Analysis of the Cost and Efficacy of Intra-Articular Knee Injections.

INTRODUCTION: Intra-articular joint injections have been used with the goal of providing patients with symptomatic relief. Recently, however, the efficacy of corticosteroid (CS) and hyaluronic acid (HA) injections in the management of knee osteoarthritis (OA) is questionable. In this analysis, we investigated the costs associated with injections by assessing overall use, conversion and average time to total knee arthroplasty (TKA), and reimbursement. METHODS: Patients aged 50 to 70 years with a knee-related diagnosis of pain, effusion, or OA were identified in the Humana insurance national data set. Patients who received intra-articular injections were stratified by the type and number of injection(s) received. The subsequent rates of TKA were compared with Kaplan-Meier curves for patients who underwent CS injections, HA injections, and a benchmarking cohort of patients with OA and no history of knee injections in the medical record. Average time to TKA was determined from index diagnosis, and total cost was compared using Wilcoxon rank sum analyses. RESULTS: A total of 778,686 patients were identified. Of these, 637,112 had no knee injection history, while 124,129 received CS and 17,445 received HA injections. The 10-year conversion to TKA was highest in HA cohort (31.6%), followed by the CS cohort (24.0%) and the noninjection cohort (7.3%) (P < 0.001). Time to TKA increased with number of injections for both injection types. For patients who underwent TKA, median cost was greater in HA ($16,687) and CS ($15,563) cohorts relative to noninjection cohort ($14,733) (P < 0.001). DISCUSSION: Compared with the noninjection cohort, both HA and CS cohorts experienced increased costs and increased time to TKA. However, while the cost incurred in HA cohort was greater than that in CS cohort, no appreciable benefit was demonstrated for conversion or time to TKA. Therefore, if intra-articular knee injections are indicated for the nonsurgical management of knee OA, the results of this study support CS over HA.

Are Comorbidities Affecting Rotator Cuff Repair Outcomes? A Retrospective Review of Postoperative Costs and complications.

Our study examines the effect of comorbidities on rotator cuff repair (RCR) postoperative costs and complication rates. A retrospective review of patients receiving RCRs from 2008-2016 using the PearlDiver database was performed. We evaluated the effect of major comorbidities on postoperative costs and complications within one year of surgery. In total, 8,747 patients underwent RCR. Patients with no comorbidities had a 6-month and 12-month postoperative cost of $3,534 and $3,853, respectively. Patients with one comorbidity had 6-month postoperative costs ranging from $2,623 to $3,466 and 1-year postoperative costs ranging from $2,992 to $5,906. Patients with 3+ comorbidities receiving arthroscopic RCR had the highest complication rates at 1-, 3- and 6-month intervals (11.8%, 19.7% and 26.8%, respectively) compared to those with no comorbidities (8.1% [p = 0.139], 12.7% [p = 0.022] and 15.9% [p = 0.001], respectively). Patients with isolated comorbidities likely require similar healthcare utilization to those without, but patients with 3+ comorbidities risk greater complications and higher post-operative costs. (Journal of Surgical Orthopaedic Advances 30(1):024-029, 2021).

Assessment of renal vascular anatomy on multi-detector computed tomography in living renal donors.

BACKGROUND: Prospective renal donors are a select population of healthy individuals who have been thoroughly screened for significant comorbidities before they undergo multi-detector computed tomography angiography and urography (MDCT). PURPOSE: The aim of this study is to describe the anatomy of potential living renal donor subjects using MDCT over a 2-year period. The primary objective is to identify the renal arterial anatomy variations, with a secondary objective of identifying venous and collecting system/ureteric variations. MATERIALS AND METHODS: A prospective study was performed of prospective living kidney transplant donors at a national kidney transplant centre. Study inclusion criteria were all potential kidney donors who underwent MDCT during the living-donor assessment process over a 2-year period. RESULTS: Our cohort included 160 potential living donors who had MDCT; mean age was 45.6 years (range, 21-71). Two renal arteries were identified on the left in 40 subjects (25%) and on the right in 42 subjects (26.3%). A total of 3 or more renal arteries were identified on the left in 7 subjects (4.4%) and on the right in 7 subjects (4.4%). On the left, the distances between multiple arteries ranged from 1 mm to 43 mm, and on the right, they were 1 mm to 84 mm. CONCLUSIONS: Conventionally described anatomy was only seen on the left side in 70.6% and 69.4% on the right side of subjects. Single renal arteries are seen in 54.4% showing that conventional anatomy has a relatively low incidence.

A reverse transcriptase-mediated ribosomal RNA depletion (RTR2D) strategy for the cost-effective construction of RNA sequencing libraries.

RNA sequencing (RNA-seq)-based whole transcriptome analysis (WTA) using ever-evolving next-generation sequencing technologies has become a primary tool for coding and/or noncoding transcriptome profiling. As WTA requires RNA-seq data for both coding and noncoding RNAs, one key step for obtaining high-quality RNA-seq data is to remove ribosomal RNAs, which can be accomplished by using various commercial kits. Nonetheless, an ideal rRNA removal method should be efficient, user-friendly and cost-effective so it can be adapted for homemade RNA-seq library construction. Here, we developed a novel reverse transcriptase-mediated ribosomal RNA depletion (RTR2D) method. We demonstrated that RTR2D was simple and efficient, and depleted human or mouse rRNAs with high specificity without affecting coding and noncoding transcripts. RNA-seq data analysis indicated that RTR2D yielded highly correlative transcriptome landscape with that of NEBNext rRNA Depletion Kit at both mRNA and lncRNA levels. In a proof-of-principle study, we found that RNA-seq dataset from RTR2D-depleted rRNA samples identified more differentially expressed mRNAs and lncRNAs regulated by Nutlin3A in human osteosarcoma cells than that from NEBNext rRNA Depletion samples, suggesting that RTR2D may have lower off-target depletion of non-rRNA transcripts. Collectively, our results have demonstrated that the RTR2D methodology should be a valuable tool for rRNA depletion.

The Effects of Chronic Preoperative Opioid Use on Single-level Lumbar Fusion Outcomes.

STUDY DESIGN: A retrospective study using a national insurance claims database. OBJECTIVE: The objective of this study was to assess the relationship between chronic preoperative opioids and the outcomes of revision surgery and nonunion after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA: Opioids are widely utilized for pain management before spine procedures. Studies have associated opioids with unfavorable postoperative outcomes, and animal models have also linked opioid administration with unstable bone healing. METHODS: Single-level lumbar fusion patients were identified. Patients with any fracture history within 1 year before surgery were excluded. A chronic preoperative opioid cohort was defined by opioids prescriptions within 3 months prior and within 4-6 months before surgery. The rates of revision surgery within 6 months and nonunion within 6-24 months after surgery were assessed. Univariate analyses of chronic preoperative opioid prescriptions and various comorbidities for revision and nonunion were conducted followed by multivariate analyses controlling for these factors. Individual analyses were run for each of the 3 single-level lumbar fusion procedures. RESULTS: A total of 8494 single-level lumbar fusion patients were identified. Of the 3929 (46.3%) patients filled criteria for the chronic preoperative opioid cohort, while 3250 (38.3%) patients had no opioid prescriptions within 6 months before surgery. The opioid cohort experienced significantly higher rates of both revisions (3.92% vs. 2.71%, P=0.005) and nonunion (3.84% vs. 2.89%, P=0.027) relative to the opioid-naive cohort. In the multivariate analyses, chronic preoperative opioids were identified as an independent risk factor for revision (odds ratio: 1.453, P=0.006). CONCLUSIONS: We report that chronic opioid prescriptions before lumbar fusion may increase the risk of revision. Although these prescriptions were also associated with increased nonunion, the comparisons did not achieve statistical significance in the multivariate model. Chronic preoperative opioid use may be considered a potential risk factor in arthrodesis populations.

General health measures in shoulder surgery: are we powered for success?

BACKGROUND: Surgeons, policymakers, and payers increasingly use changes in general health to guide decision-making. It is unknown how such measures are incorporated into shoulder surgery research, how strongly they are associated with changes in shoulder-specific outcomes, and whether they are appropriately powered. METHODS: PubMed was searched for articles reporting shoulder-specific and general health measures after rotator cuff repair and total shoulder arthroplasty. Study characteristics, results at the study group level, reporting of power calculations, and statistical significance were recorded. Meta-regression was employed to describe the association of changes between shoulder-specific and general health measures. RESULTS: Of 360 identified abstracts, 21 articles with 28 patient groups were included. Only 1 article was published before 2000. There was a strong association of changes between shoulder-specific and general health measures (r = 0.66; P < .001). Power calculations were mentioned in 33% of studies and based on shoulder-specific measures. Of 20 studies conducting hypothesis tests, 75% reported agreement regarding the statistical significance of shoulder-specific and general health tests. Of 5 discordant studies, 4 found the shoulder-specific measure statistically significant and not the general health measure. CONCLUSION: Shoulder surgery research increasingly reports changes in general health measures that are associated with changes in shoulder-specific measures, suggesting that improvements in shoulder symptoms increase quality of life. When disagreement exists, it usually results from the general health measure's not meeting statistical significance, which may simply reflect type II error. Research reporting general health measures should carefully report power considerations to avoid misinterpretation of findings failing to reach statistical significance.

A Custom Radiopaque Thermoresponsive Chemotherapy-Loaded Hydrogel for Intratumoural Injection: An In Vitro and Ex Vivo Assessment of Imaging Characteristics and Material Properties.

PURPOSE: Thermoresponsive hydrogels are gels which have different properties at varying temperatures. The objective of this study was to assess the material characteristics, imaging properties and chemotherapeutic drug release profile of a novel radiopaque thermoresponsive hydrogel in vitro, which is liquid at room temperature but solidifies at body temperature, to determine potential suitability for intratumoural delivery. MATERIALS AND METHODS: An iodinated radiopaque thermoresponsive hydrogel was formulated using iodixanol at a range of concentrations and assessed for sol-gel transition, radiopacity and imaging using CT and US. A lead formulation containing iodixanol at a concentration of 9.22% weight by weight (w/w, g of iodixanol per g of hydrogel) was evaluated in vitro for injectability, disintegration and dual drug release of cisplatin and paclitaxel from the hydrogel formulation. RESULTS: Radiopacity of the hydrogel increased in a concentration-dependent manner, but the highest concentration of iodixanol evaluated in this study (13.83% w/w) adversely affected the sol-gel transition of the hydrogel; therefore, 9.22% w/w iodixanol hydrogel was identified as the lead formulation. This formulation was readily visible on both CT and US. The formulation was hand injectable through a range of clinically relevant devices, had a sustained disintegration profile for up to 28 days and was able to deliver a sustained release of chemotherapeutic drug for up to 10 days. CONCLUSIONS: Favourable in vitro and ex vivo imaging and material characteristics of this thermoresponsive gel are demonstrated, suggesting potential interventional oncology applications for image-guided intratumoural delivery of sustained-release chemotherapy.

Transforaminal Lumbar Interbody Fusion: Traditional Open Versus Minimally Invasive Techniques.

Recently, minimally invasive spine arthrodesis has gained popularity among spine surgeons. Minimally invasive techniques have advantages and disadvantages compared with traditional open techniques. Comparisons between short-term outcomes of minimally invasive transforaminal interbody fusion and open transforaminal interbody fusion in terms of estimated blood loss, postoperative pain, and hospital length of stay have been well documented and generally favor the minimally invasive technique. However, the advantages of minimally invasive transforaminal interbody fusion must be evaluated in the context of long-term results, such as patient-reported outcomes and the success of arthrodesis. Because the literature is equivocal in identifying the superior technique for successful long-term outcomes, more study is needed. Patient safety, the risk of complications, and the cost of these techniques also must be considered.

Are We Overtreating Renal Angiomyolipoma: A Review of the Literature and Assessment of Contemporary Management and Follow-Up Strategies.

Renal angiomyolipoma (AML) are benign tumours composed of fat, muscle, and disorganised blood vessels. Historic treatment algorithms for sporadic AML based on size fail to consider additional risk factors such as tumour vascularity and pseudoaneurysm formation. As AML is now predominantly incidental, rupture is rare and its mortality low. The recent publication of the largest longitudinal series to date also suggest that growth is uncommon, challenging existing surveillance paradigms. The evidence assessing treatment strategies in AML are reviewed, with particular emphasis on incidental sporadic AML. The relative merits of various AML treatments are discussed, and areas of clinical uncertainty highlighted.

It All Depends on Who Does What: A Survey of Patient and Family Member Comfort With Surgical Trainees Operating.

OBJECTIVE: To measure patient and family member comfort with surgical trainees of varying levels performing different portions of surgery. DESIGN, SETTING, AND PARTICIPANTS: An electronic survey dividing surgery into 6 steps (prepping and positioning, initial incision, deep dissection, critical portions, deep suturing, and closing incision), differentiating surgical trainees by 4 levels of experience (medical student, intern, resident, and fellow), and specifying whether or not an attending surgeon is in the operating room (OR) was given to 200 patients and family members in the surgical waiting area of a single academic medical center. Responses were on a 7-point Likert scale from "Not Comfortable at All" to "Completely Comfortable". RESULTS: Patient and family member comfort significantly increased as trainee experience increased. It reached a nadir for all trainees performing "critical portions" of surgery. However, their average response was "Comfortable" for residents and fellows performing any surgical step when the attending surgeon is present in the OR. The percentage of "Comfortable" responses was significantly lower for all trainee levels performing any surgical step when the attending surgeon is absent from the OR. CONCLUSIONS: Patient and family member comfort with surgical trainees operating varies based on the trainee's level of experience, the step the trainee performs, and whether or not the attending surgeon is present in the OR. Patients and family members are on average "Comfortable" with surgical residents and fellows performing any surgical step when the attending surgeon is present.

Osteoporosis, obesity, and sarcopenia on abdominal CT: a review of epidemiology, diagnostic criteria, and management strategies for the reporting radiologist.

Abdominal computed tomography (CT) is a widely performed examination, with many indications. Assessment of bone, fat, and muscle on abdominal CT can be performed in a quantitative manner. Published studies have developed diagnostic cutoffs for osteoporosis, obesity, and sarcopenia, which are summarized with pictorial examples. The epidemiological and prognostic significance of these disease states are outlined. Further diagnostic steps and treatment strategies are outlined to inform both the managing clinician and reporting radiologist. This article summarizes an unglamorous yet information-rich field, which is ripe for assessment in the dawning era of personalized medicine, and one in which the radiologist is well placed to add value to patient care.

NEL-Like Molecule-1 (Nell1) Is Regulated by Bone Morphogenetic Protein 9 (BMP9) and Potentiates BMP9-Induced Osteogenic Differentiation at the Expense of Adipogenesis in Mesenchymal Stem Cells.

BACKGROUND: BMP9 induces both osteogenic and adipogenic differentiation of mesenchymal stem cells (MSCs). Nell1 is a secretory glycoprotein with osteoinductive and anti-adipogenic activities. We investigated the role of Nell1 in BMP9-induced osteogenesis and adipogenesis in MSCs. METHODS: Previously characterized MSCs iMEFs were used. Overexpression of BMP9 and NELL1 or silencing of mouse Nell1 was mediated by adenoviral vectors. Early and late osteogenic and adipogenic markers were assessed by staining techniques and qPCR analysis. In vivo activity was assessed in an ectopic bone formation model of athymic mice. RESULTS: We demonstrate that Nell1 expression was up-regulated by BMP9. Exogenous Nell1 potentiated BMP9-induced late stage osteogenic differentiation while inhibiting the early osteogenic marker. Forced Nell1 expression enhanced BMP9-induced osteogenic regulators/markers and inhibited BMP9-upregulated expression of adipogenic regulators/markers in MSCs. In vivo ectopic bone formation assay showed that exogenous Nell1 expression enhanced mineralization and maturity of BMP9-induced bone formation, while inhibiting BMP9-induced adipogenesis. Conversely, silencing Nell1 expression in BMP9-stimulated MSCs led to forming immature chondroid-like matrix. CONCLUSION: Our findings indicate that Nell1 can be up-regulated by BMP9, which in turn accelerates and augments BMP9-induced osteogenesis. Exogenous Nell1 may be exploited to enhance BMP9-induced bone formation while overcoming BMP9-induced adipogenesis in regenerative medicine.

The Spine Surgical Care and Outcomes Assessment Program (Spine SCOAP): a surgeon-led approach to quality and safety.

STUDY DESIGN: Prospective registry of spine surgery. OBJECTIVE: To identify variation in utilization, processes of care, and outcomes in spine surgery to improve statewide quality and safety. SUMMARY OF BACKGROUND DATA: Variability in the utilization and outcomes of elective spine surgery across different regions in the United States and internationally has become a growing focus of critical evaluation. In 2011, surgeons in Washington State created the Spine Surgical Care and Outcomes Assessment Program to address variability in use, process, and outcome of spine surgery. METHODS: Prospective cohort study from consecutive spine fusion cases and 30% sampling of other spine procedures from up to 20 hospitals (2011-2013). Logistic regression models were developed using data from 10 quarters to determine factors associated with combined adverse events inclusive of index hospital death, reintervention, and adverse events not requiring intervention, and then applied to patients in the last 2 quarters. RESULTS: A total of 10,166 (58.9 ± 13.4 yr, 52.2% females) underwent surgery including 3767 (37%) lumbar and 6399 (63%) cervical procedures. Of the total, 75.3% of the cohort had a spine fusion and among those, neurological symptoms were described in 92.5% of patients, with baseline limb pain numeric rating scale (NRS) scores of 5.9 among those classified as having neurological symptoms. The NRS mean score for back pain was 5.9 with a mean Oswestry Disability Index/Neck Disability Index of 44. There was significant intersite variation in rates of cigarette smoking among patients undergoing fusion surgery (range, 0%-40%) and rates of combined adverse events with 10 hospitals having a significantly lower observed/expected ratio and 3 having a significantly greater observed to expected ratio. CONCLUSION: Spine Surgical Care and Outcomes Assessment Program identified significant variability in the indications, process of care, and outcomes related to spine surgery. This variability indicates the need for continued surveillance initiatives and point to opportunities for quality improvement and research. LEVEL OF EVIDENCE: 2.

Medicaid status is associated with higher surgical site infection rates after spine surgery.

STUDY DESIGN: The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications. OBJECTIVE: Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate. SUMMARY OF BACKGROUND DATA: The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery. METHODS: The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure. RESULTS: The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured. CONCLUSION: The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations. LEVEL OF EVIDENCE: 3.

Predicting surgical site infection after spine surgery: a validated model using a prospective surgical registry.

BACKGROUND CONTEXT: The impact of surgical site infection (SSI) is substantial. Although previous study has determined relative risk and odds ratio (OR) values to quantify risk factors, these values may be difficult to translate to the patient during counseling of surgical options. Ideally, a model that predicts absolute risk of SSI, rather than relative risk or OR values, would greatly enhance the discussion of safety of spine surgery. To date, there is no risk stratification model that specifically predicts the risk of medical complication. PURPOSE: The purpose of this study was to create and validate a predictive model for the risk of SSI after spine surgery. STUDY DESIGN: This study performs a multivariate analysis of SSI after spine surgery using a large prospective surgical registry. Using the results of this analysis, this study will then create and validate a predictive model for SSI after spine surgery. PATIENT SAMPLE: The patient sample is from a high-quality surgical registry from our two institutions with prospectively collected, detailed demographic, comorbidity, and complication data. OUTCOME MEASURES: An SSI that required return to the operating room for surgical debridement. MATERIALS AND METHODS: Using a prospectively collected surgical registry of more than 1,532 patients with extensive demographic, comorbidity, surgical, and complication details recorded for 2 years after the surgery, we identified several risk factors for SSI after multivariate analysis. Using the beta coefficients from those regression analyses, we created a model to predict the occurrence of SSI after spine surgery. We split our data into two subsets for internal and cross-validation of our model. We created a predictive model based on our beta coefficients from our multivariate analysis. RESULTS: The final predictive model for SSI had a receiver-operator curve characteristic of 0.72, considered to be a fair measure. The final model has been uploaded for use on SpineSage.com. CONCLUSIONS: We present a validated model for predicting SSI after spine surgery. The value in this model is that it gives the user an absolute percent likelihood of SSI after spine surgery based on the patient's comorbidity profile and invasiveness of surgery. Patients are far more likely to understand an absolute percentage, rather than relative risk and confidence interval values. A model such as this is of paramount importance in counseling patients and enhancing the safety of spine surgery. In addition, a tool such as this can be of great use particularly as health care trends toward pay for performance, quality metrics (such as SSI), and risk adjustment. To facilitate the use of this model, we have created a Web site (SpineSage.com) where users can enter patient data to determine likelihood for SSI.