January 2012 to December 2015. Patients with supracondylar humerus fractures and at least one clinic follow-up were included. For each radiograph, the orthopedic surgeon and radiologist interpretations were reviewed and a determination was made as to whether the radiologist interpretation affected management of the patient. In films with disagreement of displacement, Baumann angle and posterior displacement based on Gartland classification with Wilkins and Leitch modifications were measured. Timing of final radiologist and orthopedic interpretations were also assessed. Finally, billing charges of radiologist interpretations were assessed. RESULTS: There were 441 pediatric supracondylar humerus fracture patients included in this study. All 441 patients had at least 1 clinic follow-up, 397 patients had at least 2 clinic follow-ups, and 123 patients had at least 3 clinic follow-ups, with a total of 716 elbow radiographs obtained. There were 17 cases (2.4%) where orthopedics and radiologist final interpretations disagreed regarding fracture displacement. In no cases did radiologist interpretations change orthopedic management. Radiographs that orthopedics interpreted as displaced were more likely to be posteriorly displaced (80.0% vs. 0.0%; P=0.002). However there was no difference in Baumann angle (P=0.125). Of the 716 films included, 28 radiologist interpretations were performed the day after the clinic visit (4%). Excluding these cases, there was an average of 57±3 minutes between radiograph acquisition and final interpretation. There were 352 cases where final orthopedic note filing time was documented, and 32% of these notes were finalized prior to the final radiologist interpretations. The total charges of radiologist interpretations was $18,772. CONCLUSIONS: The results of this study suggest that dual-interpretation of radiographs obtained in the follow-up clinic setting does not add value in management of pediatric supracondylar humerus fractures. LEVEL OF EVIDENCE: Level IV-case series.

Effects of a Prescription Drug Monitoring Program on Opioid Prescriptions Following Total Joint Arthroplasty in the State of California.

In an attempt to reduce opioid prescriptions, the state of California mandated physician participation in the Controlled Substance Utilization Review and Evaluation System (CURES). The goal of this study is to assess whether this intervention led to a change in prescribing habits after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). The 90-day postoperative narcotic use was retrospectively reviewed for 13,382 patients undergoing primary THA and TKA. Patients were divided into pre-CURES and post-CURES cohorts based on date of surgery. Narcotic use was measured in morphine milligram equivalents (MME). There was a 21.3% decrease in postoperative MME post-CURES for patients undergoing THA (756.5±759.5 MME vs 962.00±864.4 MME, P<.0001) and a 19.9% decrease in postoperative MME post-CURES for patients undergoing TKA (1274.3±2707.1 MME vs 1590.6±1725.3 MME, P<.0001). Patients post-CURES required an additional prescription at 2 weeks more frequently compared with patients pre-CURES after THA (27.5% vs 20.5%, P<.001) and TKA (54.2% vs 44.2%, P<.001). Patients undergoing THA had 40.5% and 40.6% less narcotic prescribed compared with patients undergoing TKA pre-CURES and post-CURES (P<.001), respectively. Government guidelines led to a substantial decrease in postoperative MME prescribed after TKA and THA. Patients undergoing THA had a substantially smaller amount of narcotic prescribed than patients undergoing TKA. [Orthopedics. 2023;46(2):70-75.].

Direct Anterior Versus Posterior Approach for Total Hip Arthroplasty Performed for Displaced Femoral Neck Fractures.

OBJECTIVES: To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs). DESIGN: Retrospective cohort study. SETTING: Multicenter Health care Consortium. PATIENTS: Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021. INTERVENTION: Total hip arthroplasty using either DAA or posterior approach. MAIN OUTCOME MEASUREMENTS: Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents). RESULTS: Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. CONCLUSION: When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Acute Kidney Injury With Dual NSAID Use After Outpatient Primary Total Joint Arthroplasty.

BACKGROUND: NSAIDs have been shown to be highly effective analgesic agents in the postoperative period. NSAIDs do have several potential adverse effects, including kidney injury (AKI). Little is known about AKI in the outpatient total joint arthroplasty (TJA) setting, where patient labs are not closely monitored. The objective of this study was to evaluate the renal safety of combined use of ibuprofen for pain control and aspirin for deep vein thrombosis chemoprophylaxis after outpatient primary TJA. METHODS: Patients undergoing primary total hip or total knee arthroplasty between January 2020 and July 2020 at a single center were included for analysis. All included patients were discharged on a standard regimen including aspirin 81 mg twice a day and ibuprofen 600 mg three times a day. Patients were ordered a serum creatinine test at 2 and 4 weeks postoperatively. Patients with postoperative acute kidney injury were identified per Acute Kidney Injury Network criteria. RESULTS: Between January 23, 2020, and August 30, 2020, 113 patients were included in this study, of whom creatinine levels were measured in 103 patients (90.3%) at the 2-week postoperative time point, 58 patients (50.9%) at the 4-week time point, and 48 (42.1%) at combined 2- and 4-week time points. Three patients (2.9%) were found to have an AKI. CONCLUSION: This study found a rate of AKI of 2.9% with the use of dual NSAID therapy postoperatively after primary TJA. All cases occurred at 2 weeks postoperatively and saw spontaneous resolution.

An Anatomical Evaluation of the Trapezium and Its Relationship to Basilar Joint Osteophytic Change.

BACKGROUND: To perform a comprehensive osteologic investigation into trapezium anatomy and investigate the relationship between anatomical factors and osteophyte formation, focusing on sex-specific differences. METHODS: This was a cadaveric study involving 1233 trapezia and first metacarpals. Two subgroups ("Control" and "Main Study") were established. The "Control" cohort was used to identify features of the trapezium in specimens devoid of osteophytic change. The prevalence and severity of osteophytic change were investigated in the "Main Study" cohort. Sex differences were specifically assessed. Regression analyses were used to identify factors associated with osteophyte formation. RESULTS: Three discrete surface morphologies exist at the trapezium trapeziometacarpal (TM) facet: heart, quadrilateral, and bean. Controlling for height, men have a larger trapezium TM facet surface area. However, the trapezium assumes the same off-center saddle shape in both sexes. The presence of osteophytes at the basilar joint is a common finding; no differences in osteologic prevalence exist between sexes. The progression of osteophytic change complements the radiographic Eaton-Littler classification system. The trapezium TM facet increases the surface area with incremental osteophyte involvement, with the degree of surface area expansion correlated with increases in the severity of osteophytic change. Increased age, increased surface area, bean morphology, and decreased volar joint depth are associated with more severe osteophyte formation. CONCLUSIONS: Anatomical features of the trapezium may contribute to osteophyte development. Although the prevalence of osteophytic disease appears equal between sexes, sex differences exist in some anatomical parameters. These differences may help explain the increased prevalence of symptomatic basilar joint disease in women.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

Correction to: Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

The original version of this article unfortunately contained a mistake. The spelling of Erin Ohliger's name was incorrect.

Total hip arthroplasty in the setting of tuberculosis infection of the hip: a systematic analysis of the current evidence.

INTRODUCTION: Total hip arthroplasty (THA) is a viable option to restore mobility and relieve pain in patients with severe post-tuberculous arthritis, but has been controversial due to concerns of disease reactivation. Over the past several decades, a number of authors have reported outcomes of THA for tuberculosis (TB) infections. However, there is marked heterogeneity in regard to disease activity, surgical approaches, and the use of chemoprophylaxis in these studies. AREAS COVERED: The purpose of this review was to critically assess: 1) patient characteristics; 2) perioperative planning; 3) clinical outcomes; 4) radiographic outcomes; and 5) complications of THA in the setting of tuberculosis of the hip. EXPERT OPINION: THA is an effective treatment for post-TB hip arthritis. There has been controversy regarding its safety during the past several decades, as it has been thought to increase the risk of disease reactivation. While studies thus far have shown generally favorable results, they have been limited by small sample sizes and their design as retrospective case series. Comparison of these studies reveals marked heterogeneity in the clinical management of this complex disease. However, synthesis of their findings demonstrates favorable outcomes and low rates of complication, including disease reactivation particularly when perioperative anti-tuberculosis therapy is instituted.

Predictors of Extended Length of Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Segmental Instrumented Fusion: An Analysis of 407 Surgeries Performed at a Large Academic Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). SUMMARY OF BACKGROUND DATA: Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. METHODS: A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. RESULTS: Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ±â€Š2 vs. 7 ±â€Š2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ±â€Š548 vs. 488 ±â€Š341 cm, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ±â€Š2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. CONCLUSION: Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. LEVEL OF EVIDENCE: 3.

Surgery versus Antibiotics for Uncomplicated Appendicitis: Which Would a Medical Student Want?

BACKGROUND: Recent data suggest that treatment of acute, uncomplicated appendicitis (AUA) with antibiotics is as effective as surgery. A 2015 study indicated that more than 50% of patients would choose antibiotic therapy. Medical students represent a unique population of potential patients with greater medical knowledge than the general public and possibly less bias than practicing physicians. Therefore, we aimed to evaluate what the MEDICAL STUDENT'S treatment choice for AUA would be and what factors influence these decisions. METHODS: We conducted a survey of current medical students at a single institution. Survey data included demographics, interest in surgery or a procedure-related specialty, knowledge of and experience with surgery and antibiotics, and concerns about treatments. A summary of the literature regarding the efficacy and safety of antibiotics and surgery was presented. Each participant was asked which treatment he or she would choose if affected by AUA. RESULTS: A series of 255 medical students completed the survey (mean age 24.8 ± 2.4 y; 51.5% female). The largest number of respondents (41.2%) were second-year students, and more than half (54.2%) reported an interest in a procedure-related specialty. Nearly all (93%) reported prior antibiotic use (19% reporting adverse effects), and 50% had prior surgery (20% reporting adverse events). When asked to identify concerns about each treatment choice, "surgical complications" was selected most frequently (82%) for surgery, and "adverse events and side effects" was selected most frequently for antibiotics (57%). When asked how they would treat their own AUA, 66.3% selected surgery, 24.3% selected antibiotics, and 9.4% were unsure. Race, gender, specialty of interest, year of training, and history of adverse effects related to antibiotics or surgery were not significantly related to treatment choice (all p > 0.1). CONCLUSION: When informed of the benefits and risks of surgery and antibiotics to treat AUA, medical students in our study were more likely to choose surgery.