Effect of anterior approach compared to posterolateral approach on readiness for discharge and thrombogenic markers in patients undergoing unilateral total hip arthroplasty: a prospective cohort study.

INTRODUCTION: The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA. METHODS: A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled. Readiness for discharge, length of stay (LOS), and related outcomes were additionally documented. Blood was drawn at baseline, wound closure, 5-h post-closure, and 24-h post-closure for assays of interleukin-6 (IL-6), PAP (plasmin anti-plasmin), a marker of fibrinolysis, and PF1.2 (Prothrombin fragment 1.2), a marker of thrombin generation. RESULTS: Compared to the PLA group, the DAA group was ready for discharge a mean 13 h earlier (p = 0.03), while rehabilitation milestones were met a mean 10 h earlier (p = 0.04), and LOS was 13 h shorter (p = 0.02) on average. Pain scores at all study timepoints and patient satisfaction at 6 weeks were similar (p > 0.05). At 24 h postoperatively, PAP levels were 537.53 ± 94.1 µg/L vs. 464.39 ± 114.6 µg/L (p = 0.05), and Il-6 levels were 40.94 ± 26.1 pg/mL vs. 60.51 ± 33.0 pg/mL (p = 0.03), in DAA vs. PLA, respectively. CONCLUSIONS: In the immediate postoperative period, DAA patients were ready for discharge before PLA patients. DAA patients had shorter LOS, a lower inflammatory response, and higher systemic markers of fibrinolysis. However, these differences may not be clinically significant. Future studies with larger study populations are warranted to confirm the validity and significance of these findings. LEVEL OF EVIDENCE: Level II, Therapeutic Study.

Diagnosis of Intraabdominal Fluid Extravasation After Hip Arthroscopy With Point-of-Care Ultrasonography Can Identify Patients at an Increased Risk for Postoperative Pain.

BACKGROUND: Intraabdominal fluid extravasation (IAFE) after hip arthroscopy has historically been diagnosed in catastrophic circumstances with abdominal compartment syndrome requiring diuresis or surgical decompression. A previous retrospective study found the prevalence of symptomatic IAFE requiring diuresis or decompression to be 0.16%, with risk factors including surgical procedure and high pump pressures. IAFE can be diagnosed rapidly by using point-of-care ultrasound (POCUS) via the Focused Assessment With Sonography for Trauma (FAST) examination, which is a well-established means to detect free fluid with high specificity and sensitivity. In this study, we used POCUS to determine the incidence of IAFE in patients undergoing hip arthroscopy. We predicted a higher incidence and that patients with IAFE would have symptoms of peritoneal irritation such as pain and nausea. METHODS: One hundred patients undergoing ambulatory hip arthroscopy were prospectively enrolled. A FAST examination was performed after induction by a trained anesthesiologist to exclude the preoperative presence of intraperitoneal fluid. Postoperatively, the same anesthesiologist repeated the FAST examination, and patients with new fluid in the abdominal or pelvic peritoneum were diagnosed with IAFE. Patients were followed up in the postanesthesia care unit (PACU) for 6 hours assessing pain, antiemetic and opioid use, and length of stay. RESULTS: Sixteen of 100 patients were found to have IAFE (16.0%; 99% confidence interval [CI], 8.4-28.1). These patients had, on average, a greater increase in pain score from their baseline assessment throughout their entire PACU stay (adjusted difference in means [99% CI]: 2.1 points [0.4-3.9]; P = .002). Patients with IAFE used more opioids, but this difference did not meet statistical significance (adjusted difference in means [99% CI]: 7.8 mg oral morphine equivalents [-2.8 to 18.3]; P = .053). There were no differences in postoperative nausea interventions or length of stay. CONCLUSIONS: Our incidence of IAFE was 16%, showing that IAFE occurs quite commonly in hip arthroscopy. Patients with IAFE had a greater increase in pain scores from baseline throughout the PACU stay. None of our patients required interventions. These findings suggest that even a small amount of new fluid in the peritoneum may be associated with a worse postoperative experience. This study brings awareness to a common yet potentially life-threatening complication of hip arthroscopy and highlights a unique and meaningful way that anesthesiologists in the perioperative setting can use POCUS to rapidly identify and guide management of these patients. Further studies with a larger sample size are needed to identify surgical and patient risk factors.

Gambling associated risk-taking decision in cerebellar ataxia.

INTRODUCTION: People with cerebellar ataxia (CA) can develop impulsive and compulsive behaviors that significantly affect their and their family's quality of life. To further assess the decision-making process associated with these behaviors, we used the Iowa Gambling Task (IGT) to study people with CA. METHODS: Sixty individuals with CA and thirty age-matched controls were enrolled in the study to complete the IGT. No participants had a prior or comorbid neurologic or psychiatric disorder associated with impulsivity. IGT performance in each of the five 20-trial blocks was compared between groups and the progression of participants' performance was assessed with simple linear regression models. Subgroup analyses were performed with genetic and non-genetic CA cases. RESULTS: CA cases obtained significantly lower IGT total scores than controls (-5.30 ± 37.53 vs. 21.30 ± 37.37, p = 0.004). In addition, those with CA made riskier decisions throughout the task compared to controls. Although both CA and controls learned to make decisions with more favorable outcomes over the course of completing the IGT, CA participants never matched the controls' performance. IGT performance did not correlate with ataxia severity or depressive symptoms. CONCLUSION: The IGT may capture a unique behavioral symptom of CA. Future studies may help elucidate the mechanisms underlying impaired decision-making in CA and further the understanding of a broader spectrum of cerebellar cognitive affective syndrome.

Impulsivity Trait Profiles in Patients With Cerebellar Ataxia and Parkinson Disease.

BACKGROUND AND OBJECTIVES: Individuals with cerebellar ataxia (CA) can develop impulsive behavioral symptoms, often resulting in negative interpersonal consequences, detrimentally affecting their quality of life. Limited evidence exists concerning impulsivity in CA and its associated behavioral changes. We assessed impulsive traits in CA using the Barratt Impulsivity Scale (BIS-11) and compared them with those of Parkinson disease (PD) to investigate the differences in the impulsive trait profiles between CA and PD. METHODS: We conducted a dual-center cross-sectional study with individuals with CA and PD enrolled through consecutive sampling from movement disorders clinics at Columbia University Medical Center and Vanderbilt University Medical Center, respectively. Age-matched controls were recruited at the respective institutions. Participants were excluded if they had prior or comorbid neurologic and psychiatric diseases known to be associated with impulsivity. All participants completed the BIS-11 questionnaire as a measure of impulsive traits. We used a general linear model and a least absolute shrinkage and selection operation regression to compare the total, subscale, and individual items of the BIS-11 scores between groups. Subgroup analyses were performed to isolate cerebellar contributions to impulsivity from potential effects of extracerebellar pathology and dopaminergic dysfunction or medications. RESULTS: A total of 190 participants-90 age-matched controls, 50 participants with CA, and 50 with PD-completed the assessments. Persons with CA reported 9.7% higher BIS-11 scores than controls (p < 0.001), while persons with PD reported 24.9% higher scores than controls (p < 0.001). In CA, the most affected domain of impulsivity was nonplanning. In contrast, persons with PD noted greater impulsivity across the nonplanning, attentional, and motor domains. DISCUSSION: Impulsivity in CA is uniquely driven by the nonplanning trait, unlike in PD. This suggests that the cerebellum and basal ganglia may differentially govern impulsive behaviors with the cerebellum contributing to the brain circuitry of impulsivity in a domain-specific manner.

The Impact of Compulsivity and Impulsivity in Cerebellar Ataxia: A Case Series.

Background: The cerebellum has recently been identified to have a key role in reward processing, and individuals with ataxia have been found to be more impulsive and compulsive as part of cerebellum-related cognitive and behavioral disturbances. Case Report: We reported five individuals with cerebellar ataxia who demonstrate impulsive and compulsive behaviors, including hobbyism, gambling, and compulsive medication use, to illustrate that these symptoms can be highly disabling. Discussion: These five cases provide examples of behavioral symptoms in cerebellar ataxia. Further investigations of the pathomechanism of these symptoms will advance our understanding of the cerebellum in cognition and behavior.

Clinical Indicators of the Need for Telemetry Postoperative Monitoring in Patients With Suspected Obstructive Sleep Apnea Undergoing Total Knee Arthroplasty.

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea is associated with increased complication rates postoperatively. Current literature does not provide adequate guidance on management of these patients. This study used the STOP-Bang questionnaire to diagnose patients with possible obstructive sleep apnea (score ≥3). We hypothesized that a STOP-Bang score of 3 or greater would significantly correlate with the number of oxygen desaturation episodes during the first 48 hours after total knee arthroscopy. METHODS: The STOP-Bang questionnaire was administered to 110 patients preoperatively. All patients underwent spinal-epidural anesthesia with a saphenous nerve block and sedation and were connected to the Nellcor OxiMax N-600x pulse oximeter for 48 hours postoperatively. RESULTS: Final analysis included 98 patients. There was no significant difference in the total number of desaturation events between STOP-Bang groups (score <3 vs ≥3 and score <5 vs ≥5). The total number of desaturation events on postoperative day 1 was greater than that on day 0 (32.8 ± 42.7 vs 4.1 ± 10.0, P < 0.0001). The total number of desaturation events correlated with length of hospital stay (r = 0.329, P = 0.0001). Patients with a preoperative serum CO2 of 30 mmol/L or greater had significantly longer episodes of desaturation on postoperative day 0 compared with CO2 of less than 30 mmol/L (233.7 ± 410.1 vs 82.0 ± 126.2 seconds, P = 0.044). CONCLUSIONS: A high preoperative value of CO2 should be a warning for possible prolonged episodes of desaturation postoperatively. An attempt to limit postoperative desaturation events should be made to minimize length of stay.