Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

BACKGROUND: Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. QUESTIONS/PURPOSES: When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? METHODS: An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. RESULTS: After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). CONCLUSION: Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

An Analysis of Component Positioning, Offset, and Limb Length Restoration in Computer-Assisted Hip Resurfacing Arthroplasty.

INTRODUCTION: Hip resurfacing arthroplasty (HRA) is a surgical option with positive outcomes at medium-term follow-up for young, active patients with osteoarthritis. However, early failures of HRA often occur due to improper implant placement. The purpose of this study was to assess the utility of computer-assisted navigation in the effort to optimize implant positioning following HRA. MATERIALS AND METHODS: A retrospective analysis of 262 consecutive HRAs at a single institution was performed. Radiographic analysis included measurements of cup inclination and anteversion, leg length restoration (LLR), and offset. Cup position was evaluated based on placement within Lewinnek parameters and the surgeon's preferred anteversion (10° to 20°). Chi-squared and unpaired Student's t-test were performed for all categorical and continuous variables, respectively. RESULTS: One hundred fifty-six cases were performed using conventional technique and 106 cases used computernavigation. Computer-assisted HRA (caHRA) had a longer mean surgical time (129 vs. 110 minutes; p < 0.001) but shorter average LOS (1.1 vs. 1.5 days; p < 0.001). Cup position was within the surgeon-preferred target zone in 47% of caHRA versus 22% of conventional HRA (p = 0.0001). Cup position fell within the Lewinnek safe zone in 86% of caHRA versus 60% of conventional HRA (p < 0.001). Global offset was reduced by a mean of 6.4 mm in caHRA versus 8.4 mm (p = 0.036). No differences in rates of complication (p = 0.406), reoperation (p = 1.00), or 90-day readmission (p = 0.568) were observed. CONCLUSION: Computer-assisted technology in HRA allows for comparable clinical outcomes to conventional technique. Cup position accuracy and precision is improved by computer navigation in HRA.

Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy.

BACKGROUND: Periacetabular osteotomy (PAO) has been used as a treatment modality for development dysplasia of the hip (DDH). Many patients will progress to total hip arthroplasty (THA) following PAO. There is a discrepancy in the literature regarding outcomes of THA after PAO. METHODS: A retrospective study was performed. Ten pa- tients (12 hips) with prior PAO who progressed to THA with at least 1-year follow-up after THA were identified. A control group of patients matched for age, sex, and body mass index (BMI) who underwent primary THA with minimum of 1-year follow-up were included. Demographic and radiographic parameters as well as clinical outcomes using the modified Harris Hip Score (mHHS) were collected. RESULTS: The mean age at the time of THA was 36.2 ± 9.7 years for the PAO and 37.8 ± 9.1 years for the control cohorts. There was no difference in the demographics be- tween the groups. At mean follow-up time of 22.8 ± 10.7 months for the PAO group and 25 ± 13.8 months for the control group, there was no significant difference in mHHS following THA. There was significant improvement in mHHS from preoperative to postoperative levels (p < 0.01). CONCLUSION: Total hip arthroplasty is an effective means to restore quality of life and function in patients who develop osteoarthritis following PAO, with equivalent outcomes to those undergoing primary THA.

Outcomes and complications of primary reverse shoulder arthroplasty with minimum of 2 years' follow-up: a systematic review and meta-analysis.

BACKGROUND: Primary reverse shoulder arthroplasty (rTSA) is an effective treatment option for reducing pain and improving function for patients with rotator cuff tear arthropathy, irreparable rotator cuff tears, glenoid deformity, and other challenging clinical scenarios, including fracture sequelae and revision shoulder arthroplasty. There has been a wide range of reported outcomes and postoperative complication rates reported in the literature. The purpose of this systematic review and meta-analysis is to provide an updated review of the clinical outcomes and complication rates following primary rTSA. METHODS: A systematic review and meta-analysis was performed to evaluate outcomes and complications following primary rTSA according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Demographics, range of motion, patient-reported outcome measures (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant scores), number of complications, and revisions were extracted, recorded, and analyzed from the included articles. RESULTS: Of the 1415 studies screened, 52 studies met the inclusion criteria comprising a total of 5824 shoulders. The mean age at the time of surgery was 72 years (range: 34-93), and the mean follow-up was 3.9 years (range: 2-16). Patients demonstrated a mean improvement of 56° in active flexion, 50° in active abduction, and 14° in active external rotation. Regarding functional outcome scores, rTSA patients demonstrated a mean clinically significant improvement of 37 in Constant score (minimal clinically important difference [MCID] = 5.7) and ASES score (42.0; MCID = 13.6). The overall complication rate for rTSA was 9.4% and revision rate of 2.6%. Complications were further subdivided into major medical complications (0.07%), shoulder- or surgical-related complications (5.3%), and infections (1.2%). The most frequently reported shoulder- or surgical-related complications were scapular notching (14.4%), periprosthetic fracture (0.8%), glenoid loosening (0.7%), and prosthetic dislocation (0.7%). DISCUSSION: Primary rTSA is a safe and reliable procedure with low complication, revision, infection, and scapular notching rates. Additionally, patients demonstrated clinically significant improvements in both range of motion and clinical outcome scores.

Total Knee Arthroplasty Is Safe in Jehovah's Witness Patients-A 12-Year Perspective.

Despite the evolution of blood management protocols, total knee arthroplasty (TKA) occasionally requires allogeneic blood transfusion. This poses a particular challenge for Jehovah's Witnesses (JW) who believe that the Bible strictly prohibits the use of blood products. The aim of this study was to compare JW and a matched-control cohort of non-JW candidates undergoing TKA to assess the safety using modern blood management protocols. Fifty-five JW patients (63 knees) who underwent TKA at our institution between 2005 and 2017 were matched to 63 non-JW patients (63 knees). Patient demographics, intraoperative details, and postoperative complications including in-hospital complications, revisions, and 90-day readmissions were collected and compared between the groups. Additionally, subgroup analysis was performed comparing JW patients who were administered tranexamic acid (TXA) between the two groups. Baseline demographics did not vary significantly between the study cohorts. The mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, including in-hospital complications (7.9 vs. 4.8%; p = 0.47), revision TKA (1.6 vs. 1.6%; p = 1.00), and 90-day readmission (1.6 vs. 4.8%; p = 0.31) were not significantly different between the JW and non-JW groups. Subgroup analysis demonstrated JW patients who received TXA had a significantly lower decline in postoperative hemoglobin (Hgb) (8.6 vs. 14.0%; p < 0.01). At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes equivalent to non-JW patients without the need for transfusion. Our findings support that surgeons are more likely to optimize JW patients preoperatively with iron and folate supplementation. Despite these variations in preoperative optimization efforts, no significant difference with regard to Hgb or hematocrit levels was demonstrated. Level of evidence is III, retrospective observational study.

Undetectable Hepatitis C Viral Load Is Associated With Improved Outcomes Following Total Joint Arthroplasty.

BACKGROUND: Previous reports establish that infection with hepatitis C virus (HCV) predisposes total joint arthroplasty (TJA) recipients to poor postoperative outcomes. The purpose of the present study is to assess whether variation in HCV VL influences perioperative outcomes following TJA. METHODS: A multicenter retrospective review of all patients diagnosed with HCV who underwent primary TJA between January 2005 and April 2018 was conducted. Patients were stratified into 2 cohorts: (1) patients with an undetectable VL (U-VL) and (2) patients with a detectable VL (D-VL). Kaplan-Meier survivorship analysis was calculated with revision TJA as the end point. Subanalysis on the VL profile was done. RESULTS: A total of 289 TJAs were included (U-VL:118 TJAs; D-VL:171 TJAs). Patients in the D-VL cohort had longer operative times (133.9 vs 109.2 minutes), higher intraoperative blood loss (298.4 vs 219.5 mL), longer inpatient hospital stays (4.0 vs 2.9 days), more postoperative infections (11.7% vs 4.2%), and an increased risk for revision TJA (12.9% vs 5.1%). Kaplan-Meier demonstrated that the U-VL cohort trended toward better survivorship (P = .17). On subanalysis of low and high VL, no difference in outcomes was appreciated. CONCLUSION: TJA recipients with a detectable HCV VL have longer operative times, experience more intraoperative blood loss, have longer hospital length of stay, and are more likely to experience infection and require revision TJA. The blood loss, hospital length of stay, and revision rate findings should be interpreted with caution, however, as there are confounding factors. Our findings suggest that HCV VL is a modifiable risk factor that, can reduce the risk of infection and revision surgery. Additionally, serum HCV VL was not correlated with outcomes.

Arthrofibrosis After Total Knee Arthroplasty: Pathophysiology, Diagnosis, and Management.

Arthrofibrosis is the pathologic stiffening of a joint caused by an exaggerated inflammatory response. As a common complication following total knee arthroplasty (TKA), this benign-appearing connective tissue hyperplasia can cause significant disability among patients because the concomitant knee pain and restricted range of motion severely hinder postoperative rehabilitation, clinical outcomes, and basic activities of daily living. The most effective management for arthrofibrosis in the setting of TKA is prevention, including preoperative patient education programs, aggressive postoperative physical therapy regimens, and anti-inflammatory medications. Operative treatments include manipulation under anesthesia, arthroscopic debridement, and quadricepsplasty.

Outcomes in 385 developmental dysplastic hips requiring total hip arthroplasty.

BACKGROUND: Patients with developmental dysplasia of the hip (DDH) require special surgical considerations for total hip arthroplasty (THA). Despite the difficulties posed by the population's anatomical abnormalities, few large evaluations of postoperative outcomes exist. This study seeks to characterize outcomes following primary THA among patients diagnosed with DDH. METHODS: A retrospective review was conducted at a tertiary care center on all THA patients between June 2011 and March 2018. Inclusion criteria for this study included any patient diagnosed with DDH undergoing primary THA. Baseline information, operative reports, and postoperative outcomes were pulled from the medical record. RESULTS: In total, 336 patients (385 hips) undergoing a THA between June 2011 and March 2018 were included. The average age was 52.6 ± 13.0 years and body mass index was 27.8 ± 6.0 kg/m2. Most patients were female (82%). The majority of hips (89%, n = 344) were Crowe type 1, followed by 2 (6.9%, n = 26), 3 (2.6%, n = 10), and 4 (1.3%, n = 5). Most hips were Hartofilakidis Class A (83%, n = 320), followed by Class B (15%, n = 59), then C (1.6%, n = 6). Mean follow-up was 24.8 months. Revision THA was required in 19 (4.9%) cases, with the most common indications being infection (2.1%) and periprosthetic fracture (1.0%). Readmission rates were 1.8% (7 hips) and 2.9% (11 hips) at 30-day and 90-day, respectively. The 30-day and 90-day ED visit rates were 1.3% (5 hips) and 2.1% (8 hips), respectively. No complications were seen following 344 (87%) THAs. CONCLUSION: Despite their surgical complexity, DDH patients on average have notably low rates of revision and dislocation. Longer follow-up is needed to better assess outcomes after THA in this complex patient population.

A Meta-Analysis of Outcomes in Total Hip Arthroplasty Recipients Following Pelvic Irradiation.

BACKGROUND: Alongside advances in total hip arthroplasty (THA), innovations in the treatment of cancer have led to an increasing number of patients living with this devastating disease. Radiation therapy has well-documented clinical effects on bone health, leading to pelvic insufficiency fractures and osteonecrosis of the femoral head. The purpose of this meta-analysis is to report on THA outcomes in this patient population in an effort to determine if a need to change management exists during surgical planning. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols, a systematic review of published literature through August 5th, 2018 was conducted. This resulted in 8 studies in which the primary outcome measures evaluated were rates of aseptic loosening and revision THA. RESULTS: Among 232 hips at a weighted mean follow-up time of 52 months, the aseptic loosening rate was 10% and revision THA rate was 12%. Sub-analysis of 116 THAs with cementless cups demonstrated an aseptic loosening and revision THA rate of 8% and 10%, respectively. CONCLUSION: The findings of the present study indicate that THA recipients who have received radiation therapy to the pelvis before arthroplasty surgery have higher rates of aseptic loosening and revision THA when compared with previously published rates in healthy THA recipients. Additionally, it is possible that female THA recipients who have received pelvic irradiation may be at a higher risk for aseptic loosening and revision THA. Surgeons should counsel patients with a history of pelvic irradiation about their potentially higher risk for these complications. LEVEL OF EVIDENCE: Level I, meta-analysis, and systematic review.

Total Hip Arthroplasty in Human Immunodeficiency Virus-Positive Patients: A Concise Follow-Up at 10 to 14 Years.

BACKGROUND: Advancements in the management of human immunodeficiency virus (HIV) now permit HIV-positive patients to have longer life spans, increasing their cumulative risk of developing an advanced degenerative joint disease, necessitating total hip arthroplasty (THA). The purpose of this study was to provide an extended follow-up on a previously published study on a cohort of HIV-positive THA recipients in an effort to confirm the safety and longevity of THA in this population. METHODS: This study is a follow-up on a previous study comprised of 41 hips in 31 HIV-positive THA recipients. At this follow-up, 5 patients from the original cohort required contralateral THA. Postoperative complications were recorded up to the patient's last follow-up date. A survivorship analysis was performed using the Kaplan-Meier method with revision THA as the end point. RESULTS: Since the last report, 2 additional hips were revised (one for aseptic loosening and one for a periprosthetic fracture), and 5 patients underwent contralateral THA. This resulted in a total of 5 (13.8%) hips requiring revision THA at the latest follow-up. The mean follow-up interval for the original cohort and for the contralateral 5 hips was 78.9 ± 50.2 months and 54.6 ± 45.3 months, respectively. Kaplan-Meier survivorship analysis with revision THA for any reason as the end point demonstrated survivorship of 93% (2 years), 90% (5 years), and 81% (10 and 14 years) after primary THA, respectively. CONCLUSION: Our study suggests that it is possible to achieve a low incidence of postoperative infection in HIV-positive THA recipients. In addition, our study demonstrates that non-hemophiliac HIV-positive patients have comparable revision rates to previously published reports on HIV-negative patients of similar age, underscoring the clinical efficacy of highly active antiretroviral therapy.

Preoperative optimization for vascular involvement complicating revision total hip arthroplasty.

Vascular complications in revision total hip arthroplasty may occur in cases where the components of the hip implant migrate through the acetabular wall, through the iliopectineal line of the pelvis, and into the pelvic cavity. This migration may lead to substantial intrapelvic vascular compromise, drastically increasing the surgical complexity and potential risk for morbidity and mortality in these surgical cases. Here, we present a case of a 78-year-old woman with significant acetabular protrusio, which resulted in intraoperative compromise of the external iliac artery with rapid extravasation. As a result of prudent preoperative planning, interdisciplinary collaboration, and precautionary measures, significant patient morbidity and mortality was averted. LEVEL OF EVIDENCE: Level V, Case Report.

The Historical Development of Value-Based Care: How We Got Here.

The original architects of Medicare modeled the payment system on the existing fee-for-service (FFS) structure that historically dominated the health-insurance market. Under the FFS paradigm, health-care expenditures experienced an exponential rise. In response, the managed care and capitation models of health-care delivery were developed. However, changes in Medicare reimbursement, along with an increasing volume of orthopaedic procedures and escalating implant costs, call into question the cost-effectiveness of this service line. The success of the Medicare Acute Care Episode (ACE) Demonstration Project proved the feasibility of value-based care and ushered in a new era of bundled payment initiatives.

A Rare Incidence of Pigmented Villonodular Synovitis of the Ankle in an Adolescent.

Pigmented villonodular synovitis mostly affects the knee and other large joints such as the hip. Although the disease is most commonly found in adult patients aged 30 to 40 years, rare cases in children and the elderly have been reported. We present the case of an 11-year-old female who was found to have biopsy-proven pigmented villonodular synovitis in her subtalar joint in 2012. Five years after surgical excision, the patient has continued to be involved in competitive dancing and cheerleading without any pain in her ankle. Moreover, follow-up magnetic resonance imaging studies showed no evidence of recurrence. Our case report emphasizes that the disease should not be solely considered in the middle-age population but should be included in the differential diagnosis of the pediatric patient.

Up to 18-Year Follow-Up Wear Analysis of a First-Generation Highly Cross-Linked Polyethylene in Primary Total Hip Arthroplasty.

BACKGROUND: The advent of highly cross-linked polyethylene (HCLPE) has significantly improved total hip arthroplasty survivorship. HCLPE has been shown to improve wear properties in midterm outcomes when compared to traditional polyethylene liners; however, there is a paucity of studies evaluating long-term outcomes. In addition, there is concern that wear rates may accelerate as the implant ages. Thus, the aims of this study are to report on the longest-to-date follow-up of a specific first-generation HCLPE liner and to determine whether there is a change in the annual wear rate over time. METHODS: Forty hips in 38 patients which were previously reported on in a midterm study were included in this long-term follow-up study. Patients in this cohort all received total hip arthroplasty between March 1999 and August 2004 using the Crossfire HCLPE liner. Annual wear rates (mm/y) were calculated for this cohort. Patients were contacted and asked about complications or revision procedures they may have had since the index procedure. RESULTS: Clinical follow-up averaged 12.9 years with a range of 7-18 years. The average follow-up duration was 12.5 years with a range of 10-17 years. Linear wear was found to be 0.056 ± 0.036 mm/y. Osteolysis was not observed in any of the patients with greater than 10-year radiographic follow-up. Furthermore, only 1 patient required revision surgery following a mechanical fall. CONCLUSION: Our study demonstrates the long-term wear rates associated with HCLPE liners continue to match rates published in midterm studies. Previously, we have reported that this cohort had an average annual wear rate of 0.05 mm/y over 10 years. This most recent report demonstrates a similar wear rate with up to 18-year follow-up.

Early aseptic loosening of the Tritanium primary acetabular component with screw fixation.

Ultraporous acetabular components were developed to improve osseointegration and fit for increased longevity and better outcomes after total hip arthroplasty. There is a paucity of literature detailing this acetabular component's clinical performance, with even less detailing those with screw fixation. We identify 5 patients at our institution who underwent revision total hip arthroplasty for early aseptic acetabular cup loosening of an ultraporous acetabular component known as the Tritanium primary cup with secondary screw fixation. They all presented with groin and hip pain after index surgery and underwent follow-up radiographic examination consistent with component loosening requiring revision surgery. This case series reports on the risk of early acetabular cup loosening and its associated clinical presentation, workup, and surgical management in patients with the Tritanium primary cup augmented with screws.

Appropriateness of Pediatric Orthopaedic Transfers to a Level 1 Hospital.

OBJECTIVE: To compare a cohort of transferred pediatric orthopaedic patients with orthopaedic patients who primarily presented to a Level 1 pediatric emergency department to identify risk factors for transfer. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center in New York. PATIENTS: The cohort consisted of patients younger than 18 years who presented to 1 Level 1 pediatric trauma center between January 1, 2013, and December 31, 2013, with an orthopaedic fracture diagnosis code (ICD-9 805.0-839.9). The control group included the patients who presented to that hospital primarily, and the study group included patients who were transferred to that same hospital from another institution. INTERVENTION: Demographic and injury-related data [age, sex, mechanism of injury, location of injury, injury severity score, and insurance status] were collected. MAIN OUTCOME MEASUREMENTS: Regression analysis was performed to assess for predictors of transfer to a Level 1 hospital. Subgroup analysis examined whether transfers were appropriate, based on the type of injury. RESULTS: There were 1064 patients in the nontransfer group and 67 patients in the transfer group. Transferred patients were more likely to have surgery within 24 hours (39.42% vs. 2.63%) and were more likely to have no insurance or Medicaid (50.75% vs. 33.24%). Injury severity score and insurance status were independent predictors for transfer. CONCLUSIONS: This study indicates that injury severity is the primary predictor in deciding to transfer a pediatric patient; however, insurance status may play a role in that decision. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short-term results of left subclavian artery salvage in blunt thoracic aortic injury with short proximal landing zones.

OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) is the standard treatment of blunt thoracic aortic injury (BTAI). The concept of seal was derived from the treatment of aneurysms and has been adopted for BTAI. Given the location of injury in BTAI, left subclavian artery (LSA) coverage is sometimes necessary. In these often healthier aortas, a shorter proximal landing zone may be acceptable and beneficial in avoiding some complications. Current practice patterns vary, and long-term effects of LSA coverage remain unknown. METHODS: A single-institution experience with BTAI for TEVAR was examined from 2006 to 2017. The primary outcome was failure of sealing, endoleak, or persistent aortic injury on follow-up imaging. A centerline was used to measure the length of the landing zone, aortic diameter, and other parameters. Post-TEVAR computed tomography scans were examined for evidence of residual aortic injury. RESULTS: A total of 30 TEVARs were performed for BTAI. The mean age of the patients was 38.7 years (standard deviation [SD], 19.8 years), and 70% were male. The mean injury severity score was 36.75 (SD, 13.1). Treated patients had grade 2 (36.7%) or grade 3 (63.3%) BTAI. The LSA was salvaged in 23 cases and covered in seven cases. The mean landing zone in LSA uncovered cases was 16 mm (SD, 10.4 mm). There were 15 patients (65%) who had a landing zone <20 mm, and eight (35%) patients had a landing zone >20 mm. The mean landing zone in the seven covered cases was 1.8 mm (SD, 2.4 mm). Procedural success was 96% for the uncovered group and 100% for the covered group. On follow-up imaging, there was only one residual endoleak in all surviving patients (n = 25). Five patients did not have postoperative imaging, two (7%) of whom died of nonaorta-related issues. CONCLUSIONS: TEVAR for BTAI in patients with short proximal landing zones of 10 to 20 mm as well as in select patients with landing zones of 5 to 10 mm appears to be safe and efficacious. The aorta demonstrates no residual injury after TEVAR, with the graft acting potentially more as a bridge to allow healing. Long-term issues regarding LSA coverage have been difficult to ascertain and to evaluate because of historically poor follow-up in this population of patients. However, potential issues with LSA coverage and revascularization may be avoided by preserving the subclavian artery even with shorter proximal landing zones.

Utilization of Body Contouring Procedures Following Weight Loss Surgery: A Study of 37,806 Patients.

BACKGROUND: Bariatric surgery has substantial health benefits; however, some patients desire body contouring (BC) procedures following rapid weight loss. There is a paucity of data regarding the true rate of BC following bariatric procedures. The purpose of our study is to examine the utilization of two common procedures, abdominoplasty, and panniculectomy, following bariatric surgery in New York State. METHODS: The SPARCS longitudinal administrative database was used to identify bariatric procedures by using ICD-9 and CPT codes between 2004 and 2010. Procedures included sleeve gastrectomy, Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Using a unique patient identifier, we tracked those patients who subsequently underwent either abdominoplasty or panniculectomy with at least a 4-year follow-up (until 2014). Multivariable Cox proportional hazard model was used to evaluate predictors of follow-up BC surgery. RESULTS: 37,806 patients underwent bariatric surgery between 2004 and 2010. Only 5.58% (n = 2112) of these patients subsequently had a BC procedure, with 143 of them (6.8%) having ≥1 plastic surgery. The average time to plastic surgery after band, bypass, or sleeve was 1134.83 ± 671.09, 984.70 ± 570.53, and 903.02 ± 497.31 days, respectively (P < 0.0001). Following the multivariable Cox proportional hazard model, a female, SG patients, patients with Medicare or Medicaid, and patients in either <20 or >80%ile in yearly income were more likely to have plastic surgery after adjusting for age, race/ethnicity, comorbidities and complications (P values < 0.0001). CONCLUSIONS: This study shows that plastic surgery is completed by only 6% of patients following bariatric procedures. As insurance and income are associated with pursuing surgery, improved access may increase the number of patients who are able to undergo these reconstructive procedures.

The effect of smoking on ACL reconstruction: a systematic review.

OBJECTIVE: Anterior cruciate ligament reconstruction (ACLR) depends on proper healing of the graft or bone plug at the cellular level. The effect of cigarette smoke on ACLR was not commonly reported until recently. The primary purpose of this review was to determine if smoking has a negative effect on subjective or objective outcome scores after ACLR. The secondary purpose was to identify any increased risk of complications, infection, ACL re-tear, or revision procedures. METHODS: A systematic literature review of the MEDLINE, SCOPUS and PubMed databases was performed to identify all studies that compared outcomes of ACLR surgery between smokers and nonsmokers. The frequency-weighted mean was calculated for outcome measures that were similar across several studies. RESULTS: Seventeen studies were identified that met inclusion criteria for patients undergoing ACLR (mean age, 26.8 years) with a mean follow-up of 37 months. Smokers had significantly worse subjective outcome measures and worse side-to-side difference in anterior translation compared to non-smokers (2.68 mm vs 1.89 mm, respectively). In 2 studies, smokers were found to have a significantly higher risk of developing an infection and VTE (venous thromboembolism) post-operatively. The evidence for the effect of smoking on risk for subsequent re-tear is mixed. No study reported a higher rate of development of radiographic knee osteoarthritis among smokers compared to nonsmokers. CONCLUSIONS: Cigarette smoke is associated with significantly worse clinical outcome scores, an increase in anterior translation, and increased complication rates after ACL reconstruction. These findings may help orthopaedic surgeons better inform their patients about the potential negative effects of smoking on the outcomes of ACL reconstruction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Effect of Additional Sutures per Suture Anchor in Arthroscopic Bankart Repair: A Review of Single-loaded Versus Double-loaded Suture Anchors.

PURPOSE: To directly compare single-loaded suture anchors (SSA) with double-loaded suture anchors (DSA) to help surgeons optimize the operative technique, time, and cost of Bankart repairs. METHODS: A literature review was performed using the PubMed and SCOPUS databases. Studies that directly compared SSA and DSA for Bankart repairs, or indirectly compared them by collecting relevant data despite a different objective, were included. RESULTS: A total of two studies were included, both of which were cadaveric laboratory studies. A total of 28 shoulders were tested. Tests conducted include loading to failure and cyclic loading. One study found SSA to be biomechanically equivalent to DSA, and one found DSA to be superior. CONCLUSIONS: Based on limited cadaveric study, DSA are at least equivalent biomechanically to SSA, and may be superior. By using DSA, surgeons create repair constructs that are as strong as, or stronger than, those made with SSA, but with fewer anchors. This reduces the amount of holes drilled and implants placed in the glenoid, while also minimizing cost. CLINICAL RELEVANCE: Quantifying the benefit of additional sutures in a suture anchor can help optimize the quality of repair, time, and cost in arthroscopic shoulder repair.