Is a Rapid Recovery Protocol for THA and TKA Associated With Decreased 90-day Complications, Opioid Use, and Readmissions in a Health Safety-net Hospital?

BACKGROUND: Patients treated at a health safety-net hospital have increased medical complexity and social determinants of health that are associated with an increasing risk of complications after TKA and THA. Fast-track rapid recovery protocols (RRPs) are associated with reduced complications and length of stay in the general population; however, whether that is the case among patients who are socioeconomically disadvantaged in health safety-net hospitals remains poorly defined. QUESTIONS/PURPOSES: When an RRP protocol is implemented in a health safety-net hospital after TKA and THA: (1) Was there an associated change in complications, specifically infection, symptomatic deep venous thromboembolism (DVT), symptomatic pulmonary embolism (PE), myocardial infarction (MI), and mortality? (2) Was there an associated difference in inpatient opioid consumption? (3) Was there an associated difference in length of stay and 90-day readmission rate? (4) Was there an associated difference in discharge disposition? METHODS: An observational study with a historical control group was conducted in an urban, academic, tertiary-care health safety-net hospital. Between May 2022 and April 2023, an RRP consistent with current guidelines was implemented for patients undergoing TKA or THA for arthritis. We considered all patients aged 18 to 90 years presenting for primary TKA and THA as eligible. Based on these criteria, 562 patients with TKAs or THAs were eligible. Of these 33% (183) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 67% (379) for evaluation. Patients in the historical control group (September 2014 to May 2022) met the same criteria, and 2897 were eligible. Of these, 31% (904) were excluded because they were lost before 90 days of follow-up and had incomplete datasets, leaving 69% (1993) for evaluation. The mean age in the historical control group was 61 ± 10 years and 63 ± 10 years in the RRP group. Both groups were 36% (725 of 1993 and 137 of 379) men. In the historical control group, 39% (770 of 1993) of patients were Black and 33% (658 of 1993) were White, compared with 38% (142 of 379) and 32% (121 of 379) in the RRP group, respectively. English was the most-spoken primary language, by 69% (1370 of 1993) and 68% (256 of 379) of the historical and RRP groups, respectively. A total of 65% (245 of 379) of patients in the RRP group had a peripheral nerve block compared with 54% (1070 of 1993) in the historical control group, and 39% (147 of 379) of them received spinal anesthesia, compared with 31% (615 of 1993) in the historical control group. The main elements of the RRP were standardization of preoperative visits, nutritional management, neuraxial anesthesia, accelerated physical therapy, and pain management. The primary outcomes were the proportions of patients with 90-day complications and opioid consumption. The secondary outcomes were length of stay, 90-day readmission, and discharge disposition. A multivariate analysis adjusting for age, BMI, gender, race, American Society of Anaesthesiologists class, and anesthesia type was performed by a staff biostatistician using R statistical programming. RESULTS: After controlling for the confounding variables as noted, patients in the RRP group had fewer complications after TKA than those in the historical control group (odds ratio 2.0 [95% confidence interval 1.3 to 3.3]; p = 0.005), and there was a trend toward fewer complications in THA (OR 1.8 [95% CI 1.0 to 3.5]; p = 0.06), decreased opioid consumption during admission (517 versus 676 morphine milligram equivalents; p = 0.004), decreased 90-day readmission (TKA: OR 1.9 [95% CI 1.3 to 2.9]; p = 0.002; THA: OR 2.0 [95% CI 1.6 to 3.8]; p = 0.03), and increased proportions of discharge to home (TKA: OR 2.4 [95% CI 1.6 to 3.6]; p = 0.01; THA: OR 2.5 [95% CI 1.5 to 4.6]; p = 0.002). Patients in the RRP group had no difference in the mean length of stay (TKA: 3.2 ± 2.6 days versus 3.1 ± 2.0 days; p = 0.64; THA: 3.2 ± 2.6 days versus 2.8 ± 1.9 days; p = 0.33). CONCLUSION: Surgeons should consider developing an RRP in health safety-net hospitals. Such protocols emphasize preparing patients for surgery and supporting them through the acute recovery phase. There are possible benefits of neuraxial and nonopioid perioperative anesthesia, with emphasis on early mobility, which should be further characterized in comparative studies. Continued analysis of opioid use trends after discharge would be a future area of interest. Analysis of RRPs with expanded inclusion criteria should be undertaken to better understand the role of these protocols in patients who undergo revision TKA and THA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Clinical Utility of Routine Postoperative Imaging in Spinal Fusion Surgery: A Systematic Review.

OBJECTIVE: Following spinal fusion surgery, routine imaging is often obtained in all patients regardless of clinical presentation. Such routine imaging may include x-ray, computed tomography, or magnetic resonance imaging studies in both the immediate postoperative period and after discharge. The clinical utility of this practice is questionable. Our goal is to assess the existing literature for evidence of impact on clinical care from routine radiographic surveillance following spinal fusion. METHODS: A systematic search of Embase, Scopus, PubMed, Cochrane, and Ovid databases was performed for studies investigating postoperative imaging following spinal fusion surgery. Studies were analyzed for imaging findings and rates of change in management due to imaging. RESULTS: In total, the review identified 9 studies that separated data by unique patient or by unique clinic visits. The 4 studies reporting per-patient data totaled 475 patients with 328 (69%) receiving routine imaging. Among these, 28 (8.5%) patients had abnormal routine findings with no patients having a change to their clinical course. Of the 5 studies that reported clinic visit data, 3119 patient visits were included with 2365 (76%) clinic visits accompanied by imaging. Across these 5 studies, 146 (6.2%) visits noted abnormal imaging with only 12 (0.5%) subsequent management changes. CONCLUSIONS: Our analysis found that routine imaging after spinal fusion surgery had no direct benefit on clinical management. The utility of baseline imaging for long-term comparison and medicolegal concerns were not studied and remain up to the provider's judgment. Further research is necessary to identify optimal imaging criteria following spinal fusion surgery.

Patient complaints in the postoperative period following spine surgery.

OBJECTIVE: Patient complaints are associated with a number of surgical and medical outcomes. Despite high rates of patient complaints regarding spine surgeons and efforts to study patient complaints across medicine and surgery, few studies have analyzed the complaints of patients undergoing spinal surgery. The authors present a retrospective analysis that, to their knowledge, is the first study to directly investigate the complaints of spine surgery patients in the postoperative period. METHODS: Institutional records were reviewed over a 5-year period (2015-2019) to identify patients who underwent spine surgery and submitted a complaint to the institution's ombudsman's office within 1 year of their surgery. A control group, comprising patients who underwent spine surgery without filing a complaint, was matched to the group that filed complaints by admission diagnosis and procedure codes through propensity score matching. Patient demographic and clinical data were obtained by medical record review and compared between the two groups. Patient complaints were reviewed and categorized using a previously established taxonomy. RESULTS: A total of 52 patients were identified who submitted a complaint after their spine surgery. There were 56 total complaints identified (4 patients submitted 2 each) that reported on 82 specific issues. Patient complaints were most often related to the quality of care received and communication breakdown between the healthcare team and the patient. Patients who submitted complaints were more likely to be Black or African American, have worse baseline health status, and have had prior spine surgery. After their surgery, these patients were also more likely to have longer hospital stays, experience postoperative complications, and require reoperation. CONCLUSIONS: Complaints were most often related to the quality of care received and communication breakdown. A number of patient-level demographic and clinical characteristics were associated with an increased likelihood of a complaint being filed after spine surgery, and patients who filed complaints were more likely to experience postoperative complications. Improving communication with patients could play a key role in working to address and reduce postoperative complaints. Further study is needed to better understand patient complaints after spine surgery and investigate ways to optimize the care of patients with risks for postoperative complaints.

Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility.

STUDY DESIGN: Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013 to 2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes. OBJECTIVE: To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period. METHODS: The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013 to 2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications. RESULTS: Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (P = 0.10), however, new or worsening neurologic deficits did predict reoperation (P < 0.01). CONCLUSION: New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.Level of Evidence: 3.

Spinal Dural Arteriovenous Fistula: Diagnosis, Outcomes, and Prognostic Factors.

OBJECTIVE: Typically, the clinical presentation of a spinal dural arteriovenous fistula (SDAVF) will be insidious, with patients' symptoms regularly attributed to other conditions. Although previous studies have characterized the neurologic outcomes after treatment for SDAVFs, little is known about the pretreatment patient characteristics associated with poor and/or positive patient outcomes. We sought to characterize the pretreatment patient demographics, diagnostic history, and neurologic outcomes of patients treated for SDAVFs and to identify the patient factors predictive of these outcomes. METHODS: The medical records of patients who had been treated for SDAVFs from 2006 to 2018 across 1 healthcare system were retrospectively analyzed. Neurologic status was assessed both before and after intervention using the Aminoff-Logue scales for gait and micturition disturbances. RESULTS: Of 46 total patients, 16 (35%) had a documented misdiagnosis. Patients with a history of misdiagnosis had had a significantly longer symptom duration before treatment compared with those without a misdiagnosis (median, 2.3 vs. 0.9 years; P = 0.018). A shorter symptom duration before intervention was significantly associated with both improved motor function (median, 0.8 vs. 3.1 years; P = 0.001) and improved urinary function (median, 0.8 vs. 2.2 years; P = 0.040) after intervention. CONCLUSIONS: Misdiagnosis has been relatively common in patients with SDAVFs and contributes to delays in treatment. Delays in diagnosis and treatment of SDAVFs appear to be associated with worse clinical outcomes for patients who, ultimately, receive treatment.

Diagnosis, Management, and Clinical Outcomes of Tandem Thoracic and Lumbar Stenosis: A Systematic Literature Review and Case Series.

BACKGROUND: A scarcity of data has been reported on tandem thoracic lumbar stenosis, which might be related to either the rarity or underdiagnosis of the condition. We have presented a systematic review of the clinical presentation, diagnosis, and treatment patterns for patients with symptomatic tandem thoracic and lumbar stenosis. METHODS: A PubMed/MEDLINE search was performed to find reports of patients with symptomatic tandem thoracic and lumbar stenosis. RESULTS: The review identified 10 studies with a total of 48 patients with tandem thoracic and lumbar stenosis. Most patients (n = 41; 85%) had had tandem stenosis diagnosed at the initial investigation, with 71% of the reports citing ossification of the ligamentum flavum as a contributing etiology. A few patients (n = 7; 15%) had had thoracic lesions diagnosed after neurologic deterioration that had occurred after lumbar surgery for previously suspected isolated lumbar stenosis. Surgical management varied from isolated thoracic decompression, staged decompression, and simultaneous decompression. Most patients (n = 41; 87%) showed improved neurologic status after surgery. CONCLUSION: Ossification of the ligamentum flavum might play a key role in the pathogenesis of the condition. Most patients with tandem thoracic and lumbar stenosis will show improvement after surgical decompression. Although the limited evidence available has raised concerns regarding neurologic deterioration after initial lumbar decompression in patients with coexisting thoracic stenosis, the data are insufficient to definitively determine an optimal surgical strategy. Further research is needed to identify the optimal diagnostic and management criteria for patients with symptomatic tandem thoracic and lumbar stenosis.

Extensive Pneumorrhachis Associated with Vaping-Induced Lung Injury.

BACKGROUND: Pneumorrhachis refers to air within the spinal canal and is most commonly associated with traumatic spinal injuries or spine surgery. A link between pneumorrhachis and certain pulmonary diseases, such as asthma, has also been demonstrated in the literature; however, there are no previous reports of pneumorrhachis secondary to vaping-induced lung injury. CASE DESCRIPTION: A 15-year-old boy with vaping-induced lung injury experienced acute respiratory decompensation after straining. Computed tomography of the chest revealed bilateral pneumothoraces, extensive pneumomediastinum, and pneumorrhachis. Extensive air was seen in the spinal canal from the cervical spine down to the level of the T8 vertebrae. CONCLUSIONS: The emerging condition of vaping-induced lung injury may place patients at risk for serious complications of extrapulmonary air including pneumorrhachis. To our knowledge, this is the first report of pneumorrhachis secondary to vaping-induced lung injury.

Response properties of single neurons in higher level auditory cortex of adult songbirds.

The caudomedial nidopallium (NCM) is a higher level region of auditory cortex in songbirds that has been implicated in encoding learned vocalizations and mediating perception of complex sounds. We made cell-attached recordings in awake adult male zebra finches ( Taeniopygia guttata) to characterize responses of single NCM neurons to playback of tones and songs. Neurons fell into two broad classes: narrow fast-spiking cells and broad sparsely firing cells. Virtually all narrow-spiking cells responded to playback of pure tones, compared with approximately half of broad-spiking cells. In addition, narrow-spiking cells tended to have lower thresholds and faster, less variable spike onset latencies than did broad-spiking cells, as well as higher firing rates. Tonal responses of narrow-spiking cells also showed broader ranges for both frequency and amplitude compared with broad-spiking neurons and were more apt to have V-shaped tuning curves compared with broad-spiking neurons, which tended to have complex (discontinuous), columnar, or O-shaped frequency response areas. In response to playback of conspecific songs, narrow-spiking neurons showed high firing rates and low levels of selectivity whereas broad-spiking neurons responded sparsely and selectively. Broad-spiking neurons in which tones failed to evoke a response showed greater song selectivity compared with those with a clear tuning curve. These results are consistent with the idea that narrow-spiking neurons represent putative fast-spiking interneurons, which may provide a source of intrinsic inhibition that contributes to the more selective tuning in broad-spiking cells. NEW & NOTEWORTHY The response properties of neurons in higher level regions of auditory cortex in songbirds are of fundamental interest because processing in such regions is essential for vocal learning and plasticity and for auditory perception of complex sounds. Within a region of secondary auditory cortex, neurons with narrow spikes exhibited high firing rates to playback of both tones and multiple conspecific songs, whereas broad-spiking neurons responded sparsely and selectively to both tones and songs.

Preparation of size tunable giant vesicles from cross-linked dextran(ethylene glycol) hydrogels.

We present a novel chemically cross-linked dextran-poly(ethylene glycol) hydrogel substrate for the preparation of dense vesicle suspensions under physiological ionic strength conditions. These vesicles can be easily diluted for individual study. Modulating the degree of cross-linking within the hydrogel network results in tuning of the vesicle size distribution.