Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum.

OBJECTIVE: To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. BACKGROUND: Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. METHODS: The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. RESULTS: A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. CONCLUSIONS: Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.

Using the Stratum-Specific Likelihood Ratio Method to Derive Outcome-Based Hospital Volume Categories for Total Knee Replacement.

BACKGROUND: Evidence of higher hospital volume being associated with improved outcomes for patients undergoing total knee replacement (TKR) is mostly based on arbitrary distribution-based thresholds. OBJECTIVE: We aimed to define outcome-based volume thresholds using data from a national database. METHODS: We used the MedPAR Limited Data Set inpatient data from 2010-2015 to identify patients who had undergone primary TKR. Surgical and TKR specific complications occurring within the index hospitalization and all-cause readmission within 90 days were considered adverse events. We derived an average annual TKR case volume for each hospital and applied the stratum-specific likelihood ratio method to determine volume categories indicative of a similar likelihood of 90-day post-operative complications. Hierarchical multivariable logistic regression with a random intercept for hospital nested within study year and adjusted for patient and hospital characteristics was performed to determine if these volume thresholds were still associated with the odds of 90-day readmission for complications after adjustment. RESULTS: SSLR analysis yielded 4 hospital volume categories based on the likelihood of 90-day postoperative complications: 1-31 (low), 32-127 (medium), 128-248 (high), and 429+ (very high) TKRs performed per year. The results of the hierarchical multivariable logistic regression showed significantly increased odds of 90-day complications at lower volume categories. Sensitivity analyses confirmed our main findings. CONCLUSIONS: This study is the first to provide national-level volume categories that are evidence-based. Publicizing these thresholds may enhance quality measures available to patients, providers, and payors.

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy.

INTRODUCTION: Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis. METHODS: Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed. RESULTS: Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory. CONCLUSIONS: This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy.

INTRODUCTION: Counseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients' normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy. METHODS: Children ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category. RESULTS: Among 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis. CONCLUSIONS: This study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital.

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Discordance between Subjective and Objective Assessments of Activity after Pediatric Appendectomy.

BACKGROUND: Physical activity recovery after pediatric surgery can be assessed using objective measures such as step counts, but practice currently relies on subjective assessment by proxy. It is unclear how subjective and objective assessments of activity relate. We compared caregiver assessment of return to normal physical activity after pediatric appendectomy to step count recovery measured by a Fitbit. METHODS: Pediatric patients who underwent appendectomy were recruited between 2020 and 2022 to be monitored for 21 d with a Fitbit. Patients were grouped by the postoperative day (POD) (7, 14, or 21) their caregiver first reported their activity was "back to normal." Objective return to normal step count was estimated for each group by modeling the inflection point from increasing steps to a plateau. These measures were determined discordant if the subjective report remained outside the modeled 95% confidence interval (CI) for the day the group plateaued. RESULTS: Thirty-nine simple appendicitis and 40 complicated appendicitis patients were recruited. Among simple appendicitis patients, daily steps plateaued on POD 10.8 (95% CI 7.4-14.3), POD 14.0 (95% CI 11.0-17.1), and POD 11.1 (95% CI 6.9-15.3) for the day 7, day 14, and day 21 groups, respectively. Complicated appendicitis groups plateaued on POD 12.8 (95% CI 8.7-16.9), POD 15.2 (95% CI 11.1-19.3), and POD 16.7 (95% CI 12.3-21.0), respectively. Significant discordance was observed between subjective and objective assessments for the day 7 and day 14 simple groups and for the day 7 complicated group. CONCLUSIONS: There was significant discordance between caregiver and accelerometer-assessed activity recovery after pediatric surgery. Development of objective measures of recovery could help standardize assessment of children's recovery after surgery.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure.

INTRODUCTION: The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS: This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS: Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS: We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Metabolic syndrome and the likelihood of knee pain and functional disability: evidence from a large middle eastern population-based study.

OBJECTIVES: Metabolic Syndrome (MetS) has been associated with knee osteoarthritis (KOA) in animal studies, but epidemiologic evidence of the association remains controversial. We investigated the association between MetS and knee pain and functional disability, the hallmarks of KOA, in a Middle Eastern population with high reported MetS rates. METHODS: A population-based study of adult individuals was conducted between 01/2016 and 03/2019. Data collected included age, sex, blood pressure, body mass index (BMI), waist circumference (WC), and comprehensive metabolic panel blood tests. Knee symptoms were assessed using The Western Ontario and McMaster Arthritis index (WOMAC) The Adult Treatment Panel III criteria was applied to determine if participants had MetS. Multivariable regression was used to determine the association of MetS, and its components, with the WOMAC total and subscale scores. RESULTS: Of 6,000 participants enrolled, 15.5% had MetS. The multivariate regression demonstrated that participants with MetS had significantly higher WOMAC total and subscale scores after adjusting for demographic variables; however, these associations were not significant after adjusting for BMI. Multivariate regression examining the association between MetS components and the WOMAC scores showed sex-based significant differences with WOMAC scores; however, the differences were not larger than the minimally clinical important differences. CONCLUSIONS: This study demonstrated that after adjustment for BMI, neither MetS nor its individual parameters were associated with worse knee symptoms. As such, the association between MetS and worse knee symptoms requires further study.

A Call to Expand the Scope of Digital Phenotyping.

Digital phenotyping refers to near-real-time data collection from personal digital devices, particularly smartphones, to better quantify the human phenotype. Methodology using smartphones is often considered the gold standard by many for passive data collection within the field of digital phenotyping, which limits its applications mainly to adults or adolescents who use smartphones. However, other technologies, such as wearable devices, have evolved considerably in recent years to provide similar or better quality passive physiologic data of clinical relevance, thus expanding the potential of digital phenotyping applications to other patient populations. In this perspective, we argue for the continued expansion of digital phenotyping to include other potential gold standards in addition to smartphones and provide examples of currently excluded technologies and populations who may uniquely benefit from this technology.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals.

OBJECTIVE: To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. STUDY DESIGN: We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. RESULTS: In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. CONCLUSIONS: Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis.

STUDY OBJECTIVE: To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay. DESIGN: Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS). SETTING: SPARCS from March 1, 2016, to July 1, 2017. PARTICIPANTS: Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery. INTERVENTIONS: Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified. PRIMARY AND SECONDARY OUTCOME MEASURES: Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities. RESULTS: Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/- 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities. CONCLUSIONS: Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data.

Conceptual Frameworks of Postoperative Recovery: A Scoping Review.

OBJECTIVE: We conducted a scoping review to identify existing conceptual frameworks of postoperative recovery (PR) and assess their content. BACKGROUND: PR is increasingly recognized by providers and third-party payers as a multidimensional phenomenon. Efforts to optimize PR and reduce complications and readmissions continue to evolve through changes in care (i.e., enhanced recovery protocols) and financial incentives. Delineating all factors affecting PR using a conceptual framework should aid in the design of effective interventions. METHODS: Web of Science and PubMed were queried to identify articles, between January 1980 and August of 2019, about conceptual frameworks of PR, using the search terms: "concept," "model," "framework," "recovery after surgery," "conceptual framework" "postoperative," "surgery," and "children." Articles considering PR as a concept rather than an outcome were included. Articles were examined in accordance with Walker and Avant's method for the concept analysis. Concepts identified across articles were classified as domains and subdomains of PR. RESULTS: The search yielded 183 unique articles; 8 met inclusion/exclusion criteria. Most articles defined PR as a period of days to weeks (n = 7) rather than days (n = 1). PR was mostly conceptualized as a process involving the patient and the health care system (n = 4) rather than the patient alone (n = 2). Physiological recovery (n = 8), activities of daily living (n = 8), pain (n = 5), cognitive/psychological recovery (n = 4), social recovery (n = 2), and patient perspective (n = 1) were the identified domains. Existing patient-reported outcome measures were used to assess most PR domains; however, definitions of domains and subdomains differed. None of the PR conceptual frameworks included were specific to children. CONCLUSIONS: There are few conceptual frameworks of PR in adults, and the definitions of PR differ. No framework was specific to children. Consensus on a conceptual framework of PR in adults and development of a conceptual framework of PR specific to children are needed.

Utility of Wearable Sensors to Assess Postoperative Recovery in Pediatric Patients After Appendectomy.

BACKGROUND: Despite more than two million pediatric operations performed in the United States annually, normal postoperative recovery remains difficult to define. Wearable sensors that assess physical activity and vital signs in real time represent a tool to assess postoperative recovery. This study examined the use of a wearable, the FitBit Inspire HR, to describe recovery in children after appendectomy and to determine the sensitivity of wearable data to distinguish disease severity. MATERIALS AND METHODS: Children 3-18 y old undergoing appendectomy in a tertiary children's hospital were invited to participate. Participants wore the FitBit Inpire HR after surgery for 21 d. t-tests compared daily step counts, and piecewise linear regression models were fit to examine recovery trajectories for patients with simple and complicated appendicitis. RESULTS: Thirty-two patients were enrolled, and 26 met eligibility criteria. Nine (35%) children had complicated appendicitis, and 14 (54%) were female; the mean age was 9.1 y (standard deviation: 2.9). Four hundred nineteen postoperative days were captured (range: 8-22 d; median: 16 d). Step counts increased after surgery; however, piecewise models showed that patients with simple appendicitis had a more rapid increase (P < 0.01) and reached a plateau (approximately 8000 steps/d) on postoperative day 9, whereas patients with complicated appendicitis did not reach a plateau and had lower step counts during the entire 21-postoperative day period (P < 0.01). CONCLUSIONS: Recovery in children after surgery can be characterized using wearables, which can also distinguish recovery trajectories based on disease severity. Establishing such "normative" recovery patterns may lead to earlier detection of complications.

Real World Performance of Sacral Neuromodulation and OnabotulinumtoxinA for Overactive Bladder: Focus on Safety and Cost.

PURPOSE: We aimed to determine the real world safety and cost of third line overactive bladder therapies, including onabotulinumtoxinA and sacral neuromodulation. MATERIALS AND METHODS: We performed an all-inclusive, population based cohort study of third line therapies of overactive bladder (sacral neuromodulation or onabotulinumtoxinA) using the statewide surgical data captured in the New York Statewide Planning and Research Cooperative System. The main outcome measures were 30-day safety events, and 1 and 3-year health care utilization costs. Propensity score matching was done to control for confounding factors and comparative analyses of safety events were also performed. RESULTS: Our cohort included 2,680 patients, of whom 1,328 underwent sacral neuromodulation and 1,352 received onabotulinumtoxinA from January 1, 2013 through December 31, 2016. Average ± SD age was 61.7 ± 16.3 years and 82.7% of the patients were female. Sacral neuromodulation implantation led to re-intervention in 15.8% of cases within 1 year and in 26.1% at 3 years. In this comparative analysis patients who received onabotulinumtoxinA therapy were at higher risk for urinary tract infection, hematuria, urinary retention and an emergency room visit compared to those treated with sacral neuromodulation. The overall cost of onabotulinumtoxinA was lower than the cost of the sacral neuromodulation device (cost at 1 year $2,896 vs $15,343 and at 3 years $3,454 vs $16,189, each p <0.01). CONCLUSIONS: Sacral neuromodulation implantation was more expensive than onabotulinumtoxinA injection. However, patients who underwent sacral neuromodulation had a lower complication rate than patients treated with onabotulinumtoxinA. A quality improvement collective database must be created to track information on onabotulinumtoxinA and sacral neuromodulation treatment. This would help generate better performance and comparative data for patient and physician decision making.

Applicability of the AAOS appropriate-use criteria for distal radius fractures in surgical practice.

PURPOSE: The appropriate-use criteria (AUC) for distal radius fracture (DRF) was developed by the American Academy of Orthopedic Surgeons (AAOS) to aid surgeons in making evidence-based treatment decisions for DRFs. The aim of our study was to cross-reference the management of operatively treated DRFs with the web-based AAOS published AUC recommendations. METHODS: The AUC for DRF evaluates the appropriateness of ten treatment options for each of 240 mutually exclusive patient scenarios based on the combination of five factors. For every scenario, each treatment is classified as appropriate, maybe appropriate or rarely appropriate. We retrospectively reviewed the medical charts and radiographs of all adult patients ≥19 years who underwent surgery for DRFs between 1 January and 31 December 2014 and determined the rate of appropriateness of treatment in this consecutive series of patients. RESULTS: Over the study period, 108 patients (83.3% men; mean age 39.8 years) with 113 DRFs (five bilateral) were treated surgically. The most frequent scenario was represented by a type C fracture, high-energy mechanism, normal functional demand, American Society Anesthesiologists (ASA) status 1-3 and no associated injuries. The most frequently used treatment was volar locking plate (54.0%). Based on the AUC, treatment was appropriate for 96 cases (85.0%), maybe appropriate for 15 (13.2%), and rarely appropriate for two (1.8%). CONCLUSIONS: A web-based electronic AUC application can be an attractive and easy decision-making aid for orthopaedic surgeons. Application of the AUC to clinical data was relatively simple, and most operatively treated DRFs were managed appropriately. LEVEL OF EVIDENCE: IV.

A Crosswalk Between UCLA and Lower Extremity Activity Scales.

BACKGROUND: The University of California, Los Angeles (UCLA) activity scale and the Lower Extremity Activity Scale (LEAS) are the two most-widely used and rigorously developed scales for assessing activity level in patients having joint replacement. However, the two scales are not convertible, and the level of correlation between the two is not clear. Creating a crosswalk between these scales; that is, a concordance table to convert scores from one scale to the other and vice versa, will help compare results from existing studies using either scale, and pool those results for meta-analyses. It also will facilitate pooling data from multiple registries and data sources. QUESTIONS/PURPOSE: To create a crosswalk between the UCLA and the LEAS activity scales for patients having THA or TKA. METHODS: Preoperative and 2-year postoperative UCLA and LEAS scores for a cohort of patients undergoing primary TKA or THA at the Hospital for Special Surgery between May 2007 and December 2011 were matched from two registries. The scales were self-administered by patients. Three hundred sixty-four patients having TKAs (67% women; mean age, 67 years) and 403 having THA (66% women; mean age, 66 years) had both scores available. The equipercentile equating method was used to create the crosswalk. The standard response mean was used to assess responsiveness of the converted versus actual UCLA and LEAS scores from baseline to 2 years. Crosswalk validation also included comparing the area under the receiver operating characteristic curve of the actual and converted scores to evaluate their ability to discriminate different levels of function measured using the Hip dysfunction and Osteoarthritis Outcome Score activities of daily living subscale for patients having THA and the Knee injury and Osteoarthritis Outcome Score activities of daily living subscale for patients having TKA. Difference between scores was assessed using the inequality test. RESULTS: For patients having TKA, converted mean scores (UCLA to LEAS, 9.5 ± 3.0; LEAS to UCLA, 4.7 ± 2.1) were not different from the actual scores (UCLA, 4.8 ± 2.1; LEAS, 9.4 ± 2.9). Standard response means for the converted scores (UCLA to LEAS, 0.47; LEAS to UCLA, 0.52) were not different from those of the actual scores (UCLA, 0.48; LEAS, 0.56). The areas under the receiver operating characteristic curve also were not different for actual and converted scores for THA and TKA. CONCLUSION: We have developed and validated a crosswalk to easily convert UCLA to LEAS scores (and vice versa) for THA and TKA. Reproducing the crosswalk for other lower extremity conditions or surgical procedures may extend its utility to studies assessing activity in patients having these conditions or procedures.