Venous Thromboembolism and Prevention Strategies in Patients with Cushing's Disease: A Systematic Review.

BACKGROUND: There is a well-documented association between Cushing's Syndrome (CS) and hypercoagulability. However, there is limited data on the risk of venous thromboembolic events (VTE) after surgery for Cushing's disease (CD). There is no consensus on optimal postoperative anticoagulation strategies in this group. This review gathers information on the rates of VTE after surgery for CD, as well as reported prophylaxis strategies in this population. METHODS: A literature search was performed using Cochrane Library, EMBASE, and Ovid MEDLINE databases according to PRISMA guidelines. A narrative review of papers discussing mechanisms of hypercoagulability in CS was conducted. RESULTS: Twenty-five relevant papers were identified out of 944 papers yielded. Pooled postoperative VTE incidence in patients undergoing transsphenoidal surgery (TSS) for CD was 2% (58 out of 2997). The pooled rate of VTE-associated mortality based on the 23 studies that reported this information was 0.2% (6 out of 2077). There were no cases of postoperative VTE in the 191 patients undergoing adrenalectomy for benign ACTH-independent CS. Ten studies reported information on perioperative thromboprophylaxis strategies in TSS for CD and adrenalectomy for ACTH-independent CS. CONCLUSION: Postoperative VTE in CD is a source of morbidity, with a rate of 2% and mortality rate of 0.2%, highlighting that surgical resection of the corticotroph adenoma does not necessarily result in immediate resolution of hypercoagulability. Increased production of coagulation factors, impaired fibrinolysis, inflammation, and CS-associated metabolic risk factors all factor into the pathogenesis of CS-associated hypercoagulability. Further study is needed on an optimal pharmacologic prophylaxis strategy.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty.

BACKGROUND: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider. METHODS: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio. RESULTS: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187). CONCLUSIONS: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

Modified S1 Pedicle Subtraction Osteotomy.

STUDY DESIGN: Surgical technique video. OBJECTIVE: To report a surgical technique to revise patients with previous fusions at L4-S1 leading to an iatrogenic flat back and sagittal imbalance using L5-S1 transforaminal interbody fusion combined with a small S1 corner osteotomy. BACKGROUND: This is a case of a woman (51 y old) with a history of multiple lumbar surgeries, severe back pain, sagittal imbalance, and loss of lordosis. METHODS: We describe a feasible revision technique in a complex patient with the goal of attaining optimal distribution of lumbar lordosis and sagittal balance through a modified S1 pedicle subtraction osteotomy, and the use of an interbody cage to enhance the fusion rate and facilitate closure of the 3-column osteotomy. RESULTS: The preoperative patient lordosis angle of 31 degrees at L1-L4 and 16 degrees at L4-S1 became 12 degrees at L1-L4 and 44 degrees at L4-S1 postoperatively. CONCLUSION: The combination of L5-S1 transforaminal interbody fusion and S1 corner osteotomy is a feasible technique for the restoration of lumbar lordosis in patients with previous fusion and consequent loss of lordosis.

Journal Metrics of Orthopaedic Journals between 2016 and 2021: Trends and Comparisons with Other Specialties.

Bibliometric analysis plays a crucial role in elucidating publication trends and aids scholars in gauging the reach of prospective journals for their research dissemination. Concerns with impact factor (IF) have led us to examine the trends in IF, corrected IF (cIF), and Citescore in orthopaedic journals from 2016 to 2021 and compare them with internal medicine and general surgery journals. Journal IF and cIF were obtained from Journal Citation Reports and Citescore data from the Elsevier Scopus database for the years 2016 to 2021. Orthopaedic journals were categorized, and 10 medicine and surgery journals were selected for comparison. Mean values were analyzed to identify trends. The study included 52 orthopaedic journals, evenly split between the United States and the rest of the world, predominantly publishing in English. Mean IF in orthopaedic journals increased from 1.93 (2016) to 2.78 (2021), with similar rises in cIF and Citescore. These trends were consistent in specialty and general orthopaedic journals. No significant differences were found in mean IF between these categories. Medicine and surgery journals also experienced significant IF increases. Orthopaedic journals have experienced growing esteem and extent from 2016 to 2021. Specialty and general orthopaedic journals showed parallel growth. Researchers can utilize this analysis for informed publishing decisions, potentially expanding their readership.

Custom three-dimensional printed implants for reconstruction of oncologic pelvic defects.

The use of three-dimensional printed implants in the field of orthopedic surgery has become increasingly popular and has potentiated hip reconstruction in the setting of oncologic resections of the pelvis and acetabulum. In this review, we examine and discuss the indications and technical considerations for custom implant reconstruction of pelvic defects.

A Longitudinal Analysis of Weight Changes before and after Total Knee Arthroplasty: Weight Trends, Patterns, and Predictors.

Longitudinal data on patient trends in body mass index (BMI) and the proportion that gains or loses significant weight before and after total knee arthroplasty (TKA) are scarce. This study aimed to observe patients longitudinally for a 2-year period and determine (1) clinically significant BMI changes during the 1 year before and 1 year after TKA and (2) identify factors associated with clinically significant weight changes.A prospective cohort of 5,388 patients who underwent primary TKA at a tertiary health care institution between January 2016 and December 2019 was analyzed. The outcome of interests was clinically significant weight changes, defined as a ≥5% change in BMI, during the 1-year preoperative and postoperative periods, respectively. Patient-specific variables and demographics were assessed as potential predictors of weight change using multinomial logistic regression.Overall, 47% had a stable weight throughout the study period (preoperative: 17% gained, 15% lost weight; postoperative: 19% gained, 16% lost weight). Patients who were older (odds ratio [OR] = 0.95), men (OR = 0.47), overweight (OR = 0.36), and Obese Class III (OR = 0.06) were less likely to gain weight preoperatively. Preoperative weight loss was associated with postoperative weight gain 1 year after TKA (OR = 3.03). Preoperative weight gain was associated with postoperative weight loss 1 year after TKA (OR = 3.16).Most patients maintained a stable weight before and after TKA. Weight changes during the 1 year before TKA were strongly associated with reciprocal rebounds in BMI postoperatively, emphasizing the importance of ongoing weight management during TKA and the recognition of patients at higher risk for weight gain.Level of evidence II (prospective cohort study).

Preoperative and Postoperative Weight Change has Minimal Influence on Health Care Utilization and Patient-Reported Outcomes Following Total Knee Arthroplasty.

As obesity becomes more prevalent, more patients are at risk of lower extremity osteoarthritis and subsequent total knee arthroplasty (TKA). This study aimed to test (1) the association of preoperative weight change with health care utilization and (2) the association of pre- and postoperative weight changes with failure to achieve satisfaction and minimal clinically important difference (MCID) in Knee injury and Osteoarthritis Outcome Score for pain (KOOS-Pain) and function (KOOS-PS) 1 year after TKA. Prospectively collected monocentric data on patients who underwent primary TKA were retrospectively reviewed. Multivariable logistic regression assessed the influence of BMI and weight change on outcomes while controlling for confounding variables. Outcomes included prolonged length of stay (LOS >3 days), nonhome discharge, 90-day readmission rate, satisfaction, and achievement of MCID for KOOS-Pain and KOOS-PS. Preoperative weight change had no impact on prolonged LOS (gain, p = 0.173; loss, p = 0.599). Preoperative weight loss was associated with increased risk of nonhome discharge (odds ratio [OR]: 1.47, p = 0.003). There was also increased risk of 90-day readmission with preoperative weight gain (OR: 1.27, p = 0.047) and decreased risk with weight loss (OR: 0.73, p = 0.033). There was increased risk of nonhome discharge with obesity class II (OR: 1.6, p = 0.016) and III (OR: 2.21, p < 0.001). Weight change was not associated with failure to achieve satisfaction, MCID in KOOS-Pain, or MCID in KOOS-PS. Obesity class III patients had decreased risk of failure to reach MCID in KOOS-Pain (OR: 0.43, p = 0.005) and KOOS-PS (OR: 0.7, p = 0.007). Overall, pre- and postoperative weight change has little impact on the achievement of satisfaction and clinically relevant differences in pain and function at 1 year. However, preoperative weight gain was associated with a higher risk of 90-day readmissions after TKA. Furthermore, patients categorized in Class III obesity were at increased risk of nonhome discharge but experienced a greater likelihood of achieving MCID in KOOS-Pain and KOOS-PS. Our results raise awareness of the dangers of using weight changes and BMI alone as a measure of TKA eligibility.

Beyond the Surgical Margin: Patterns of Recurrence in World Health Organization Grade 2 Intracranial Meningiomas.

OBJECTIVE: To characterize and classify the location of recurrence in surgically resected World Health Organization (WHO) grade 2 intracranial meningiomas that did not receive adjuvant radiation and compare the recurrence pattern of those who underwent gross total resection (GTR) versus subtotal resection (STR). METHODS: We performed a retrospective review of patients who underwent surgical resection of a newly diagnosed WHO grade 2 meningioma at our institution between 1996 and 2019. Patients who were observed postoperatively without adjuvant radiation and subsequently developed a recurrence were included in the study. All patients who received adjuvant therapy were excluded. Recurrence was defined as any evidence of radiographic progression on postoperative surveillance magnetic resonance imaging. Location of recurrence was categorized as follows: 1) central-growth observed inside the area of the previously resected tumor more than 1 cm inside the original tumor margin; 2) marginal-growth observed within 1 cm (inside or outside) of the original tumor margin; and 3) remote-growth observed >1 cm outside the original tumor margin. Patterns of recurrence were evaluated by 2 observers after coregistering preoperative and postoperative magnetic resonance imaging, and any differences were reconciled by discussion. RESULTS: A total of 22 patients matched the inclusion criteria. Twelve (55%) underwent GTR, and 10 (45%) underwent STR. In 12 patients in whom GTR was achieved, the mean preoperative tumor volume was 50.6 cm3, with 5 (41.7%) in a skull base location. The average time to recurrence for these tumors was 22.7 months, with a mean recurrent tumor volume of 9.0 cm3. Ten patients (83.3%) had central recurrence, 11 patients (91.7%) had marginal recurrence, and only 4 patients (33.3%) had remote recurrence. In 10 patients in whom STR was achieved, mean preoperative tumor volume was 44.8 cm3, with 7 (70.0%) in a skull base location. The average time to recurrence for these tumors was 23.0 months, with a mean recurrent tumor volume of 21.8 cm3. Of these 10 patients, 9 (90.0%) had central recurrence, all 10 (100.0%) had marginal recurrence, and only 4 (40.0%) patients had remote recurrence. CONCLUSIONS: The present study evaluating patterns of recurrence for WHO grade 2 meningiomas after surgical resection (GTR or STR) showed that recurrence occurred centrally and/or at the original tumor margin, with only a few recurring >1 cm outside the original tumor margin. The results of this study suggest that treatment, whether initial surgical resection or adjuvant radiation, may benefit from including at least a 1-cm dural margin when safe, to optimize tumor control, but further clinical study is needed.

Is High Body Mass Index Protective or Detrimental in Surgical Fixation of Hip Fractures?: A Spline Regression Analysis of 22,388 Patients.

OBJECTIVE: We aimed to characterize the association between BMI as a continuous variable and 30-day postoperative outcomes following hip fracture surgery through (1) 30-day readmission and reoperation; (2) local wound-related; and (3) systemic complications. METHODS: The National Surgical Quality Improvement Program database (January 2016-December 2019) was queried for patients undergoing hip fracture open reduction and internal fixation. Baseline patient demographics, comorbidities, and patient outcomes were recorded. Multivariable regression models accounted for baseline demographics, comorbidities, and fracture patterns. Significant associations were analyzed using spline regression models to evaluate the continuous association between BMI and the aforementioned outcomes. RESULTS: Spline models demonstrated a U-shaped curve for the odds of 30-day readmission and 30-day reoperation with nadirs at the BMI of 27.5 and 22.0 kg/m 2 . The odd ratios of superficial infection, deep infection, any wound complication, and inability to weight bear on POD 1 rose progressively starting at a BMI of 25.6, 35.5, 25.6, and 32.7 kg/m 2 respectively. Odds of 30-day mortality, transfusion, pneumonia, and delirium were greatest at the lowest recorded BMI (11.9 kg/m 2 ). CONCLUSION: BMI has a U-shaped association with 30-day readmission and reoperation. Conversely, the highest risk of mortality and systemic complications (transfusion, pneumonia, and delirium) were within the lower BMI range, with diminishing risk as BMI increased. Local wound complications and systemic sepsis exhibited a third unique pattern with progressive rise in odds as BMI increased. The odds of any complications demonstrated a U-shaped pattern with a nadir in the overweight to obese I categories, suggesting that patients may be at lowest risk within this range. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictive Factors for Postoperative Opioid Use in Elective Endoscopic Endonasal Skull Base Surgery.

OBJECTIVE: In 2017, the United States opioid epidemic was declared a public health emergency. Increased efforts have been made to understand and reduce patient opioid use in neurosurgery. However, the factors associated with postoperative opioid use remain understudied in endoscopic endonasal skull base surgery (EESBS). We identified the demographic and surgical factors associated with postoperative opioid use in EESBS. METHODS: A retrospective review was conducted of patients who underwent elective EESBS between January 2015 and December 2020. Patient demographics, relevant clinical history, and operative data were collected and analyzed. Total opioid use was calculated 24, 48, and 72 hours postoperatively. Multivariable linear regression analyses were performed to identify factors associated with opioid use. RESULTS: There were 454 patients included. A history of anxiety/depression and younger patient age were associated with a significant increase in opioid use at 24 (28.2 MME, p < 0.001), 48 (53.4 MME, p < 0.001), and 72 (89.4 MME, p < 0.001) hours after surgery. Nasoseptal flap use was significantly associated with increased opioid use at 24 (12.8 MME, p < 0.49) and 48 (19.6 MME, p < 0.048) h postoperatively while controlling for intraoperative variables and surgical approach (trans-sellar vs. expanded). No significant association was observed for patient sex, history of migraines, preoperative opioid use, length of surgery, or surgical approach. CONCLUSION: In patients undergoing EESBS, patient history of anxiety/depression, younger patient age, and nasoseptal flap use are associated with increased postoperative opioid use. Knowledge of these risk factors may guide perioperative prescribing patterns to both adequately control postoperative pain and reduce opioid use. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:494-499, 2023.

Predictive Factors for Postoperative Opioid Use in Elective Skull Base Craniotomies.

Objective In 2017, the United States officially declared opioid overuse a public health emergency. Due to a paucity of published benchmark data in skull base neurosurgery, we quantified postoperative opioid use in patients undergoing skull base craniotomies and identified factors that influence postoperative opioid use. Setting Tertiary academic medical center. Participants Patients who underwent elective craniotomies by two skull base neurosurgeons between January 2015 and May 2020. Main Outcome Measures Demographic and perioperative data were retrospectively extracted from the electronic medical record. Surgical approaches were categorized as having either "significant" or "minimal" muscle dissection. Univariate and multivariate linear regression analyses were performed to identify predictors of postoperative opioid use at 24, 48, and 72 hours. Results We included 300 craniotomies, 206 were supratentorial and 94 were infratentorial. This included 195 women and 105 men, with a mean age of 54.9 years. In multivariable analysis, a history of anxiety or depression, preoperative opioid use, and a history of migraines independently predicted a significantly greater opioid use at 24, 48, and 72 hours. Increased age and minimal muscle dissection independently predicted lower opioid consumption. Sex, infratentorial versus supratentorial approach, length of surgery, and postoperative steroid use did not impact total opioid use. Conclusion Younger age, history of anxiety or depression, preoperative opioid consumption, preexisting history of migraines, and significant intraoperative muscle dissection were associated with higher postoperative opioid consumption. These risk factors provide insight on potential targets for minimizing postoperative opioids in craniotomies.

Natural history and volumetric analysis of meningiomas in neurofibromatosis type 2.

OBJECTIVE: The objective of this paper was to describe the volumetric natural history of meningiomas in patients with neurofibromatosis type 2 (NF2). METHODS: The authors performed a retrospective descriptive study by reviewing NF2 patients with meningiomas at their institution between 2000 and 2019. Demographic data were collected from the electronic medical records. Tumor volume was collected using volumetric segmentation software. Imaging characteristics including peritumoral brain edema (PTBE) and tumor calcification were collected for each patient from their first to most recent MRI at the authors' institution. An increase of 15% or more per year from original tumor size was used as the cutoff to define growth. RESULTS: A total of 137 meningiomas from 48 patients were included in the analysis. The average number of tumors per person was 2.9. Ninety-nine (72.3%) tumors were in female patients. The median length of follow-up from first imaging to last imaging was 32 months (IQR 10.9, 68.3 months). Most tumors were located in the cerebral convexity (24.8%), followed by the falcine region (18.2%) and spine (10.2%). The median tumor growth was 0.12 cm3/yr (IQR 0.03, 0.52 cm3/yr). At the time of first imaging, 21.9% of tumors had calcifications, while 13.9% of meningiomas had PTBE. Of 137 tumors, 52 showed growth. Characteristics associated with tumor growth included PTBE (OR 9.12, 95% CI 1.48-56.4), tumor volume (per cm3) at first imaging (OR 0.91, 95% CI 0.83-0.99), and 10-year increased age at first imaging (OR 0.57, 95% CI 0.43-0.74). PTBE had the shortest median time to growth at 9.2 months. CONCLUSIONS: Although the majority of NF2-associated meningiomas do not grow in the short term, a wide range of growth patterns can be seen. Younger age at first imaging and presence of PTBE are associated with growth. Patients with these characteristics likely benefit from closer follow-up.

Epidemiology of primary malignant non-osseous spinal tumors in the United States.

BACKGROUND CONTEXT: Primary malignant non-osseous spinal tumors are relatively rare and this has led to a paucity of studies specifically examining the epidemiology of malignant spinal tumors. PURPOSE: To provide an updated and more comprehensive study examining the epidemiology and relative survival of these rare tumors. STUDY DESIGN/SETTING: Data was retrospectively acquired from the Central Brain Tumor Registry of the United States (CBTRUS). PATIENT SAMPLE: Primary malignant non-osseous spinal tumor cases diagnosed between 2000 and 2017 in the United States. OUTCOME MEASURES: Incidence rates (IRs), relative survival rates, and hazard ratios (HR) were measured. METHODS: IRs were calculated only for histologically-confirmed cases between 2000 and 2017. Relative survival estimates were calculated from survival information on malignant spinal tumors between 2001 and 2016 for death from any cause. Multivariable Cox proportional hazards regression models were constructed to control for age, sex, race, and ethnicity. RESULTS: From 2000 to 2017, approximately 587 new cases of malignant non-osseous spinal tumors were diagnosed every year in the United States. The overall IR was 0.178 per 100,000 persons. Ependymomas were the most commonly diagnosed tumor in all age groups. The 10-year relative survival rates were 94.1%, 62.1%, 62.0%, and 13.3% for ependymomas, lymphomas, diffuse astrocytomas, and high-grade astrocytomas, respectively. Females have a significantly lower risk of death as compared with males for ependymomas (HR: 0.74, p<.001) and diffuse astrocytomas (HR: 0.70, p=.005). African-Americans have a significantly higher risk of death compared with Caucasians when diagnosed with ependymomas (HR: 1.52, p=.009) or lymphomas (HR: 1.55, p=.009). CONCLUSION: Primary malignant non-osseous spinal tumors are primarily diagnosed in adulthood or late adulthood. Ependymal tumors are the most commonly diagnosed primary malignant non-osseous spinal tumors and have the highest 10-year relative survival rates. High-grade astrocytomas are rare and portend the worst prognosis.