Extreme thrombocytosis with an aggressive evolution harboring a novel variant of calreticulin (CALR) in exon 3.

We describe the case of a patient with extreme thrombocytosis whose evolution was rapidly fatal. No cause of secondary thrombocytosis was found. There was no sign of myelofibrosis but the megakaryocytes were small and dysplastic. The patient presented a calreticulin (CALR) variant in exon 3 (C105S), as well as concomitant mutations of ASXL1, U2AF1, and EZH2. This variant of CALR has never been described before, and after sorting, all identified mutations were found in myeloid cells but not in lymphoid cells. Therefore, the diagnosis of a frontier case of myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) was made. A treatment with hydroxycarbamide was started because of a high risk of thrombosis. Upon worsening of the hematological status two new mutations appeared, SETBP1 and ETV6, and the CALR mutation was still detectable, as well as the three other mutations found in the chronic stage. Our results show that this variant could contribute to MDS/MPN pathogenesis in that patient.

What Is the Optimal Criteria to Use for Detecting Periprosthetic Joint Infections Before Total Joint Arthroplasty?

BACKGROUND: The purposes of this study were to (1) test the accuracy of α-defensin and combined α-defensin-aspiration cultures in diagnosing periprosthetic joint infection (PJI) before revision total knee and hip arthroplasty and (2) evaluate Musculoskeletal Infection Society (MSIS) criteria and α-defensin as predictors of successful reimplantation (second-stage) at 1 year after surgery. METHODS: We retrospectively evaluated a total of 97 synovial fluid aspirations performed between August 2014 and September 2016 before revision due to septic or aseptic failures (n = 70) or before second-stage (n = 27) joint arthroplasty. Revisions were categorized as either septic or aseptic according to the MSIS criteria. Synovial fluid was tested for α-defensin, cell count with differential, and cultures. Reimplantations were assessed for success or failure (defined as the need for reoperation due to infection) within 1 year after surgery. RESULTS: For septic and aseptic revision arthroplasty, the sensitivity, specificity, positive predictive value, and negative predicted value of α-defensin was 97% while for the combined α-defensin and aspiration culture, it was 96%, 100%, 100%, and 97%. Despite being performed with negative MSIS criteria and α-defensin test results, 11% (3/27) of reimplantations (second-stage) failed within 1 year postoperatively because of infection. CONCLUSION: Alpha-defensin is an accurate diagnostic test for the diagnosis of PJI before revision arthroplasty. The combination of α-defensin and aspiration cultures has higher specificity and positive predictive value. MSIS criteria and α-defensin may help predict the success of reimplantations within 1 year after surgery.

Effectiveness of Novel Adjuncts in Pain Management Following Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: Total knee arthroplasty (TKA) can be associated with significant pain which can negatively impact outcomes. Multiple strategies have been employed to reduce pain. The aim of this study is to compare the effectiveness of 3 different pain management modalities after TKA that included (1) our standardized knee injection cocktail and oral acetaminophen, (2) liposomal bupivacaine periarticular injection and oral acetaminophen, and (3) our standardized knee injection cocktail and intravenous (IV) acetaminophen. METHODS: A prospective randomized clinical trial was conducted with 3 perioperative pain management regimes: oral acetaminophen and our standardized knee injection cocktail (standard group), oral acetaminophen and liposomal bupivacaine periarticular injection (LB group), and IV acetaminophen and our standardized knee injection cocktail (IVA group). Primary outcome measures included visual analog scale, total morphine equivalents, and the opioid-related symptoms distress scale at 24 and 48 hours postoperatively. RESULTS: There were no significant differences on visual analog scale/opioid-related symptoms distress scale scores 24 hours after surgery. The LB group required significantly more narcotics (total morphine equivalents) than the standard (P = .025) and IVA groups (P = .032). No significant differences were observed on any of the outcomes measured at 48 hours after surgery. CONCLUSION: Our data suggest that there is no added benefit in the routine use of IV acetaminophen or liposomal bupivacaine after TKA.

Factors influencing physical therapy utilization after shoulder surgery: a retrospective review.

Background: Postoperative physical therapy (PT) is a cornerstone to achieve optimal patient outcomes. Access to postoperative PT can be limited by insurance type, coverage, and cost. With copayments (CP) for PT as high as $75 per visit, PT can be costprohibitive for patients. The purpose of this study was to evaluate factors affecting PT utilization among patients that underwent shoulder surgery. Methods: A retrospective analysis was performed of 80 shoulder surgery patients with postoperative PT sessions attended at a single institution from 2017 to 2019. Patients were divided based on insurance type: private insurance (PI), and Medicare with or without supplemental insurance (MI), and CP or no copayment. Demographics, CP, total, and postoperative number of PT sessions utilized was collected and analyzed. Results: The cohort had 53 females and an average age of 62. There was no significant difference between PI and MI at baseline other than surgery performed (P = .03), older MI group (69 years vs. 56 years: P < .01), and more females in PI group (76% vs. 55%; P = .05). There was no significant difference in the number of PT sessions between groups. The PI group was more likely to have a CP (P < .01). The CP group more often had PI and significantly more total PT visits (P = .05), while the no copayment group more often had Medicare (P < .01). CP was not independently associated with a change in the number of PT visits or total PT visits. Conclusions: The utilization of PT after shoulder surgery was found to not be influenced by insurance type or CP as determined by the number of PT sessions attended. Further investigations are necessary to better understand the relationship between CP and different insurance types and develop effective strategies to increase access to PT for postoperative shoulder patients.

Impact of the 7-Day Disabled List Rule Change on Economics and Performance After Reported Concussion Injuries in Major League Baseball.

BACKGROUND: The incidence of concussions is increasing in Major League Baseball (MLB), and the cost of these injuries in 2008 was reportedly as high as US$423 million. Team officials are more aware of concussion injuries, and one measure to address this issue was the creation of a concussion-specific 7-day disabled list (DL) in 2011. PURPOSE: To evaluate concussion trends among MLB players and the impact of concussion-specific 7-day DL status on postinjury player performance and team financials. STUDY DESIGN: Descriptive epidemiology study. METHODS: From 2005 to 2016, a total of 112 players placed on the DL because of a concussion were identified using the MLB website and were verified using established news databases. Salary information for players was collected using MLB published data, and cost was calculated with a previously published formula utilizing the injured player's salary per game and adding the cost of his replacement. Performance metrics were compared before and after the rule change. RESULTS: The mean number of days on the DL decreased from 38.8 before 2011 to 29.2 after 2011. The mean annual cost per player before 2011 was $1.1 million and decreased to $565,000 after the rule change. Regression analyses demonstrated a downward trend in the mean cost (R = -0.61, P < .001). A comparison of postinjury performance metrics showed no significant differences with decreased time on the DL. CONCLUSION: The minimum 7-day DL change has not had a negative impact on reporting; instead, it has demonstrated decreased time on the DL and lower associated team costs. Performance metrics demonstrated no differences compared with before the rule change, suggesting that players are not negatively affected by decreased time on the DL.

Diagnosis can predict opioid usage and dependence in reverse shoulder arthroplasty.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) has seen exponential growth over the past 2 decades. In addition, the recent focus on opioid usage and dependence has led to an increased understanding of the risk factors that lead to dependence. The purpose of this study was to examine associations between diagnosis and opioid consumption and dependence in RSA. METHODS: A retrospective review was performed of 441 patients who had undergone a primary RSA from 2012 to 2016. Demographics were collected and patients were categorized based on top 4 diagnoses: glenohumeral osteoarthritis (n = 129), irreparable rotator cuff tear (n = 85), rotator cuff arthropathy (RCA) (n = 184), and proximal humerus fracture (n = 69). Opioid consumption within 90 days surrounding surgery was recorded from Prescription Drug Monitoring Programs. Logistic regression was performed. RESULTS: Baseline characteristics for sex (P = .0001), ethnicity (P = .04), age (P = .01), and preoperative opioid use (P = .029) were significantly different. Patients with osteoarthritis had the lowest preoperative total morphine equivalents (TMEs) at 22.82 compared with fractures (53.36, P = .02) and RCA (46.54, P = .02). There was no significant difference in preoperative opioid dependence based on diagnosis (P = .16); however, postoperatively, the RCA group had the highest dependence at 40.3% (P = .03). In addition, there were no significant differences postoperatively in TMEs prescribed (P = .197). The preoperatively dependent patients were 8 times more likely to remain dependent regardless of diagnosis. CONCLUSION: Patients with fractures consume the highest amounts of opioids surrounding surgery. Surgeons should tailor their preoperative education and pain management protocols accordingly based on diagnoses for RSA. In addition, increased awareness and protocols need to be implemented for preoperative opioid-dependent patients regardless of diagnosis.

The Practice of Overlapping Surgery Is Safe in Total Knee and Hip Arthroplasty.

BACKGROUND: Overlapping surgery occurs when a surgeon performs 2 procedures in an overlapping time frame. This practice is commonplace in the setting of total joint arthroplasty and is intended to increase patient access to experienced surgeons, improve efficiency, and advance the surgical competence of surgeons and trainees. The practice of overlapping surgery has been questioned because of safety and ethical concerns. As the literature is scarce on this issue, we evaluated the unplanned hospital readmission and reoperation rates associated with overlapping and non-overlapping total joint arthroplasty procedures. METHODS: We reviewed 3,290 consecutive primary total knee and hip arthroplasty procedures that had been performed between November 2010 and July 2016 by 2 fellowship-trained senior surgeons at a single institution. Overlapping surgery was defined as the practice in which the attending surgeon performed a separate procedure in another room with an overlapping room time of at least 30 minutes. Patient baseline characteristics and 90-day rates of complications, readmissions, and reoperations were compared between overlapping and non-overlapping procedures. Subanalyses also were done on patients with a body mass index (BMI) of ≥30 kg/m2 and those with an American Society of Anesthesiologists (ASA) score of 3 or 4. The level of significance was set at 0.05. RESULTS: Of the 2,833 procedures that met the inclusion criteria, 57% (1,610) were overlapping and 43% (1,223) were non-overlapping. Baseline demographics, BMI, and ASA scores were similar between the groups. No significant differences were found between the overlapping and non-overlapping procedures in terms of the 90-day rates of complications (5.2% vs. 6.6%, respectively; p = 0.104), unplanned readmissions (3.4% vs. 4.3%; p = 0.235), or reoperations (3.1 vs. 3.1; p = 1.0) in the analysis of the entire cohort or in subgroup analyses of obese patients and patients with an ASA score of 3 or 4. The total mean operating room time was 5.8 minutes higher for overlapping procedures. CONCLUSIONS: Overlapping procedures showed no increase in terms of the 90-day rates of complications, readmissions, or reoperations when compared with non-overlapping procedures. There was just over a 5-minute increase in mean operating room time for overlapping procedures. Our data suggest that overlapping surgery does not lead to detrimental outcomes following total knee arthroplasty or total hip arthroplasty. Future investigations evaluating patient-oriented outcomes and satisfaction are warranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.