Evolution of an Opioid Sparse Pain Management Program for Total Knee Arthroplasty With the Addition of Intravenous Acetaminophen.

BACKGROUND: Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS: Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS: The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION: An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.

3D-MRI versus 3D-CT in the evaluation of osseous anatomy in femoroacetabular impingement using Dixon 3D FLASH sequence.

OBJECTIVE: To determine if hip 3D-MR imaging can be used to accurately demonstrate femoral and acetabular morphology in the evaluation of patients with femoroacetabular impingement. MATERIALS AND METHODS: We performed a retrospective review at our institution of 17 consecutive patients (19 hips) with suspected femoroacetabular impingement who had both 3D-CT and 3D-MRI performed of the same hip. Two fellowship-trained musculoskeletal radiologists reviewed the imaging for the presence and location of cam deformity, anterior-inferior iliac spine variant, lateral center-edge angle, and neck-shaft angle. Findings on 3D-CT were considered the reference standard. The amount of radiation that was spared following introduction of 3D-MRI was also assessed. RESULTS: All 17 patients suspected of FAI had evidence for cam deformity on 3D-CT. There was 100% agreement for diagnosis (19 out of 19) and location (19 out of 19) of cam deformity when comparing 3D-MRI with 3D-CT. There were 3 type I and 16 type II anterior-inferior iliac spine variants on 3D-CT imaging with 89.5% (17 out of 19) agreement for the anterior-inferior iliac spine characterization between 3D-MRI and 3D-CT. There was 64.7% agreement when comparing the neck-shaft angle (11 out of 17) and LCEA (11 out of 17) measurements. The use of 3D-MRI spared each patient an average radiation effective dose of 3.09 mSV for a total reduction of 479 mSV over a 4-year period. CONCLUSION: 3D-MR imaging can be used to accurately diagnose and quantify the typical osseous pathological condition in femoroacetabular impingement and has the potential to eliminate the need for 3D-CT imaging and its associated radiation exposure, and the cost for this predominantly young group of patients.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Knee Arthroplasty?

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA). METHODS: Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed. RESULTS: In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/m2. Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05). CONCLUSION: HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Revision Versus Primary Hospital Consumer Assessment of Healthcare Providers and Systems Scores in Total Joint Arthroplasty.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's inpatient experience. This study aims to assess whether HCAHPS scores differ between patients undergoing primary total joint arthroplasty (TJA) and patients undergoing revision TJA. METHODS: Patients who underwent primary or revision total hip or total knee arthroplasty (THA or TKA) and returned a completed HCAHPS survey were included in this study. HCAHPS scores were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried. Appropriate statistical analyses were performed using MatLab 2017a and P-values less than .05 were deemed significant. RESULTS: In total, 523 primary and 59 revision THA recipients completed HCAHPS surveys at our institution between October 2011 and November 2016. During this same period, 507 primary TKA recipients and 40 revision TKA recipients completed HCAHPS surveys. Compared to revision THA, primary THA patients had a significantly higher top box for overall hospital ratings (58.46% vs 41.38%), felt that nurses listened to them carefully (84.3% vs 72.88%), and felt that they clearly understood the role of each medication (69.48% vs 56.90%). Moreover, 18 of 20 HCAHPS question responses favored primary THA despite not reaching significance for the majority of HCAHPS questions. Patients with revision TKA demonstrated a significantly higher incidence of "top box" choices for quieter rooms and a trend favoring better HCAHPS scores in revision TKA in a further 12 of 20 HCAHPS responses. CONCLUSION: Patients undergoing primary THA report higher HCAHPS scores than those undergoing revision THA, while revision TKA demonstrated a general trend toward higher scores when compared to primary TKA patients. This publicly reported quality measurement metric which factors into physician reimbursement may be biased by the patient's health status, the complexity of the surgical procedure, and length of stay in hospital rather than a true reflection of the quality of their hospital experience.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Hip Arthroplasty?

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score is a nationally standardized measure of a patient's hospital experience. This study aims to assess whether HCAHPS scores vary by demographic or surgical factors in patients undergoing primary total hip arthroplasty. METHODS: Patients who completed an HCAHPS survey after a primary total hip arthroplasty between October 2011 and November 2016 were included in this study. Patient demographics and surgical factors were evaluated for correlations with individual HCAHPS questions. RESULTS: One thousand three hundred eighty-three HCAHPS questionnaires were reviewed for this study. Patients with a submitted HCAHPS response had an average age of 63.83 ± 10.17 years. Gender distribution was biased toward females at 57.27% (792 females) versus 42.73% (591 males). The average body mass index (BMI) was 28.68 ± 5.86 kg/m2. Race distribution was predominantly Caucasian at 81.49% (1127 patients), followed by "unknown" at 8.60% (119 patients) and African-American at 8.46% (117 patients). Home discharge occurred for 93.06% (1287 patients) versus 6.94% for facility discharge (96 patients). Mean length of stay was 2.41 ± 1.17 days. Each 1-year increase in age was positively correlated with a 0.16% increase in top-box response rate (ß = 0.0016 ± 0.0008; P < .05). Male gender was correlated with a 4.61% increase in top-box response rate when compared to female gender (ß = 0.0461 ± 0.0118; P < .01). BMI was found to be correlated with a 0.20% increase in HCAHPS response rates for each 1 kg/m2 increase (ß = 0.0020 ± 0.0010; P < .05). For each day increase in length of stay, HCAHPS top-box response rates decrease by 3.41% (ß = -0.0341 ± 0.0051; P < .0001). Race, marital status, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCAHPS top-box response rate (P > .05). CONCLUSION: The HCAHPS quality measurement metric affects physician reimbursement and may be biased by a number of variables including sex, length of stay, and BMI, rather than a true reflection of the quality of their hospital experience. Further research is warranted to determine whether HCAHPS scores are an appropriate measure of the quality of care received.

Does femoral morphology and stem alignment influence outcomes of cementless total hip arthroplasty with proximally coated double-tapered titanium stems?

INTRODUCTION: Stem subsidence and thigh pain can cause significant patient dissatisfaction after cementless THA. The purpose of this study was to examine the effect of proximal-femoral morphology and stem alignment on clinical outcomes using a double-tapered, cementless titanium femoral component. METHODS: We retrospectively reviewed 281 consecutive, primary THAs from 2012 to 2014 with a mean follow-up of 4 years. Preoperative radiographs were used to assess femoral neck shaft angle (FNS), canal flare index (CFI), Dorr classification, and greater trochanter (GT) overhang. Postoperative radiographs were used to determine stem alignment and 6-week follow-up radiographs were used to determine subsidence. Clinical outcomes included thigh pain, leg-length discrepancy (LLD), patient-reported outcome measures (PROMs) and revision surgeries. RESULTS: 271 stems (96%) did not subside (<4 mm) and 10 (4%) showed evidence of subsidence (>4 mm). Subsidence was significantly associated with subsequent revision surgery (p < 0.01). 278 stems (99%) were in neutral alignment and 3 in varus (1%). Alignment did not significantly influence subsidence, thigh pain, LLD, revisions, or PROMs. Femoral morphology measures (FNS, CFI, Dorr classification, and GT overhang) were not significantly associated with stem alignment, subsidence, LLD, or revisions. CFI was significantly associated with intraoperative calcar fractures (p = 0.02). GT overhang was associated with thigh pain (p = 0.03) and FNS was inversely associated with postoperative HOOS scores. CONCLUSIONS: Subsidence and proximal-femoral morphology are potential sources of postoperative morbidity in certain cementless THA patients. In accordance with prior studies, CFI was identified as a potential risk factor for intraoperative calcar fractures. More research into preoperative femoral morphologies, such as GT overhang and FNS, is warranted as these may contribute to unsatisfactory results related to cementless THA.

2021 Otto Aufranc Award: A simple Hip-Spine Classification for total hip arthroplasty : validation and a large multicentre series.

AIMS: Patients with spinal pathology who undergo total hip arthroplasty (THA) have an increased risk of dislocation and revision. The aim of this study was to determine if the use of the Hip-Spine Classification system in these patients would result in a decreased rate of postoperative dislocation in patients with spinal pathology. METHODS: This prospective, multicentre study evaluated 3,777 consecutive patients undergoing THA by three surgeons, between January 2014 and December 2019. They were categorized using The Hip-Spine Classification system: group 1 with normal spinal alignment; group 2 with a flatback deformity, group 2A with normal spinal mobility, and group 2B with a stiff spine. Flatback deformity was defined by a pelvic incidence minus lumbar lordosis of > 10°, and spinal stiffness was defined by < 10° change in sacral slope from standing to seated. Each category determined a patient-specific component positioning. Survivorship free of dislocation was recorded and spinopelvic measurements were compared for reliability using intraclass correlation coefficient. RESULTS: A total of 2,081 patients met the inclusion criteria. There were 987 group 1A, 232 group 1B, 715 group 2A, and 147 group 2B patients. A total of 70 patients had a lumbar fusion, most had L4-5 (16; 23%) or L4-S1 (12; 17%) fusions; 51 patients (73%) had one or two levels fused, and 19 (27%) had > three levels fused. Dual mobility (DM) components were used in 166 patients (8%), including all of those in group 2B and with > three level fusions. Survivorship free of dislocation at five years was 99.2% with a 0.8% dislocation rate. The correlation coefficient was 0.83 (95% confidence interval 0.89 to 0.91). CONCLUSION: This is the largest series in the literature evaluating the relationship between hip-spine pathology and dislocation after THA, and guiding appropriate treatment. The Hip-Spine Classification system allows surgeons to make appropriate evaluations preoperatively, and it guides the use of DM components in patients with spinopelvic pathology in order to reduce the risk of dislocation in these high-risk patients. Cite this article: Bone Joint J 2021;103-B(7 Supple B):17-24.

Posteromedial Approach to Tibial Plateau Fracture Nonunion.

Tibial plateau fractures can involve planes that require reduction and stabilization from a posterior approach. This includes posteromedial, posterolateral, and posterior column shear type injuries. This video outlines the prone posteromedial approach to the tibial plateau for posterior column fracture exposure, reduction, and fixation.

The Hip-Spine Relationship Simplified.

Much attention has recently been focused on the relationship between the hip and spine and its contribution to postoperative instability following total hip arthroplasty. However, the terminology can be confusing. Through an understanding of spinopelvic parameters, spinopelvic motion, and the interplay between the spine and pelvis, the surgeon can plan for and decrease the risk of instability after total hip arthroplasty. This review details spinopelvic parameters that predispose to instability and guides readers in understanding spinopelvic motion as it relates to THA instability.

Fate of Two-Stage Reimplantation After Failed Irrigation and Debridement for Periprosthetic Hip Infection.

BACKGROUND: Irrigation and debridement is an attractive treatment option for acute perioperative and acute hematogenous periprosthetic hip infections. We ask the following questions: (1) What are the results of a two-stage reimplantation if preceded by debridement, antibiotics, and implant retention (DAIR) compared with two-stage reimplantation without an antecedent DAIR? and (2) Do McPherson Musculoskeletal Infection Society (MSIS) host criteria influence results? METHODS: A total of 114 patients were treated with two-stage exchange for periprosthetic hip infection. Sixty-five patients were treated initially with a two-stage exchange, whereas 49 patients underwent an antecedent DAIR before a two-stage exchange. Patients were classified based on MSIS host criteria. Demographics demonstrated homogeneity between cohorts. Failure was defined as return to the operating room for infection, draining sinus, or systemic infection. RESULTS: Treatment failure occurred in 42.9% (21 of 49) of patients treated with an antecedent DAIR. In contrast, treatment failure occurred in only 12.3% (8 of 65) of two-stage only procedures (P < .001). Relative risk of return to the operating room after a two-stage reimplantation with an antecedent DAIR compared with initial resection was 4.52 (95% confidence interval: 1.71, 11.9). MSIS host grading was similar between groups and did not influence the rate of failure in a regression model. The DAIR cohort was also found to consume more resources in terms of hospitalization length and operative procedures (P < .001). CONCLUSIONS: Two-stage exchange procedures for prosthetic hip infections have a higher failure rate and consume more health-care resources when preceded by a failed DAIR. Surgeons and patients should be aware that a failed DAIR may compromise the results of future two-stage procedures.

Thirty-Day Outcomes After Bilateral Total Hip Arthroplasty in a Nationwide Cohort.

BACKGROUND: Approximately 42% of patients with end-stage osteoarthritis have bilateral disease. Although bilateral total hip arthroplasty (THA) is physiologically demanding, certain patients may benefit from simultaneous rather than staged bilateral procedures. This study examines the intraoperative differences and 30-day outcomes in patients receiving bilateral THA compared with those who underwent unilateral THA. METHODS: Patients undergoing THA were selected from the National Surgical Quality Improvement Program database from 2008 to 2015. Patients were selected according to those with primary and concurrent coding for Current Procedural Terminology 27130. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether concurrent THA was a risk factor for poor outcomes. RESULTS: A total of 97,804 patients and 587 patients who underwent unilateral and bilateral THA, respectively, were identified. Patients who underwent bilateral procedures were younger (57.3 vs 64.6 years, P < .001), were of lower body mass index (29.2 vs 30.2, P < .001), and had fewer comorbidities than patients who underwent unilateral procedures. Length of stay was not increased for bilateral recipients (3.13 vs 2.93 days, P = .308), although fewer were discharged to home (62.8% vs 77.6%, P < .001). The bilateral recipients required postoperative transfusions at a higher rate (29.8% vs 10.9%, P < .001) and had an increased incidence of deep wound infections on univariate analysis (1.2% vs 0.3%, P = .002). There was no increased risk of superficial infection, medical complications, or thromboembolic events for the bilateral cohort. CONCLUSIONS: Although bilateral THA recipients are younger with fewer preoperative comorbidities, bilateral THA is associated with an increased rate of transfusion in a nationwide setting. With this knowledge, specific interventions should be instituted to target these procedure-specific risks.

When Can I Trust The Robot? An Algorithm for CT-Based Robotic-Assisted Total Hip Arthroplasty.

INTRODUCTION: Robotic-assisted total hip arthroplasty (THA) has been shown to demonstrate a variety of clinical benefits for patients, including reductions in dislocation rates, decreased impingement, and improved implant longevity. However, variability in surgeon experience with robotic systems can lead to inconsistent results. Mastery of the initial acetabular registration step is critical to performing a predictable and accurate robotic-assisted total hip replacement. METHODS: We retrospectively reviewed 100 consecutive patients who underwent unilateral THA with MAKOplasty®. From this data, we reviewed where errors in planning or registration occurred. These cases either required a repeat registration if the error was caught early, or the errors were realized on postoperative imaging when the x-ray did not match the preoperative plan. Subsequently, we developed an algorithm to ensure accurate registration and implemented its use on the next 100 cases, again reviewing the intraoperative case data and postoperative x-rays for any errors. RESULTS: Initial analysis revealed that 87 of the first 100 cases were correctly registered, where postoperative acetabular cup position matched the plan on first attempt. Of the remaining 13 cases that had a registration error, eight cases were identified intra-operatively and re-registered. There were five cases where the postoperative x-ray did not match the plan despite a "good" registration. For incorrectly registered cases (N = 13), seven of 13 were found to exhibit a type I error (initial registration), while six of 13 demonstrated a type II error (fine point registration). Following the implementation of our registration algorithm, we were able to decrease the discrepancy between the preoperative plan (planning) and the postoperative x-rays (execution) from 13% to 0% of cases. CONCLUSION: In this study, we present a detailed method to examine registration errors during robotic-navigated THA with MAKOplasty®. From this analysis, we were able to develop a successful algorithm that allows the surgeon to ensure correct registration and ultimately a postoperative x-ray that matches the preoperative plan. Our algorithm presents a principled approach that provides the surgeon and patient confidence in the safety and efficacy a roboticassisted total hip replacement.

American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete, motor complete) in gunshot-related spinal cord injury.

BACKGROUND CONTEXT: We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers. PURPOSE: To determine if ASIA classifications A and B are important distinctions for patients with SCIs secondary to civilian gunshot wounds. DESIGN/SETTING: A retrospective chart review was performed on all patients with civilian gunshot-induced SCI transferred to Rancho Los Amigos Rehabilitation Center between 1999 and 2014. Outcome measures were occurrence of pressure ulcers and surgical intervention for pressure ulcers. PATIENT SAMPLE: We included a total of 487 patients who sustained civilian gunshot wounds to the spine and were provided care at Rancho Los Amigos Rehabilitation Center from 2001 to 2014. OUTCOME MEASURES: Occurrence of pressure ulcers and surgical intervention for pressure ulcers among patients who suffered civilian-induced gunshot wounds to the spine. METHODS: Retrospective chart review identified 487 SCIs due to gunshot wounds that were treated at Rancho Los Amigos from 2001 to 2014. Injury characteristics including ASIA classification, pressure ulcers, and pressure ulcer surgeries were recorded. Comprehensive surgical data were obtained for all patients. Chart reviews and telephone interviews were performed to determine the occurrence of any pressure ulcers and pressure ulcer surgeries. Statistical analysis was performed to compare data by spinal region and ASIA grade. There were no conflicts of interest from any of the authors, and there was no funding obtained for this study. RESULTS: There was no statistical difference for cervical ASIA A versus ASIA B for the occurrence of pressure ulcers or the percentage requiring surgery, nor for thoracic A versus B. When grouped, there was a statistically higher occurrence of pressure ulcers in cervical A or B classification than in thoracic A or B classification, but a higher rate of surgery for thoracic A or B classification. Lumbosacral cauda equina levels were not statistically different in occurrence of pressure ulcers or pressureulcer surgery by ASIA grades A-D. Overall, when grouped C1-T12, cord-level cervicothoracic A and B classifications were statistically equivalent. C1-T12 cord level C or D classification with motor sparing had statistically lower occurrence and need of surgery for pressure ulcers and were equivalent to lumbosacral cauda equina level A-D. CONCLUSION: ASIA A and B distinctions are not meaningful at spinal cord levels in the cervicothoracic spine due to gunshot wounds as shown by similar occurrence of pressure ulcers and pressure ulcer surgery, and should be treated as if the same. Meaningful decrease of pressure ulcers at cord levels does not occur until there is motor sparing ASIA C or D. Furthermore, cauda equina lumbosacral injuries are a lower risk, which is independent of ASIA grade A-D and statistically equivalent to cord level C or D. Motor sparing at cord levels or any cauda equina level is most determinative neurologically for the occurrence of pressure ulcers or pressure ulcer surgery.

Three-Dimensional Templating for Acetabular Component Alignment During Total Hip Arthroplasty.

Appropriate placement of the acetabular cup is an important determinant of implant stability and longevity. Malposition of acetabular cups negatively influences prosthesis survival and leads to an increased dislocation rate. The objective of the study was to determine the role of 3-dimensional templating in obtaining accurate acetabular component placement in total hip arthroplasty. In this computed tomography-based study, the authors identified 93 patients who underwent primary total hip arthroplasty with computer-assisted navigation. Using 3-dimensional planning, the authors templated the acetabular component at an inclination of 40° and anteversion of 20°. To classify acetabular cup coverage by bone, the acetabulum was used as a clock face with the center of the transverse acetabular ligament (TAL) as 6-o'clock. Analyses revealed that 72% of cups were uncovered between 9- to 1-o'clock for right hips. On the left side, 88% of cups were uncovered between 11- to 3-o'clock. Across all hips, 74% of cups had a 1-o'clock position at the most lateral aspect. Further analysis revealed that 46% of acetabular cups had a teardrop at the same level of the most inferior aspect of the cup, whereas only 37% of cups had a teardrop above the inferior aspect of the cup. Finally, the acetabular component was aligned with the TAL in 76% of hips, retroverted to the TAL in 16%, and anteverted to the TAL in 8%. The current study demonstrates a useful gross intraoperative reference tool to standardize cup position without the need for additional equipment and reliance on anatomical landmarks. [Orthopedics. 2017; 40(4):e708-e713.].

Surgical Management of Civilian Gunshot-Induced Spinal Cord Injury: Is It Overutilized?

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Assess appropriate utilization of surgery for civilian gunshot-induced spinal cord injuries (CGSWSCI) according to literature standards in a large cohort. SUMMARY OF BACKGROUND DATA: CGSWSCI are mechanically stable injuries that rarely require surgery. Nonetheless, we continue to see high numbers of these patients undergo surgical treatment. This study compares indications for surgeries performed in a large cohort of CGSWSCI patients to established indications for surgical management of such injuries. The rate of over-utilization of surgical management was calculated. METHODS: Four hundred eighty-nine CGSWSCI patients transferred for rehabilitation to our institution between 2000 and 2014 were identified. Retrospective chart review was performed to identify patients who underwent initial surgical treatment, the specific surgeries performed, and indications given. We assessed appropriateness of surgery according to literature standards. Patients treated surgically were followed to assess for complications and the need for additional intervention and compared to nonsurgical patients. Secondarily, visual analog scale pain scores (0-10) and patient perceived improvement were compared between surgical and nonsurgical patients after telephone survey of both groups. RESULTS: Of 489 patients, 91 (18%) underwent initial surgery. Of 91 surgeries, 69 (75%) were not indicated by literature standards. Five of 91 (5.5%) of initially operated patients required a secondary surgery compared with two of 398 (0.5%) of the nonoperative group (P = 0.003). Over-utilization rate of the entire cohort was 14.1%. No difference was seen for pain scores or patient perceived improvement between operative and nonoperative patients. CONCLUSION: We report a high overutilization rate (14%) of surgery for CGSWSCI in our cohort. Surgical management was associated with higher infection and secondary surgery rates compared to nonsurgical management. Surgery done without a clear, demonstrable benefit poses unnecessary risk to patients and accumulates unwarranted healthcare costs. LEVEL OF EVIDENCE: 3.

What Is the Association of Elite Sporting Activities With the Development of Hip Osteoarthritis?

BACKGROUND: Male athletes participating in certain elite sporting activities may be at an increased risk for development of hip osteoarthritis (OA) later in life. However, the strength of the association of participation in sporting activities with the increased risk of hip OA has not been well summarized. PURPOSE: To investigate the association of certain high-impact sporting activities with the risk of development of hip OA in elite athletes by conducting a systematic review of the available literature. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: PubMed, Cochrane, and EMBASE databases were searched to identify all potential studies. Eleven studies met the inclusion criteria, which included participation in elite-level sporting activities, greater than 50% male athletes in the study population, diagnosis of hip OA by radiograph, hospital admission or total hip arthroplasty (THA), and greater than 80% follow-up. Exclusion criteria were recreational sporting activities, primarily female cohorts as there was a dearth of available literature on the topic, and self-reported symptoms without radiographic confirmation of diagnosis. Most studies were with European athletes, where elite-level was defined as involvement in national- or professional-level competition. RESULTS: Participation across elite-level impact sports was associated with increased risk of development of hip OA when compared with matched controls (odds ratio, 1.8-8.7). Twelve of 15 studies reviewed demonstrated an odds ratio of 1.8 or greater of developing hip OA in elite-level athletes. Handball was associated with the highest rate of OA of any sport, nearly 5 times that of matched controls. Soccer players demonstrated between 2 and 9 times increased risk of hip OA as defined by radiography or THA. Hockey players demonstrated 2 to 3 times increased risk of hip OA (THA or hospital admission). Five studies investigating the association of competitive long-distance running with hip OA demonstrated inconsistent results. CONCLUSION: Currently available literature suggests that male athletes participating in elite impact sports (soccer, handball, track and field, or hockey) are at an increased risk of developing hip OA, while those participating in high-level long-distance running do not have a clearly elevated risk. Further research is warranted to elucidate the pathomechanics of development of hip OA in these patients.

Overutilization of bracing in the management of penetrating spinal cord injury from gunshot wounds.

OBJECTIVE Penetrating gunshot wounds (GSWs) to the spinal column are stable injuries and do not require spinal orthoses or bracing postinjury. Nonetheless, a high number of GSW-related spinal cord injury (SCI) patients are referred with a brace to national rehabilitation centers. Unnecessary bracing may encumber rehabilitation, create skin breakdown or pressure ulcers, and add excessive costs. The aim of this study was to confirm the stability of spinal column injuries from GSWs and quantify the overutilization rate of bracing based on long-term follow-up. METHODS This retrospective cohort study was performed at a nationally renowned rehabilitation center. In total, 487 GSW-related SCI patients were transferred for rehabilitation and identified over the last 14 years. Retrospective chart review and telephone interviews were conducted to identify patients who were braced at the initial treating institution and determine if late instability, deformity, or neurological deterioration resulted in secondary surgery or intervention. In addition, 396 unoperated patients were available for analysis after 91 patients were excluded for undergoing an initial destabilizing surgical dissection or laminectomy, thereby altering the natural history of the injury. All of these 396 patients who presented with a brace had bracing discontinued upon reaching the facility. RESULTS In total, 203 of 396 patients were transferred with a spinal brace, demonstrating an overutilization rate of 51%. No patients deteriorated neurologically or needed later surgery for spinal column deformity or instability attributable to the injury. All patients had stable injuries. The patterns of injury and severity of neurological injury did not vary between patients who were initially braced or unbraced. The average follow-up was 7.8 years (range 1-14 years) and the average age was 25 years (range 10-62 years). CONCLUSIONS The incidence of brace overutilization for penetrating GSW-related SCI was 51%. Long-term follow-up in this study confirmed that these injuries were stable and thus did not require bracing. No patients deteriorated neurologically, whether or not they were initially braced. The unnecessary use of spinal orthoses increases costs and patient morbidity. Reeducation and dissemination of this information is warranted.