Perioperative Dexamethasone is Associated With a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients.

BACKGROUND: Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS: Patients who have a history of VTE who underwent primary elective TJA from 2015 to 2021 were identified using a commercial health care database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS: Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < .001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < .001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < .001) and DVT (2.37 versus 3.01%, P < .001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio: 0.78, 95% confidence interval: 0.66 to 0.93, P = .006) and DVT (adjusted odds ratio: 0.84, 95% confidence interval: 0.74 to 0.95, P = .006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > .05). CONCLUSIONS: The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA. LEVEL OF EVIDENCE: Level III.

Dexamethasone-Associated Hyperglycemia is Not Associated With Infectious Complications After Total Joint Arthroplasty in Diabetic Patients.

BACKGROUND: Postoperative infection is a devastating complication of total joint arthroplasty (TJA). Perioperative use of dexamethasone in patients who have diabetes mellitus (DM) remains controversial due to concern for increased infection risk. This study aimed to evaluate the association between dexamethasone and infection risk among patients who have DM undergoing TJA. METHODS: This was a retrospective cohort study conducted on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) between January 2016 and December 2021 using a large national database. We identified 110,568 TJA patients (TKA: 66.6%; THA: 33.4%), 31.0% (34,298) of which had DM. Patients who received perioperative dexamethasone were compared to those who did not. The primary end points were the 90-day risk of postoperative periprosthetic joint infection, surgical site infection (SSI), and other non-SSI (urinary tract infection, pneumonia, sepsis). RESULTS: When modeling the association between dexamethasone exposure and study outcomes while accounting for the interaction between dexamethasone and morning blood glucose levels, dexamethasone administration conferred no increased odds of postoperative periprosthetic joint infection nor SSI in diabetics. However, dexamethasone significantly lowered the adjusted odds of other postoperative infections in diabetic patients (TKA: adjusted odds ratio = 09, 95% confidence interval = 0.8 to 1.0, P = .030; THA: adjusted odds ratio = 0.7, 95% confidence interval = 0.6 to 0.9, P = .001); specifically in patients with morning blood glucose levels between 110 to 248 mg/dL in TKA and ≤ 172 mg/dL in THA. CONCLUSIONS: This study provides strong evidence against withholding dexamethasone in diabetic patients undergoing TJA based on concern for infection. Instead, short-course perioperative dexamethasone reduced infection risk in select patients. The narrative surrounding dexamethasone should shift away from questions about whether dexamethasone is appropriate for diabetic patients, and instead focus on how best to optimize its use.

Perioperative Dexamethasone Associated With Decreased Length of Stay After Total Hip and Knee Arthroplasty.

INTRODUCTION: Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA. METHODS: All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences. RESULTS: Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061). CONCLUSION: Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.

Driving performance and turning reaction time following hip arthroscopy for FAIS: does capsular repair matter?

PURPOSE: (1) To compare the pre- and postoperative driving performance in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS); (2) to examine the differences in driving performance between patients with versus without capsular repair. METHODS: Patients who underwent arthroscopic hip surgery for FAIS were included. Driving performance of participating patients was collected using a driving simulator preoperatively and at 2 weeks, 4-6 weeks and 8-12 weeks postoperatively. Data collected included demographics, surgery laterality, intraoperative procedures, left and right turn reaction time, total turn reaction time, gas off time (GOF), and break reaction time (BRT). Repeated measures analysis of variance (ANOVA) was used for statistical analysis. RESULTS: 21 subjects (9 males, 12 females) with a mean age of 30 ± 9 years were included and 57.1% of the subjects had right-sided surgery. There was no difference between the mean preoperative and the 2-week postoperative left (0.72 seconds and 0.75 seconds, respectively) right (0.77 seconds and 0.75 seconds, respectively), and total (0.74 seconds and 0.75 seconds, respectively) turn reaction times as well as GOF (0.62 seconds and 0.60 seconds, respectively) and BRT (0.92 seconds and 0.93 seconds, respectively), indicating that the patients' driving performance returned to the preoperative level as early as 2 weeks following hip arthroscopy for FAIS. There was no significant difference amongst any of the driving variables between patients who underwent capsular repair (50%) and those who did not. There was no significant difference amongst any of the driving variable s between patients who underwent left versus right hip arthroscopy. CONCLUSIONS: Patients' driving performance returns to the preoperative level as early as 2 weeks after hip arthroscopy for FAIS. Surgery laterality nor capsular repair make any significant difference in the time for driving abilities to return to baseline. The impact of intraoperative procedures performed, and the analgesic medications used postoperatively on the driving ability of patients undergoing hip arthroscopy warrants further investigation in larger patient populations.

Hypoalbuminemia and Elevated CRP are Risk Factors for Deep Infections and Urinary Tract Infections After Lumbar Spine Surgery in a Large Retrospective Patient Population.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVES: To determine if pre-operative albumin and CRP can predict post-operative infections after lumbar surgery. METHODS: Patients who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lumbar discectomy were identified using a patient record database (PearlDiver) and were included in this retrospective study. Patients were stratified by Charlson Comorbidity Index (CCI) scores and pre-operative albumin and CRP status. Post-operative complications included deep infections and urinary tract infections within 3 months of the surgery and revisions within 1 year of the surgery. RESULTS: 74,280 patients were included in this study. 21,903 had pre-operative albumin or CRP lab values. 7,191 (33%), 12,183 (56%), and 2,529 (12%) patients underwent an ALIF, PLIF, and a lumbar discectomy, respectively. 16,191 did not have any complication (74%). The most common complication was UTI (16%). Among all patients, hypoalbuminemia was a significant risk factor for deep infection and UTI after ALIF, deep infection, UTI, and surgical revision after PLIF, and deep infection after lumbar discectomy. Elevated CRP was a significant risk factor for deep infection after ALIF, UTI after PLIF, and deep infection after lumbar discectomy in patients with a CCI ≤ 3. CONCLUSIONS: Pre-operative hypoalbuminemia and elevated CRP were significant risk factors for deep infection, UTI, and/or revision, after ALIF, PLIT, and/or lumbar discectomy. Future studies with a larger population of patients with low albumin and high CRP values are needed to further elaborate on the current findings.

Demographic, clinical, and operative risk factors associated with postoperative adjacent segment disease in patients undergoing lumbar spine fusions: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Adjacent segment disease (ASD) is a potential complication following lumbar spinal fusion. PURPOSE: This study aimed to demonstrate the demographic, clinical, and operative risk factors associated with ASD development following lumbar fusion. STUDY DESIGN/SETTING: Systematic review and meta-analysis. PATIENT SAMPLE: We identified 35 studies that reported risk factors for ASD, with a total number of 7,374 patients who had lumbar spine fusion. OUTCOME MEASURES: We investigated the demographic, clinical, and operative risk factors for ASD after lumbar fusion. METHODS: A literature search was done using PubMed, Embase, Medline, Scopus, and the Cochrane library databases from inception to December 2019. The methodological index for non-randomized studies (MINORS) criteria was used to assess the methodological quality of the included studies. A meta-analysis was done to calculate the odds ratio (OR) with the 95% confidence interval (CI) for dichotomous data and mean difference (MD) with 95% CI for continuous data. RESULTS: Thirty-five studies were included in the qualitative analysis, and 22 studies were included in the meta-analyses. The mean quality score based on the MINORS criteria was 12.4±1.9 (range, 8-16) points. Significant risk factors included higher preoperative body mass index (BMI) (mean difference [MD]=1.97 kg/m2; 95% confidence interval [CI]=1.49-2.45; p<.001), floating fusion (Odds ratio [OR]=1.78; 95% CI=1.32-2.41; p<.001), superior facet joint violation (OR=10.43; 95% CI=6.4-17.01; p<.001), and decompression outside fusion construct (OR=1.72; 95% CI=1.25-2.37; p<.001). CONCLUSIONS: The overall level of evidence was low to very low. Higher preoperative BMI, floating fusion, superior facet joint violation, and decompression outside fusion construct are significant risk factors of development of ASD following lumbar fusion surgeries.

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes.

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature.

CONTEXT: Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint. EVIDENCE ACQUISITION: PubMed was searched for relevant articles published from 1979 to 2019. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required. CONCLUSION: Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Clinical Effectiveness of Interlaminar Epidural Injections of Local Anesthetic with or without Steroids for Managing Chronic Neck Pain: A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic neck pain is reportedly considered the fourth leading cause of disability. Cervical interlaminar epidural injections are among the commonly administered nonsurgical interventions for managing chronic neck pain, secondary to disc herniation and radiculitis, spinal stenosis, or chronic neck pain of discogenic origin. OBJECTIVES: To systematically review the differences in the effectiveness of cervical epidural injections with local anesthetics with or without steroids for the management of chronic neck pain. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive search of the literature of randomized controlled trials (RCTs) that compared epidural injections with local anesthetic with or without steroids was performed, including a search of PubMed, EMBASE, and Cochrane databases for all years up to May 2019. Meta-analysis was done for pain relief based on the Numeric Rating Scale, functional status based on the Neck Disability Index, and opioid intake dosage. RESULTS: Four studies met the inclusion criteria. A total of 370 patients were divided into 2 groups: the experimental group received cervical epidural injection with steroid and local anesthetic, and the control group received injection with local anesthetic only. Regrading pain relief, no significant difference was observed between both groups (weighted mean difference [WMD], -0.006; 95% confidence interval (CI), -0.275 to 0.263; P = 0.963; I² = 0.0% at 12 months). There was also no significant difference in the improvement of the functional status (WMD, 0.159; 95% CI, -1.231 to 1.549; P = 0.823; I² = 9.8% at 12 months). Similarly, there was no significant difference in opioid dosage (WMD, -0.093; 95% CI, -5.952 to 5.766; P = 0.975; I² = 0.0% at 12 months). LIMITATIONS: Only a few studies on this premise were found in the literature. There was also a lack of heterogeneity of the included RCT studies. CONCLUSIONS: The addition of steroids to anesthetic injectates was not associated with better pain and functional score outcomes compared with anesthetic injectate alone in patients with chronic neck pain. KEY WORDS: Chronic neck pain, cervical radiculopathy, cervical disc disease, spinal stenosis, facet joint pathology, cervical epidural injections, steroid injections, local anesthetic injections, systematic review, meta-analysis, randomized control trial.

Buchwald-Hartwig amination using Pd(i) dimer precatalysts supported by biaryl phosphine ligands.

We report the synthesis of air-stable Pd(i) dimer complexes featuring biaryl phosphine ligands. Catalytic experiments suggest that these complexes are competent precatalysts that can mediate cross-coupling amination reactions between aryl halides with both aliphatic and aromatic amine nucleophiles. This work represents an expansion of the air-stable precatalyst toolbox for Pd-catalyzed cross-coupling transformations.