Growth Arrest in Type IV Osteogenesis Imperfecta After Fassier-Duval Rod Insertion Treated by a Lengthening Magnetic Intramedullary Nail: A Case Report.

CASE: A child with Type IV Osteogenesis Imperfecta (OI) sustained a growth arrest of the distal femur after fixation of a left femur fracture with a Fassier-Duval expanding rod at 3 years old. Despite bar resection with fat interposition, the discrepancy progressed to 7.5 cm at maturity. Because the femur had grown to a sufficient diameter, he underwent successful lengthening with a magnetic intramedullary rod. CONCLUSION: Although it is a potential complication, growth arrest has not been reported in association with placement of an expanding nail in a child with osteogenesis imperfecta. This case illustrates this rare complication and treatment using a magnetic intramedullary rod.

Cost Analysis of Conversion Total Knee Arthroplasty: A Multi-Institutional Database Study.

BACKGROUND: Total knee arthroplasty (TKA) after prior knee surgery, also known as conversion TKA (convTKA), has been associated with higher complications, resource utilization, time, and effort. The increased surgical complexity of convTKA may not be reflected by the relative value units (RVUs) assigned under the current U.S. coding guidelines. The purpose of this study was to compare the RVUs of primary TKA and convTKA and to calculate the RVU per minute to account for work effort. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was analyzed for the years 2005 to 2020. Current Procedural Terminology (CPT) code 27447 alone was used to identify patients who underwent primary TKA, and 27447 plus 20680 were used to identify convTKA. After 1:1 propensity score matching, 1,600 cases were assigned to each cohort. The 2023 Medicare Physician Fee Schedule RVU-to-dollar conversion factor from the U.S. Centers for Medicare & Medicaid Services (CMS) was used to calculate RVU dollar valuations per operative time. Complication rates were compared using a multivariate logistic regression model controlling for baseline characteristics. RESULTS: The mean operative time for TKA was 97.8 minutes, with a corresponding RVU per minute of 0.25, while the mean operative time for convTKA was 124.3 minutes, with an RVU per minute of 0.19 (p < 0.0001). Using the conversion factor of $33.06 per RVU, this equated to $8.11 per minute for TKA versus $6.39 per minute for convTKA. ConvTKA was associated with higher overall complication (10.9% versus 6.5%, p < 0.0001), blood transfusion (6.6% versus 3.7%, p < 0.01), reoperation (2.3% versus 0.94%, p < 0.0001), and readmission (3.7% versus 1.8%, p < 0.001) rates. CONCLUSIONS: The current billing guidelines lead to lower compensation for convTKA despite its increased complexity. The longer operative time, higher complication rate, and increased resource utilization may incentivize providers to avoid performing this operation. CPT code revaluation is warranted to reflect the time and effort associated with this procedure. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Total Knee and Hip Arthroplasty in Patients With Perioperative Thrombocytopenia.

BACKGROUND: Thrombocytopenia is an abnormally low level of blood platelets (less than 150,000/mL) resulting in an increased risk for bleeding. Typically, patients with platelet levels below 50,000/mL should delay arthroplasty or be transfused with platelets before surgery. However, existing studies are mixed regarding the effects of more moderate thrombocytopenia in terms of total knee and hip arthroplasty outcomes. METHODS: This level III retrospective chart review examined the effects of different severities of preoperative thrombocytopenia on length of hospitalization, readmission, and transfusion rates in 5,617 primary total knee and hip arthroplasties at one tertiary academic medical center. Preoperative platelet levels were sectioned into clinically relevant groups and compared with clinical outcomes using univariable and multivariable models. RESULTS: On univariate analysis, having platelet levels of <100,000/mL and 100 to 149,000/mL was associated with a longer length of stay. However, after controlling individual demographics, there was no association between platelet levels and length of stay, nor with 30-day readmission. Finally, on univariate analysis, patients with platelet levels of <100,000/mL and 100 to 149,000/mL were more likely to have a blood transfusion, which remained true for those with <100,000/mL after controlling for individual demographics. CONCLUSIONS: Total hip and total knee arthroplasty are safe in patients with varying platelet levels and not associated with increased length of stay or 30-day readmission. However, patients with more severe thrombocytopenia are more likely to receive red blood cell transfusions than patients with milder thrombocytopenia.

Health Insurance Coverage and Survival Outcomes among Nasopharyngeal Carcinoma Patients: A SEER Retrospective Analysis.

Objectives Insurance coverage plays a critical role in head and neck cancer care. This retrospective study examines how insurance coverage affects nasopharyngeal carcinoma (NPC) survival in the United States using the Surveillance, Epidemiology, and End Results (SEER) program database. Design, Setting, and Participants A total of 2,278 patients aged 20 to 64 years according to the International Classification of Diseases for Oncology (ICD-O) codes C11.0-C11.9 and ICD-O histology codes 8070-8078 and 8080-8083 between 2007 and 2016 were included and grouped into privately insured, Medicaid, and uninsured groups. Log-rank test and multivariable Cox's proportional hazard model were performed. Main Outcome Measures Tumor stage, age, sex, race, marital status, disease stage, year of diagnosis, median household county income, and disease-specific survival outcomes including cause of death were analyzed. Results Across all tumor stages, privately insured patients had a 59.0% lower mortality risk than uninsured patients (hazard ratio [HR]: 0.410, 95% confidence interval [CI]: [0.320, 0.526], p < 0.01). Medicaid patients were also estimated to have 19.0% lower mortality than uninsured patients (HR: 0.810, 95% CI: [0.626, 1.048], p = 0.108). Privately insured patients with regional and distant NPC had significantly better survival outcomes compared with uninsured individuals. Localized tumors did not show any association between survival and type of insurance coverage. Conclusion Privately insured individuals had significantly better survival outcomes than uninsured or Medicaid patients, a trend that was preserved after accounting for tumor grade, demographic and clinicopathologic factors. These results underscore the difference in survival outcomes when comparing privately insured to Medicaid/uninsured populations and warrant further investigation in efforts for health care reform.

Embolization in Juvenile Nasopharyngeal Angiofibroma Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare outcomes of juvenile nasopharyngeal angiofibroma (JNA) resection between embolized and non-embolized cohorts, and between transarterial embolization (TAE) and direct puncture embolization (DPE). DATA SOURCES: Per PRISMA guidelines, PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched for publications prior to or in 2021. MATERIALS AND METHODS: Original English manuscripts investigating the resection of JNA with and without preoperative embolization were included. Embolization type, recurrence rate, complication rates, blood loss, and transfusions were extracted. Risk of bias was assessed by the Risk of Bias in Non-randomized Studies-of Interventions method. RESULTS: There were 61 studies with 917 patients included. Preoperative embolization was performed in 79.3% of patients. Of those embolized, 75.8% (N = 551) underwent TAE and 15.8% (N = 115) underwent DPE. JNA recurrence in embolized patients was lower than in non-embolized patients (9.3% vs. 14.4%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.35, 1.06). DPE resulted in lower rates of disease recurrence (0% vs. 9.5%; OR: 0.066, 95% CI: 0.016, 0.272) and complications (1.8% vs. 21.9%; OR: 0.07, 95% CI: 0.02, 0.3) than TAE. A random effects Bayesian model was performed to analyze the difference in mean blood loss in 6 studies that included both embolized and non-embolized patients. This analysis showed a mean reduction in blood loss of 798 mL in the embolized group. CONCLUSIONS: We found embolization decreases blood loss in JNA resection. DPE led to improved recurrence and complication rates when compared to TAE, but future prospective studies are needed to further evaluate which embolization technique can optimize outcomes in JNA. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1529-1539, 2023.

Determining the association of insurance coverage and survival outcomes in patients with olfactory neuroblastoma utilizing machine learning.

KEY POINTS: We use machine learning to examine health insurance and mortality in olfactory neuroblastoma. Private insurance significantly improved survival even after adjusting for confounders. The regression model also found no statistical difference between Medicare and no insurance.

Simultaneous Quantification of Ankle, Muscle, and Tendon Impedance in Humans.

OBJECTIVE: Regulating the impedance of our joints is essential for the effective control of posture and movement. The impedance of a joint is governed mainly by the mechanical properties of the muscle-tendon units spanning it. Many studies have quantified the net impedance of joints but not the specific contributions from the muscles and tendons. The inability to quantify both muscle and tendon impedance limits the ability to determine the causes underlying altered movement control associated with aging, neuromuscular injury, and other conditions that have different effects on muscle and tendon properties. Therefore, we developed a technique to quantify joint, muscle, and tendon impedance simultaneously and evaluated this technique at the human ankle. METHODS: We used a single degree of freedom actuator to deliver pseudorandom rotations to the ankle while measuring the corresponding torques. We simultaneously measured the displacement of the medial gastrocnemius muscle-tendon junction with B-mode ultrasound. From these experimental measurements, we were able to estimate ankle, muscle, and tendon impedance using non-parametric system identification. RESULTS: We validated our estimates by comparing them to previously reported measurements of muscle and tendon stiffness, the position-dependent component of impedance, to demonstrate that our technique generates reliable estimates of these properties. CONCLUSION: Our approach can be used to clarify the respective contributions from the muscle and tendon to the net mechanics of a joint. SIGNIFICANCE: This is a critical step forward in the ultimate goal of understanding how muscles and tendons govern ankle impedance during posture and movement.

Pulmonary Parenchymal Changes in COVID-19 Survivors.

BACKGROUND: As the COVID-19 pandemic moves into the survivorship phase, questions regarding long-term lung damage remain unanswered. Previous histopathologic studies are limited to autopsy reports. We studied lung specimens from COVID-19 survivors who underwent elective lung resections to determine whether postacute histopathologic changes are present. METHODS: This multicenter observational study included 11 adult COVID-19 survivors who had recovered but subsequently underwent unrelated elective lung resection for indeterminate lung nodules or lung cancer. We compared these against an age- and procedure-matched control group who never contracted COVID-19 (n = 5) and an end-stage COVID-19 group (n = 3). A blinded pulmonary pathologist examined the lung parenchyma focusing on 4 compartments: airways, alveoli, interstitium, and vasculature. RESULTS: Elective lung resection was performed in 11 COVID-19 survivors with asymptomatic (n = 4), moderate (n = 4), and severe (n = 3) COVID-19 infections at a median 68.5 days (range 24-142 days) after the COVID-19 diagnosis. The most common operation was lobectomy (75%). Histopathologic examination identified no differences between the lung parenchyma of COVID-19 survivors and controls across all compartments examined. Conversely, patients in the end-stage COVID-19 group showed fibrotic diffuse alveolar damage with intra-alveolar macrophages, organizing pneumonia, and focal interstitial emphysema. CONCLUSIONS: In this study to examine the lung parenchyma of COVID-19 survivors, we did not find distinct postacute histopathologic changes to suggest permanent pulmonary damage. These results are reassuring for COVID-19 survivors who recover and become asymptomatic.