Assessing the Diagnostic Accuracy of Next-Generation Sequencing in Patients With Antibiotic Spacers Before Reimplantation.

Use of molecular sequencing modalities in periprosthetic joint infection diagnosis and organism identification has gained popularity recently. To date, there is no diagnostic test that reliably predicts infection eradication in patients with antibiotic spacers. The purpose of this study was to compare the diagnostic accuracy of next-generation sequencing (NGS), culture, the Musculoskeletal Infection Society (MSIS) criteria, and the criteria by Parvizi et al in patients with antibiotic spacers. In this retrospective study, aspirate or tissue samples were collected from 38 knee and 19 hip antibiotic spacers for routine diagnostic workup for the presence of persistent infection and sent to the laboratory for NGS. The kappa statistic along with statistical differences between diagnostic studies were calculated using the chi-square test for categorical data. The kappa coefficient for agreement between NGS and culture was 0.27 (fair agreement). The percentages of positive and negative agreement were 22.8% and 42.1%, respectively, with a total concordance of 64.9%. There were 12 samples that were culture positive and NGS negative. Eight samples were NGS positive but culture negative. The kappa coefficient was 0.42 (moderate agreement) when comparing NGS with MSIS criteria. In our series, NGS did not provide sufficient agreement compared with culture or MSIS criteria in the setting of an antibiotic spacer. A reliable diagnostic indicator for reimplantation has yet to be identified. [Orthopedics. 2024;47(1);46-51.].

The characteristics of opioid use in patients with proximal humerus fractures.

BACKGROUND: Orthopaedic surgeons prescribe more opioid narcotics than any other surgical specialty. Proximal humerus fractures (PHF) often occur in the high-risk elderly population. The opioid epidemic has led to public policy aimed at reductions in opioid prescription. This study aimed to evaluate the impact that new legislation has had on opioid prescription patterns in patients who sustained proximal humerus fractures. METHODS: A retrospective review of all patients who sustained PHF at a single academic institution from 1/1/2015-12/31/2019 was performed. A total of 762 proximal humerus fractures were identified and final analysis included 383 patients. Collected data included basic demographics and opioid prescriptions obtained through review of the electronic medical record. The North Carolina Strengthen Opioid Misuse Prevention act legislation that went into effect on July 1, 2017. RESULTS: There was no difference in the number of pre- or postoperative opioid prescriptions provided with the new legislation. Our data showed a significant reduction in MeQs prescribed preoperatively pre-STOP act (188.1 MeQs) and post-STOP act (99.4 MeQs). There was also a significant difference in the amount of postoperative narcotics prescribed in the pre-STOP (972.6 MeQs) and post-STOP act (508.6 MeQs) groups (p < 0.01). CONCLUSIONS: With the enactment of the STOP act in North Carolina, we have seen a significant reduction in the amount of narcotic prescribed after sustaining a proximal humerus fracture preoperatively and postoperatively. This data demonstrates the impact that implementation of state-wide regulatory changes in opioid prescribing policy has had for a common orthopedic condition.

Ulnar Resection Length: A Risk Factor for Nonunion in Ulnar Shortening Osteotomy.

BACKGROUND: Nonunion rates following ulnar shortening osteotomy (USO) are reported up to 18% with few known risk factors. While resection length is variable in practice, little is known about the prognostic implications on healing. The purpose of this study was to evaluate whether longer resection lengths increased the odds of nonunion. METHODS: A retrospective review was performed on patients who underwent an elective USO at a single institution over a 6-year period. Demographic, social, comorbidity, and surgical data were reviewed. Ulnar resection length was obtained from operative notes and dichotomized into smaller (<5.5 mm) and larger (≥5.5 mm) groups. The primary outcome was the rate of nonunion. Univariate analyses and a multivariable logistic regression model were used to assess for significant predictors of nonunion. RESULTS: A total of 87 patients were included with a mean age of 45 years. Patient comorbidities included 12.6% with diabetes, 29.9% with an American Society of Anesthesiologists score of ≥ 3, 5.8% reporting current tobacco use, and 29.9% reporting former tobacco use. There were 55 patients (63.2%) with resection lengths < 5.5 mm and 32 patients (36.8%) with ≥ 5.5 mm resections. Multivariable analysis identified longer resection length (≥5.5 mm) and current tobacco use as independent risk factors for nonunion. Patients with a resection length of ≥ 5.5 mm had 20.2 times greater odds of nonunion compared with patients with smaller resections, and current smokers had 72.2 times greater odds of nonunion compared with nonsmokers. CONCLUSION: Longer ulnar resection length (≥5.5 mm) significantly increases the risk of nonunion following USO.

Fracture Severity Based on Neer Classification Does Not Predict Short-term Complications Following Reverse Shoulder Arthroplasty.

Proximal humerus fractures (PHF) are common in elderly and osteoporotic patients, and these fractures are often described using the Neer classification. As reverse shoulder arthroplasty (RSA) for PHF becomes more common, it is helpful to identify the utility of Neer classification in predicting postoperative outcomes for patients undergoing RSA. The medical records of patients undergoing primary RSA for PHF at a single academic institution from 2013-2019 were identified using medical billing codes. A multivariable logistic regression analysis identified independent factors associated with all cause 90-day readmissions, reoperation, and length of stay (LOS) greater than three days. Fifty-five patients (average age of 72.3 ± 8.6 years) were included. No statistically significant differences among two-, three-, and four-part fractures with regard to LOS, discharge location, 90-day readmission, revision surgery, postoperative dislocation, or deep infection were detected. These findings suggest that Neer classification for PHF is not predictive of short-term complications after RSA. (Journal of Surgical Orthopaedic Advances 31(2):104-108, 2022).

Cutibacterium Positive Cultures in Total Hip Arthroplasty: Contaminant or Pathogen?

BACKGROUND: Cutibacterium spp. is an emerging pathogen in total hip arthroplasty (THA) that is not well evaluated in the literature. This study reported on the presentation and management of THA complicated by positive intraoperative Cutibacterium cultures. METHODS: This is a retrospective review of 27 revision THAs with positive monomicrobial intraoperative Cutibacterium cultures from 2014 to 2020 at one academic center. These patients were divided into two cohorts based on meeting Musculoskeletal Infection Society (MSIS) criteria for prosthetic joint infections (PJI). Patient demographics, preoperative labs, and hip aspirate results were collected. Procedure performed, postoperative antibiotic regimens, and repeat infections were recorded. Data were compared with univariate analysis. RESULTS: Nine of the 27 patients preoperatively met MSIS criteria for PJI. Patients with positive MSIS criteria had significantly higher median synovial cell count (P = .048) and neutrophil percentage in a preoperative aspirate (P = .050). Eight patients with positive MSIS criteria received six weeks of postoperative antibiotics compared to two patients with negative criteria. Two patients with positive MSIS criteria had a postoperative infection that required further surgical intervention. Four patients with negative criteria who required further surgical intervention did not receive postoperative antibiotics after initial revision. CONCLUSION: While often categorized as a contaminant, Cutibacterium is an increasingly recognized pathogen in THA. Cutibacterium can often present with normal serology, which may result in misdiagnosis as aseptic THA failure. Without the administration of postoperative antibiotics after positive cultures, there is a risk for persistent infection requiring further surgical intervention.

Heterotopic Ossification Prophylaxis Following Operative Fixation of Acetabular Fractures: A Systematic Review.

INTRODUCTION: Heterotopic ossification (HO) is a well-recognized complication following operative fixation of acetabular fractures with a range of severity and clinical consequences. The purpose of this review was to: (1) report the incidence of heterotopic ossification (HO) formation following operative fixation of acetabular fractures; (2) determine the effectiveness of prophylactic treatments for HO; and (3) assess the radiographic severity of HO with and without prophylactic treatment. MATERIALS AND METHODS: A literature search for peer-reviewed articles was conducted utilizing a variety of research databases. PRISMA guidelines were followed and included in this review were full-length, English language manuscripts published before September 2019, using the following search criteria: "heterotopic ossification AND acetabulum OR acetabular." Studies that reported HO as one of the reported outcomes were included. Articles were excluded if radiographic HO was not reported and if it was evaluated in surgeries other than those involved in acetabular fractures. Extracted data included, but was not limited to: type of prophylaxis; incidence of HO; severity of HO based on the Brooker classification; and statistical significance. A methodologic quality appraisal of the included studies was also conducted. A total of 54 full-text studies with 5,890 patients with operatively fixed acetabular fractures met inclusion criteria. There were four level I studies, four level II study, 26 level III studies, and 20 level IV studies. RESULTS: The overall incidence of HO after acetabular fracture surgery was 28.4%. The rate of HO formation was: 34.9% without prophylaxis, 28.3% with non-steroidal anti-inflammatory drugs (NSAID) prophylaxis, and 21.2% with radiation therapy (RT). Patients receiving a combination of both RT and NSAIDs developed HO 21.8% of the time. The rate of radiographic severe HO was 13.9% (range, 0-75%) in patients without prophylaxis, 9.4% (range, 0-50%) with NSAID prophylaxis, 5.7% (range, 0-12.8%) with RT prophylaxis, and 11.7% (range, 0-18.5%) with the combination of RT and NSAIDs. CONCLUSION: With the current literature collected in this systematic review, there was a lower incidence and severity of heterotopic bone formation following acetabular fracture fixation using radiation prophylaxis compared to NSAIDs or no treatment. The available literature is heterogeneous in fracture characteristics, surgical approaches, and prophylactic regimens with a general lack of randomized control trials. Further prospective studies are required to make definitive claims on the optimal prophylactic strategy to prevent heterotopic ossification.

Preoperative Weight Loss and Postoperative Weight Gain Independently Increase Risk for Revision After Primary Total Knee Arthroplasty.

BACKGROUND: The current American Association of Hip and Knee Surgeons (AAHKS) guidelines recommend preoperative weight loss before total knee arthroplasty (TKA) in patients with body mass index (BMI) ≥40 kg/m2. However, there is a paucity of evidence on TKA outcomes after preoperative weight loss. This study therefore evaluated predictors of preoperative and postoperative BMI changes and their impact on outcomes after TKA. METHODS: This is a retrospective review of 3058 primary TKAs at an academic institution from 2015 to 2019. BMI was collected on the day of surgery. Preoperative and postoperative BMI at 6 months and 1 year were also obtained. BMI change of ≥5% was considered clinically significant. Mean follow-up was 3.2 years. Patient demographics, acute postoperative outcomes, and all-cause revisions were compared between patients who gained, lost, or maintained weight using univariate and multivariable analyses. RESULTS: Preoperative weight loss was predictive of postoperative weight gain (P < .001), and preoperative weight gain was predictive of postoperative weight loss (P < .001). Cox regression analysis revealed that ≥5% BMI loss preoperatively increased risk for all-cause revisions (P = .030), while ≥5% BMI gain postoperatively increased risk for prosthetic joint infections (P = .016). Patients who lost significant weight both before and after surgery had the highest risk for all-cause revisions (P = .022). CONCLUSION: Weight gain postoperatively was associated with inferior outcomes. Significant weight loss before surgery led to a "rebound" in weight gain, and independently increased risk for all-cause revision. Therefore, current recommendations for weight loss before TKA in morbidly obese patients should be re-evaluated.

Quantifying the Economic Impact of Depression for Spine Patients in the United States.

STUDY DESIGN: This was a retrospective cross-sectional analysis. OBJECTIVE: The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden. SUMMARY OF BACKGROUND DATA: Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery. MATERIALS AND METHODS: Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index. RESULTS: A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort. CONCLUSIONS: Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.

Increasing age and modifiable comorbidities are associated with short-term complications after open reduction and internal fixation of ankle fractures.

BACKGROUND: Ankle fractures are common orthopedic injuries with complication rates fixation of up to 40%. Limited evidence exists in the literature regarding complications in the elderly population, and moreover, these studies frequently define elderly arbitrarily at 60-65 years old. The purpose of the present study was to utilize a large, validated database to evaluate whether there is an inflection point of age when postoperative complications after an ankle fracture significantly increase. METHODS: A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent fixation of an ankle fracture between 2012 and 2018 was performed. Patients were identified within the database using the Current Procedural Terminology codes. Appropriate statistical analysis was performed with p value less than 0.05 considered statistically significant. RESULTS: A total of 27,633 fractures were including and comprised of 221 posterior malleolar, 1567 medial malleolar, 8495 lateral malleolar, 10,175 bimalleolar, and 7175 trimalleolar. A total of 1545 complications were encountered (5.6%). There was a statistically significant association between increasing age and complications (OR = 1.03; p < 0.001). Further analysis shows the largest spike in complications within the age 78 + bracket. There were no overall interaction effects between age and fracture subtype (p = 0.223). CONCLUSION: ORIF of ankle fractures is a common orthopedic procedure performed on patients of all ages, with complications ranging in severity. In order to best counsel patients on their individual postoperative risks, large datasets are often necessary to prognosticate. This study found that postoperative complications increase with advanced age. The incidence of complications did not spike for patients around the age of 65, but rather followed an incremental linear pattern with the largest increase in odds ratio occurring at age 78 and above. Complication rate was not associated with specific fracture type based off of ICD codes.

The Impact of Smoking in Workers' Compensation Patients Receiving Spinal Cord Stimulation.

The objective of this study was to determine the impact of smoking on clinical outcomes in workers' compensation (WC) patients receiving spinal cord stimulation (SCS). One hundred and ninety-six patients from the Ohio Bureau of Workers' Compensation were identified who received SCS with implantation occurring between 2007-2012. Patients were divided into smokers (n = 120) and nonsmokers (n = 76). Population characteristics before and after implantation were analyzed between the two groups. A multivariate logistic regression was run to determine predictors of return to work (RTW) status. Our regression determined smoking (p = 0.006; odds ratio [OR] = 0.260) and body mass index (p = 0.036; OR = 0.905) to be negative predictors of RTW status. After implantation, smokers were less likely to RTW after 6 months and had higher pain scores after 6 and 12 months. Both smokers and nonsmokers had significance reductions in opioid use after SCS implantation. (Journal of Surgical Orthopaedic Advances 30(3):185-189, 2021).

Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis.

PURPOSE: To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair. METHODS: A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ2 tests were used to determine differences between group proportion categorical variables. Significance was considered at a P ≤ .05. RESULTS: From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South (P < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females (P < .01). CONCLUSIONS: MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin. LEVEL OF EVIDENCE: IV, Therapeutic Case Series.

Efficacy of common antiseptic solutions against clinically relevant microorganisms in biofilm.

AIMS: Periprosthetic joint infections (PJIs) are among the most devastating complications after joint arthroplasty. There is limited evidence on the efficacy of different antiseptic solutions on reducing biofilm burden. The purpose of the present study was to test the efficacy of different antiseptic solutions against clinically relevant microorganisms in biofilm. METHODS: We conducted an in vitro study examining the efficacy of several antiseptic solutions against clinically relevant microorganisms. We tested antiseptic irrigants against nascent (four-hour) and mature (three-day) single-species biofilm created in vitro using a drip-flow reactor model. RESULTS: With regard to irrigant efficacy against biofilms, Povidone-iodine treatment resulted in greater reductions in nascent MRSA biofilms (logarithmic reduction (LR) = 3.12; p < 0.001) compared to other solutions. Bactisure treatment had the greatest reduction of mature Pseudomonas aeruginosa biofilms (LR = 1.94; p = 0.032) and a larger reduction than Vashe or Irrisept for mature Staphylococcus epidermidis biofilms (LR = 2.12; p = 0.025). Pooled data for all biofilms tested resulted in Bactisure and Povidone-iodine with significantly greater reductions compared to Vashe, Prontosan, and Irrisept solutions (p < 0.001). CONCLUSION: Treatment failure in PJI is often due to failure to clear the biofilm; antiseptics are often used as an adjunct to biofilm clearance. We tested irrigants against clinically relevant microorganisms in biofilm in vitro and showed significant differences in efficacy among the different solutions. Further clinical outcome data is necessary to determine whether these solutions can impact PJI outcome in vivo. Cite this article: Bone Joint J 2021;103-B(5):908-915.

Risk of suprascapular nerve injury during glenoid baseplate fixation for reverse total shoulder arthroplasty: a cadaveric study.

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) is an effective treatment for patients with advanced rotator cuff arthropathy. During implantation of the glenoid baseplate, screws are inserted through the glenoid face into the scapular body to achieve adequate fixation. Placement of peripheral baseplate screws in the superior and posterior glenoid may increase the risk of injury to the suprascapular nerve (SSN). The purpose of this cadaveric study was to evaluate the risk of SSN injury with placement of baseplate screws in the superior and posterior direction. METHODS: Twelve cadaveric shoulders were implanted with glenoid baseplates. A bicortical 44-mm screw was placed in both the superior and posterior glenoid baseplate screw holes. Following implantation, the SSN was dissected and visualized through a posterior shoulder approach. The distance from the tip of the screws to the SSN and the distance from the screw's scapular exiting hole to the SSN was recorded. Average distances were calculated for each measurement. RESULTS: The superior screw contacted the SSN in 8 of the 12 specimens (66%). For the superior screw, the average distance from the exiting point in the scapula to the SSN was 9.2 ± 6.3 mm, with the shortest distance being 3.9 mm. The posterior screw contacted the SSN in 6 of 12 specimens (50%). For the posterior screw, the average distance from the exiting point to the SSN was 8.9 ± 3.8 mm, with the shortest distance to the nerve being 2.2 mm. CONCLUSION: Placement of the superior and posterior screws in the glenoid baseplate during rTSA risks injury to the SSN. The safe zone for superior- and posterior-directed baseplate screw is <2 mm from its exiting point on the scapula. Therefore, precise measurements of screw lengths in this area is important in avoiding injury to the SSN.

Time to Surgery Affects Return to Work Rates for Workers' Compensation Patients With Single-Level Lumbar Disk Herniation.

The optimal timing of lumbar diskectomy in patients with lumbar disk herniation and radiculopathy has not been studied in the workers' compensation (WC) population. A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disk herniation between 2005 and 2012. The primary outcome was whether subjects return to work (RTW). To determine the impact time to surgery had on RTW status, the authors performed a multivariate logistic regression analysis. They compared other secondary outcomes using chi-square and t tests. The authors identified 1287 WC patients with single-level disk herniation and radiculopathy. Average time from injury to surgery was 364 days (range, 2-2710 days). The WC patients with shorter duration of radiculopathy before diskectomy had higher RTW rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses (P<.05). A multivariate logistic regression model showed that time to surgery was an independent, negative predictor of RTW (odds ratio [OR], 0.97 per month; P<.01). Legal representation (OR, 0.56; P<.01), psychological comorbidity (OR, 0.32; P=.01), and mean household income (OR, 1.01 per $1000; P<.01) also significantly affected RTW status. These results confirm that the duration of radiculopathy due to single-level lumbar disk herniation has a predictive value for the WC population undergoing diskectomy. Within 12 weeks of injury, post-diskectomy patients do reasonably well, with 70.0% of subjects returning to work. [Orthopedics. 2021;44(1):e43-e49.].

Shorter Time to Surgery Is Associated With Better Outcomes for Spondylolisthesis in the Workers' Compensation Population.

This study sought to determine the impact of time to surgery on clinical outcomes in patients with spondylolisthesis in the workers' compensation (WC) population. There is conflicting evidence regarding the effect of time to surgery on patients with spondylolisthesis. Patients receiving WC are known to have worse outcomes following spine surgery compared with the general population. A total of 791 patients from the Ohio Bureau of Workers' Compensation were identified who underwent lumbar fusion for spondylolisthesis between 1993 and 2013. The patients were divided into those who had surgery within 2 years of injury date and after 2 years. Confounding factors were corrected for in a multivariate logistic regression to determine predictors of return to work (RTW) status. Multivariate logistic regression determined that longer time to surgery (P=.003; odds ratio, 0.89 per year), age at index fusion (P=.003; odds ratio, 0.98 per year), and use of physical therapy before fusion (P=.008; odds ratio, 0.54) were negative predictors of RTW status. Patients who had surgery within 2 years were more likely to RTW and have fewer days absent from work, lower medical costs, and fewer sessions of psychotherapy, physical therapy, and chiropractor care. The authors demonstrated that for WC patients with spondylolisthesis, longer time to surgery was a negative predictor of RTW status. Patients who had surgery within 2 years of injury date were significantly more likely to RTW compared with after 2 years. [Orthopedics. 2020;43(3):154-160.].

Modern Dual-Mobility Cups in Revision Total Hip Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The purpose of this systematic review is to analyze the outcomes of dual-mobility (DM) cups in revision total hip arthroplasty (THA). Specifically, we evaluated the following: (1) all-cause and aseptic survivorship rates; (2) dislocation rates; (3) complications; and (4) clinical outcomes reported using validated health status measures. METHODS: A comprehensive literature search included studies that reported the following: (1) re-revision rates, (2) complications, and (3) clinical outcomes following DM use in revision THA. The following exclusion criteria were used: (1) studies that did not stratify their analysis between primary and revision THA, (2) studies that utilized off-label techniques, (3) review articles, (4) case studies, (5) basic science articles, (6) non-English language reports, and (6) reports on patients who underwent surgery before 2010, in order to reflect modern DM implants use and technology. A total of 9 studies were included in our final analysis. RESULTS: Aseptic and all-cause survivorship rates were 97.7% and 94.5%. Prevalence of dislocation was 2.2%, and 0.3% for intraprosthetic dislocation. Meta-analysis comparing DM to fixed-bearing prostheses demonstrated a significantly lower odds of dislocation in the DM cohort (odds ratio 0.24, P = .002). Complications occurred in 7.4% of revision THAs with DM cups, while infection rates totaled to 3.3% of cases. Studies comparing outcomes using Harris Hip Scores did not demonstrate a statistically significant difference in improved postoperative scores (P > .05). CONCLUSION: DM cups have demonstrated excellent survivorship, low dislocation, and overall complication rates. Therefore, it can be considered a safe and effective option, particularly in the high-risk patients who undergo revision THA.

Lumbar Discography Is Associated With Poor Return to Work Status Following Lumbar Fusion Surgery in a Workers' Compensation Setting.

Lumbar discography (LD) is used to guide surgical decision making in patients with degenerative disc disease (DDD). Its safety and diagnostic accuracy are under contention. This study evaluates LD's efficacy within the workers' compensation (WC) population. Multivariate logistic regression analysis was used to determine the impact that undergoing LD before lumbar fusion for DDD had on return to work (RTW) rates among 1407 WC subjects. Discography was negatively associated with RTW status (p = .042; OR 0.76); 22.2% (142/641) of LD subjects met the RTW criteria, compared with 29.6% (227/766) of controls. Additional preoperative risk factors included psychological comorbidity (p < .001; OR 0.34), age greater than 50 (p < .005; OR 0.64), male gender (p < .037; OR 0.75), chronic opioid use (p < .001; OR 0.53), legal representation (p < .034; OR 0.72), and fusion technique (p < .043). LD subjects used postoperative narcotics for an average of 123 additional days (p < .001). This raises concerns regarding the utility of discography in the WC population. (Journal of Surgical Orthopaedic Advances 27(1):25-32, 2018).

Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD). SUMMARY OF BACKGROUND DATA: The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. METHODS: Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). RESULTS: Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. CONCLUSION: Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. LEVEL OF EVIDENCE: 3.

Treatment of Recurrent Lumbar Disc Herniation With or Without Fusion in Workers' Compensation Subjects.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine outcomes after reoperation discectomy with or without fusion surgery for recurrent lumbar disc herniation (RLDH) in the workers' compensation (WC) population. SUMMARY OF BACKGROUND DATA: RLDH is estimated to occur in 7% to 24% of patients after discectomy. There are two main surgical options after reherniation: a revision discectomy (RD), or an RD combined with fusion (RDF). METHODS: A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with lumbar spine comorbidities, a smoking history, or multilevel surgery were excluded. One hundred two patients had RD alone for RLDH and 196 had RDF procedures. The primary outcome was whether subjects returned to work (RTW). RESULTS: A total of 298 WC patients met our study criteria, including 230 (77.2%) men and 68 (22.8%) women with an average age of 39.4 years (range 19-66). The RDF group had lower rates of RTW than the RD group (27.0% vs 40.2%; P = 0.03). Multivariate regression analysis showed that reoperation with discectomy and fusion (P = 0.04; odds ratio [OR] = 0.56), psychiatric illness (P < 0.01; OR = 0.19), and opioid analgesic use within 1 month of reoperation (P < 0.01; OR = 0.44) were independent negative predictors of RTW. RDF patients were supplied with opioids for 252.3 days longer (P < 0.01) and incurred $34,914 (31.8%) higher medical costs (P < 0.01) than the RD alone group. CONCLUSION: We analyzed outcomes after operative management of RLDH in the WC population. WC patients receiving RDF had lower RTW rates, higher costs, and a longer duration of postoperative opioid use than those receiving RD alone. This information allows for informed patient management decisions and suggests that fusion should be reserved for patients with clear indications for its use. We are unable to conclude what treatment method is best, but rather we provide a baseline for future studies. LEVEL OF EVIDENCE: 3.