Emergent Subtotal Colectomies Have Higher Leak Rates in Subsequent J-Pouch Stages.

PURPOSE: The most common surgery for ulcerative colitis (UC) is the staged restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). On occasion, an emergent first-stage subtotal colectomy must be performed. The purpose of this study was to compare rates of postoperative complications in three-stage IPAA patients who underwent emergent vs non-emergent first-stage subtotal colectomies in the subsequent staged procedures. METHODS: This was a retrospective chart review conducted at a single tertiary care inflammatory bowel disease (IBD) center. All UC or IBD-Unspecified patients who underwent a three-stage IPAA between 2008 and 2017 were identified. Emergent surgery was defined as that performed on an inpatient who had perforation, toxic megacolon, uncontrolled hemorrhage, or septic shock. The primary outcomes were the presence of anastomotic leak, obstruction, bleeding, and the need for reoperation for each within a 6-month postoperative period of the second (RPC with IPAA and DLI) and third surgical stages (ileostomy reversal). RESULTS: A total of 342 patients underwent a three-stage IPAA, of which 30 (9.4%) had emergent first-stage operations. Patients who underwent an emergent STC were more likely to have a post-operative anastomotic leak and need an additional procedure following the subsequent second and third-staged operations on both univariate and multivariate analysis (p < 0.05). No difference was found for obstruction, wound infection, intra-abdominal abscess, or bleeding (p > 0.05). CONCLUSION: Three-stage IPAA patients with emergent first-stage subtotal colectomies were more likely to have a post-operative anastomotic leak and need an additional procedure for a leak following the subsequent second- and third-stage operations.

Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation.

INTRODUCTION: Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes. STUDY DESIGN: We conducted a retrospective cohort study using our level-1 trauma center's trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test. RESULTS: We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001). CONCLUSION: TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most Worth Your Time?

BACKGROUND: Relative value units (RVUs) are assigned to Current Procedural Technology (CPT) codes and give relative economic values to the services physicians provide. This study compared the RVU reimbursements for the surgical options of proximal humerus fractures in the elderly, which include arthroplasty (reverse [RSA] and total [TSA]), hemiarthroplasty (HA), and open reduction and internal fixation (ORIF). METHODS: Using the National Surgical Quality Improvement Program, a total of 1,437 patients of at least 65 years of age with proximal humerus fractures between 2008 and 2016 were identified. Of those, 259 underwent RSA/TSA (CPT code 23472), 418 underwent HA (CPT codes 23470 and 23616), and 760 underwent ORIF (CPT code 23615). Univariate analysis compared RVU per minute, reimbursement rate, and the average annual revenue across cohorts based on respective operative times. RESULTS: RSA/TSA generated a mean RVU per minute of 0.197 (SD 0.078; 95%CI [0.188, 0.207]), which was significantly greater than the mean RVU per minute for 23470 HA (0.156; SD 0.057; 95%CI [0.148, 0.163]), 23616 HA (0.166; SD 0.065; 95%CI [0.005, 0.156]), and ORIF (0.135; SD 0.048; 95%CI [0.132, 0.138]; P<0.001). This converted to respective reimbursement rates of $6.97/min (SD 2.78; 95%CI [6.63, 7.31]), $5.48/min (SD 2.05; 95%CI [5.22, 5.74]), $5.83/min (SD 2.28; 95%CI [5.49, 6.16]) and $4.74/min (SD 1.69; 95%CI [4.62, 4.87]). After extrapolation, respective average annual revenues were $580,386, $456,633, $475,077, and $395,608. CONCLUSION: RSA/TSA provides significantly greater reimbursement rates compared to HA and ORIF. Orthopaedic surgeons can use this information to optimize daily procedural cost-effectiveness in their practices.

Superior gluteal artery pseudoaneurysm after a gunshot wound to the buttock: A case.

INTRODUCTION: Penetrating trauma to the buttock can rarely result into the development of a gluteal artery pseudoaneurysm. Here we present the case of a patient with a superior gluteal pseudoaneurysm after a gunshot wound to the left buttock. PRESENTATION OF CASE: A 48-year-old male presented with fullness and tenderness at the left gluteal wound that resulted from a gunshot 18 days prior. At the time of initial trauma, imaging showed minimal extravasation of contrast at the left superior gluteal artery, but the bleeding stopped and patient was discharged. On his return, examination showed palpable fluctuance but no bleeding. A superior gluteal artery pseudoaneurysm was identified on CT scan. Patient also complained of intermittent subjective fever and new onset of SOB. CT chest demonstrated a pulmonary embolism at the right basilar segmental artery. Coil embolization was performed to treat the pseudoaneurysm and patient was subsequently started on anticoagulation therapy. DISCUSSION: Penetrating wounds to the buttock can result in associated vascular or visceral injuries. Pseudoaneurysms can develop days to years after the initial injury. On exam, presence of pain, swelling, tenderness, bleeding from wound, thrill, bruit or a pulsating mass should raise suspicion for pseudoaneurysm, which can be diagnosed on CT scan and treated with embolization. CONCLUSION: Proper management of traumatic wounds to the buttock with associated vascular injuries, with follow up protocols and patient education is necessary to prevent life-threatening complications such as hemorrhage from pseudoaneurysm.

Thirty-Day Complications in Osteonecrosis Patients Following Total Hip Arthroplasty.

BACKGROUND: Thirty-day complications in osteonecrosis (ON) patients undergoing total hip arthroplasty (THA) are inconsistently reported. Therefore, the purpose of this study is to evaluate (1) the incidence of THA, (2) operative times, (2) length of stay, (3) reoperation rates, (4) readmission rates, and (5) complication rates, in the general vs ON THA populations. We also substratified and compared these cohorts based on ON-specific risk factors. METHODS: Using the National Surgical Quality Improvement Program database, Current Procedural Terminology code 27130, International Classification of Disease, Ninth Edition code 733.42, and a 1:1 propensity score match, a total of 8344 matched ON and non-ON THA patients were identified. ON patients were also substratified based on key risk factors. The above variables were compared between the matched ON and non-ON cohorts as well as for patients with each risk factor using Pearson's chi-square and Student t-tests. RESULTS: The proportion of THAs performed on ON patients decreased by 35% from 2008 to 2015. Mean operative times were constant between the ON and non-ON patients (102 minutes). ON patients had shorter mean length of stay (3.1 vs 3.4 days, P = .002). Of the 17 different 30-day complications evaluated, superficial surgical site infection (1.2% vs 0.6%, P = .004), pneumonia (0.8% vs 0.2%, P = .001), transfusion (15.6% vs 5.4%, P < .001), and readmission (5.1% vs 2.3%, P = .012) were higher among ON patients. ON patients with a history of corticosteroid use, higher American Society of Anesthesiologists score, and smoking were also found to have higher complication rates compared to non-ON patients with the same risk factors. CONCLUSION: This is one of the first studies to compare postoperative THA outcomes between matched ON vs non-ON patients, while also taking into consideration specific risk factors between the cohorts.

The top 100 classic papers on adolescent idiopathic scoliosis in the past 25 years: a bibliometric analysis of the orthopaedic literature.

STUDY DESIGN: Bibliometric analysis. OBJECTIVES: To identify the 100 most cited orthopedic papers in adolescent idiopathic scoliosis (AIS) over the past 25 years and characterize them by study type, topic, and country and assess study quality (design, level of evidence, and impact factor) to provide an updated account of the most impactful AIS evidence. AIS represents a three-dimensional deformity that drives a significant number of investigations. Although available evidence continues to grow, recent impactful studies pertaining to AIS have not been identified; their quality has not been thoroughly assessed. METHODS: Web of Science was reviewed to identify the top 1000 cited AIS studies published from 1992 to 2017. Articles were organized by number of citations. Titles and abstracts were screened for inclusion/relevance, and the top 100 articles by citation count were identified, and study and publication characteristics were extracted. RESULTS: Among the top 100 articles, 42 were cited ≥ 100 times. Mean number of authors and citations of these studies was 5.6 and 118.3, respectively. Study types were predominantly retrospective (n = 53), followed by prospective (n = 18), cross-sectional (n = 13), and systematic review/meta-analysis (n = 7). Topics covered in these studies included clinical/patient outcomes (n = 47), methodology/validation (n = 22), basic science (n = 15), radiographic analyses (n = 12), and gait/biomechanics (n = 4). Most studies originated in the United States of America (n = 65) and were published in Spine (n = 76), with 8266 total citations. Most studies were of Level III (n = 55) or Level II (n = 23) evidence. Mean impact factor was 3.47. CONCLUSIONS: Despite recent studies' shorter time frames for impact, citations of AIS research have progressively increased during the past 25 years. The top 100 cited orthopedic studies were predominantly Level III, retrospective, nonrandomized studies, and therefore, were subject to biases. The low proportion of prospective studies (18%) reflects an area of future improvement, underscoring the need for higher-quality studies to support our practice. LEVEL OF EVIDENCE: N/A.

A comparison of peri-operative outcomes between elective and non-elective total hip arthroplasties.

BACKGROUND: Elective total hip arthroplasties (THAs) entail a more extensive pre-operative planning process compared to non-elective THAs and this may contribute to a disparity in outcomes. However, the differences in peri- and post-operative outcomes between elective and non-elective THAs remain unclear. Therefore, the purpose of this study was to: (I) determine nationwide trends in operative times and (II) evaluate the association between surgery type, elective or non-elective with respect to (I) operative times; (II) hospital lengths-of-stay (LOS); (III) discharge disposition; (IV) 30-day post-operative complications; (V) reoperations; and (VI) readmissions. METHODS: The NSQIP database was queried for all primary THAs (CPT code 27130) performed between 2011 and 2016. This yielded 130,261 cases, which were then stratified into elective (n=125,293) and non-elective (n=4,968) cases. One-way analysis of variance (ANOVA) were used to evaluate the associations between operative times and surgery year. Univariate analyses of surgery type with the following outcomes of interest were also performed: operative times, LOS, and discharge disposition as well as 30-day complication, reoperation, and readmission rates. A multiple linear regression model was used to evaluate the relationships of operative times and LOS with surgery types after adjusting for surgery year and patient factors [age, sex, body mass index (BMI), and American Society of Anesthesiologists (ASA) score]. A log-transformed dependent variable was used to calculate the percentage difference in mean operative times and LOS. Multivariate logistic regression models adjusted for patient factors and year of surgery were used to evaluate associations of surgery type with complication, reoperation, and readmission rates. RESULTS: Over the 6-year period, mean operative times (93 vs. 103 minutes, P<0.001) and LOS (3 vs. 6 days, P<0.001) were significantly shorter in elective cases compared to non-elective cases. The relationships between operative times or LOS and surgery type remained significant even after adjusting for age, sex, BMI, ASA, and year of surgery (P<0.001). Compared to the non-elective cohort, patients in the elective cohort were more likely to be discharged home (74% vs. 69%, P<0.001). Elective patients had lower rates of several 30-day complications including deep SSI (P<0.001), transfusions (P<0.001), sepsis (P<0.001), and readmission (P<0.005) compared to non-elective patients. These associations remained significant after accounting for potential confounders with multivariate logistic regression. CONCLUSIONS: Findings from this study showed that elective THAs, in which there is more potential for pre-operative planning, were associated with shorter operative times and LOS, as well as fewer complication and readmission rates. These results likely reflect the development of more efficient surgical techniques and improved pre- and intra-operative planning guides.

A Nationwide Analysis of Preoperative Planning on Operative Times and Postoperative Complications in Total Knee Arthroplasty.

Compared with nonelective total knee arthroplasties (TKAs), elective procedures have more time for preoperative planning, which allows for potentially improved patient optimization, risk factor modification, and patient education. The purpose of this study was to (1) determine nationwide trends in operative times and (2) evaluate associations between surgery type, elective or nonelective, with respect to (a) operative times, (b) length of stay (LOS), (c) discharge dispositions, (d) 30-day postoperative complications, (e) reoperations, and (f) readmissions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all primary TKAs performed between 2011 and 2016. This yielded 209,178 cases which were stratified into elective and nonelective cases. Elective cases were those in which patients were brought from their normal living environment for scheduled procedures. One-way ANOVA (analysis of variance) was used to evaluate associations between operative times and year of surgery. Multivariate linear and logistic regression models adjusted for surgery year and patient factors (age, sex, BMI [body mass index], and ASA [American Society of Anesthesiologists] score) were used to evaluate associations of surgery type with peri- and postoperative outcomes. A significant inverse correlation between operative times and operative year was observed (p < 0.001). Mean operative times and LOS were significantly shorter in elective cases compared with nonelective cases (93 vs. 112 minutes, p < 0.005; 3 vs. 5 days, p < 0.001). Multivariate analysis showed these associations remained significant even after adjusting for potential confounders (p < 0.001). Compared with the nonelective cohort, patients in the elective cohort were more likely to be discharged home (74 vs. 69%, p < 0.001). Nonelective patients had higher rates of pneumonia (0.7 vs. 0.3%, p = 0.005), organ-space surgical site infections (SSI; 0.4 vs. 0.2%, p = 0.004), transfusions (10.9 vs. 6.5%, p < 0.001), sepsis (0.6 vs. 0.2%, p = 0.001), and septic shock (0.2 vs. 0.1%, p = 0.005) compared with elective patients. These associations remained significant with multivariate logistic regression. This study demonstrated that preoperative planning can help shorten operative times and LOS as well as reduce complication and reoperation rates. Alongside the direct advantages identified in this study, potential greater effects include superior patient outcomes and reduced health care costs.

Bilateral Spontaneous Quadriceps Tendon Ruptures after Staged Bilateral Total Knee Arthroplasties: A Case Report.

Quadriceps tendon ruptures are rare complications of total knee arthroplasty (TKA) and may be associated with preexisting tendon degeneration, vascular injuries during surgery, damage to the quadriceps tendon with over resection of the patella, or incomplete healing after a particular surgical approach. Moreover, postoperative causes include tissue necrosis due to component malalignment, trauma, and infection. Patient factors such as chronic systemic diseases, medications, increased body weight, and sedentary lifestyle could also be responsible. The number of reported cases on bilateral spontaneous quadriceps tendon ruptures is limited and cases are often not associated with TKA, but are likely associated with chronic diseases and medication use. Therefore, the purpose of the present study was to report on a patient who underwent bilateral TKA with sequential bilateral spontaneous quadriceps tendon ruptures postoperatively and to discuss their management.