Exploring the incidence and risk factors of reoperation for symptomatic adjacent segment disease following cervical decompression and fusion.

Background: Patients with long-term follow-up after cervical decompression and fusion have often been noted to have development of adjacent segment degeneration with a smaller subset of these patients progressing to adjacent segment disease (ASD), which results in the development of new symptomatic radiculopathy or myelopathy referable to a site either directly above or below a prior fused segment. The cause of ASD is multifactorial often involving natural age-related progression of spondylosis, accelerated progression following cervical decompression and fusion, operative technique, and patient-related factors. The effect of age at the time of index cervical decompression and fusion on the need for reoperation for ASD is not fully understood. This study aims to establish underlying risk factors for the development of symptomatic cervical ASD following cervical decompression and fusion requiring reoperation in patients of various age groups. Methods: A retrospective database review of patients aged 20 or greater with insurance claims of primary cervical decompression and fusion over the course of 11 years and 10 months (January 01, 2010-October 31, 2022) was conducted using an insurance claims database. The primary outcome was to evaluate the incidence of cervical ASD requiring reoperation amongst patients stratified by age at the time of their primary procedure. Secondary outcomes included an evaluation of various risk factors for ASD following cervical decompression and fusion including surgeon-controlled factors such as the number of levels fused and approach taken, patient cervical pathology including cervical disc disorder and cervical spondylosis, and underlying patient medical comorbidities including osteoporosis and vitamin D deficiency, and substance use. Results: A total of 60,292 patient records were analyzed, where the overall reoperation incidence for symptomatic ASD was 6.57%, peaking at 8.12% among those aged 30 to 39 and decreasing with age. Regression analysis revealed ages lower than 50 years as more predictive for the development of symptomatic ASD requiring reoperation. Multivariate regression analysis identified predictive factors for reoperation, including age, Elixhauser Comorbidity Index (ECI), multiple-level surgery, cervical spondylosis, cervical disc disorder, osteoporosis, and vitamin D deficiency. Notably, these factors had a variable impact across various age groups, as revealed by subgroup analysis. Conclusions: The incidence of reoperation secondary to symptomatic ASD is 6.57%, highest in those aged 30 to 39. The surgical approach had no significant impact on the need for reoperation, but multiple-level fusions posed a consistent risk in the development of symptomatic ASD requiring reoperation. Patient factors like degenerative disc disease, spondylosis, osteoporosis, and vitamin D deficiency were associated, urging further age-specific risk assessment and nonoperative intervention exploration.

Chronic Achilles Tendon Avulsion Repair: Central Third Fascia Slide Technique with Flexor Hallucis Longus Transfer.

Background: Chronic Achilles tendon defects are commonly associated with substantial impairment in gait and push-off strength, leading to decreased function1. These injuries cause a unique surgical dilemma, with no consensus surgical reconstruction technique for >6-cm gaps3. There are a multitude of surgical reconstruction techniques that rely on gap size as a determinant for preoperative planning1,2. The present article describes a technique for chronic Achilles tendon defects of >6 cm. The central third fascia slide (CTFS) technique with flexor hallucis longus (FHL) transfer provides adequate excursion and strength while avoiding use of allograft.2.The CTFS technique is a reconstructive technique that is utilized to treat large chronically gapped Achilles tendon tears, usually larger than 5 to 6 cm; however, recent literature has shown that intermediate gaps can be fixed with use of a combination of tendon transfers. The technique described here is a variation of the V-Y tendinoplasty and fascia turndown method in which the gastrocnemius complex fascia is slid down rather than being "turned down." This reconstructive technique, like its predecessor, restores function in damaged Achilles tendons3. Chronic gapping from a chronic Achilles tendon rupture can lead to decreased function and weakness. Patients may also experience fatigue and gait imbalance, leading to the need for surgical reconstruction to help restore functionality. Description: The CTFS technique utilizes a posterior midline incision, maintaining full-thickness flaps. A complete debridement of the degenerative Achilles tendon is performed, and the gap is measured. If the gap is >6 cm, the central third of the remaining Achilles and gastrocnemius fascia are sharply harvested. The FHL is transferred to the proximal Achilles footprint and held with use of an interference screw. The ankle is held in 15° to 25° of plantar flexion while the FHL shuttling suture is pulled plantarly and secured with a bio-interference screw. The fascial graft is then anchored to the calcaneus with use of a double-row knotless technique, maximizing osseous contact potential healing. Soft-tissue clamps are placed on the graft and on the gastrocnemius complex harvest site. The ankle is tensioned in nearly 30° of plantar flexion to account for known postoperative elongation. FiberWire (Arthrex) is utilized to secure the tension, then the remaining suture tape from the proximal insertional row is run up each side of the fascial graft in a running locking stitch, continuing proximally to close the harvest site. The use of an anchor-stay stitch helps to prevent elongation and maximizes construct strength. Alternatives: For patients who are poor surgical candidates or those with acceptable function, alternatives include nonoperative treatment and/or the use of a molded ankle foot orthosis. Most chronic Achilles tendon ruptures require surgery. Generally, a gap of <2 cm can be treated through primary repair with use of longitudinal and distally applied traction. For an Achilles gap of >2 cm but <6 cm, a V-Y gastrocnemius-lengthening procedure can utilized. Other methods such as autologous and local tendon transfers, advancement procedures, or a combination of these have been described as ways to treat gaps within this range. For gaps of >6 cm, there is insufficient literature to establish a single gold-standard reconstructive technique. Some surgeons have opted to utilize the turndown flap procedure, the FHL tendon transfer technique, or a combination of both. Rationale: The Achilles turndown flap technique can lead to the formation of scar tissue at the focal point of the turndown, a region also known as the hinge joint, and thus can perpetuate scarring of the repair site. To avoid this scarring, the central third fascia slide technique with FHL transfer is presented as a suitable reconstructive technique for chronic tendon defects of >6 cm. Expected Outcomes: Postoperatively, patients are managed according to a standard protocol. The first 2 weeks are non-weight-bearing with the foot in equinus in an L & U splint. At 2 to 4 weeks postoperatively, a walking boot with a 1.5-cm heel lift is applied, and crutches are utilized as the primary weight-bearing aid. At 4 to 6 weeks, the patient is transitioned to a 1-cm heel lift and may discontinue the use of crutches if they are able to walk without a limp. At 8 weeks, the patient may discontinue the use of the walking boot. At week 6 to 12, no heel lift is required. By approximately 12 weeks postoperatively, the patient should have regained full range of motion and should be able to walk without a limp. The patient should be able to resume activities of daily living by 3 to 4 months, with a gradual return to all physical activities by 4 to 6 months This postoperative protocol has produced favorable results. Ahmad et al. have reported the use of a similar protocol, with patients showing increased Foot and Ankle Ability Measure scores and decreased visual analog scale pain scores compared with the preoperative measurement2. Important Tips: Debride the Achilles until viable tendon is reached, then measure the defect.Tension the FHL and the fascia slide with the foot in 15° to 25° of plantar flexion.Perform a meticulous layered closure, preserving the paratenon as much as possible.Incomplete debridement may result in incompetent tissue.Incomplete closure of the fascia harvest site may predispose to seroma or hematoma formation.Not splinting for 10 to 14 days potentially predisposes the patient to wound breakdown. Acronyms and Abbreviations: CTFS = central third fascia slideFHL = flexor hallucis longusATTF = Achilles tendon turndown flapHPI = history of present illnessNWB = non-weight-bearingCAM = controlled ankle motionDVT = deep vein thrombosisMRI = Magnetic resonance imagingPMHx = past medical historyHTN = hypertensionSHx = social historyPE = physical examinationDF = dorsiflexionNVI = neurovascularly intactROM = range of motion.

Arthroscopic Assisted, Lateral Ligament Reconstruction with Suture Tape Augmentation and Knotless All Suture Anchors: A Technique Guide.

More than 30,000 ankle sprains occur each day in the United States, and the majority of ankle sprains involve the anterior talofibular ligament. Up to 30% of patients develop functional ankle instability and chronic pain after a severe ankle sprain. When nonoperative measures are unsuccessful, operative reconstruction of the lateral ankle ligaments is recommended. To further strengthen the repair, accelerate rehabilitation, and allow for a quicker return to sport, augmentation with suture tape has recently become an alternative among surgeons in the reconstruction of the lateral ankle ligaments. Moreover, the advent of knotless all-suture anchors decreases the number of knots required in the procedure and, in theory, reduces lateral soft tissue irritation and accentuates recovery after surgery. Here we present our technique for arthroscopic assisted, lateral ligament reconstruction with suture tape augmentation and knotless all suture anchors.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities.

BACKGROUND: Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS: A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS: A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS: This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review.

BACKGROUND: The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery. METHODS: A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected. RESULTS: A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy. CONCLUSIONS: Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The utility and cost of atypical cultures in revision shoulder arthroplasty.

BACKGROUND: At the time of revision shoulder arthroplasty, it is common practice to take cultures to evaluate for prosthetic joint infection even when an alternative cause of failure has been identified. Although isolation of fungal or acid-fast organisms is rare, it remains common practice to send all specimens for aerobic, anaerobic, and atypical (fungal and acid-fast) cultures. We hypothesize that the rate of positive atypical cultures at the time of revision shoulder arthroplasty is very low and routine use imposes a considerable financial burden on the health care system. METHODS: A retrospective review of all revision shoulder arthroplasties performed between January 1, 2010, and December 31, 2019, at our institution was performed. Patients with a hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, or pre-existing antibiotic spacer who underwent revision to hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, antibiotic spacer, or resection arthroplasty were included. Electronic patient charts were reviewed to gather patient, surgical, and culture data. An analysis of the hospital billing charges associated with each culture was performed using our hospital billing database and the current procedural terminology (CPT) codes for aerobic, anaerobic, fungal, and acid-fast cultures. A secondary outcome analysis was performed to identify factors associated with positive cultures. RESULTS: A total of 237 revision shoulder arthroplasties performed on 189 patients were analyzed. Cultures were sent on 158 of 237 (66.7%) surgeries with an average of 2.2 specimens per surgery. A total of 341 aerobic, 331 anaerobic, 187 fungal, and 174 acid-fast cultures were collected. Positive cultures were found in 52 of 341 (15.2%) aerobic cultures and 36 of 331 (10.9%) anaerobic cultures. The most commonly isolated organism was Cutibacterium acnes (42.2%), followed by methicillin-resistant Staphylococcus aureus (15.6%), coagulase-negative Staphylococcus species (13.3%), and methicillin-sensitive S. aureus (12.2%). There were zero positive fungal or acid-fast cultures in our series. The total billing charges for aerobic, anaerobic, fungal, and acid-fast cultures over the study period were $77,748, $23,832, $8,789, and $106,662, respectively, with atypical cultures accounting for 53.2% of the total charges for all cultures. For a single sample sent for all 4 culture types, atypical cultures account for 69% of the total amount charged. CONCLUSION: Isolation of fungal or acid-fast organisms at the time of revision shoulder arthroplasty is rare and imposes a considerable financial burden when these atypical cultures are sent on a routine basis. The collection of fungal and acid-fast cultures should be reserved for patients in whom risk factors for these atypical organisms have been identified.

Bearing failure in a mobile bearing unicompartmental knee arthroplasty: an uncommon presentation of an implant-specific complication.

BACKGROUND: We present two cases of unicompartmental knee arthroplasty (UKA) bearing failure in this report-one case of bearing dislocation and one case of bearing fracture. The causes of failure in both cases are evaluated in depth and recommendations are provided regarding intraoperative technique to reduce risk of bearing failure in mobile bearing UKAs. CASE PRESENTATION: In the first case, intraoperative evidence of metallosis and chronic pain preceding the traumatic event may indicate that the patient had attenuation of her collateral ligaments that precipitated the instability event. In the second case, the relatively atraumatic nature of the bearing fracture-dislocation and intraoperative evidence of extensive poly wear suggest that the bearing fracture was likely due to a 3-mm bearing selection in the initial surgery. CONCLUSIONS: This case report shows that late bearing in mobile bearing unicompartmental knee arthroplasty can often be a multifactorial event and treatment must address all the risk factors that led to bearing dislocation. Bearing fracture is a very rare complication associated with mobile bearing UKA and patients with thin polyethylene inserts are at risk for bearing fracture even in the absence of poly wear.

Analysis of Risks and Consequences of Postcatheter Urinary Retention After Primary Total Hip and Knee Arthroplasty.

BACKGROUND: Postoperative urinary retention (POUR) in total joint arthroplasty (TJA) is common. However, risk factors for POUR and its consequences, specifically on postoperative renal function, have not been well defined. METHODS: We performed a review of prospectively collected data on consecutive adult patients undergoing primary total joint arthroplasty from August 2014 to December 2015. Catheters were placed preoperatively and removed on the first or second postoperative day. The exclusion criterion was traumatic catheter insertion or the presence of fracture or neoplasm. Univariate and multiple logistic regression identified associations with POUR and its invasive therapies. Subgroup analysis of renal function by incidence of preoperative bladder outlet obstruction (BOO) and POUR was performed with nonparametric testing. RESULTS: A total of 591 operations met inclusion criteria. The incidence of POUR was 6.4% and was directly related to a positive history of BOO (odds ratio [OR]: 4.15) and increased the duration of urinary catheterization (OR: 1.04). These factors, in addition to preoperative incontinence (OR: 8.36, 28.69) and lengthier hospitalizations (OR: 1.37, 1.30), were significantly associated with intermittent straight catheterization and reinsertion of an indwelling catheter to treat POUR. Serum creatinine increased with combined preoperative BOO and POUR (+0.22 mg/dL) but was preserved in others (+0.02-0.04 mg/dL) (P < 0.01). CONCLUSIONS: Preoperative BOO and longer catheterization increased the risk of POUR and were associated with the use of invasive modalities to treat POUR. POUR was associated with a longer hospitalization and impaired renal function in those with preoperative BOO; therefore, renal function should be monitored closely and nephrotoxic medications used cautiously when using urinary catheters in this patient population. LEVEL OF EVIDENCE: Retrospective Analysis, Level IV.