Hardware failure following multilevel posterior percutaneous fixation using the minimally invasive antepsoas (MIS-ATP) approach in adult spine deformity.

Background: Adult spinal deformities (ASDs) requiring long fusions to the lumbosacral junction are notorious for L5-S1 pseudarthrosis and hardware-related complications. The minimally invasive surgery antepsoas (MIS-ATP) technique allows for substantial anterior column reconstruction thereby reducing the risk of posterior hardware-related complications. This study investigates the incidence of posterior hardware-related complications following long-segment fusion (seven or more vertebrae) using MIS-ATP and posterior percutaneous fixation (PPF). Methods: This is a retrospective review of patients who underwent long spinal fusion (MIS-ATP + PPF) to the sacrum and pelvis for the management of ASD between 2008 and 2019. Postoperative clinical complications and radiographic parameters were collected and analyzed. The following postoperative variables were collected: surgical site infections, neuro-vascular injuries, implant fracture, implant displacement, hardware prominence and related pain, pseudarthrosis, junctional disease (proximal and distal), and need for surgical revision. Results: A total of 143 patients were included in this study. The most common indications for fusion included: degenerative scoliosis (76.9%) and degenerative spondylolisthesis (17.5%). The average number of fused vertebrae per individual was 8.7. The most common levels fused were: T12-S1 anterior/T10-S1 posterior (53.1%). Forty-four patients (30.8%) experienced a total of 48 complications: pseudarthrosis (2.1%), deep infections (4.2%), painful iliac hardware (5.6%), pedicle screw complications (6.3%), and proximal junctional disease (PJD) (9.8%). Of these, 30 patients (21%) required revision surgery, mostly due to PJD (8 patients; 5.6%). Conclusions: Long spinal fusions to the sacrum and pelvis are technically challenging and notorious for hardware failure (HF) and revision surgeries. The use of MIS-ATP fusion coupled with PPF could provide a safe and effective strategy against posterior HF. Furthermore, additional benefits of the MIS-ATP technique are inherent to its relatively safe approach-related profile.

Increased Risk of 10-Year Revision Following Total Hip Arthroplasty for Femoral Neck Fracture.

BACKGROUND: As the incidence of femoral neck fractures (FNFs) increases with the aging population, understanding its impact on surgical outcomes is important to improving implant survival and patient satisfaction. Despite increasing use of total hip arthroplasty (THA) as management for FNF, few studies have examined long-term implant survivability. Thus, this study sought to determine the 10-years cumulative incidence of revision and indications for revision in patients undergoing THA for FNF in comparison to osteoarthritis. METHODS: Patients who underwent primary THA for FNF or osteoarthritis were identified using a national administrative claims database and propensity-score matched in a 1:2 ratio based on age, gender, the Charlson Comorbidity Index (CCI), smoking, obesity, and diabetes mellitus. Kaplan-Meier and Cox proportional hazards analyses were used to observe the cumulative incidence and risk of all-cause revision, periprosthetic joint infection (PJI), dislocation, mechanical loosening, and periprosthetic fracture (PPF) within 10 years of primary THA. In total, 19,735 patients who underwent THA for FNF and 39,383 patients who underwent THA for osteoarthritis were included. RESULTS: The 10-years cumulative incidences of all-cause revision (7.1 versus 4.9%), PJI (5.0 versus 3.3%), dislocation (6.8 versus 3.8%), mechanical loosening (3.1 versus 1.9%), and PPF (7.8 versus 4.0%) were significantly higher for those who underwent THA for FNF versus osteoarthritis. Femoral neck fractures were associated with higher risks of revision (hazard ratio [HR]: 1.6), PJI (HR: 1.7), dislocation (HR: 2.0), mechanical loosening (HR: 1.6), and PPF (HR: 2.2) (P < 0.001 for all). CONCLUSIONS: Despite the advantages of THA, femoral neck fractures remain a major risk factor for long-term complications. Tailored preoperative planning, surgical techniques, and postoperative bone health optimization in these patients may help minimize poor outcomes.

Modified frailty index can help predict complications following tibial plateau fracture fixation: a NSQIP study involving 2213 patients.

PURPOSE: The 5-item modified frailty index (mFI-5) has been established as a reliable indicator of poor postoperative outcomes following a variety of orthopaedic procedures. This study aims to determine whether the mFI-5 can be used by surgeons to predict the likelihood of postoperative complications in patients undergoing open reduction internal fixation (ORIF) for tibial plateau fractures. METHODS: From 2006 to 2019, patients aged 50 years or older undergoing ORIF for tibial plateau fracture were identified in the National Surgical Quality Improvement Program database. The mFI-5 was calculated based on the sum of the presence of 5 conditions: diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent functional status. Chi-squared tests and multivariable regression analysis were used to evaluate the association of different mFI-5 scores with postoperative complications. RESULTS: The study analyzed 2213 patients with an average age of 63 years. Multivariable regression analysis demonstrated that in comparison to patients with a mFI-5 score of 0, those with a score of 1 had an increased risk of prolonged hospital stay (OR 1.31) and discharge to a non-home location (OR 1.50) while those with a score of 2 or greater were at an increased risk of readmission (OR 2.30), wound complication (OR 5.37), pulmonary complication (OR 4.56), urinary tract infection (OR 4.79), prolonged hospital stay (OR 1.89), and discharge to a non-home location (OR 3.01). CONCLUSION: The mFI-5 is a reliable instrument for determining the likelihood of postoperative complications following ORIF for tibial plateau fracture repair. LEVEL OF EVIDENCE: III.

AIDS but not asymptomatic HIV is associated with lower 2-10-year implant survivorship following total knee arthroplasty.

INTRODUCTION: Prior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. METHODS: Patients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. RESULTS: The 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02-1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77-1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51-4.99, p < 0.001; HR 2.19, 95% CI 1.17-4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54-15.51, p = 0.007; HR 3.86, 95% CI 1.12-13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16-2.74, p = 0.002; HR 3.82, 95% CI 1.08-13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DISCUSSION: This study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients' serum CD4 level is sufficient, ideally in the normal range of 500-1500 cells per mm3, before undergoing TKA.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022.

BACKGROUND: In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns. METHODS: A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection. RESULTS: From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population. CONCLUSIONS: Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

Trends of Venous Thromboembolism After Total Hip Arthroplasty in the United States: Analysis From 2011 to 2019.

BACKGROUND: In 2011, the American Academy of Orthopaedic Surgeons released a Clinical Practice Guideline` that recommended routine venous thromboembolism (VTE) prophylaxis after total joint arthroplasty. The purpose of this study was to examine (1) the change in the incidence of 90-day VTE, deep vein thrombosis, and pulmonary embolism, (2) the change in the utilization of antithrombotic agents; and (3) the change in the economic burden associated with VTE after total hip arthroplasty (THA) from 2011 to 2019. METHODS: National, administrative claims data from 2011 to 2019 were used to identify patients who underwent primary THA for osteoarthritis. Exclusions entailed liver pathology, coagulopathy, malignancy, or those on prior prescribed blood thinners before THA. Multivariable regression was used, controlling for age and Charlson Comorbidity Index for all years, with 2011 as the reference year. RESULTS: From 2011 to 2019, there was a significant reduction in 90-day VTE rates after THA, with a significant reduction in deep vein thrombosis and pulmonary embolism during this time frame as well. Of the antithrombotic agents prescribed after THA, the utilization of prescribed aspirin significantly increased and that of nonaspirin anticoagulants significantly decreased. Among nonaspirin anticoagulants, the utilization of direct factor Xa inhibitors and direct thrombin inhibitors significantly increased. The added reimbursements associated with VTE after THA significantly decreased during this period. CONCLUSION: Since 2011, the incidence and economic burden associated with VTE after THA have significantly declined. In addition, there has been an increase in prescription aspirin and direct oral anticoagulants. LEVEL OF EVIDENCE: Therapeutic, III.

Diagnostic and Invasive Colonoscopy Are Not Risk Factors for Revision Surgery Due to Periprosthetic Joint Infection.

BACKGROUND: Colonoscopy is routinely performed for colorectal cancer screening in patients who have a preexisting unicompartmental knee arthroplasty (UKA), total knee arthroplasty (TKA), or total hip arthroplasty (THA) prostheses. However, colonoscopy is theorized to provoke transient bacteremia, providing a potential nidus for periprosthetic joint infection. This study aimed to investigate the risk of aseptic and septic revision surgery in patients who underwent diagnostic colonoscopy or invasive colonoscopy within one year following UKA, TKA, or THA. METHODS: A retrospective cohort analysis was performed using a national database. Patients were identified using Current Procedural Terminology. In total, 52,891 patients underwent UKA, 1,049,218 underwent TKA, and 526,296 underwent THA. Data were analyzed with univariate analysis preceding multivariable logistic regressions to investigate outcomes of interest at 2 and 3 years from the index procedure. RESULTS: Diagnostic colonoscopy resulted in no increase in odds of all-cause or septic revision surgery for any prostheses. At both time points, invasive colonoscopy resulted in lower odds of all-cause revision (P < .05) for patients with UKA, decreased odds of septic revision (P < .001) for patients with TKA, and decreased odds of both all-cause and septic revision (P < .05) for patients with THA. CONCLUSION: Our results show that diagnostic colonoscopy was not a significant risk factor for revision following UKA, TKA, or THA. Paradoxically, invasive colonoscopy was protective against revision, even with very minimal use of antibiotic prophylaxis observed. This study addresses the theory that colonoscopy procedures may threaten an existing joint prosthesis via transient bacteremia and shows no increase in revision outcomes following colonoscopy. LEVEL OF EVIDENCE: Level III.

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Antibiotic Spacer Placement for Chronic Periprosthetic Joint Infection following Total Joint Arthroplasty.

BACKGROUND: The relationship of chronic periprosthetic joint infection (PJI) treatment on the development and relapse of mood disorders remains largely unreported. This study aims to compare the incidence of different mental health disorders following antibiotic spacer placement for chronic PJI when compared to aseptic revisions and primary procedures. METHODS: Patients who underwent antibiotic spacer for septic total hip and knee arthroplasty (PJI THA/TKA) were identified in the PearlDiver Database using Current Procedure Terminology (CPT) codes for hip and knee antibiotic spacers. Patients who underwent aseptic revision and primary-THA/TKA were also identified using CPT codes. The incidences of depressive, anxiety, bipolar, psychotic, and stress disorders were identified within 2 years following the index procedures via Kaplan-Meier Analysis. RESULTS: The risk of depressive (hazard ratio (HR): 1.5; P < .001) and stress (HR: 1.5; P < .001) disorders were significantly higher in those who underwent PJI-THA when compared to aseptic revision, with the added risk of bipolar when compared to primary THA. The risk of depressive (HR: 1.6; P < .001), stress (HR: 1.4; P < .001), bipolar (HR: 1.3; P < .001), and psychotic disorders (HR: 1.5; P = .003) were significantly higher in those who underwent PJI-TKA when compared to aseptic revision, with the added risk of anxiety when compared to primary TKA. CONCLUSION: Patients who undergo spacer placement for septic-THA/TKA have a disproportionately higher incidence of mental health disorders within 2 years following surgery when compared those undergoing aseptic revisions and primary procedures. Due to this higher risk, physicians should strongly consider collaborative care with psychiatrists or mental health professionals. LEVEL OF EVIDENCE: III.

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.

Asthma and Its Impact on Pediatric Patients Undergoing Surgical Management of Tibial Shaft Fractures.

Introduction Tibial shaft fractures are a common presenting injury among the pediatric population. Asthma is also a common diagnosis that is frequently encountered in this population and has a significant impact on healthcare utilization, quality of life, and mortality. Given the high prevalence of these conditions and risks of peri-anesthetic respiratory complications, the purpose of this study was to evaluate an association between asthma and the incidence of 30-day postoperative complications following the surgical management of tibial shaft fractures in the pediatric population. Methods The National Surgical Quality Improvement Program-Pediatric database was used to identify pediatric patients who underwent surgical treatment for tibial shaft fractures from 2013-2019. Patients were categorized into two groups: patients with a history of asthma and patients without a history of asthma. Differences in patient demographics, comorbidities, and postoperative complications were assessed using bivariate and multivariate analyses. Results Of the 2,649 patients who underwent surgical treatment for tibial shaft fractures, 115 (4.3%) had asthma. Compared to those without asthma, patients with a history of asthma were more likely to have other medical comorbidities. After controlling for the differences in baseline characteristics between the two groups, patients with asthma had an increased risk of prolonged hospital stay (OR 5.78; 95% CI 1.67 to 20.00; p=0.006). Conclusion Pediatric patients being surgically treated for tibial shaft fractures with asthma had an increased risk of prolonged hospital stay. It is important that proper preoperative workup, perioperative care, and understanding of the implications of asthma on postoperative recovery are appreciated to reduce prolonged hospitalization lengths and minimize hospital costs associated with tibial shaft fracture surgery.

The Antepsoas (ATP) Surgical Corridor for Lumbar and Lumbosacral Arthrodesis: A Radiographic, Anatomic, and Surgical Investigation.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To investigate the size of prepsoas surgical corridors, developed between the iliopsoas and prespinal vessels, at all disk levels between L1 and S1 granted by left and right lateral antepsoas (ATP) approaches. Secondary aims include evaluation of presurgery radiographic prepsoas windows between L1 and S1 with respect to the intraoperative findings. SUMMARY OF BACKGROUND DATA: The ATP technique is an evolving alternative to the transpsoas and direct anterior exposures for lumbar fusion. However, the vascular morphometric data of the ATP approach remain underexplored, especially at L5-S1. MATERIALS AND METHODS: Patients indicated for ATP lumbar-lumbosacral fusion between September 2018 and February 2020 were enrolled (n=121). Data were collected prospectively, including the following (in mm): intraoperative manual measurements of the premobilization psoas-vessel (pre-PV) window, the final postmobilization psoas-vessel (post-PV) window, and the preoperative radiographic psoas-to-vessel distance at the respective studied disk levels. RESULTS: A total of 121 patients (75 female, mean age: 55.3 yr, 81.8% right-sided approach) underwent a total of 279 levels of spinal fusion. Irrespective of the ATP access laterality, we noted ample postmobilization psoas-vessel (post-PV differential) corridors: largest at L4-L5 (36-38 mm) followed by L5-S1 (31-35 mm), L3-L4 (32-33 mm), L2-L3 (28-30 mm), and L1-L2 (20-24 mm). Similarly, the relative increases of the psoas-vessel corridors (post-PV and pre-PV differentials, averaged: 31 mm at L5-S1, 32 mm at L4-L5, 26 mm at L3-L4, 25 mm at L2-L3, and 14 mm at L1-L2) were also significant in both lateral approaches. In right flank approaches, the right vascular structures projected more dorsally compared with left-sided vasculature ( P <0.05). CONCLUSION: The ATP access offers generous bilateral prepsoas surgical windows to L1-S1 intervertebral disks, allowing for a safe anterior column release, decompression, instrumentation, and fusion.

Pseudarthrosis Following Lumbar and Lumbosacral Fusion Using the Antepsoas Technique.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: The aim of this study was to evaluate the prevalence of pseudarthrosis following antepsoas (ATP) lumbar and lumbosacral fusions. SUMMARY OF BACKGROUND DATA: Pseudarthrosis is a feared complication following spinal fusions and may affect their clinical outcomes. To date there are no sufficient data on the fusion rate following ATP lumbar and lumbosacral arthrodesis. METHODS: This is a retrospective review of 220 patients who underwent lumbar minimally invasive antepsoas (MIS-ATP) fusions between January 2008 and February 2019 who have at least 1-year postoperative computed tomography (CT) follow-up scans. Fusion was graded using CT scans imaging and adopting a 1-4 grading scale (1, definitely fused; 2, likely fused; 3, likely not fused; 4, definitely not fused/nonunion). Grades 3 or 4 indicate pseudarthrosis. RESULTS: A total of 220 patients (average age: 66 years, 82 males (37.2%), and 127 (57.7%) smokers) were included. Eight patients (3.6%) developed pseudarthrosis. A total of 693 discs were addressed using the ATP approach. Of those, 681 (98.3%) were considered fused (641 levels [92.5%] were "definitely fused" and 40 levels [5.8%] were "Likely fused") and 12 discs (1.7%) developed pseudarthrosis (seven levels [1.0%] were "likely not fused" and five levels (0.7%) were "definitely not fused"). The highest rate of pseudarthrosis was found at L5-S1 (4.8%) compared to the L1-L5 discs (0-2%). Of 127 smokers, six developed pseudarthrosis (odds ratio = 2.3, P = 0.3). The fusion rates were 95.3% and 97.8% for smokers and nonsmokers, respectively. Of the eight patients who developed pseudarthrosis, only four (50%) were symptomatic, of whom two (25%) required revision surgery. Both of these patients were smokers. The overall revision rate due to pseudarthrosis was 0.9% (two of 220 patients). CONCLUSION: The MIS-ATP technique results in a high fusion rate (96.4% of patients; 98.3% of levels). Pseudarthrosis was noted mostly at the L5-S1 discs and in smokers.Level of Evidence: 4.

Evaluation of Validity and Specificity of the Cottle Maneuver in Diagnosis of Nasal Valve Collapse.

BACKGROUND: Despite the widespread use of the Cottle maneuver as a finding to define nasal valve collapse, no studies have confirmed the association between a positive Cottle maneuver and need for nasal valve repair. This study demonstrates the low construct validity of the Cottle maneuver. METHODS: One hundred healthy volunteer students and employees at Boston Medical Center were recruited for this study. Participants were asked to evaluate their breathing on a 10-point scale, rating their subjective airflow in each nostril while occluding the contralateral nostril, where 0 indicated complete obstruction and 10 indicated complete patency. Following the baseline ratings, participants were asked to rate their breathing once again while examiners preformed the Cottle and modified Cottle maneuvers. RESULTS: Overall, 97 percent of participants reported improved airflow in each nostril following the Cottle maneuver (p < 0.00001); 98 percent reported improved airflow in each nostril following the modified Cottle maneuver (p < 0.00001). CONCLUSIONS: If the clinical consensus regarding the observed improvement in nasal airflow is to be followed, nearly all the participants recruited are experiencing some surgically correctable nasal obstruction. Given the population from which our cohort was collected-students and residents from a medical campus-such a conclusion seems extremely unlikely. We believe the more likely explanation for the high positive test rate is flawed assumptions of the Cottle and modified Cottle maneuvers. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.