The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate.

BACKGROUND: Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative. HYPOTHESIS: Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection. STUDY DESIGN: Cohort Study; Level of evidence, 3. METHODS: All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort. RESULTS: There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3). CONCLUSION: Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.

Chaplain Training in Evidence-Based Practices to Promote Mental Health and Improve Care for Suicidality in Veterans and Service Members.

OBJECTIVE: Chaplains are key care providers in a comprehensive approach to suicide prevention, which is a priority area for the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD). In a cohort of 87 VA and military chaplains who completed the Mental Health Integration for Chaplain Services (MHICS) training-an intensive, specialty education in evidence-based psychosocial and collaborative approaches to mental health care-we assessed chaplains' self-perceptions, intervention behaviors, and use of evidence-based practices, including Acceptance and Commitment Therapy (ACT), Problem-Solving Therapy (PST), and Motivational Interviewing (MI), in providing care for suicidality. METHOD: Chaplains responded to a battery of items Pre- and Post-training and provided deidentified case examples describing their use of evidence-based practices in spiritual care for service members and veterans (SM/V) on various levels of a suicide prevention continuum. RESULTS: Post-training, chaplains reported increased abilities to provide care and mobilize collaborative resources. Over the course of MHICS, 87% of chaplains used one or more evidence-based practices with a SM/V at risk for suicide or acutely suicidal. Fifty-six percent of chaplains reported intervening with an acutely suicidal SM/V by using principles from ACT, 36% PST, and 48% MI. With persons at risk for suicide, 81% used principles from ACT, 66% PST, and 71% MI. Cases exemplified diverse evidence-based practice applications. CONCLUSIONS: Findings indicate chaplains trained in evidence-based practices report effective application in caring for SM/V who are suicidal, thus offering a valuable resource to meet needs in a priority area for VA and DoD.HIGHLIGHTSChaplains provide essential care for SM/V who are at risk for suicide or acutely suicidalTraining helps chaplains mobilize interdisciplinary and community resources in suicide careEvidence-based practices can effectively integrate within the scope of chaplaincy practice for suicide care.

Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal-Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0-13.0] vs. 11.5 [9.5-15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.

Meniscal Treatment as a Predictor of Worse Articular Cartilage Damage on MRI at 2 Years After ACL Reconstruction: The MOON Nested Cohort.

BACKGROUND: Patients undergoing anterior cruciate ligament reconstruction (ACLR) are at an increased risk for posttraumatic osteoarthritis (PTOA). While we have previously shown that meniscal treatment with ACLR predicts more radiographic PTOA at 2 to 3 years postoperatively, there are a limited number of similar studies that have assessed cartilage directly with magnetic resonance imaging (MRI). HYPOTHESIS: Meniscal repair or partial meniscectomy at the time of ACLR independently predicts more articular cartilage damage on 2- to 3-year postoperative MRI compared with a healthy meniscus or a stable untreated tear. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A consecutive series of patients undergoing ACLR from 1 site within the prospective, nested Multicenter Orthopaedic Outcomes Network (MOON) cohort underwent bilateral knee MRI at 2 to 3 years postoperatively. Patients were aged <36 years without previous knee injuries, were injured while playing sports, and had no history of concomitant ligament surgery or contralateral knee surgery. MRI scans were graded by a board-certified musculoskeletal radiologist using the modified MRI Osteoarthritis Knee Score (MOAKS). A proportional odds logistic regression model was built to predict a MOAKS-based cartilage damage score (CDS) relative to the contralateral control knee for each compartment as well as for the whole knee, pooled by meniscal treatment, while controlling for sex, age, body mass index, baseline Marx activity score, and baseline operative cartilage grade. For analysis, meniscal injuries surgically treated with partial meniscectomy or meniscal repair were grouped together. RESULTS: The cohort included 60 patients (32 female; median age, 18.7 years). Concomitant meniscal treatment at the time of index ACLR was performed in 17 medial menisci (13 meniscal repair and 4 partial meniscectomy) and 27 lateral menisci (3 meniscal repair and 24 partial meniscectomy). Articular cartilage damage was worse in the ipsilateral reconstructed knee (P < .001). A meniscal injury requiring surgical treatment with ACLR predicted a worse CDS for medial meniscal treatment (medial compartment CDS: P = .005; whole joint CDS: P < .001) and lateral meniscal treatment (lateral compartment CDS: P = .038; whole joint CDS: P = .863). Other predictors of a worse relative CDS included age for the medial compartment (P < .001), surgically observed articular cartilage damage for the patellofemoral compartment (P = .048), and body mass index (P = .007) and age (P = .020) for the whole joint. CONCLUSION: A meniscal injury requiring surgical treatment with partial meniscectomy or meniscal repair at the time of ACLR predicted worse articular cartilage damage on MRI at 2 to 3 years after surgery. Further research is required to differentiate between the effects of partial meniscectomy and meniscal repair.

Compartment Syndrome Secondary to Intraosseous Access Abutting Tibial Stem Cement Mantle of a Total Knee Arthroplasty: A Case Report.

CASE: A 79-year-old man 6 days status-post left total knee arthroplasty (TKA) presented to our institution from an outside hospital (OSH) after a suspected STEMI and ventricular fibrillation arrest. At the OSH, intraosseous (IO) access was placed in his right tibia. Orthopaedics was consulted for compartment syndrome at the IO access site. X-rays demonstrated this was secondary to the IO access abutting the cement mantle of a stemmed tibial component of a remote TKA, for which the patient required emergent fasciotomies. CONCLUSIONS: Healthcare providers should be cognizant of potential orthopaedic hardware that can impede proper introduction of IO access.

A 79-year-old man 6 days status-post left total knee arthroplasty (TKA) presented to our institution from an outside hospital (OSH) after a suspected STEMI and ventricular fibrillation arrest. At the OSH, intraosseous (IO) access was placed in his right tibia. Orthopaedics was consulted for compartment syndrome at the IO access site. X-rays demonstrated this was secondary to the IO access abutting the cement mantle of a stemmed tibial component of a remote TKA, for which the patient required emergent fasciotomies. Healthcare providers should be cognizant of potential orthopaedic hardware that can impede proper introduction of IO access.

Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains.

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Do Bone-Patellar Tendon-Bone ACL-Reconstructed Knees Have More Signs of Patellofemoral Posttraumatic Osteoarthritis Than Their Uninjured Contralateral Knees at 2 Years?

BACKGROUND: The prevalence of patellofemoral joint (PFJ) osteoarthritis ranges from 8% to 47% at 7 to 10 years after anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone (BTB) autograft. In performing BTB ACLR, some hypothesize that either trauma caused by harvest of the BTB autograft or altered biomechanics contributes to PFJ posttraumatic osteoarthritis. PURPOSE/HYPOTHESIS: To determine whether knees with ACLR using a BTB autograft show early signs of posttraumatic osteoarthritis as compared with the contralateral uninjured knee 2 years after ACLR. We hypothesized that a BTB autograft will not increase the prevalence of PFJ osteoarthritis. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Bilateral knee 3-T magnetic resonance imaging (MRI) scans were collected in 57 patients (mean age, 20.3 years; 28 men) from a single site at a minimum of 2 years after ACLR. Structural MRI assessment of the knees was performed using the MRI Osteoarthritis Knee Score semiquantitative scoring system by a board-certified musculoskeletal radiologist. The presence of cartilage defects in the patellofemoral compartment was compared between the reconstructed and contralateral uninjured knees using logistic regression analyses. RESULTS: There were no significant differences in the prevalence of cartilage defects (full thickness or any thickness) in the PFJ between the BTB ACLR knees and the contralateral control knees: 38.6% of BTB ACLR knees had PFJ cartilage defects versus 31.6% of contralateral control knees (P > .391). The 95% CI for the difference between these groups was -9.0% to 23.0%. CONCLUSION: When comparing BTB ACLR knees with the uninjured contralateral knees in the study patients, we failed to observe statistically significant differences in the prevalence of PFJ cartilage lesions of full thickness or any thickness. These results should be used in shared decision-making with athletes when choosing the appropriate autograft during reconstruction. Our wide 95% CIs secondary to a smaller sample size demonstrate a need for larger studies in this area to more accurately describe the difference between the operative and contralateral knees.

Radiographic evaluation of knee osteoarthritis in predicting outcomes after arthroscopic partial meniscectomy.

BACKGROUND: Knee osteoarthritis (OA) severity is a predictor of outcomes after arthroscopic partial meniscectomy (APM). Magnetic resonance imaging (MRI) grading of OA is predictive of postoperative outcomes; this prospective study assessed whether radiographic grading is also predictive of outcomes. METHODS: Patients who underwent APM between February 2015 and January 2016, underwent radiography and MRI ≤6 months before surgery, and had outcomes from the surgery date and one year later were included. Surgical failure was defined as <10-point improvement in the Knee Osteoarthritis Outcome Score pain subscore. Radiographs were evaluated using Kellgren-Lawrence (KL) grading and continuous and ordinal minimum joint space width (mJSW) measurements; cartilage loss on MRI was evaluated using a modified Outerbridge system. Predictive abilities were estimated using area under the receiver operating characteristic curve (AUC) with 95% confidence intervals (CIs). RESULTS: The study cohort included 66 knees from 64 patients (32 women; mean age, 57.1 years; range, 45-77). Radiographic grading was not predictive of outcomes (KL, AUC = 0.541 [95% CI: 0.358, 0.724]; continuous mJSW, AUC = 0.482 [95% CI: 0.305, 0.659]; ordinal mJSW, AUC = 0.534 [95% CI: 0.433, 0.634]). Comparison of radiographs showing no joint space narrowing (KL grade 0-2) with corresponding MR images demonstrated that 48% of radiographs missed a clinically significant lesion (modified Outerbridge grade ≥ 3). MRI grading was predictive of outcomes (AUC = 0.720 [95% CI: 0.581, 0.859]). CONCLUSIONS: Radiographic grading of OA is not predictive of outcomes after APM; radiographs may miss clinically significant lesions. For outcome prediction, MRI should be used.

Predicting the need for surgical intervention prior to first encounter for individuals with shoulder complaints: a unique approach.

BACKGROUND: Increasing demand for musculoskeletal care necessitates efficient scheduling and matching of patients with the appropriate provider. However, up to 47% to 60% of orthopedic visits are made without formal triage. The purpose of this study was to develop a method to identify, prior to the initial office visit, the probability that a patient with shoulder symptoms will need surgery so that he or she can be appropriately matched with an operative or nonoperative provider. We hypothesized that patients who had an injury, previously saw an orthopedic provider, or previously underwent magnetic resonance imaging on the affected shoulder would be more likely to undergo surgery. METHODS: Drawing from expert opinion on potential risk factors (which could be identified prior to the initial office visit) for requiring operative intervention for a chief complaint of shoulder symptoms, we developed a branching-logic questionnaire that required a maximum of 7 responses from the patient during the scheduling process. We administered the questionnaire to patients calling with a chief complaint of shoulder symptoms at the time of initial appointment scheduling in a sports health network. A chart review was later completed to determine the ultimate treatment (operative vs. nonoperative) of each patient's complaint. A multivariate predictive model was then developed to determine the characteristics of patients with a higher surgical risk. RESULTS: We successfully developed a model capable of determining surgical risk from 7% to 90% based on patient sex, previous magnetic resonance imaging status, and injury status. CONCLUSIONS: Our predictive model can aid in patient clinical scheduling and ensure optimal matching of a patient with the best provider for the patient's care. Decreased wait times and appropriate matching may lead to increased patient satisfaction, superior outcomes, and more efficient use of health care resources.

Correction to: Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

The original version of this article unfortunately contained a mistake. The spelling of Erin Ohliger's name was incorrect.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis.

OBJECTIVES: In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR? STUDY DESIGN: Retrospective cohort. BACKGROUND: EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued. METHODS: A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed. RESULTS: Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204). CONCLUSION: In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost. LEVEL OF EVIDENCE: III.

Positive "Surprise" Broth Cultures in Nonunion Surgery Do Not Require Antibiotic Treatment.

The objective of this study was to review the efficacy of a treatment approach for patients with positive intraoperative cultures during fracture nonunion surgery. The authors performed a retrospective case series at a level I trauma center. In this series, 60 patients without preoperative concern for infection were surgically treated for fracture nonunion. The treatment course of patients after fracture nonunion surgery, including culture results, antibiotic administration, and the presence of clinical infection and radiographic union, was studied. Sixty patients underwent fracture nonunion surgery. Twenty-four patients had a positive intraoperative culture. Fourteen patients had only a positive broth culture, 6 had only a positive routine culture, and 4 had positive mixed (routine and broth) cultures. The most common bacteria was coagulase-negative staphylococci, isolated in 19 of 24 patients, and the only isolated organism in 13 of 24 patients. Patients with a positive broth culture were not treated with antibiotics. Four of 10 patients with either a positive routine or mixed culture grown within 3 days of surgery were treated with antibiotics. All patients achieved clinical healing without signs of infection, and all but 2 patients achieved radiographic union at a mean follow-up of approximately 5 years. In the setting of fracture nonunion surgery, patients with only a positive broth culture and those with only a positive routine or mixed cultures that grew in a delayed fashion (>3 days postoperatively) did not require antibiotic treatment to achieve healing. [Orthopedics. 2019; 42(6):e532-e538.].

Remote Patient Monitoring Using Mobile Health for Total Knee Arthroplasty: Validation of a Wearable and Machine Learning-Based Surveillance Platform.

BACKGROUND: Recent technologic advances capable of measuring outcomes after total knee arthroplasty (TKA) are critical in quantifying value-based care. Traditionally accomplished through office assessments and surveys with variable follow-up, this strategy lacks continuous and complete data. The primary objective of this study was to validate the feasibility of a remote patient monitoring (RPM) system in terms of the frequency of data interruptions and patient acceptance. Second, we report pilot data for (1) mobility; (2) knee range of motion, (3) patient-reported outcome measures (PROMs); (4) opioid use; and (5) home exercise program (HEP) compliance. METHODS: A pilot cohort of 25 patients undergoing primary TKA for osteoarthritis was enrolled. Patients downloaded the RPM mobile application preoperatively to collect baseline activity and PROMs data, and the wearable knee sleeve was paired to the smartphone during admission. The following was collected up to 3 months postoperatively: mobility (step count), range of motion, PROMs, opioid consumption, and HEP compliance. Validation was determined by acquisition of continuous data and patient tolerance at semistructured interviews 3 months after operation. RESULTS: Of the 25 enrolled patients, 100% had uninterrupted passive data collection. Of the 22 available for follow-up interviews, all found the system motivating and engaging. Mean mobility returned to baseline within 6 weeks and exceeded preoperative baseline by 30% at 3 months. Mean knee flexion achieved was 119°, which did not differ from clinic measurements (P = .31). Mean KOOS improvement was 39.3 after 3 months (range: 3-60). Opioid use typically stopped by postoperative day 5. HEP compliance was 62% (range: 0%-99%). CONCLUSIONS: In this pilot study, we established the ability to remotely acquire continuous data for patients undergoing TKA, who found the application to be engaging. RPM offers the newfound ability to more completely evaluate the patients undergoing TKA in terms of mobility and rehabilitation compliance. Study with more patients is required to establish clinical significance.

Top 100 Most-Cited Clinical Studies of Hip and Knee Arthroplasty: The Foundation of Practice.

Total number of citations has been considered a proxy for a published study's importance within a given field. However, there are multiple pitfalls to correlating the total number of citations alone with the quality of a study. In this review, the authors aimed to identify the top 100 most-cited studies of hip and knee arthroplasty and then assess study design and quality of reporting. More than half of these studies were level IV evidence, unblinded, not randomized, and not controlled. This underscores the need for higher-quality study design to support practice. [Orthopedics. 2019; 42(2):e151-e161.].

Predictors of Extended Length of Hospital Stay in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Segmental Instrumented Fusion: An Analysis of 407 Surgeries Performed at a Large Academic Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aims of this study were to (1) compare patient and procedure-specific characteristics among those who had short versus long hospital stays and (2) identify independent risk factors that may correlate with extended length of hospital stay (LOS) in patients with adolescent idiopathic scoliosis (AIS) who underwent posterior segmental instrumented fusion (PSIF). SUMMARY OF BACKGROUND DATA: Reducing the LOS and identifying risk factors associated with extended admission have become increasingly relevant to healthcare policy makers. There is currently limited research identifying risk factors that correlate with extended stay in patients undergoing PSIF for AIS. METHODS: A single-institution, longitudinally maintained database was queried to identify 407 patients who met specific inclusion and exclusion criteria. Based on the distribution and median LOS in the cohort (4 days), patients were divided into those who had long versus short LOS. In both groups, patient demographics, comorbidities, preoperative scoliosis curve measurements, surgery-related characteristics, and complications were analyzed. A univariate and multivariate regression analysis was then conducted to identify independent risk factors associated with extended LOS. RESULTS: Patients who had extended LOS tended to be women (84.6% vs. 75%, P = 0.01), had more levels fused (9 ±â€Š2 vs. 7 ±â€Š2 levels, P < 0.001), had more major postoperative complications (0.8% vs. 7.4%, P = 0.002), had more blood loss during surgery (723 ±â€Š548 vs. 488 ±â€Š341 cm, P < 0.001), and received less epidural analgesia for pain control (69% vs. 89%, P < 0.001). Except for higher thoracic kyphosis, long LOS patients did not have worse preoperative radiographic curve parameters. Multivariate logistic analysis identified female sex, having ≥9 ±â€Š2 levels of fusion, operative blood loss, major postoperative complications, lack of epidural analgesia, and higher thoracic kyphosis as independent risk factors correlating for extended LOS. CONCLUSION: Independent risk factors identified by this study may be used to recognize patients with AIS at risk of prolonged hospital stay. LEVEL OF EVIDENCE: 3.

Operative Times Have Remained Stable for Total Hip Arthroplasty for >15 Years: Systematic Review of 630,675 Procedures.

Understanding trends in operative times has become increasingly important in light of total hip arthroplasty (THA) being added to the Centers for Medicare & Medicaid Services (CMS) 2019 Potentially Misvalued Codes List. The purpose of this review was to explore the mean THA operative times reported in the literature in order (1) to determine if they have increased, decreased, or remained the same for patients reported on between 2000 and 2019 and (2) to determine what factors might have contributed to the difference (or lack thereof) in THA operative time over a contemporary study period. METHODS: The PubMed and EBSCOhost databases were queried to identify all articles, published between 2000 and 2019, that reported on THA operative times. The keywords used were "operative," "time," and "total hip arthroplasty." An article was included if the full text was available, it was written in English, and it reported operative times of THAs. An article was excluded if it did not discuss operative time; it reported only comparative, rather than absolute, operative times; or the cohort consisted of total knee arthroplasties (TKAs) and THAs, exclusively of revision THAs, or exclusively of robotic THAs. Data on manual or primary THAs were extracted from studies including robotic or revision THAs. Thirty-five articles reporting on 630,675 hips that underwent THA between 1996 and 2016 met our criteria. RESULTS: The overall weighted average operative time was 93.20 minutes (range, 55.65 to 149.00 minutes). When the study cohorts were stratified according to average operative time, the highest number fell into the 90 to 99-minute range. Operative time was stable throughout the years reported. Factors that led to increased operative times included increased body mass index (BMI), less surgical experience, and the presence of a trainee. CONCLUSIONS: The average operative time across the included articles was approximately 95 minutes and has been relatively stable over the past 2 decades. On the basis of our findings, we cannot support CMS lowering the procedural valuation of THA given the stability of its operative times and the relationship between operative time and cost.

Total knee arthroplasty in the face of a previous tuberculosis infection of the knee: what do we know in 2018?

INTRODUCTION: TB of the knee is often associated with marked morbidity because of its late and non-specific presentation. The use of TKA (total knee arthroplasty) in the face of a previous tuberculous knee infection has been criticized with multiple controversies. Therefore, the purpose of this review is to assess: (1) clinical outcomes, (2) radiographic outcomes, and (3) complications of TKA in the face of a previous healed TB infection. Our analysis has demonstrated that previous TB infection of the knee joint does not preclude TKA if indicated and suggests placing patients who have ESR or CRP results out of normal range on pre-operative anti-TB prophylactic antibiotic for a minimum of 2 weeks. In case of local recurrence following TKA, antibiotic therapy alone can be an effective treatment option. AREAS COVERED: We examined reported outcomes of performing TKA in patients with previous TB infection of the knee. Different strategies recommended by different authors to maximize the success of TKA in this situation are also discussed. EXPERT COMMENTARY: TKA has been proven to be effective in patients who are status post tuberculous arthritis when thoughtful patient selection and peri-operative planning is conducted. Tuberculosis continues to have a rising incidence and increasing spread of multi-drug resistant strains.

Cervical sagittal alignment and the impact of posterior spinal instrumented fusion in patients with Lenke type 1 adolescent idiopathic scoliosis.

BACKGROUND: Clinical decision making, preoperative planning, and surgical correction for adolescent idiopathic scoliosis (AIS) has traditionally focused on obtaining the maximum coronal plane correction to improve cosmesis and function. More recently, restoring sagittal alignment has also received increasing attention in AIS patients, correlating with positive health-related quality of life (HRQOL) outcomes in multiple studies. In this realm, cervical sagittal alignment (CSA) has also emerged as one of the variables that may correlate with clinical and functional outcomes in AIS patients undergoing surgical correction. Several studies have focused on studying the cervical sagittal plane parameters in patients with spinal deformity, while few have investigated the impact of surgical correction on CSA. In this study, we aimed to capture the baseline cervical sagittal characteristics and evaluate the changes in CSA in a cohort of AIS patients with Lenke type I curves following posterior spinal instrumented fusion (PSIF). METHODS: We evaluated our longitudinal database of patients who had surgical correction for AIS between January 1, 2015 and September 1, 2017. The initial search yielded 270 patients. Next, the following inclusion criteria were applied to identify the study cohort: (I) patients who had Lenke type 1 curves, (II) patients with adequate pre-operative and post-operative radiographs (posterior-anterior and lateral), (III) patients who had a minimum radiographic follow-up of 6 months, and (IV) patients who were treated with the same standard rod instrumentation system. In addition, the following exclusion criteria were applied: (I) patients with neuromuscular disorders, (II) patients with prior spine surgery, and (III) those who received greater than Schwab-2 osteotomies. A total of 30 patients were included in our final analysis. The C2-C7 angle, C0-C2 angle, C2-C7 sagittal vertical axis (SVA), McGregor slope (McGS), and the T1 slope angle were measured preoperatively and at 6 months. A kyphotic measurement was assigned a negative value while positive values were used to describe lordotic measurements. Descriptive statistics and paired sample t-test were used to compare pre-and post-operative data with a cutoff P value of 0.05 to determine statistical significance. RESULTS: Overall, CSA improved in most patients post-operatively, with 19/30 (63%) resulting in improved lordosis. Pre-operatively, mean C2-C7 cervical lordosis was -4.3°, which improved to -0.5° postoperatively (P=0.075), with a mean difference of 3.7°. Simultaneously, mean C0-C2, C2-C7 SVA, McGS, and T1 slope changed from 17° (range, -18° to 41°), 26.5 mm (range, 10 to 45 mm), 4° (range, -7.5° to 25°), and 17.4° (range, 1° to 42°) to 16° (range, 0° to 34.4°, mean difference =1.01°, and P=0.548), 28.2 mm (range, 9 to 57 mm, mean difference =2 mm, and P=0.244), 4.03°, (range, -7.8° to 25°, mean difference =0.16, and P=0.916), and 18° (range, 5.4° to 42°, mean difference =0.37, and P=0.761) (mean change of C2-C7 angle of 3.76°). CONCLUSIONS: This study demonstrated baseline cervical kyphosis and a trend towards cervical lordosis restoration in patients with AIS and a Lenke type 1 curve who underwent PSIF. This study adds to emerging evidence and, together with further studies, will help estimate the impact of PSIF on the cervical sagittal profile, the effect of CSA on patient reported outcomes, and ways to address cervical sagittal malalignment when undertaking the surgical correction for specific curve types in AIS.

Synthesis and PI3 Kinase Inhibition Activity of a Wortmannin-Leucine Derivative.

Wortmannin is a potent covalent inhibitor of PI3K that shows substantial in vivo toxicity and thus is unsuitable for systemic therapeutic applications. One possible approach to minimize systemic toxicity is to generate a latent wortmannin pro-drug that will be selectively activated in target tissues. To test this approach, a wortmannin derivative with a leucine linker attached to C20 has been synthesized and tested for inhibition of PI3K activity in prostate cancer cells. Analysis of PI3K pathway inhibition by Wormannin-Leu (Wn-L) and intact Wortmannin (Wn) showed that attachment of Leu at C-20 decreased potency of PI3K pathway inhibition 10-fold compared to intact wortmannin, yet exceeded the potency of a competitive PI3K inhibitor LY294002.

Evidence-Based Management of Trunnionosis in Metal-on-Polyethylene Total Hip Arthroplasty: A Systematic Review.

Multiple recent reports have indicated a rising awareness of trunnionosis-related implant failures, accounting for up to 3% of all total hip arthroplasty revisions. Moreover, aseptic loosening and osteolysis from local release of metal debris can be the presenting manifestations, and thus the true incidence of trunnionosis is thought to be underreported. Furthermore, the relatively unclear and multifactorial pathogenesis and the widely variable clinical presentations pose a diagnostic challenge. A consensus regarding the ideal intervention and its timing is also lacking. Because of the relative paucity of reports regarding the diagnosis and management of trunnionosis, we conducted this evidence-based review to evaluate the (1) incidence, (2) pathogenesis, (3) diagnosis, and (4) treatment of trunnionosis in metal-on-polyethylene total hip arthroplasty. We then propose an algorithm for the diagnostic work-up and management of this condition.