Transcatheter Arterial Radioembolization-Induced Gastric Ulcer in an Excluded Stomach After Roux-en-Y Gastric Bypass.

Transcatheter arterial radioembolization (TARE) is a common locoregional treatment for hepatocellular carcinoma. It is associated with peptic ulcer disease in up to 5% of patients. A 70-year-old man with Roux-en-Y gastric bypass and liver cirrhosis with hepatocellular carcinoma treated with TARE 6 months earlier was evaluated for continued melena and was found to have an ulcer in the excluded stomach. This was successfully treated with liquid proton pump inhibitor through gastrostomy tube to the excluded stomach. This represents a unique case of successful management of TARE-induced peptic ulcer disease in the excluded stomach of a Roux-en-Y gastric bypass patient.

Delays in definitive endoscopic resection of previously manipulated colorectal polyps as a risk factor for inferior resection outcomes.

BACKGROUND AND AIMS: Manipulation of colorectal polyps by biopsy, incomplete resection, or tattoo placement under the lesion has been shown to cause submucosal fibrosis and associated inferior outcomes. The effect of delays between index manipulation and definitive resection on the incidence of fibrosis is unknown. METHODS: Patients undergoing EMR of previously manipulated colorectal polyps ≥10 mm from 2016 to 2021 at a tertiary referral center were included. Time from index manipulation to definitive resection and the presence of fibrosis were noted. The effects of fibrosis on EMR outcomes were assessed. RESULTS: Among 221 previously manipulated lesions (180 biopsy, 23 incomplete/failed resection, 1 tattoo under lesion, 17 multiple types of manipulation), 51 (23%) demonstrated fibrosis. Fibrotic lesions were found to have been resected significantly later than nonfibrotic lesions (76 vs 61 days; P = .014). In a multivariate analysis controlling for other predictors of fibrosis, each 2-week delay was associated with a 14% increase in the odds of fibrosis. Fibrotic lesions had inferior outcomes with a lower en-bloc resection rate (8% vs 24%; P = .014) and longer procedure time (71 vs 52 minutes; P < .001). Adverse event and recurrence rates were similar between groups. CONCLUSIONS: Delays in definitive resection of previously manipulated polyps are associated with an increased incidence of fibrosis with time and associated inferior outcomes. Manipulation should be discouraged, and if it occurs, prompt referral and scheduling for definitive resection should be prioritized.

Tuning mobile phase properties to improve empty and full particle separation in adeno-associated virus productions by anion exchange chromatography.

In the past decade, recombinant adeno-associated virus (rAAV) has gained increased attention as a prominent gene therapy technology to treat monogenetic diseases. One of the challenges in rAAV production is the enrichment of full rAAV particles containing the gene of interest (GOI) payload. By adjusting the mobile phase properties of anion-exchange chromatography (AEX), it was demonstrated that empty and full separation of rAAV was improved in monolith based preparative AEX chromatography. When compared to the baseline method using NaCl, the use of tetraethylammonium acetate (TEA-Ac) in the AEX mobile phase resulted in enhanced resolution from 0.75 to 1.23 between "Empty" and "Full" peaks by salt linear gradient elution, as well as increased the percentage of full rAAV particles from 20% to 36% and genome recovery from 59% to 62%. Furthermore, a dual wash plus step elution AEX method was developed. Wherein, the first wash step harnesses TEA-Ac to separate empty and full capsids, which is followed by a second wash step that ensures no TEA-Ac salt is carried over into AEX eluate. The resulting optimized AEX purification method has the potential to be adapted for manufacturing and purification processes involving various rAAV production platforms that experience empty and full rAAV separation challenges.

Improved adeno-associated virus empty and full capsid separation using weak partitioning multi-column AEX chromatography.

Recombinant adeno-associated virus (rAAV) empty and full capsid separation has been a topic of interest in the rAAV gene therapy community for many years and the anion exchange chromatography (AEX) step has undergone various process optimizations to improve rAAV empty capsid separation, including AEX stationary phase, mobile phase, and process parameters. Here, we present a new AEX method that employs both weak partitioning chromatography (WPC) and multi-column chromatography (MCC) to achieve improved full rAAV percentage in the AEX pool. The WPC technology allows empty rAAV to be displaced by full rAAV during loading, while the MCC technology enables parallel column processing which further increases AEX step productivity. Our results show that, compared to baseline AEX batch chromatography, the AEX-WPC-MCC method demonstrated improvements in both AEX pool full rAAV percentage (∼ 20% increase) and rAAV genome recovery (∼ 20% increase). As a result, the productivity (full capsid generated per liter of AEX column per hour of processing time) of the AEX step increased by ∼34-fold from the baseline AEX batch run to the AEX-WPC-MCC run. It is foreseeable that this AEX-WPC-MCC method could find applications in large-scale rAAV manufacturing processes to improve AEX yield and reduce the cost of goods of rAAV manufacturing.

Reduced Tumor Size of Untreated Papillary Thyroid Carcinoma After Immune Checkpoint Inhibitor-Induced Thyroiditis.

Background/Objective: Immune checkpoint inhibitors (CPIs) activate antitumoral immune responses and are used to treat multiple types of primary and metastatic malignancies. Thyroid dysfunction is a known immune-related adverse event of CPI therapy. There are few data on the effect of CPI and CPI-induced thyroiditis on primary papillary thyroid carcinoma (PTC). We present a patient who developed CPI-induced thyroiditis during treatment for a nonthyroid malignancy and subsequent regression of a coexisting untreated primary PTC. Case Report: A 49-year-old man with metastatic colon adenocarcinoma was found to have a large right thyroid nodule with biopsy confirmation of PTC. He did not have compressive symptoms or evidence of metastatic PTC. Resection was not performed because of colon cancer therapy. Treatment with CPI (ezabenlimab, an anti-programmed cell death protein 1 antibody) was initiated for the treatment of colon cancer. Four months after the initiation of CPI therapy, testing showed thyroid-stimulating hormone and free thyroxine levels of 174.9 (0.3-4.0 mIU/L) and 0.67 (0.93-1.70 ng/dL), respectively, consistent with CPI-induced hypothyroidism. Levothyroxine therapy was initiated. Repeat imaging 3 months later demonstrated a decrease in the tumor size to 4.1 × 4.9 × 4.2 cm (calculated volume change, -8.3% from baseline). At the last imaging, 1 year after the onset of CPI-induced thyroiditis, the PTC continued to decrease in size and measured 2.9 × 3.9 × 3.2 cm (volume change, -60.7% from baseline). Discussion: CPI-induced thyroiditis suggests the development of an immune response against thyroid tissue and may reflect a similar increased immune response against PTC cells leading to tumor regression in this case. Conclusion: Further research to assess the immunologic mechanism underlying this association is warranted to potentially develop improved immunotherapy for PTC.

Treatment of Hepatitis C Virus Prior to Posterior Lumbar Fusion: No Difference in Medical Outcomes or Reoperation.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To analyze and confirm the rates of postoperative complications of patients with hepatitis C virus (HCV) undergoing primary posterior lumbar fusion (PLF) and assess whether treatment of HCV before surgery reduces complications. BACKGROUND CONTEXT: HCV causes chronic disease, leading to increased risk of cirrhosis and chronic illness. Currently, there is a lack of research regarding whether the patient's HCV is a modifiable risk factor for postoperative complications after spinal procedures. METHODS: The Mariner database was utilized to find patients from 2010 to 2018 undergoing PLF with active follow-up for a year. Cases involving same-day revision procedures and patients with a history of spine, infection, trauma, human immunodeficiency virus, hepatitis B, or neoplasm were excluded. Patients with a history of HCV diagnosis were identified and further stratified whether they had prior treatment using the national drug codes for antiviral, interferons, or ribavirin. Patients with HCV were matched with those without respect to age, sex, and comorbidity of burden. Outcome measured included 90-day medical complications, infection, readmission, and 1-year reoperation. RESULTS: There were 2,129 patients with HCV and 10,544 patients in the matched control group who underwent primary PLF. Out of the 2,129 patients, 469 (22.0.%) were treated with HCV medications before surgery. Patients with prior history of HCV had a significantly increased risk of wound complications (4.4% vs. 3.2%, odds ratio 1.56, 95% confidence interval 1.24-1.96, P =0.009), and infection (7.7% vs. 5.7%, odds ratio 1.26, 95% confidence interval 1.07-1.53, P =0.009) within 90 days of surgery. Patients treated before surgery did not have a difference in major ( P =0.205) or minor medical complications ( P =0.681) after surgery. CONCLUSIONS: Patients with prior history of HCV are at increased risk for many complications after surgery; however, this risk factor does not seem to be modifiable as the treatment group did not experience any improvement in postoperative outcomes. LEVEL OF EVIDENCE: Level III.

Outcomes following Total Hip Arthroplasty for Femoral Head Osteonecrosis in Patients with History of Solid Organ Transplant.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients with solid organ transplant (SOT) are at increased risk of postoperative complications after THA for osteoarthritis. The objective of the present study is to evaluate SOT as a potential risk factor for complication after THA for ONFH. METHODS: This is a retrospective study that identified patients with SOT who underwent THA for ONFH from 2005 to 2014 in a national insurance database and compared them to 5:1 matched controls without transplant. Subgroup analyses of patients with renal transplant (RT) and those with non-RT were also analyzed. A logistic regression analysis was used to compare rates of mortality, hospital readmission, emergency room (ER) visits, infection, revision, and dislocation while controlling for confounders. Differences in hospital charges, reimbursement, and length of stay (LOS) were also compared. RESULTS: 996 patients with SOT who underwent THA were identified and compared to 4,980 controls. SOT patients experienced no increased risk of early postoperative complications compared to controls. Solid organ transplant was associated with higher resource utilization and LOS. Renal transplant patients were found to have significantly higher risk of hospital readmission at 30 days (odds ratio [OR] 1.77; p = 0.001) and 90 days (OR 1.62; p < 0.001) and hospital LOS (p < 0.001), but had lower risk of infection (OR 0.65; p = 0.030). Non-RT patients had higher rate of ER visits at 30 days (OR 2.26; p = 0.004) but lower rates of all-cause revision (OR 0.22; p = 0.043). CONCLUSIONS: Patients with history of SOT undergoing THA for ONFH utilize more hospital resources with longer LOS and greater risk of readmission but are not necessarily at an increased risk of early postoperative complications.

Outcomes Following Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients on Hemodialysis.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients on hemodialysis (HD) are at increased risk for complications after THA for osteoarthritis, however there is limited information on outcomes of THA for ONFH in patients on HD. With increasing prevalence of chronic kidney disease (CKD) requiring HD, studies are needed to characterize the risk of complications in these patients. Therefore, the purpose of this study was to evaluate HD as a potential risk factor for complication after THA in patients with ONFH on HD. METHODS: Patients on HD with ONFH who underwent THA with at least 2 years of follow-up were identified using a combination of ICD-9 and CPT codes in a national insurance database. A 10:1 matched control cohort of patients with ONFH not on HD was created for comparison. A logistic regression analysis was used to evaluate rates of death, hospital readmission, emergency room (ER) visit, infection, revision, and dislocation between cohorts. Differences in hospital charges, reimbursement, and length of stay between the two groups were also assessed. RESULTS: One thousand one hundred thirty-seven patients on HD who underwent THA for ONFH were compared to a matched control cohort of 11,182 non-HD patients who underwent THA for ONFH. Patients on HD experienced higher rates of death (HD 4.1%, non-HD 0.9%; odds ratio [OR] 3.35, p < 0.01), hospital readmission (HD 16.1%, non-HD 5.9%; OR 2.69, p < 0.01) and ER visit (HD 10.4%, non-HD 7.4% OR 1.5, p < 0.01). Hemodialysis was not associated with higher risk of infection, revision, or dislocation, but was associated with significantly higher charges (p < 0.01), reimbursement (p < 0.01), and hospital length of stay (p < 0.01). CONCLUSIONS: While patients on HD do not have increased risk of implant-related complications, they are at increased risk of developing medical complications following THA for ONFH and subsequently may require more resources. Orthopedic surgeons and nephrologists should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management. LEVEL OF EVIDENCE: Therapeutic Level III.

Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion: No Increased Complications.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim were to (1) evaluate differences in postoperative outcomes and cost associated with outpatient anterior lumbar interbody fusion (ALIF) compared with inpatient ALIF, and to (2) identify independent factors contributing to complications after outpatient ALIF. SUMMARY OF BACKGROUND: While lumbar fusion is traditionally performed inpatient, outpatient spinal surgery is becoming more commonplace as surgical techniques improve. METHODS: The study population included all patients below 85 years of age who underwent elective ALIF (CPT-22558). Patients were then divided into those who underwent single-level fusion and multilevel fusion using the corresponding additional level fusion codes (CPT-22585). These resulting populations were then split into outpatient and inpatient cohorts by using a service location modifier. To account for selection bias, propensity score matching was performed; the inpatient cohorts were matched with respect to the outpatient cohorts based on age, sex, and Charlson Comorbidity Index. Statistical significance was set at P<0.05 and the Bonferroni correction was used for each multiple comparison (P<0.004). RESULTS: Patients undergoing outpatient procedure had decreased rates of medical complications following both single-level and multilevel ALIF. In addition, age above 60, female sex, Charlson Comorbidity Index>3, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, hypertension, and tobacco use were all identified as independent risk factors for increased complications. Finally, the cost of outpatient ALIF was $12,013 while the cost of inpatient ALIF was $27,271 (P<0.001). CONCLUSION: The findings add to the growing body of literature advocating for the utilization of ALIF in the outpatient setting for a properly selected group of patients. LEVEL OF EVIDENCE: Level IV.

Hemostatic efficacy of pathogen-reduced platelets in children undergoing cardiopulmonary bypass.

BACKGROUND: Pediatric patients undergoing cardiopulmonary bypass (CPB) often require blood component transfusions. Pathogen-reduction (PR) of platelets reduces the risk of microbial contamination; however, its effect on hemostatic efficacy in this population is unclear. This study sought to characterize the hemostatic efficacy of PR platelets in children undergoing CPB. STUDY DESIGN AND METHODS: We performed a retrospective chart review of patients admitted to a pediatric intensive care unit following CPB surgery from 2015 to 2019. Demographic data, validated scoring of repair complexity, products received, and outcomes were compared. The primary outcome was postoperative chest tube bleeding. RESULTS: A total of 140 patients were enrolled. The majority of surgeries (124/140) were Risk Adjustment for Congenital Heart Surgery (RACHS) 1-3 repairs. Seventy-four percent of patients (104/140) received only standard platelets whereas 26% (36/140) received PR platelets. There were no differences between the groups in the age (p = .90), sex (p = .20) or RACHS score (p = .06). Postoperatively, there was no difference in the median chest tube output for 1 h (p = .27), 2 h (p = .26), 4 h (p = .09), 8 h (p = .16), or for the first 24 h following surgery (p = .23) in patients who received standard versus PR platelets. There was also no difference in receipt of platelets (p = .18), cell saver (p = .79), or cryoprecipitate (p = .28). CONCLUSION: Patients receiving PR platelets did not have more blood loss or require more transfusions than those who received standard platelets. This suggests that PR platelets may provide acceptable hemostasis with the additional benefits of reduced risk of microbial contamination in pediatric patients undergoing CPB.

Postoperative Complications Following Ankle Arthrodesis in Patients With Hepatitis C: Matched Propensity Score Analysis.

BACKGROUND: Hepatitis C is associated with increased adverse events following surgery. The goals of this study were therefore to evaluate postoperative outcomes in patients with hepatitis C following ankle arthrodesis. MATERIALS AND METHODS: A review of Medicare patients was performed to identify patients who underwent ankle arthrodesis. Patients were then divided into those with a preoperative history of hepatitis C and those who did not and were matched using propensity scores. Outcomes of interest were analyzed using multivariate logistic regression. RESULTS: A diagnosis of hepatitis C was associated with a significantly increased risk of myocardial infarction, emergency department visits, and readmission within 90 days following surgery. In addition, hepatitis C is associated with an increased length of stay, cost of hospitalization, and total hospital charge. CONCLUSIONS: A diagnosis of hepatitis C was associated with a significant increase in hospital resource utilization during the initial inpatient stay and the immediate post-discharge period.Level of Evidence: III.

Obesity and Postoperative Complications Following Ankle Arthrodesis: A Propensity Score Matched Analysis.

Obese patients undergoing orthopedic procedure have been reported to have higher rates of postoperative complications, but the published associations have numerous confounders. This study aims to evaluate the independent effect of obesity on postoperative complications and hospital utilization following ankle arthrodesis. A database review of a Medicare database was performed on patients less than 85 years old who underwent ankle arthrodesis between 2005 and 2014. Patient cohorts were defined using International Classification of Diseases-9 coding for body mass index (BMI)-obese (30-40 kg/m2), and morbidly obese (>40 kg/m2). Normal BMI patients were defined as those without the respect codes for obesity (30-40 kg/m2), morbidly obese (>40 kg/m2), or underweight (<19 kg/m2). All groups were propensity score matched by demographics and comorbidities. Outcomes of interest included 90-day major and minor medical complications, and hospital burden. Morbid obesity was associated with an increased risk of acute kidney injury (4.4% vs 2.4%, OR 1.94, 95% CI 1.37-2.74, p < .001), urinary tract infection (5.2% vs 3.2%, OR 1.66, 95% CI 1.21-2.25, p = .001), readmission (13.6% vs 10.8%, OR 1.33, 95% CI 1.10-1.61, p = .003), and overall minor complications (16.0% vs 11.8%, OR 1.44, 95% CI 1.19-1.74, p < .001) compared to normal BMI patients, and an increased risk for acute kidney injury (4.4% vs 1.9%, OR 2.25, 95% CI 1.32-3.97, p = .003) compared to obese patients. Obesity was not associated with increased medical complications (p > .05). While morbid obesity was associated with an increase in the postoperative complications, obesity was not associated with any increase in postoperative complications following ankle arthrodesis.

Reimbursements for Revision Total Hip Arthroplasty Have Increased for Hospitals but Not for Surgeons.

BACKGROUND: With increases in total hip arthroplasty procedures the need for revision total hip arthroplasty (rTHA) has increased as well. This study aims to analyze the trends in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for rTHA for aseptic revisions, stage 1 and stage 2 revisions. METHODS: The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 4449 patients undergoing aseptic revision, 517 for stage 1 revision, and 300 for stage 2 revision in between the years 2004 and 2014. Two values were calculated: (1) the ratio of hospital to surgeon charges (CM) and (2) the ratio of hospital to surgeon payments (PM). Year-to-year variation and trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), CM, and PM were evaluated. RESULTS: The mean CCI for aseptic revisions and stage 1 revisions did not significantly change (P < .088 and P < .063). The CCI slightly increased for stage 2 revisions (P < .04). The mean LOS decreased significantly over time in all 3 procedure types. The CM increased by 39% (P < .02) in aseptic revisions, 109% in stage 1 revisions (P < .001) but did not significantly change in stage 2 revisions (P < .877). PM for aseptic revisions increased around 103% (P < .001), 107% for stage 1 revisions (P < .001), and 9.7% for stage 2 revisions (P < .176). CONCLUSION: Hospital charges and payments relative to surgeon charges and payments have increased substantially for THA aseptic revisions, stage 1 revisions, and stage 2 revisions despite stable patient complexity and decreasing LOS.

Trends in Hospital and Surgeon Charges and Reimbursements for Revision Total Knee Arthroplasty.

BACKGROUND: The relationship between surgeon and hospital charges and reimbursements for revision total knee arthroplasty (TKA) has not been well examined. The objective of this study is to report trends and variations in hospital charges and payments compared to surgeons for stage 1 (S1) vs stage 2 (S2) septic revision TKA and aseptic revision (AR) TKA. METHODS: The 5% Medicare sample was used to capture hospital and surgeon data for revision TKA from 2005 to 2014. The charge multiplier (CM) and ratio of hospital to surgeon charges, and the payment multiplier (PM) and ratio of hospital to surgeon payments were calculated. Year-to-year variation and regional trends in-patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. RESULTS: In total, 4570 AR, 1323 S1, and 863 S2 TKA patients were included. CM increased for all cohorts: 8.1-13.8 for AR (P < .001), 21.0-22.5 (P = .07) for S1, and 11.8-22.0 (P < .001) for S2. PM followed a similar trend, increasing 8.1-13.8 (P < .001) for AR, 19.8-27.3 (P = .005) for S1, and 14.7-30.7 (P < .001) for S2. Surgeon reimbursement decreased for all cohorts. LOS decreased for AR (3.8-2.8 days), S1 (12.8-6.9 days), and S2 (4.5-3.9 days). Charlson Comorbidity Index remained stable for AR patients but increased significantly for S1 and S2 cohorts. CONCLUSION: Hospital charges and payments relative to the surgeons have significantly increased for revision TKA in the setting of stable or increasing patient complexity and decreasing LOS.

Racial disparities in receipt of standard chemoradiation in anal squamous cell carcinoma, an analysis of the National Cancer Database.

BACKGROUND: Standard treatment for locally advanced anal squamous cell carcinoma (SCC) consists of concurrent chemoradiation. We evaluated whether racial differences exist in the receipt of standard treatment and its association with survival. METHODS: From the National Cancer Database, we identified patients diagnosed with anal SCC (Stages 2-3) between 2004 and 2015. Using logistic regression, we evaluated racial differences in the probability of receiving standard chemoradiation. We used Cox proportional hazards models to evaluate associations between race, receipt of standard therapy and survival. RESULTS: Our analysis included 19,835 patients. Patients receiving standard chemoradiation had better survival than patients receiving nonstandard therapy (hazard ratio [HR] 0.64; 95% confidence interval [CI] 0.61-0.68; p < 0.001). Compared to White patients, Black patients were less likely to receive standard therapy (odds ratio [OR] 0.85; 95% CI 0.76-0.96; p < 0.008). We observed no statistical difference in mortality between Black and White patients overall (HR 1.05, 95% CI 0.97-1.15; p = 0.24). However, for the subgroup of patients receiving nonstandard therapy, Black patients had an increased mortality risk compared to White patients (HR 1.17, CI 1.01-1.35; p = 0.034). We observed no survival differences in the subgroup of patients receiving standard treatment (HR 1.00, CI 0.90-1.11, p = 0.99). CONCLUSION: Standard treatment in anal SCC is associated with better survival, but Black patients are less likely to receive standard treatment than White patients. Although Black patients had higher mortality than White patients in the subgroup of patients receiving nonstandard therapy, this difference was ameliorated in the subset receiving standard therapy.

Urinary Self-Catheterization is Not Associated with Increased Risk of Major Complications Following Total Hip and Knee Arthroplasty.

BACKGROUND: The objective of this study is to evaluate urinary self-catheterization as a potential risk factor for postoperative complications following total hip (THA) and knee (TKA) arthroplasty procedures. METHODS: Self-catheterization patients who underwent total joint arthroplasty from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visit, infection, revision, and dislocation for THA or arthrofibrosis for TKA were calculated, as well as cost and length of stay. Self-catheterizing patients were then compared to a 4:1 matched control cohort using a logistic regression analysis to control for confounding factors. RESULTS: Sixty-nine patients underwent THA, and 128 patients who underwent TKA and who actively self-catheterized at the time of surgery were identified. Self-catheterization was not associated with infection, emergency room visits, readmissions, revision surgery, arthrofibrosis, or cost compared to the 4:1 matched control cohort. However, self-catheterization was associated with significantly longer length of stay (difference for THA = 1.91 days, confidence interval = 0.97-2.86, P < .001; difference for TKA = 0.61, odds ratio = 0.16-1.06, P = .01). CONCLUSION: Self-catheterization does not appear to be associated with increased risk of major complications following total joint arthroplasty with the numbers available in this study. Reassurance can be given regarding concerns for infection and other complications following surgery in this patient population.

Preoperative Pain Management: Is Tramadol a Safe Alternative to Traditional Opioids Before Total Hip Arthroplasty?

BACKGROUND: Preoperative opioid use has been associated with worse clinical outcomes and higher rates of prolonged opioid use following lower extremity arthroplasty. Tramadol has been recommended for management of osteoarthritis-related pain; however, outcomes following total hip arthroplasty (THA) in patients taking tramadol in the preoperative period have not been well described. The aim of this study is to examine the effect of preoperative tramadol use on postoperative outcomes in patients undergoing elective THA. METHODS: A total of 5304 patients who underwent primary THA for degenerative hip pathology from 2008 to 2014 were identified using the Humana Claims Database. Patients were grouped by preoperative pain management modality into 3 mutually exclusive populations including tramadol, traditional opioid, or nonopioid only. A multivariate logistic regression was used to evaluate all postsurgical outcomes of interest. RESULTS: Tramadol users had an increased risk of developing prolonged narcotic use (odds ratio [OR], 2.17; confidence interval [CI], 1.89-2.49; P < .001) following surgery compared to nonopioid-only users. When compared to traditional opioid use, tramadol use was associated with decreased risk of subsequent 90-day minor medical complications (OR, 0.75; CI, 0.62-0.90; P = .002), emergency department visits (OR, 0.70; CI, 0.57-0.85; P < .001), and prolonged narcotic use (OR, 0.43; CI, 0.37-0.49; P < .001). Traditional opioid use significantly increased length of stay by 0.20 days (P = .001) when compared to tramadol use. CONCLUSION: Preoperative tramadol use is associated with prolonged opioid use following THA but is not associated with other postoperative complications. Patients taking tramadol preoperatively appear to have a lower risk of postoperative complications compared to patients taking traditional opioids preoperatively.

Postoperative Venous Thromboembolism and other Complications after Anatomic Total Shoulder Arthroplasty in Patients With a History of Prostate or Breast Cancer.

INTRODUCTION: As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS: Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS: Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION: Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.