The Large Language Model ChatGPT-4 Demonstrates Excellent Triage Capabilities and Diagnostic Performance for Patients Presenting with Various Causes of Knee Pain.

PURPOSE: To provide a proof-of-concept analysis of the appropriateness and performance of ChatGPT-4 to triage, synthesize differential diagnoses, and generate treatment plans concerning common presentations of knee pain. METHODS: Twenty knee complaints warranting triage and expanded scenarios were input into ChatGPT-4, with memory cleared prior to each new input to mitigate bias. For the 10 triage complaints, ChatGPT-4 was asked to generate a differential diagnosis which was graded for accuracy and suitability in comparison to a differential created by two orthopaedic sports medicine physicians. For the 10 clinical scenarios, ChatGPT-4 was prompted to provide treatment guidance for the patient, which was again graded. To test the higher-order capabilities of ChatGPT-4, further inquiry into these specific management recommendations was performed and graded. RESULTS: All ChatGPT-4 diagnoses were deemed appropriate within the spectrum of potential pathologies on a differential. The top diagnosis on the differential was identical between surgeons and ChatGPT-4 for 70% of scenarios, and the top diagnosis provided by the surgeon appeared as either the first or second diagnosis in 90% of scenarios. Overall, 16/30 (53.3%) of diagnoses in the differential were identical. When provided with 10 expanded vignettes with a single diagnosis, the accuracy of ChatGPT-4 increased to 100%, with the suitability of management graded as appropriate in 90% of cases. Specific information pertaining to conservative management, surgical approaches, and related treatments was appropriate and accurate in 100% of cases. CONCLUSION: ChatGPT-4 provided clinically reasonable diagnoses to triage patient complaints of knee pain due to various underlying conditions that was generally consistent with differentials provided by sports medicine physicians. Diagnostic performance was enhanced when providing additional information, allowing ChatGPT-4 to reach high predictive accuracy for recommendations concerning management and treatment options. However, ChatGPT-4 may demonstrate clinically important error rates for diagnosis depending on prompting strategy and information provided; therefore, further are necessary to prior to implementation into clinical workflows.

Current Concepts on the Management of Shoulder Instability in Throwing Athletes.

PURPOSE OF REVIEW: The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments. RECENT FINDINGS: The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

The Number of Patients Lost to Follow-Up May Exceed the Fragility Index of a Randomized Controlled Trial Without Reversing Statistical Significance: A Systematic Review and Statistical Model.

PURPOSE: To (1) analyze trends in the publishing of statistical fragility index (FI)-based systematic reviews in the orthopaedic literature, including the prevalence of misleading or inaccurate statements related to the statistical fragility of randomized controlled trials (RCTs) and patients lost to follow-up (LTF), and (2) determine whether RCTs with relatively "low" FIs are truly as sensitive to patients LTF as previously portrayed in the literature. METHODS: All FI-based studies published in the orthopaedic literature were identified using the Cochrane Database of Systematic Reviews, Web of Science Core Collection, PubMed, and MEDLINE databases. All articles involving application of the FI or reverse FI to study the statistical fragility of studies in orthopaedics were eligible for inclusion in the study. Study characteristics, median FIs and sample sizes, and misleading or inaccurate statements related to the FI and patients LTF were recorded. Misleading or inaccurate statements-defined as those basing conclusions of trial fragility on the false assumption that adding patients LTF back to a trial has the same statistical effect as existing patients in a trial experiencing the opposite outcome-were determined by 2 authors. A theoretical RCT with a sample size of 100, P = .006, and FI of 4 was used to evaluate the difference in effect on statistical significance between flipping outcome events of patients already included in the trial (FI) and adding patients LTF back to the trial to show the true sensitivity of RCTs to patients LTF. RESULTS: Of the 39 FI-based studies, 37 (95%) directly compared the FI with the number of patients LTF. Of these 37 studies, 22 (59%) included a statement regarding the FI and patients LTF that was determined to be inaccurate or misleading. In the theoretical RCT, a reversal of significance was not observed until 7 patients LTF (nearly twice the FI) were added to the trial in the distribution of maximal significance reversal. CONCLUSIONS: The claim that any RCT in which the number of patients LTF exceeds the FI could potentially have its significance reversed simply by maintaining study follow-ups is commonly inaccurate and prevalent in orthopaedic studies applying the FI. Patients LTF and the FI are not equivalent. The minimum number of patients LTF required to flip the significance of a typical RCT was shown to be greater than the FI, suggesting that RCTs with relatively low FIs may not be as sensitive to patients LTF as previously portrayed in the literature; however, only a holistic approach that considers the context in which the trial was conducted, potential biases, and study results can determine the merits of any particular RCT. CLINICAL RELEVANCE: Surgeons may benefit from re-examining their interpretation of prior FI reviews that have made claims of substantial RCT fragility based on comparisons between the FI and patients LTF; it is possible the results are more robust than previously believed.

Platelet-Rich Plasma Versus Alternative Injections for Osteoarthritis of the Knee: A Systematic Review and Statistical Fragility Index-Based Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Based in part on the results of randomized controlled trials (RCTs) that suggest a beneficial effect over alternative treatment options, the use of platelet-rich plasma (PRP) for the management of knee osteoarthritis (OA) is widespread and increasing. However, the extent to which these studies are vulnerable to slight variations in the outcomes of patients remains unknown. PURPOSE: To evaluate the statistical fragility of conclusions from RCTs that reported outcomes of patients with knee OA who were treated with PRP versus alternative nonoperative management strategies. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 2. METHODS: All RCTs comparing PRP with alternative nonoperative treatment options for knee OA were identified. The fragility index (FI) and reverse FI were applied to assess the robustness of conclusions regarding the efficacy of PRP for knee OA. Meta-analyses were performed to determine the minimum number of patients from ≥1 trials included in the meta-analysis for which a modification on the event status would change the statistical significance of the pooled treatment effect. RESULTS: In total, this analysis included outcomes from 1993 patients with a mean ± SD age of 58.0 ± 3.8 years. The mean number of events required to reverse significance of individual RCTs (FI) was 4.57 ± 5.85. Based on random-effects meta-analyses, PRP demonstrated a significantly higher rate of successful outcomes when compared with hyaluronic acid (P = .002; odds ratio [OR], 2.19; 95% CI, 1.33-3.62), as well as higher rates of patient-reported symptom relief (P = .019; OR, 1.55; 95% CI, 1.07-2.24), not requiring a reintervention after the initial injection treatment (P = .002; OR, 2.17; 95% CI, 1.33-3.53), and achieving the minimal clinically important difference (MCID) for pain improvement (P = .007; OR, 6.19; 95% CI, 1.63-23.42) when compared with all alternative nonoperative treatments. Overall, the mean number of events per meta-analysis required to change the statistical significance of the pooled treatment effect was 8.67 ± 4.50. CONCLUSION: Conclusions drawn from individual RCTs evaluating PRP for knee OA demonstrated slight robustness. On meta-analysis, PRP demonstrated a significant advantage over hyaluronic acid as well as improved symptom relief, lower rates of reintervention, and more frequent achievement of the MCID for pain improvement when compared with alternative nonoperative treatment options. Statistically significant pooled treatment effects evaluating PRP for knee OA are more robust than approximately half of all comparable meta-analyses in medicine and health care. Future RCTs and meta-analyses should consider reporting FIs and fragility quotients to facilitate interpretation of results in their proper context.

Femoral Head Osteonecrosis: Computed Tomography Not Needed to Identify Collapse When Using the Association Research Circulation Osseous Staging System.

Background: The 2019 Revised Association Research Circulation Osseous (ARCO) Staging Criteria for Osteonecrosis of the Femoral Head (ONFH) only requires plain radiographs and magnetic resonance imaging (MRI) to diagnose and stage ONFH; however, the effectiveness of the 2019 ARCO criteria in the absence of computed tomography (CT) scans has not been investigated. Therefore, the purpose of this study was to evaluate whether CT scanning is a necessary modality for diagnosing/staging ONFH using the ARCO staging system. More specifically, do CT scans help differentiate pre- and post-collapse lesions more than MRI scans? Methods: A study was conducted on 228 ONFH patients diagnosed between January 1, 2008, and December 31, 2018, at a single academic medical center. CT and MRI scans were reviewed by the senior author and other contributors. The ONFH classification was compared between the 2 scans to determine if CT scans were able to further differentiate staging of collapsed lesions vs MRI scans. Results: A diagnosis of ONFH was made by MRI first in 57% (129/228) while 21% (48/228) used MRI and CT simultaneously. Only 22% (51/228) of cases were diagnosed by CT scans first. There were no cases where collapse was found by a CT scan that were not diagnosed by standard x-rays and/or MRIs. Conclusions: CT scans are not a useful adjunct for diagnosing or treating ONFH and are not necessary if MRI is ordered when using the Revised ARCO Staging System for ONFH diagnosis.

Survival analyses and their applications in orthopaedics.

Survival analyses are a powerful statistical tool used to analyse data when the outcome of interest involves the time until an event. There is an array of models fit for this goal; however, there are subtle differences in assumptions, as well as a number of pitfalls, that can lead to biased results if researchers are unaware of the subtleties. As larger amounts of data become available, and more survival analyses are published every year, it is important that healthcare professionals understand how to evaluate these models and apply them into their practice. Therefore, the purpose of this study was to present an overview of survival analyses, including required assumptions and important pitfalls, as well as examples of their use within orthopaedic surgery.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes.

Background: The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament. Purpose: To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique. Study Design: Case series; Level of evidence, 4. Methods: The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs. Results: A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively. Conclusion: Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Trends in Outpatient Cervical Spine Surgery: Are There Emerging Disparities?

STUDY DESIGN: Retrospective analysis on prospectively collected data. OBJECTIVE: The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time. SUMMARY OF BACKGROUND DATA: Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist. METHODS: A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities. RESULTS: Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients ( P <0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR ( e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses. CONCLUSIONS: To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.

Association Between Surgical Opioid Prescriptions and Opioid Initiation by Opioid-naïve Spouses.

OBJECTIVE: To determine whether surgical opioid prescriptions are associated with increased risk of opioid initiation by operative patients' spouses. SUMMARY OF BACKGROUND DATA: Adverse effects of surgical opioids on operative patients have been well described. Whether risks of surgical opioids extend to operative patients' family members is unknown. METHODS: This was a retrospective cohort study of opioid-naïve, married patients undergoing 1 of 11 common surgeries from January 1, 2011 to June 30, 2017. The adjusted association between surgical opioid prescriptions and opioid initiation by the operative patient's spouse in the 6-months after surgery was assessed. Secondary analyses assessed how this association varied with postoperative time. RESULTS: There were 318,022 patients (mean ± standard deviation age 48.8 ±9.3 years; 49.5% women). Among the 50,833 (16.0%) patients that did not fill a surgical opioid prescription, 2152 (4.2%) had spouses who filled an opioid prescription within 6-months of their surgery. In comparison, among the 267,189 (84.0%) patients who filled a surgical opioid prescription, 15,026 (5.6%) had spouses who filled opioid prescriptions within 6-months of their surgery [unadjusted P < 0.001; adjusted odds ratio (aOR) 1.37, 95% confidence interval (CI) 1.31-1.43, P < 0.001]. Associated risks were only mildly elevated in postoperative month 1 (aOR 1.11, 95% CI 1.00-1.23, P = 0.04) before increasing to a peak in postoperative month 3 (aOR 1.57,95% CI 1.391.76, P < 0.001). CONCLUSIONS: Surgical opioid prescriptions were associated with increased risk of opioid initiation by spouses of operative patients, suggesting that risks associated with surgical opioids may extend beyond the surgical patient. These findings may highlight the importance of preoperative counseling on safe opioid use, storage, and disposal for both patients and their partners.

Evidence-Based Hamstring Injury Prevention and Risk Factor Management: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Hamstring injuries are common among athletes. Considering the potentially prolonged recovery and high rate of recurrence, effective methods of prevention and risk factor management are of great interest to athletes, trainers, coaches, and therapists, with substantial competitive and financial implications. PURPOSE: To systematically review the literature concerning evidence-based hamstring training and quantitatively assess the effectiveness of training programs in (1) reducing injury incidence and (2) managing injury risk factors. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 1. METHODS: A computerized search of MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, and SPORTDiscus with manual screening of selected reference lists was performed in October 2020. Randomized controlled trials investigating methods of hamstring injury prevention and risk factor management in recreational, semiprofessional, and professional adult athletes were included. RESULTS: Of 2602 articles identified, 108 were included. Eccentric training reduced the incidence of hamstring injury by 56.8% to 70.0%. Concentric hamstring strength increased with eccentric (mean difference [MD], 14.29 N·m; 95% CI, 8.53-20.05 N·m), concentric, blood flow-restricted, whole-body vibration, heavy back squat, FIFA 11+ (Fédération Internationale de Football Association), and plyometric training methods, whereas eccentric strength benefited from eccentric (MD, 26.94 N·m; 95% CI, 15.59-38.30 N·m), concentric, and plyometric training. Static stretching produced greater flexibility gains (MD, 10.89°; 95% CI, 8.92°-12.86°) than proprioceptive neuromuscular facilitation (MD, 9.73°; 95% CI, 6.53°-12.93°) and dynamic stretching (MD, 6.25°; 95% CI, 2.84°-9.66°), although the effects of static techniques were more transient. Fascicle length increased with eccentric (MD, 0.90 cm; 95% CI, 0.53-1.27 cm) and sprint training and decreased with concentric training. Although the conventional hamstring/quadriceps (H/Q) ratio was unchanged (MD, 0.03; 95% CI, -0.01 to 0.06), the functional H/Q ratio significantly improved with eccentric training (MD, 0.10; 95% CI, 0.03-0.16). In addition, eccentric training reduced limb strength asymmetry, while H/Q ratio and flexibility imbalances were normalized via resistance training and static stretching. CONCLUSION: Several strategies exist to prevent hamstring injury and address known risk factors. Eccentric strengthening reduces injury incidence and improves hamstring strength, fascicle length, H/Q ratio, and limb asymmetry, while stretching-based interventions can be implemented to improve flexibility. These results provide valuable insights to athletes, trainers, coaches, and therapists seeking to optimize hamstring training and prevent injury.

Multivariable regression: understanding one of medicine's most fundamental statistical tools.

Multivariable regression is a fundamental tool that drives observational research in orthopaedic surgery. However, regression analyses are not always implemented correctly. This study presents a basic overview of regression analyses and reviews frequent points of confusion. Topics include linear, logistic, and time-to-event regressions, causal inference, confounders, overfitting, missing data, multicollinearity, interactions, and key differences between multivariable versus multivariate regression. The goal is to provide clarity regarding the use and interpretation of multivariable analyses for those attempting to increase their statistical literacy in orthopaedic research.

Complications and predictors of morbidity for hip fracture surgery in patients with chronic liver disease.

BACKGROUND: Despite the fact that patients with chronic liver disease (CLD) are at increased risk of complications after a fracture of the hip, there remains little information about the risk factors for acute postoperative complications and their overall outcome.The aim of this study was to describe inpatient postoperative complications and identify predictors of postoperative morbidity. METHODS: Patients with CLD who had been treated for a fracture of the hip between April 2005 and August 2019 were identified from a retrospective search of an intramural trauma registry based in the Northeastern United States. Medical records were reviewed for baseline demographics, preoperative laboratory investigations, and outcomes. RESULTS: The trauma registry contained 110 patients with CLD who had undergone surgery for a fracture of the hip. Of these, patients with a platelet-count of ⩽100,000/µL were 3.81 (95% CI, 1.59-9.12) times more likely to receive a transfusion than those with a platelet-count of >100,000/µL. Those with a Model for End-stage Liver Disease (MELD) score of >9 were 5.54 (2.33-13.16) times more likely to receive a transfusion and 3.97 (1.06-14.81) times more likely to develop postoperative delirium than those with a MELD score of ⩽9.Of patients without chronic kidney disease, those with a creatinine of ⩾1.2 mg/dL were 6.80 (1.79-25.87) times more likely to develop acute renal failure (ARF) than those with a creatinine of <1.2 mg/dL. In a multivariable model, as MELD score was increased, the odds of developing a composite postoperative complication, which included transfusion, ARF, delirium, or deep wound infection, were 1.29 (1.01-1.66). Other tools used to assess surgical risks, Charlson Comorbidity Index, Elixhauser, and American Society of Anesthesiologist scores, were not predictive. CONCLUSIONS: Patients with CLD who undergo surgery for a hip fracture have a high rate of postoperative complications which can be predicted by the preoperative laboratory investigations identified in this study and MELD scores, but not by other common comorbidity indices.

Racial and Ethnic Disparities in Total Joint Arthroplasty Care: A Contemporary Systematic Review and Meta-Analysis.

BACKGROUND: Total joint arthroplasty (TJA) is one of the most common surgical procedures in the United States; however, racial and ethnic disparities in utilizations and outcomes have been well documented. This systematic review and meta-analysis investigated associations between race/ethnicity and several metrics in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: In August 2021, PubMed, Scopus, CINAHL, and SPORTDiscus databases were queried. Sixty three studies investigating racial/ethnic disparities in TJA utilizations, complications, mortalities, lengths of stay (LOS), discharge dispositions, readmissions, and reoperations were included. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS: A majority of studies demonstrated disparities in TJA utilizations and outcomes. Black patients exhibited higher rates of 30-day complications (THA odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.29; TKA OR 1.20, 95% CI 1.10-1.31), 30-day mortality (THA OR 1.27, 95% CI 1.08-1.48), prolonged LOS (THA mean difference [MD] +0.27 days, 95% CI 0.21-0.33; TKA MD +0.30 days, 95% CI 0.20-0.40), nonhome discharges (THA OR 1.47, 95% CI 1.37-1.57; TKA OR 1.65, 95% CI 1.38-1.96), and 30-day readmissions (THA OR 1.13, 95% CI 1.08-1.19; TKA OR 1.19, 95% CI 1.16-1.21) than White patients. Rates of complications (THA 1.18, 95% CI 1.03-1.36), prolonged LOS (TKA MD +0.20 days, 95% CI 0.17-0.23), and nonhome discharges (THA OR 1.26, 95% CI 1.10-1.45; TKA OR 1.37, 95% CI 1.22-1.53) were also increased among Hispanic patients, while Asian patients experienced longer LOS (TKA MD +0.09 days, 95% CI 0.05-0.12) but fewer readmissions. Outcomes among American Indian-Alaska Native and Pacific Islander patients were infrequently reported but similarly inequitable. CONCLUSION: Racial and ethnic disparities in TJA utilizations and outcomes are apparent, with minority patients often demonstrating lower rates of utilizations and worse postoperative outcomes than White patients. Continued research is needed to evaluate the efficacy of recent efforts dedicated to eliminating inequalities in TJA care. LEVEL OF EVIDENCE: IV.

Same-Day Discharge Total Knee Arthroplasty in Octogenarians.

BACKGROUND: One of the most important aspects of the transition to outpatient (OP) arthroplasty is patient selection, with guidance traditionally recommending that OP total knee arthroplasty (TKA) be reserved for patients <80 years old. However, there are limited data as to whether older age should really be considered a contraindication to OP-TKA. The purpose of this study is to assess the risk of complications and readmissions following OP-TKA in patients ≥80 years old. METHODS: This is a retrospective, propensity-matched cohort study of the National Surgical Quality Improvement Program database from 2011 to 2019. Patients ≥80 years undergoing OP (same-day discharge) TKA were propensity matched to patients ≥80 years undergoing inpatient (IP) TKA based on age, gender, race, body mass index, American Society of Anesthesiologists classification, functional status, smoking status, anesthetic type, and medical comorbidities. There were 1,418 patients (709 IPs and 709 OPs) included. All baseline factors were successfully matched between IP-TKA versus OP-TKA (P ≥ .18 for all). Thirty-day complications, readmissions, reoperations, and mortality were subsequently analyzed. RESULTS: Thirty-day readmission rates were identical between patients undergoing IP-TKA and OP-TKA (3.5% versus 3.5%, P = 1.0). Similarly, there was no significant difference in the incidence of major complications (2.7% versus 2.0%, P = .38), reoperations (1.3% versus 0.8%, P = .44), or mortalities (0.3% versus 0.3%, P = 1.0) within 30 days. CONCLUSION: Octogenarians undergoing OP-TKA had comparable complication rates to similar patients undergoing IP-TKA. OP-TKA can be performed safely in select octogenarians and age ≥80 years likely does not need to be a uniform contraindication to OP-TKA.

Inappropriate prescribing of opioids for patients undergoing surgery.

In response to the opioid epidemic in the United States, states have passed policies aimed at regulating how opioids are prescribed by physicians. For such policies to be effective, however, opioids must be prescribed to the patients for whom they are intended. Whether opioid prescriptions are written for those who are not intended to consume them is empirically difficult to show. In a commercially insured population, we examined opioid prescriptions written for and filled by spouses of patients undergoing outpatient surgery on the day of a patient's surgery compared with the surrounding days. Because patients may be unable to fill prescriptions themselves immediately after surgery, surgeons may prescribe opioids to a patient's spouse, which would be clinically inappropriate. Among 450,125 opioid-naïve couples studied, for patients who did not fill perioperative opioid prescriptions themselves, the rate of spousal fills on the day of surgery (DOS) was 2.39 fills per 1,000 surgeries compared with 0.44 fills on all other perioperative days (adjusted odds ratio (aOR), 5.5, 95% CI, 4.6-6.5). Increases in spousal opioid fills were not present for patients that filled opioid prescriptions themselves. These findings suggest intentional, clinically inappropriate prescribing of opioids.

Comparative Outcomes and Surgical Timing for Operative Fragility Hip Fracture Patients during the COVID-19 Pandemic: A Retrospective Cohort Study.

The COVID-19 pandemic had wide-reaching effects on healthcare delivery, including care for hip fractures, a common injury among older adults. This study characterized factors related to surgical timing and outcomes, length-of-stay, and discharge disposition among patients treated for operative hip fractures during the first wave of the COVID-19 pandemic, compared to historical controls. A retrospective, observational cohort study was conducted from 16 March-20 May 2020 with a consecutive series of 64 operative fragility hip fracture patients at three tertiary academic medical centers. Historical controls were matched based on sex, surgical procedure, age, and comorbidities. Primary outcomes included 30-day mortality and time-to-surgery. Secondary outcomes included 30-day postoperative complications, length-of-stay, discharge disposition, and time to obtain a COVID-19 test result. There was no difference in 30-day mortality, complication rates, length-of-stay, anesthesia type, or time-to-surgery, despite a mean time to obtain a final preoperative COVID-19 test result of 17.6 h in the study group. Notably, 23.8% of patients were discharged to home during the COVID-19 pandemic, compared to 4.8% among controls (p = 0.003). On average, patients received surgical care within 48 h of arrival during the COVID-19 pandemic. More patients were discharged to home rather than a facility with no change in complications, suggesting an opportunity for increased discharge to home.

Arthroscopic Acetabular Labral Repair Versus Labral Debridement: Long-term Survivorship and Functional Outcomes.

Background: Arthroscopic treatment for labral tears includes debridement and repair. Long-term studies have failed to demonstrate a difference between these treatments in terms of conversion to total hip arthroplasty (THA). Purpose: To investigate 2 different labral treatments, debridement and repair, using an adjusted analysis to evaluate long-term conversion to THA. Study Design: Cohort study; Level of evidence, 3. Methods: This was a retrospective cohort study of patients who underwent hip arthroscopy by a single surgeon between April 2007 and October 2014. Postoperative follow-up information included conversion to THA, patient satisfaction, and patient-reported outcome measures (modified Harris Hip Score; Hip Outcome Score, Activities of Daily Living and Sports Specific subscales; International Hip Outcome Tool; Nonarthritic Hip Score; and Lower Extremity Functional Scale). Results: Of the 204 hips included in the study, 99 (48.5%) underwent labral repair, and 105 (51.5%) underwent debridement. In total, 28 (13.7%) of the 204 patients underwent conversion to THA within 10 years after hip arthroscopy (labral repair: 5 [5.0%] vs labral debridement: 23 [21.9%]). Labral repair was associated with a significantly lower risk of conversion to THA compared with debridement (hazard ratio [HR] = 0.24; 95% CI, 0.07-0.74; P = .014). Additional factors associated with risk of conversion to THA included older age at the time of arthroscopy (HR = 1.06 per year; 95% CI, 1.02-1.11; P = .002) and Tönnis grade (HR = 2.39; CI, 1.14-5.41; P = .026). Abrasion chondroplasty, acetabuloplasty, body mass index, Outerbridge grade, and radiographic femoroacetabular impingement were not found to be significantly associated with risk of THA. No significant difference in patient satisfaction was found between treatment groups, and for patients who did not convert to THA, there was no difference in mean patient-reported outcome scores at final follow-up. Conclusion: Patients who underwent labral repair were less likely to convert to THA compared with patients who underwent labral debridement, despite adjustment for differences in baseline patient characteristics and preexisting pathology. Additional factors associated with a lower rate of hip survival were older age and osteoarthritis at the time of hip arthroscopy.

Optimizing Spinal Anesthesia in Same-Day Discharge Knee Arthroplasty Patients: Mepivacaine Versus Ropivacaine.

BACKGROUND: Short-acting spinal anesthetics are playing an increasing role in same-day discharge total joint arthroplasty though their direct comparison remains to be studied. Therefore, this study aims to compare two formulations of spinal anesthesia regarding time to discharge following knee arthroplasty surgery. METHODS: A retrospective study was performed on 207 patients who underwent unicompartmental knee arthroplasty (UKA, n = 172) and total knee arthroplasty (TKA, n = 35) from May 2018 to December 2020 at a single institution and were discharged the same day. Two formulations of the spinal anesthetic were routinely administered in this population: 1) mepivacaine 1.5% 3-4 mL (n = 184) and 2) ropivacaine 0.5% 2.3-2.7 mL (n = 23). Discharge times were subsequently compared between mepivacaine and ropivacaine spinal anesthesia for each surgical procedure and between surgical procedures. RESULTS: There was no significant difference in discharge times between patients receiving mepivacaine versus ropivacaine for UKA (202 minutes [range = 54-449] versus 218 minutes [range = 175-385], P = .45) or TKA (193 minutes [range = 68-384] versus 196 minutes [range = 68-412], P = .93). Similarly, no difference was found in discharge times between UKA and TKA patients receiving mepivacaine (P = .68) or ropivacaine (P = .51). CONCLUSION: There was no significant difference in discharge times between anesthetic agents among knee surgery patients. Therefore, either agent may be recommended for same-day discharge.

Synovial Fluid and Serum Neutrophil-to-Lymphocyte Ratio: Novel Biomarkers for the Diagnosis and Prognosis of Native Septic Arthritis in Adults.

BACKGROUND: Septic arthritis (SA) is a musculoskeletal emergency for which prompt diagnosis and treatment are critical. However, traditional diagnostic criteria of a synovial fluid (SF) white blood-cell count (WBC) of >50,000 cells/mm 3 or >90% polymorphonuclear leukocytes (%PMN) are not particularly sensitive or specific for the diagnosis of SA. Furthermore, prognostic markers are lacking. The purposes of this study were to assess the discriminative ability of the SF neutrophil-to-lymphocyte ratio (NLR) in the diagnosis of SA and of the serum NLR in the prognosis of SA. METHODS: A multi-institution, retrospective study of 598 patients with native shoulder, hip, or knee SA in 2000 to 2018 was conducted. SF-NLR was calculated from the arthrocentesis cell count with differential. Receiver operating characteristic curves were analyzed, and the optimal threshold of SF-NLR for SA diagnosis was determined using the Youden index. Results were compared with traditional SF diagnostic criteria. Similar analyses assessed the association of serum NLR with 90-day treatment failure and mortality for the subset of patients with confirmed hip or knee SA and with serum complete blood-cell counts with differentials (n = 235). Results were compared with traditional serum prognostic markers (WBC, C-reactive protein [CRP], and erythrocyte sedimentation rate [ESR]). RESULTS: The SF-NLR (area under the receiver operating characteristic curve [AUC], 0.85 [95% confidence interval (CI), 0.82 to 0.88]) was significantly more accurate for an SA diagnosis than SF-WBC (AUC, 0.80 [95% CI, 0.76 to 0.83]; p = 0.002) and SF-%PMN (AUC, 0.81 [95% CI, 0.77 to 0.84]; p = 0.01). The optimal threshold of SF-NLR was 25 (78% sensitivity and 81% specificity), compared with >50,000 cells/mm 3 for SF-WBC (56% sensitivity and 80% specificity) and >90% for SF-%PMN (65% sensitivity and 78% specificity). Elevated serum NLR was independently associated with 90-day treatment failure (odds ratio [OR], 7.04 [95% CI, 3.78 to 13.14]; p < 0.001) and mortality (OR, 7.33 [95% CI, 2.00 to 26.92]; p = 0.003); elevated serum WBC and CRP were also associated with treatment failure, and WBC, CRP, and ESR were not associated with mortality. CONCLUSIONS: This study provides compelling data on the superior diagnostic and prognostic ability of serum NLR and SF-NLR for SA compared with current clinical standards. Given that this biomarker requires no additional cost or time to return than current laboratory tests already being performed, pending validation, it can readily be used to aid clinicians in the diagnosis and prognostication of SA. LEVEL OF EVIDENCE: Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Comparison of perioperative complications following surgical treatment of shoulder instability.

Background: Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow. Methods: This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time. Results: This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P trend < .001). Conclusion: In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.