Racial Differences in Patient Satisfaction With the Hospital Experience Undergoing Primary Unilateral Hip and Knee Arthroplasty: A Retrospective Study.

Background: Press Ganey (PG) inpatient survey is widely used to track patient satisfaction with the hospital experience. Our aim was to use the PG survey to determine if there are racial differences in overall hospital experience and perception of nurses and surgeons following hip and knee arthroplasty. Methods: We retrospectively analyzed Black and White patients from hip and knee arthroplasty registries from a single institution between July 2010 and February 2012. The overall assessment score for the hospital experience and perception of the nurse and surgeon questions from the PG inpatient survey were dichotomized as "not completely satisfied" or "completely satisfied". Multivariable logistic regression models were developed to determine the impact of race on the likelihood of being 'completely satisfied' in the hip and knee cohorts. Results: There were 2517 hip and 2114 knee patients who underwent surgery and completed the PG survey, of whom 3.9% were Black and 96.0% were White. Black patients were less likely to be completely satisfied with their hospital experience compared to White patients in the hip (odds ratio 0.62, confidence interval 0.39-1.00, P = .049) and knee (odds ratio 0.52, confidence interval 0.33-0.82, P = .005) cohorts. Black patients were also less likely to be completely satisfied with multiple aspects of care they received from the nurse and surgeon in both cohorts. Conclusions: We found that the PG Survey shows Black patients were less likely to be completely satisfied than White patients with the hospital experience, including their interactions with nurses and surgeons. More work is needed to understand this difference.

Black Patients are More Likely to Undergo Early Revision Total Knee Arthroplasty in a Matched Cohort Regardless of Surgeon Experience.

BACKGROUND: Black patients are at an increased risk of aseptic revision total knee arthroplasty (TKA) when compared to White patients. The goal of this study was to determine whether racial disparities in revision TKA risk are related to surgeon characteristics. METHODS: This was an observational cohort study. We used inpatient administrative data to identify Black patients who underwent unilateral primary TKA in New York State. There were 21,948 Black patients who were matched 1:1 to White patients on age, sex, ethnicity, and insurance type. The primary outcome was aseptic revision TKA within 2 years of primary TKA. We calculated annual surgeon TKA volume and identified surgeon characteristics such as training in North America, board certification, and years of experience. RESULTS: Black patients had a higher odds of aseptic revision TKA (odds ratio (OR) 1.32, 95% CI 1.12-1.54, P < .001) and were disproportionately cared for by low volume surgeons (≤12 TKA/year). The relationship between low volume surgeons and risk of aseptic revision was not statistically significant (OR 1.24, 95% CI 0.72-2.11, P = .436). The adjusted odds ratio (aOR) for aseptic revision TKA in Black versus White patients varied across surgeon/hospital TKA volume category pairs, with the greatest aOR when TKA were performed by the highest volume surgeons at the highest volume hospitals (aOR 2.8, 95% CI 0.98- 8.09, P = .055). CONCLUSION: Black patients were more likely to undergo aseptic TKA revision than matched White patients. This disparity was not explained by surgeon characteristics.

Blood management in direct anterior versus posterior primary total hip arthroplasty using tranexamic acid: a matched cohort study.

INTRODUCTION: Proponents of the direct anterior approach (DAA) for THA claim patients recover faster compared to primary THA through the posterior approach (PA). Blood loss and transfusion have substantially declined with the use of tranexamic acid (TXA). However, it is still controversial if hemoglobin drops and transfusion rates are affected by the surgical approach when TXA is routinely used. MATERIALS AND METHODS: 2418 patients undergoing DAA THA were matched 1:1 with patients undergoing PA THA according to preoperative hemoglobin (± 1 g/dl), age (± 5 years), sex, BMI (± 5 kg/m2) and year of surgery (± 2 years). All patients received perioperative TXA. None of the patients donated autologous blood. Hemoglobin levels, drain placement and output, blood transfusion rates and volume as well as length of stay were recorded. RESULTS: A closed suction drain was used in 121 (5.0%) DAA and in 135 (5.6%) PA THAs (p = 0.369). Mean drain output was higher in the DAA compared to the PA group (134 ml (0-520 ml) versus 92.3 ml (0-600 ml), p = 0.004). There was no difference in hemoglobin drop [2.6 g/dl versus 2.6 g/dl (p = 0.143)] and transfusion rate [n = 31 (1.3%) versus n = 29 (1.2%), p = 0.793)] between DAA and PA THA. Mean transfusion amounts were 421.8 ml (250-1120.8 ml) in the DAA and 353.9 ml (250-560 ml) in the PA group (p = 0.801). The length of stay was shorter in the DAA group with a mean 1.6 days versus 2.1 days in the PA group (p ≤ 0.001). CONCLUSION: In this large matched cohort study, there was no difference in the perioperative hemoglobin drop, the transfusion rate and the transfusion amount between DAA and PA THA.

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty.

BACKGROUND: Patient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA. RESULTS: In total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001). CONCLUSION: We found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.

Assessment of Racial Disparities in the Risks of Septic and Aseptic Revision Total Knee Replacements.

Importance: Black patients are at higher risk of revision total knee replacement (TKR) than White patients, but whether racial disparities exist for both septic and aseptic revision TKR and the reason for any disparities are unknown. Objective: To assess the risk of septic and aseptic revision TKR in Black and White patients and to examine interactions among race and socioeconomic and hospital-related variables that are associated with revision TKR risk. Design, Setting, and Participants: This cohort study included residents of New York, California, and Florida who underwent TKR. Patient-level data were obtained from the New York Statewide Planning and Research Cooperative System, California's Office of Statewide Health Planning and Development Patient Discharge Database, and Florida's Healthcare Utilization Project State Inpatient Database from January 1, 2004, to December 31, 2014. Community characteristics were calculated from the US Census and linked to discharges by patient zip code. American Hospital Association Annual Survey data were linked to discharges using hospital identifiers. The analyses were performed from March 1 to October 30, 2020, with subsequent analyses in April 2021. Main Outcomes and Measures: Cox proportional hazards regression modeling was used to measure the association of race with septic and aseptic revision TKR. Results: A total of 722 492 patients underwent primary TKR, of whom 445 616 (61.68%) were female and 61 092 (8.46%) were Black. Black patients were at higher risk of septic (hazard ratio [HR], 1.11; 95% CI, 1.03-1.20) and aseptic (HR, 1.39; 95% CI, 1.33-1.46) revision TKR compared with White patients. Other risk factors for septic revision TKR were diabetes (HR, 1.24; 95% CI, 1.17-1.30), obesity (HR, 1.13; 95% CI, 1.17-1.30), kidney disease (HR, 1.42; 95% CI, 1.29-1.57), chronic obstructive pulmonary disease (HR, 1.22; 95% CI, 1.15-1.30), inflammatory arthritis (HR, 1.53; 95% CI, 1.39-1.69), surgical site complications during the index TKR (HR, 2.19; 95% CI, 1.87-2.56), Medicaid insurance (HR, 1.17; 95% CI, 1.04-1.31), and low annual TKR volume at the hospital where the index TKR was performed (HR, 1.54; 95% CI, 1.41-1.68). Risk factors for aseptic revision TKR were male sex (HR, 1.03; 95% CI, 1.00-1.06), workers' compensation insurance (HR, 1.61; 95% CI, 1.51-1.72), and low hospital TKR volume (HR, 1.14; 95% CI, 1.07-1.22). Patients with obesity had a lower risk of aseptic TKR revision (HR, 0.81; 95% CI, 0.77-0.84). In an analysis within each category of hospital TKR volume, the HR for aseptic revision among Black vs White patients was 1.20 (95% CI, 1.04-1.37) at very-low-volume hospitals (≤89 TKRs annually) compared with 1.68 (95% CI, 1.48-1.90) at very-high-volume hospitals (≥645 TKRs annually). Conclusions and Relevance: In this cohort study, Black patients were at significantly higher risk of aseptic revision TKR and, to a lesser extent, septic revision TKR compared with White patients. Racial disparities in aseptic revision risk were greatest at hospitals with very high TKR volumes.

Periprosthetic Joint Infection Is Associated with an Increased Risk of Venous Thromboembolism Following Revision Total Knee Replacement: An Analysis of Administrative Discharge Data.

BACKGROUND: Little is known about the relationship between infection and the risk of risk of venous thromboembolism (VTE) following orthopaedic surgery. We assessed the 90-day risk of VTE following revision total knee replacement to measure the association between periprosthetic joint infection and the risk of postoperative VTE. METHODS: We used New York Statewide Planning and Research Cooperative System data to identify all New York State residents undergoing revision total knee replacement from 1998 to 2014. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes were used to identify comorbidities and to classify the indication for revision total knee replacement as aseptic, infection, or fracture. The primary outcome was any diagnosis code for VTE recorded for the revision surgery and/or subsequent admissions within 90 days. A multivariable logistic regression model that included demographic characteristics and comorbidities was used to estimate the risk of VTE after revision for infection or fracture, with aseptic revision as the reference group. RESULTS: The present study included 25,441 patients who were managed with revision total knee replacement; the indication for revision was aseptic for 17,563 patients (69%), infection for 7,075 (28%), and fracture for 803 (3%). The mean age (and standard deviation) was 66 ± 12 years, 15,592 (61%) of the patients were female, 3,198 (13%) were Black, 1,192 (5%) were smokers, and 4,222 (17%) were obese. Seven hundred and nineteen patients (2.8%) had VTE within the 90 days after revision total knee replacement, including 387 (1.5%) during the admission for the revision procedure. The 90-day incidence of VTE was 2.1% after aseptic revision, 4.3% after revision for infection, and 5.9% after revision for fracture. The adjusted odds ratio (aOR) for VTE relative to aseptic revision was 2.01 (95% confidence interval [CI], 1.72 to 2.35) for septic revision total knee replacement and 2.62 (95% CI, 1.91 to 3.6) for fracture. A history of VTE was also a strong risk factor for VTE following revision total knee replacement (aOR, 2.01; 95% CI, 1.48 to 2.71). CONCLUSIONS: We found that the odds of VTE after revision total knee replacement for infection were double those after aseptic revision total knee replacement. Although fracture accounts for a small percentage of revision total knee replacements, the risk of VTE was 2.6-fold higher after these procedures. The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of non-linear growth curve models in the Vietnamese indigenous Mia chicken.

Understanding of animal growth is important for the improvement of management and feeding practices; however, little is known about the growth curve in Vietnamese indigenous chicken. This study was performed to determine the most appropriate models for describing the growth curve of Vietnamese Mia chicken. The study evaluated the performances of the Logistic, Gompertz, Richards, and Bridges models of body weights in 224 Mia chickens. Models were fitted using minpack.lm package in R software and Akaike's information criterion and Bayesian information criterion were used for model comparison. Based on these criteria, the Gompertz and Bridges were the best models for males and females, respectively. Estimated asymmetric weights (α) were ranged from 2,241.91 ± 14.74 (g) (Logistic) to 2,623.86 ± 30.23 (g) (Gompertz) for males and from 1,537.36 ± 10.97 (g) (Logistic) and 1,958.36 ± 72.92 (g) (Bridges) for females, respectively. The age at the inflection point was estimated from 9.32 to 10.5 weeks and from 8.51 to 9.86 weeks for males and females, respectively. In conclusion, the Gompertz model is the most suitable model for describing the growth curve of Mia chicken. The parameters obtained from growth models could help define feeding programs to meet nutritional needs from hatching to the age of maximum growth, reproduction programs, and marketing strategies.

Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty.

BACKGROUND: Ankle distraction arthroplasty has emerged as an alternative treatment for ankle arthritis. There are few reports on the magnetic resonance imaging (MRI) findings after distraction arthroplasty. This study sought to determine whether there are positive changes on MRI after ankle distraction and improvements on X-ray. Additionally, patient-reported outcomes and joint range of motion (ROM) after ankle distraction are described. MATERIALS AND METHODS: Thirty-two patients (mean age 49 years) who underwent ankle distraction had pre-operative and one-year postoperative MRIs, which were graded using a modified whole-organ magnetic resonance imaging score (WORMS). Ankle joint space and ROM were measured. A non-validated three-item questionnaire was administered to assess functional outcomes. RESULTS: Although the anterior quadrant of the ankle showed a trend to improvement in cartilage morphology on the postoperative MRI, the WORMS did not demonstrate a significant difference in any of its subcategories. While reduction in joint osteophytes was observed and maintained short term, this was mainly due to resection intraoperatively. X-rays revealed a significant increase in joint space, and there was a significant increase in ankle dorsiflexion. Eight-seven percent of the patients were satisfied with their functional outcome. CONCLUSION: At short-term follow-up, MRI scores after ankle distraction arthroplasty did not demonstrate significant improvement despite positive changes on X-ray and improved clinical outcomes and ankle ROM. Further study on larger patient numbers with longer follow-up is required. LEVEL OF EVIDENCE: IV, Case Series. HOW TO CITE THIS ARTICLE: Haleem AM, Galal S, Nwawka OK, et al. Short-term Results of Magnetic Resonance Imaging after Ankle Distraction Arthroplasty. Strategies Trauma Limb Reconstr 2020;15(3):157-162.

Health State Utilities in Children and Adolescents With Osteochondritis Dissecans of the Knee.

BACKGROUND: The impact of osteochondritis dissecans (OCD) lesions of the knee on a child's health-related quality of life has not previously been quantified. Preference-based health utility assessment allows patients to assign quality-of-life valuations (utilities) to different health states and conditions. PURPOSE: To determine (1) patient-reported utility scores for health states associated with pediatric OCD lesions of the knee and (2) whether these scores are associated with patient demographics or disease severity. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Children, adolescents, and young adults being treated for OCD of the knee were interviewed to assess utilities for each of the 6 health states commonly encountered in the treatment of OCD: (1) symptomatic lesion, (2) nonoperative rehabilitation, (3) postoperative rehabilitation, (4) intermediate treatment success, (5) early degenerative knee changes, and (6) successful treatment (asymptomatic). Patients were asked to assign health utilities to each state using a standardized feeling thermometer (scale, 0-100), which were converted to a health state utility (scale, 0-1 [1 = perfect health]). Utilities were reported with descriptive statistics, and comparative analyses were performed to test whether assignments were associated with patient age, sex, or whether the OCD lesion required surgical intervention. RESULTS: A total of 100 participants treated or undergoing treatment for OCD were prospectively enrolled; 74% were male (n = 74). The median age at the time of survey was 15 years (interquartile range, 13-16.5 years). Utility scores were as follows: symptomatic OCD lesion, 0.15; nonoperative rehabilitation, 0.30; postoperative rehabilitation, 0.30; early degenerative changes, 0.58; intermediate treatment success, 0.65; and successful treatment, 1.0. Utility scores were not associated with age, sex, or whether the participant underwent surgical treatment for the OCD lesion. CONCLUSION: The current study quantified patient-reported utilities for 6 OCD lesion health states, which may be used for future health-related quality of life, decision analysis, and quality/safety/value studies. These utility scores were stable and not affected by patient age, sex, or treatment strategy.

Incidence of Nerve Repair Following Endoscopic Carpal Tunnel Release Is Higher Compared to Open Release in New York State.

BACKGROUND: Carpal tunnel release (CTR) has traditionally been performed through an open approach, although in recent years endoscopic CTR has gained in popularity. QUESTIONS/PURPOSES: We sought to assess whether a difference exists between the rates of nerve repair surgery following open versus endoscopic CTR in New York State (NYS). METHODS: Patients undergoing endoscopic and open CTR from 1997 to 2013 were identified from the Statewide Planning and Research Cooperative System (SPARCS) database from the NYS Department of Health using Current Procedural Terminology, 4th Revision (CPT-4) codes 29848 and 64721, respectively. The primary outcome measure was subsequent nerve repair surgery (as identified using CPT-4 codes 64831-64837, 64856, 64857, 64859, 64872, 64874, and 64876). Other variables analyzed included patient age, sex, payer, and surgery year. RESULTS: There were 294,616 CTRs performed in NYS from 1997 to 2013. While the incidence of open CTR remained higher than endoscopic CTR, the proportion of endoscopic CTR steadily increased, from 16% (2984/19,089) in 2007 to 25% (5594/22,271) in 2013. For the 134,143 patients having a single CTR, the rate of subsequent nerve repair was significantly higher following endoscopic CTR (0.09%) compared to open CTR (0.04%). The Cox model showed that factors significantly associated with a higher risk of subsequent nerve repair surgery were endoscopic CTR and younger age. CONCLUSIONS: Endoscopic CTR has been increasingly performed in NYS and associated with a higher rate of subsequent nerve repair. This rate likely underestimates the incidence of nerve injuries because it only captures those patients who had subsequent surgery. While this catastrophic complication remains rare, further investigation is warranted, given the rise of endoscopic CTR in the setting of equivalent outcomes, but favorable reimbursement, versus open CTR.

Ultrasound Is an Alternative to X-ray for Diagnosing Developmental Dysplasia of the Hips in 6-Month-Old Children.

BACKGROUND: Infants previously treated for developmental dysplasia of the hips (DDH) are routinely imaged with ultrasound initially and reimaged with an anteroposterior (AP) pelvis X-ray at 6 months of age to assess for dysplasia. It has become convention to transition from ultrasound to AP X-ray at 6 months of age, but no study has demonstrated that ultrasound is inadequate at this age. QUESTION/PURPOSE: The purpose of this study was to confirm that ultrasound for the 6-month DDH evaluation is a feasible alternative to the standard X-ray. PATIENTS AND METHODS: Thirty-one 5- to 7-month-old infants undergoing AP pelvis X-ray related to previous Pavlik harness treatment for DDH or to a history of breech presentation were prospectively enrolled. All patients were imaged with an AP pelvis X-ray and bilateral hip ultrasounds. Three senior orthopedic surgeons unfamiliar with the patient histories evaluated both types of imaging for standard measures of hip dysplasia, including acetabular index (AI), alpha angle, and bony rim percent coverage of the femoral head. Pearson correlation coefficients were calculated for the X-ray and ultrasound measures. RESULTS: Good quality ultrasound images were obtained in all patients, despite the presence of the ossific nucleus in 66% of the hips. All three reviewers correctly diagnosed the one dislocated hip via both X-ray and ultrasound. There were no false negatives on ultrasound, and none of the patients with negative ultrasounds required treatment during the mean 26 months of follow up. An increased AI on X-ray was correlated with lower percent coverage of the femoral head on ultrasound. CONCLUSIONS: Ultrasound is a technically feasible DDH imaging modality that can be used as an alternative to X-ray for 6-month-olds.

Risk of Ischemic Stroke After Perioperative Atrial Fibrillation in Total Knee and Hip Arthroplasty Patients.

BACKGROUND: To determine if new-onset perioperative atrial fibrillation during arthroplasty represents a benign response to intraoperative cardiac stress or is a risk factor for stroke, we evaluated the subsequent risk of ischemic stroke in patients with new-onset atrial fibrillation occurring during primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Discharge data of all adult patients undergoing primary TKA or THA from 1997 to 2013 were queried via the New York Statewide Planning and Research Cooperative System database to find patients with new-onset perioperative atrial fibrillation. These patients were then followed up over time to determine their risk of ischemic stroke. RESULTS: Of the 312,636 TKA and 215,610 THA unique patient admissions, 3646 (0.7%) had a diagnosis of new-onset perioperative atrial fibrillation. The cohort of patients with this finding was 58.9% female with an average age of 73.6 years and higher prevalence of vascular risk factors. Adjusting for validated stroke risk factors, the risk of ischemic stroke within 1 year after THA or TKA in patients with new-onset atrial fibrillation was 2.7 times higher than in those without a history of atrial fibrillation (odds ratio: 2.7, 95% confidence interval: 1.5-4.8). Hospital length of stay and charges for patients with new-onset atrial fibrillation were also greater than patients with either a prior diagnosis or no diagnosis of atrial fibrillation. CONCLUSION: New-onset atrial fibrillation during TKA and THA may indicate risk of ischemic stroke following surgery that should warrant medical follow-up and may increase hospital length of stay and charges.

Contribution of Medial Cuneiform Osteotomy to Correction of Longitudinal Arch Collapse in Stage IIb Adult-Acquired Flatfoot Deformity.

Background Residual forefoot supination after correcting the hindfoot in stage IIb adult-acquired flatfoot deformity can be addressed with a dorsal opening wedge medial cuneiform (Cotton) osteotomy. The amount of correction is generally judged clinically, and there currently are no preoperative guides that can predict the size of graft needed. The aim of this study was to evaluate the correlation between patient and operative factors and the correction achieved with the Cotton osteotomy. METHODS: Seventy-nine feet in 74 patients undergoing Cotton osteotomy as part of flatfoot reconstruction were reviewed retrospectively. Preoperative and minimum 40-week postoperative lateral foot weightbearing radiographs were compared to assess correction of longitudinal arch collapse as measured by 13 radiographic parameters, with particular emphasis on the cuneiform articular angle (CAA). Additional demographic and intraoperative variables analyzed for association with radiographic change included age, gender, body mass index, amounts and graft types of Cotton osteotomy and lateral column lengthening, and amount of medializing calcaneal osteotomy. A multivariate linear regression model was developed for each variable found to be significant in univariate analysis. RESULTS: The Cotton osteotomy graft size was significantly associated with changes in the CAA ( P < .001), calcaneal pitch ( P = .03), lateral talonavicular Cobb angle ( P = .03), and lateral naviculomedial cuneiform Cobb angle ( P = .03). The Cotton graft size was the only factor found to significantly predict a change in the CAA in the final linear regression model ( P < .001, R2 = 0.27), with each millimeter of Cotton corresponding to a 2.1-degree decrease of the CAA. CONCLUSION: Correction of longitudinal arch collapse, as measured by the CAA, was primarily influenced by the size of the graft used for the Cotton osteotomy in a linear fashion. The preoperative CAA may help surgeons titrate the proper amount of graft placed intraoperatively. LEVEL OF EVIDENCE: Level IV, Retrospective Case Series.

Influence of Diagnosis and Other Factors on Patients' Expectations of Foot and Ankle Surgery.

BACKGROUND: Many patient factors have been associated with higher or lower expectations of orthopedic surgery. In foot and ankle surgery, the diverse diagnoses seen may also influence expectations. The aim of this study was to investigate the relationship between diagnosis and patients' preoperative expectations of elective foot and ankle surgery. METHODS: Two hundred seventy-eight patients undergoing elective foot or ankle surgery for 1 of 7 common diagnoses were enrolled in a prospective cohort study. Preoperative expectations were assessed with the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey. Patients also completed the Foot & Ankle Outcome Score, Short Form 12, pain visual analog scale, and questionnaires for depressive and anxiety symptoms. Demographic and clinical data were collected. Patient factors and diagnosis were analyzed using multivariate regression analysis to identify independent predictors of higher expectations and determine the effect of diagnosis relative to other patient factors on expectations. RESULTS: The multivariate regression analysis adjusting for demographics and other clinical characteristics showed that diagnosis contributed the most to the model, accounting for 10.5% of the variation in expectations survey scores. Patients with mid- or hindfoot arthritis ( P < .001), hallux valgus ( P = .001), or hallux rigidus ( P = .005) had lower scores (lower expectations) than those with ankle instability or osteochondral lesion. In the model, female sex ( P = .001), non-Caucasian race ( P = .031), and lower scores on the Foot & Ankle Outcome Score daily activities subscale ( P = .024) were associated with higher scores. CONCLUSIONS: Diagnosis of ankle instability or osteochondral lesion, female sex, non-Caucasian race, and lower Foot & Ankle Outcome Score daily activities subscale score were all associated with higher expectations. These findings may help inform and guide surgeons as they counsel patients preoperatively. LEVEL OF EVIDENCE: Level II, cross-sectional study.

Platelet-Rich Plasma and Hyaluronic Acid Are Not Synergistic When Used as Biological Adjuncts with Autologous Osteochondral Transplantation.

Introduction Autologous osteochondral transplantation (AOT) is a treatment for osteochondral lesions with known concerns, including histological degradation of the graft and poor cartilage integration. Platelet-rich plasma (PRP) and hyaluronic acid (HA) have been described has having the potential to improve results. The aim of this study was to evaluate the effect of PRP and HA on AOT in a rabbit model. Methods Thirty-six rabbits underwent bilateral knee AOT treated with either the biological adjunct (PRP, n = 12; HA, n = 12; PRP + HA, n = 12) or saline (control). PRP and HA were administered as an intra-articular injection. The rabbits were euthanized at 3, 6, or 12 weeks postoperatively. The graft sections were assessed using the modified International Cartilage Repair Society (ICRS) scoring system. The results from the PRP alone group is from previously published data. Results The mean modified ICRS histological score for the PRP-treated group was higher than its control ( P = 0.002). The mean modified ICRS histological score for the HA-treated group showed no difference compared with its control ( P = 0.142). The mean modified ICRS histological score for the PRP + HA-treated group was higher than its control ( P = 0.006). There was no difference between the mean modified ICRS scores of the PRP- and the PRP + HA-treated grafts ( P = 0.445). Conclusion PRP may decrease graft degradation and improve chondral integration in an animal model. In this model, the addition of HA was not synergistic for the parameters assessed. LEVEL OF EVIDENCE: Basic science, Level V. CLINICAL RELEVANCE: PRP can be used as an adjunct to AOT, which may decrease graft degeneration and improve clinical outcomes. HA may not influence AOT.

Reliability and Reproducibility of Subject Positioning with EOS Low-Dose Biplanar X-ray.

BACKGROUND: EOS low-dose biplanar X-ray used with tantalum bead implantation is an appealing imaging modality to evaluate limb length and physeal growth due its relatively low radiation exposure, excellent inter- and intra-observer reliability, and minimal magnification/shrinkage error. QUESTIONS/PURPOSES: The purpose of this study was to establish the error in total length and inter-bead distances using EOS and tantalum beads due to variable positioning in the EOS gantry, by assessing variation in measurements made on the same subject repeatedly positioning by one positioner (intra-positioner measurement error) and variation in measurements made on the same subject with positioning by multiple positioners (inter-positioner measurement error). METHODS: Tantalum bead markers were placed about the distal femoral physis of a cadaveric lamb femur. Three investigators positioned the femur in the EOS gantry 10 times, totaling 30 EOS scans. Total limb length and inter-bead distances were measured on AP and lateral views; mean and standard error were calculated. A random effects analysis of variance for nested data was used to determine the proportion of variation due to differences between positioners and differences between positioning by the same positioner. RESULTS: Intra-positioner measurement error ranged from 0.01 to 0.06 mm. Inter-positioner measurement error ranged from 0.00 to 0.09 mm. CONCLUSIONS: EOS has relatively low radiation and allows standing assessment of limb length and alignment. In this study, length measurements and inter-bead distances demonstrated minimal error due to positioning in the EOS gantry, documenting that there is minimal error from positioning, minimal magnification/shrinkage error, and exceptional inter and intra-rater reliability. EOS is the preferred method for length and angular measurements, and with tantalum beads, is ideal for measuring growth about the physis.

In Vivo Plantar Pressures in Adult-Acquired Flatfoot Compared to Control Using an Intraoperative Pedobarographic Device.

BACKGROUND: Intraoperative pedobarography has the potential to aid surgical decisions, but no parameters exist to guide its use. QUESTIONS/PURPOSES: This study compared supine plantar pressures between flatfoot patients and controls using a previously validated intraoperative pedobarographic device and examined associations between supine, walking, and standing plantar pressures. METHODS: Ten preoperative patients with stage II adult-acquired flatfoot deformity (AAFD) were compared to ten healthy controls. Supine plantar pressures were assessed using the pedobarographic device. Standing and walking plantar pressures were assessed with an EMED-XT sensor array (Novel). Maximum force (MF) and peak pressure (PP) were calculated for nine anatomical foot regions adjusting for age and BMI. RESULTS: No differences in plantar pressures were found between flatfoot patients and controls in the supine or standing positions. During walking, flatfoot patients had greater MF of the first, second, and third metatarsals (p ≤ 0.018) and greater PP of the first and second metatarsals than controls (p ≤ 0.010). Supine MF and PP were both strongly positively correlated with their respective pressure measurements for both standing and walking in multiple foot regions (p ≤ 0.05, all analyses). Correlations in the first metatarsal region were generally weak and not statistically significant. CONCLUSION: This device did not show differences in supine plantar pressures of flatfoot patients and healthy subjects, highlighting the limitations of intraoperative devices in guiding flatfoot correction. The differences between flatfoot and controls during walking and the correlations between supine and walking conditions suggest that dynamic plantar pressures are a more useful parameter in guiding flatfoot reconstruction.

Perioperative Morbidity of Same-Day and Staged Bilateral Total Hip Arthroplasty.

BACKGROUND: Management strategies for bilateral hip degenerative disease include same-day or staged bilateral total hip arthroplasty (THA), but information on outcomes remains sparse. We sought to describe in-hospital complications and blood transfusion rates after same-day and staged bilateral THAs at different time intervals and to assess risk factors for these events. METHODS: We retrospectively reviewed administrative data for 3785 patients treated with same-day bilateral (n = 1946; group A) and staged bilateral THA within (1) 0-3 months apart (n = 328; group B); (2) 3-6 months apart (n = 703; group C); and (3) 6-12 months apart (n = 808; group D), between 1999 and 2014. We recorded demographics, the Charlson-Deyo comorbidity index and in-hospital local and systemic (minor and major) complications. Complication and blood transfusion rates among groups were compared. A logistic regression model was developed to identify risk factors for major complications. RESULTS: Local complications were rare. Minor complications were less frequent in group A (P < .001). Major complications were more frequent in group D (P = .012). Group A had higher overall (P < .001) and allogeneic blood transfusion rates (P < .001) compared with the staged groups. Staged procedures within 6-12 months apart vs same-day bilateral THA, older age, Charlson-Deyo index ≥2 vs 0, and earlier vs recent admission year were associated with higher adjusted odds for major complications. CONCLUSION: Same-day bilateral THA in a high-volume joint replacement center may be a safe option for younger and healthier patients, given the relatively low incidence of adverse events reported in this study.

Validation of Patient-Reported Outcomes Measurement Information System Computerized Adaptive Tests Against the Foot and Ankle Outcome Score for 6 Common Foot and Ankle Pathologies.

BACKGROUND: The field of foot and ankle surgery lacks a widely accepted gold-standard patient-reported outcome instrument. With the changing infrastructure of the medical profession, more efficient patient-reported outcome tools are needed to reduce respondent burden and increase participation while providing consistent and reliable measurement across multiple pathologies and disciplines. The primary purpose of the present study was to validate 3 Patient-Reported Outcomes Measurement Information System computer adaptive tests (CATs) most relevant to the foot and ankle discipline against the Foot and Ankle Outcome Score (FAOS) and the Short Form 12 general health status survey in patients with 6 common foot and ankle pathologies. METHODS: Patients (n = 240) indicated for operative treatment for 1 of 6 common foot and ankle pathologies completed the CATs, FAOS, and Short Form 12 at their preoperative surgical visits, 1 week subsequently (before surgery), and at 6 months postoperatively. The psychometric properties of the instruments were assessed and compared. RESULTS: The Patient-Reported Outcomes Measurement Information System CATs each took less than 1 minute to complete, whereas the FAOS took 6.5 minutes, and the Short Form 12 took 3 minutes. CAT scores were more normally distributed and had fewer floor and ceiling effects than those on the FAOS, which reached as high as 24%. The CATs were more precise than the FAOS and had similar responsiveness and test-retest reliability. The physical function and mobility CATs correlated strongly with the activities subscale of the FAOS, and the pain interference CAT correlated strongly with the pain subscale of the FAOS. The CATs and FAOS were responsive to changes with operative treatment for 6 common foot and ankle pathologies. CONCLUSIONS: The CATs performed as well as or better than the FAOS in all aspects of psychometric validity. The Patient-Reported Outcomes Measurement Information System CATs show tremendous potential for improving the study of patient outcomes in foot and ankle research through improved precision and reduced respondent burden. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The tomato I gene for Fusarium wilt resistance encodes an atypical leucine-rich repeat receptor-like protein whose function is nevertheless dependent on SOBIR1 and SERK3/BAK1.

We have identified the tomato I gene for resistance to the Fusarium wilt fungus Fusarium oxysporum f. sp. lycopersici (Fol) and show that it encodes a membrane-anchored leucine-rich repeat receptor-like protein (LRR-RLP). Unlike most other LRR-RLP genes involved in plant defence, the I gene is not a member of a gene cluster and contains introns in its coding sequence. The I gene encodes a loopout domain larger than those in most other LRR-RLPs, with a distinct composition rich in serine and threonine residues. The I protein also lacks a basic cytosolic domain. Instead, this domain is rich in aromatic residues that could form a second transmembrane domain. The I protein recognises the Fol Avr1 effector protein, but, unlike many other LRR-RLPs, recognition specificity is determined in the C-terminal half of the protein by polymorphic amino acid residues in the LRRs just preceding the loopout domain and in the loopout domain itself. Despite these differences, we show that I/Avr1-dependent necrosis in Nicotiana benthamiana depends on the LRR receptor-like kinases (RLKs) SERK3/BAK1 and SOBIR1. Sequence comparisons revealed that the I protein and other LRR-RLPs involved in plant defence all carry residues in their last LRR and C-terminal LRR capping domain that are conserved with SERK3/BAK1-interacting residues in the same relative positions in the LRR-RLKs BRI1 and PSKR1. Tyrosine mutations of two of these conserved residues, Q922 and T925, abolished I/Avr1-dependent necrosis in N. benthamiana, consistent with similar mutations in BRI1 and PSKR1 preventing their interaction with SERK3/BAK1.