Evaluation of Mid-term Outcomes Following Shoulder Hemiarthroplasty for Avascular Necrosis of the Humeral Head in Patients 40 Years and Younger.

In order to evaluate postoperative function and failure rates among younger patients undergoing hemiarthroplasty for humeral head avascular necrosis (AVN), data from patients < 40 years treated between December 2008 - January 2018 was retrospectively analyzed. Pain was assessed preoperatively and at final follow up using a visual analogue scale (VAS). The American Shoulder and Elbow Surgeons (ASES) standardized assessment, single assessment numeric evaluation (SANE) score, and patient satisfaction were assessed at final follow up, as well as surgical revision rates. In total, eight shoulders were included in the final analysis, with a follow up of 6.6 + 3.6 years. Analysis indicated a statistical improvement in VAS pain (p = 0.001), while comparison of postoperative function between surgical and non-surgical limbs did not demonstrate statistical differences in SANE or ASES averages (p > 0.05). At final follow up, 25% of patients expressed dissatisfaction; however, there were no cases of revision surgery. In conclusion, younger patients undergoing hemiarthroplasty for humeral head AVN experienced pain improvement and no revisions at short-to-mid-term follow up, but one-in-four indicated dissatisfaction. Level of evidence: IV, case series. (Journal of Surgical Orthopaedic Advances 32(2):118-121, 2023).

Tracking the evolution of CNS remyelinating lesion in mice with neutral red dye.

Animal models of central nervous system (CNS) demyelination, including toxin-induced focal demyelination and immune-mediated demyelination through experimental autoimmune encephalomyelitis (EAE), have provided valuable insights into the mechanisms of neuroinflammation and CNS remyelination. However, the ability to track changes in transcripts, proteins, and metabolites, as well as cellular populations during the evolution of a focal lesion, has remained challenging. Here, we developed a method to label CNS demyelinating lesions by the intraperitoneal injection of a vital dye, neutral red (NR), into mice before killing. We demonstrate that NR-labeled lesions can be easily identified on the intact spinal cord in both lysolecithin- and EAE-mediated demyelination models. Using fluorescence microscopy, we detected NR in activated macrophages/microglia and astrocytes, but not in oligodendrocytes present in lesions. Importantly, we successfully performed RT-qPCR, Western blot, flow cytometry, and mass spectrometry analysis of precisely dissected NR-labeled lesions at 5, 10, and 20 d postlesion (dpl) and found differential changes in transcripts, proteins, cell populations, and metabolites in lesions over the course of remyelination. Therefore, NR administration is a simple and powerful method to track and analyze the detailed molecular, cellular, and metabolic changes that occur within the lesion microenvironment over time following CNS injury. Furthermore, this method can be used to identify molecular and metabolic pathways that regulate neuroinflammation and remyelination and facilitate the development of therapies to promote repair in demyelinating disorders such as multiple sclerosis.

Editorial Commentary: The Evolution of Regional Anesthesia in Arthroscopic Rotator Cuff Repair: From Throbbing Shoulders to Paralyzed Diaphragms.

Rotator cuff repair may result in significant postoperative pain. Although opioids were once the gold standard, addiction and other side effects are of significant concern. Nonsteroidal anti-inflammatory drugs reduce pain, sleep disturbance, and need for opioids, but they may impair soft tissue healing. The use of gabapentinoids is equivocal. Intralesional analgesia carries a risk of glenohumeral chondrolysis. Cryotherapy is beneficial, but it is often not covered by insurance companies. Suprascapular nerve block addresses innervation of only 70% versus interscalene block, but the latter has a higher incidence of unintended, temporary motor and sensory deficits of the upper extremity and hemidiaphragmatic paresis, despite similar pain scores. Although neurodeficits and diaphragmatic hemiparesis resolve by 3 weeks, temporary complications affect length of hospital stay, initiation of physical therapy, and patient satisfaction. These variables contribute to the challenge of postoperative pain control amid a growing wave of modalities aimed at improving the extent and duration of patient-focused analgesia, especially the application of continuous block infusions.

Influence of Prior Hip Salvage Surgery on Outcomes After Total Hip Arthroplasty in Young Patients.

BACKGROUND: As the indications for total hip arthroplasty (THA) have expanded, this procedure is being increasingly performed in young patients. Oftentimes, this population has undergone one or more salvage procedures in an attempt to delay or forestall a THA. However, it is unclear whether patients with prior salvage procedure have higher risk of adverse events. METHODS: From 2004 to 2014, 215 THAs performed in patients less than 30 years at a single institution were identified. These patients were screened to identify 37 THAs in which one or more salvage procedures were performed prior to the THA (salvage group). The prior salvage procedures were open in 30 (pelvic osteotomy = 5, femoral osteotomy = 15, combined osteotomy = 2, core decompression = 7, bone graft = 1) and arthroscopic in 7. Medical and surgical complications within 90 days and overall survivorship at a minimum follow-up of 2 years were recorded. Nonparametric tests and Kaplan-Meier survival curves were used to compare the groups. RESULTS: Salvage group had a higher rate of wound complications (P = .037), superficial infections (P = .005), and reoperations (P = .015). The 5-year survivorships in the salvage and nonsalvage groups were 97.1% and 96.7%, respectively (P = .787). CONCLUSION: Patients less than 30 years who undergo THA after a previous salvage procedure have a higher risk of wound complications, superficial infections, and reoperations, but similar survivorship, compared to those who did not have any prior salvage procedures. This information is helpful in counseling young patients while offering various surgical options for the management of various hip pathologies.

Success of Two-Stage Reimplantation in Patients Requiring an Interim Spacer Exchange.

BACKGROUND: Some patients undergoing a 2-stage revision for a periprosthetic joint infection require a repeat spacer in the interim (removal of existing spacer with insertion of a new spacer or spacer exchange) due to persistent infection. The objectives of this study are to (1) determine the factors associated with patients who receive a repeat spacer and (2) compare the infection-free survival (overall and stratified by joint type) of reimplantation in patients who did or did not receive a repeat spacer. METHODS: From 2001 to 2014, 347 hip or knee 2-stage revisions that finally underwent reimplantation and had a minimum 2-year follow-up were identified. An interim spacer exchange was performed in 59 (17%) patients (exchange cohort). Patient-related and organism-related factors were compared between the exchange and non-exchange cohorts. Kaplan-Meier survival curves were performed to assess the success (absence of signs of infection, reoperation for infection, periprosthetic joint infection-related mortality) of both cohorts. RESULTS: Patients in the exchange group had higher comorbidity score (P = .020), prolonged time to reimplantation (P < .001), and higher prevalence of resistant organisms, though not statistically significant (P = .091). The 5-year infection-free survival rates were 64% (knee 62%, hip 64%) in the exchange cohort, and 78% (knee 77%, hip 78%) in the non-exchange cohort (P = .020). CONCLUSIONS: Patients requiring an interim spacer exchange were found to have more comorbidities, prolonged treatment period, and were more likely to be infected with a resistant organism. About one-third of such patients became reinfected within 5 years compared to only one-fifth of the patients without an interim spacer exchange.

Changes in Antibiotic Susceptibility of Staphylococcus aureus Between the Stages of 2-Stage Revision Arthroplasty.

BACKGROUND: Staphylococcus aureus is the predominant cause of periprosthetic joint infection (PJI) and can persist at the time of planned second stage of 2-stage revision arthroplasty, despite antibiotic cement spacer insertion and parenteral antibiotic therapy. Given the rapid emergence of antibiotic resistance, it is important to determine whether the antibiotic susceptibility of microorganisms changes between the stages of a 2-stage revision. METHODS: A total of 1614 2-stage revision hip/knee arthroplasties performed for PJI at 2 academic institutions from 2000 to 2015 were identified. S aureus (methicillin susceptible and/or resistant) was isolated by culture in 402 (24.9%) cases during the first stage (resection arthroplasty). S aureus persisted and was cultured in 30 cases (knees = 18, hips = 12) during the second stage. Minimum inhibitory concentrations (MICs), demographics, antibiotic therapy, and surgical history were collected. The MICs at the time of the first-stage and second-stage surgeries were compared. RESULTS: Nine (30%) revisions had an increase in vancomycin MIC. Six had an increase from ≤0.5 to 1 µg/mL, 2 had an increase from ≤0.5 to 2 µg/mL, and 1 had an increase from 1 to 2 µg/mL. All of the 9 revisions with an increase in vancomycin MIC had vancomycin in spacer. CONCLUSION: Increases in the MICs were observed for vancomycin, the antibiotic widely used in cement spacers, in about one-third of the revisions. Despite the small sample size, the data from this preliminary study raise concern about the potential for emergence of resistant organisms between the stages of a 2-stage revision.

Adding Lateral Retinacular Release to Medial Patellofemoral Ligament Reconstruction Fails to Demonstrate Clinical Benefit Compared With Isolated Medial Patellofemoral Ligament Reconstruction.

Purpose: To compare functional outcomes and failure rates between medial patellofemoral ligament (MPFL) reconstructions with and without lateral retinacular release (LRR) at minimum 1-year follow up. Methods: A retrospective review identified consecutive patients from 2013 to 2019 at a single center who met all of the following inclusion criteria: at least 1 confirmed patellar dislocation, patellar tilt (evidenced by tight retinaculum on operative examination or patellar tilt on radiographs), underwent either MPFL reconstruction alone or combined with LRR, had available preoperative documentation and imaging, and were at least 1 year out of surgery. Patients were excluded if they had previous surgery to the ipsilateral limb or had any concomitant procedure performed. Demographics and preoperative imaging were evaluated. Failure rates and functional outcome scores were obtained including Kujala, Patient-Reported Outcomes Measurement Information System, International Knee Documentation Committee, Single Assessment Numeric Evaluation, and Knee injury and Osteoarthritis Outcome Scores. Clinical failure was defined as revision MPFL reconstruction on the affected knee or at least 1 instance of postoperative patellar dislocation. Results: A total of 18 patients underwent isolated MPFL reconstruction (mean follow-up = 29.3 ± 8.3 months, range = 15.1-42.8 months), and 31 underwent MPFL reconstruction combined with LRR (mean follow up = 36.0 ± 11.3 months, range = 14.0-51.9 months). At final follow-up, there were no statistical differences between the isolated MPFL and MPFL combined with LRR cohorts for any of the functional outcome scores (P > .05 for all). At the time of final follow-up, no patients who underwent isolated MPFL and 19.3% (n = 6) or patients undergoing MPFL combined with LRR experienced clinical failure (P = .073), as defined by subsequent patellar dislocation or revision MPFL reconstruction. Of these, 2 patients underwent revision MPFL reconstructions with distal tubercle transfer for borderline abnormal TT:TG (i.e., >15 mm). Conclusions: MPFL reconstruction surgery combined with LRR failed to demonstrate significantly different functional outcome scores and failure rates compared with isolated MPFL reconstruction at minimum 1-year follow up. In addition, there were no differences in rates of achieving MCID between both groups. Level of Evidence: Level III, retrospective cohort study.

Late-week Multilevel Anterior Cervical Discectomy and Fusion Associated with Increased Length of Stay.

STUDY DESIGN: Retrospective analysis of clinical data from a single institution. OBJECTIVE: To assess the day of surgery during the week as a possible predictor of length of stay (LOS) following anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Surgeries later in the week may result in longer LOS and higher costs for joint arthroplasty, yet this is unclear following spine surgery. Procedures performed later in the week may lead to weekend admissions when there are limited services that may contribute to an extended LOS. We attempt to identify associations between day of surgery and LOS, readmission, and complications following single- and multilevel ACDF. MATERIALS AND METHODS: Patients at a single institution undergoing ACDF by 7 primary surgeons in both orthopedic and neurosurgery spine departments between 2015 and 2019 were retrospectively reviewed. Patients were stratified by surgery day at either the beginning (Monday/Tuesday) or end (Thursday/Friday) of the week and by single- or multilevel ACDF. Surgery for trauma, infections, adjacent level disease, or revision were excluded. Patient demographics, Charlson Comorbidity Index (CCI), LOS, postoperative complications, and readmission rates were assessed. RESULTS: Six hundred fifty-two patients underwent ACDF. For single-level ACDF, 222 were reviewed, with 112 having surgery at the beginning and 110 at the end of the week. For multilevel ACDF, 431 were reviewed, with 192 having surgery at the beginning and 239 at the end of the week. No differences in pre- or postoperative variables were determined for single-level ACDF. Despite no differences in pre-operative variables, CCI, operative duration, or number of levels, late-week multilevel ACDF had longer average LOS (2.8±3.0 days) compared to early-week surgery (2.0±2.0 days) (P=0.018). CONCLUSIONS: Late-week multilevel ACDF was associated with an increased LOS, as it may prove beneficial to surgical planning. This conflicts with previous reports that day of week was not associated with LOS following ACDF. LEVEL OF EVIDENCE: III.

Increased risk of postoperative wound complications among obesity classes II & III after ALIF in 10-year ACS-NSQIP analysis of 10,934 cases.

BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) procedures for lumbar spine disease have been increasing amid a growing obese patient population with limited studies available focusing exclusively on risk-factors for post-operative ALIF complications. PURPOSE: The objective of this study was to compare 30-day post-operative complications among different obesity World Health Organization classes according to body mass index (BMI) in comparison to non-obese patients who underwent an ALIF procedure. STUDY DESIGN/SETTING: Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2009 to 2019. PATIENT SAMPLE: A total of 10,934 patients undergoing an ALIF. OUTCOME MEASURES: Primary outcome measures include 30 day cardiac, pulmonary, urinary, infectious, and wound complications. Secondary outcomes included rates of blood transfusion, reintubation, deep vein thrombosis, pulmonary embolism, 30-day return to the operating room (OR), and 30 day mortality. METHODS: Patients were identified by use of the current procedural terminology codes 22558 and 22585 from 2009 to 2019. Patients were divided into the following groups: non-obese (BMI 18.5-29.9 kg/m2), Obese I (BMI 30-34.9 kg/m2), Obese II (BMI 35-39.9 kg/m2), and Obese III (BMI ≥40 kg/m2). Age, gender, race, American Society of Anesthesiologists status, smoking status, hypertension requiring medication, steroid used, chronic obstructive pulmonary disease, history of a bleeding disorder, and diabetes was identified as risk factors after a univariate analysis conducted for demographic variables and pre-operative comorbidities. A multivariate logistic regression analysis was then performed to adjust for these preoperative risk factors and compare obesity classes I-III to non-obese patients. RESULTS: Obesity classes II and III had a significant odds ratio (OR) for superficial infection (OR:2.7, 95%CI(1.7-4.5); OR:2.8, 95%CI(1.5-5.2) respectively), organ space infection (OR:3.8, 95%CI(1.6-7.4); OR:3.2, 95%CI(1.1-9.9) respectively), wound disruption (OR:2.8, 95%CI(1.1-7.4); OR:4.6, 95%CI(1.6-13.6) respectively), and total wound complication (OR:2.6, 95%CI(1.8-3.9); OR:3.4, 95%CI(2.2-5.4) respectively) following a multivariate logistic regression analysis. CONCLUSIONS: Risk for post-operative wound complications following an ALIF were found to be significantly higher for obesity classes II-III in comparison to non-obese patients. These findings can further support the use of additional wound care in the perioperative setting for certain levels of obesity.

Current Resident and Faculty Mentorship Satisfaction and Important Mentee Functions in Orthopedic Surgery: An American Orthopedic Association North American Traveling Fellowship Project.

OBJECTIVE: While mentorship remains important in orthopedic training, few studies have delineated specific priorities for creating successful mentorship programs and reciprocal satisfaction among contemporary trainees and faculty. The purpose of this study was to define beneficial mentor qualities along with specific mentee characteristics to facilitate improved mentoring relationships in orthopedic surgery. DESIGN: This is a cross-sectional study with a 16 multi-item self-reported survey. SETTING: This study was conducted at 11 tertiary orthopedic surgery training programs during the 2017 American Orthopaedic Association (AOA) North American Traveling Fellowship Tour. PARTICIPANTS: Eighty orthopedic resident trainees and 90 academic faculty members completed the survey. RESULTS: Around 55.0% of residents and 48.9% of faculty acknowledged a formal mentorship program at their institution. Furthermore, 61.3% of residents and 61.1% of faculty reported having a current mentor. The top 3 qualities valued by residents were a mentor who modeled work-life balance, remained in touch with contemporary issues in training, and provided timely counseling. Faculty valued a mentor who accepted their goals and priorities, provided counseling, and enhanced exposure in their subspecialty. Surveyed faculty were more satisfied than their corresponding residents with how their mentor promoted them, enhanced their exposure, was a friend, and protected them from exploitative collaborations. Mentee participation was considered the most important variable for a successful mentor relationship, while mentee acknowledgement of their mentors was the least prioritized quality. CONCLUSIONS: Faculty had a higher overall satisfaction with their mentoring relationships in orthopedic surgery. Residents reported more favorable results when their mentor was a role model of work-life balance. For optimal success, mentors identified active participation and openness to feedback as the most important quality for a mentee to display. These qualities contribute to a heightened sense of satisfaction among mentors and mentees and can be utilized to further guide development of both formal and informal programs for residents and faculty.

Incidence and Characteristics of Osteoarticular Infections in Patients With Infective Endocarditis.

Osteoarticular infections (OAIs) in the setting of infective endocarditis (IE) are uncommon. Although morbidity and mortality have been widely studied, details of the characteristics of patients with concurrent IE and OAI are limited. Therefore, the purpose of this study was to determine the (1) incidence, (2) mortality, (3) clinical features, and (4) microbiological profiles of OAIs in the setting of IE. A retrospective review was conducted of 1280 IE cases at a large academic institution between 2009 and 2015. Patients were categorized according to the following OAI types: spondylodiskitis, large joint septic arthritis, other site infections, or multiple affected joints. Inpatient mortality rates, clinical findings, and microbiological characteristics were compared between OAI types. Overall, the incidence of OAI among IE patients was 6.8% (n=87). The in-hospital mortality rate was 9.2% (n=8) and was not significantly associated with OAI type (P=.801). Eighteen patients had multiple affected joints resulting in a total of 114 infected sites. Of these, 39% (n=44) were spondylodiskitis, 29% (n=33) were large joint septic arthritis, and 32% (n=37) were infections of smaller joints. Back pain was most common among patients with spondylodiskitis (P<.001), whereas fever and general fatigue were most common with septic arthritis (P<.001). Of the available bone/ joint cultures, 69% were positive. Overall, Staphylococcus aureus was the most common IE pathogen in patients with both IE and OAI (63%). Clinicians should maintain a high suspicion for OAI in patients with IE caused by Staphylococcus aureus, particularly spondylodiskitis among those presenting with back pain. [Orthopedics 2020; 43(1):24-29.].