Fluoroscopy Learning Curve in Hip Arthroscopy-A Single Surgeon's Experience.

PURPOSE: To determine if (1) absorbed radiation dose and (2) fluoroscopy time decreased with experience over the first 100 cases of a single surgeon's hip arthroscopy practice. METHODS: Subjects who underwent hip arthroscopy for symptomatic femoroacetabular impingement and labral injury were eligible for analysis. Inclusion criteria included the first 100 subjects who underwent hip arthroscopy by a single surgeon (December 2013 to December 2014). Subject demographics, procedure details, fluoroscopy absorbed dose (milligray [mGy]), and time were recorded. Subjects were categorized by date of surgery to one of 4 possible groups (25 per group). One-way analysis of variance was used to determine if a significant difference in dose (mGy) or time was present between groups. Simple linear regression analysis was performed to determine the relation between case number and both radiation dose and fluoroscopy time. RESULTS: Subjects underwent labral repair (n = 93), cam osteoplasty (n = 90), and pincer acetabuloplasty (n = 65). There was a significant (P < .001 for both) linear regression between case number and both radiation dose and fluoroscopy time. A significant difference in mGy was observed between groups, group 1 the highest and group 4 the lowest amounts of radiation (P = .003). Comparing individual groups, group 4 was found to have a significantly lower amount of radiation than group 1 (P = .002), though it was not significantly lower than that of group 2 (P = .09) or group 3 (P = .08). A significant difference in fluoroscopy time was observed between groups, group 1 the highest and group 4 the lowest times (P = .05). Comparing individual groups, group 4 was found to have a significantly lower fluoroscopy time than group 1 (P = .039). Correction for weight, height, and body mass index all revealed the same findings: significant (P < .05) differences in both dose and time across groups. CONCLUSIONS: The absorbed dose of radiation and fluoroscopy time decreased significantly over the first 100 cases of a single surgeon's hip arthroscopy practice learning curve. LEVEL OF EVIDENCE: Level IV, therapeutic, retrospective, noncomparative case series.

Cardiac Emboli Documented by Intraoperative Transesophageal Echocardiogram During Administration of a Topical Hemostatic Agent Prior to Pedicle Subtraction Osteotomy.

STUDY DESIGN: This is a case report. OBJECTIVE: Describe the occurrence of cardiac emboli recorded on transesophageal echocardiogram (TEE) after the injection of a topical hemostatic agent into a vertebra prior to performing a pedicle subtraction osteotomy (PSO). SUMMARY OF BACKGROUND DATA: Hemostasis during spinal surgery is critical for adequate visualization and to reduce the risk of perioperative complications. Adult spinal deformity surgery can involve performing PSOs which are useful in cases of fixed spinal deformities and are associated with increased blood loss secondary to epidural and cancellous bleeding. Prior to performing a PSO, a topical hemostatic agent can be injected into the vertebra through the pedicle screw pilot holes in an attempt to decrease cancellous bleeding. Injected hemostatic agents can pressurize the vertebral body similar to cementation in vertebroplasty and during fracture reaming and prosthetic implantation in the femur. Patients with cardiac defects such as patent foramen ovale or atrial septal defect may be more prone to systemic embolic events resulting in morbidity or mortality. METHODS: We injected a topical hemostatic matrix agent through the pedicle screw pilot holes into the L1 vertebral body prior to performing a PSO while simultaneously recording with TEE. RESULTS: The TEE recorded large visible emboli traveling through the heart into the pulmonary vasculature. The patient remained stable throughout the remainder of the case and a postoperative spiral computed tomography (CT) scan was negative for filling defects. The patient had an uneventful hospital course. CONCLUSION: Questions remain about the exact consistency of these emboli, when they are most likely to occur, how much cardiopulmonary insult can be tolerated without resulting in complications, or how to prevent their occurrence. Patients undergoing spinal surgery with the plan to inject hemostatic matrix agents into the vertebral body may benefit from a preoperative TEE to reduce the risk of complications associated with embolic events, especially in patients with undiagnosed patent foramen ovale or atrial septal defect. LEVEL OF EVIDENCE: 5.

Hip Dislocation or Subluxation After Hip Arthroscopy: A Systematic Review.

PURPOSE: To determine patient- and surgery-specific characteristics of patients sustaining postarthroscopic hip dislocation or subluxation. METHODS: A systematic review of multiple medical databases was registered with PROSPERO and performed using Preferred Reporting Items for Systemic Reviews and Meta-Analysis guidelines. Level I to IV clinical outcome studies reporting the presence of hip dislocation or subluxation after hip arthroscopy were eligible. Length of follow-up was not an exclusion criterion. All patient- and surgery-specific variables were extracted from each, specifically evaluating osseous morphology and resection details; labral, iliopsoas, ligamentum teres, and capsular management; generalized ligamentous laxity; instability direction and mechanism; management; and outcome. Study authors were individually contacted to assess most recent outcome. RESULTS: Ten articles with 11 patients were analyzed (mean patient age: 36.6 ± 12.3 years). There were 9 hip dislocations and 2 subluxations. Mean time between surgery and dislocation was 3.2 ± 4.0 months (range: recovery room to 14 months). Anterior was the most frequent dislocation direction (8 cases). Acetabular undercoverage (preoperative dysplasia or iatrogenic rim over-resection) was observed in 5 cases. Labral debridement was performed in 5 cases, iliopsoas tenotomy in 3 cases, and ligamentum teres debridement in 1 case. A "T" capsulotomy was created in 1 case (isolated interportal in other 10 cases). Capsular closure was performed in 2 cases (both interportal). Generalized ligamentous laxity was diagnosed in 1 case. A combination of external rotation and extension was observed in 5 of the 6 cases reporting the mechanism of anterior dislocation. Four cases were successfully treated with closed reduction; 4 required total hip arthroplasty; and 3 required revision capsulorrhaphy. CONCLUSIONS: Postarthroscopic hip instability was observed in patients with acetabular undercoverage (including iatrogenic resection), labral debridement, capsular insufficiency, or iliopsoas tenotomy. Most dislocations were anterior, occurring with hip extension and external rotation. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

The Effects of a Hospitalist Comanagement Model for Joint Arthroplasty Patients in a Teaching Facility.

BACKGROUND: The goal of this study was to compare postoperative medical comanagement of total hip arthroplasty and total knee arthroplasty patients using a hospitalist (H) and nonhospitalist (NH) model at a single teaching institution to determine the clinical and economic impact of the hospitalist comanagement. METHODS: We retrospectively reviewed the records of 1656 patients who received hospitalist comanagement with 1319 patients who did not. The NH and H cohorts were compared at baseline via chi-square test for the American Society of Anesthesiologists classification, the t test for age, and the Wilcoxon test for the unadjusted Charlson Comorbidity Index score and the age-adjusted Charlson Comorbidity Index score. Chi-square test was used to compare the postoperative length of stay, readmission rate at 30 days after surgery, diagnoses present on admission, new diagnoses during admission, tests ordered postoperatively, total direct cost, and discharge location. RESULTS: The H cohort gained more new diagnoses (P < .001), had more studies ordered (P < .001), had a higher cost of hospitalization (P = .002), and were more likely to be discharged to a skilled nursing facility (P < .001). The H cohort also had a lower length of stay (P < .001), but we believe evolving techniques in both pain control and blood management likely influenced this. There was no significant difference in readmissions. CONCLUSION: Any potential benefit of a hospitalist comanagement model for this patient population may be outweighed by increased cost.