Does obesity and varying body mass index affect the clinical outcomes and safety of biportal endoscopic lumbar decompression? A comparative cohort study.

BACKGROUND: Endoscopic spine surgery has recently grown in popularity due to the potential benefits of reduced pain and faster recovery time as compared to open surgery. Biportal spinal endoscopy has been successfully applied to lumbar disc herniations and lumbar spinal stenosis. Obesity is associated with increased risk of complications in spine surgery. Few prior studies have investigated the impact of obesity and associated medical comorbidities with biportal spinal endoscopy. METHODS: This study was a prospectively collected, retrospectively analyzed comparative cohort design. Patients were divided into cohorts of normal body weight (Bone Mass Index (BMI)18.0-24.9), overweight (BMI 25.0-29.9) and obese (BMI > 30.0) as defined by the World Health Organization (WHO). Patients underwent biportal spinal endoscopy by a single surgeon at a single institution for treatment of lumbar disc herniations and lumbar spinal stenosis. Demographic data, surgical complications, and patient-reported outcomes were analyzed. Statistics were calculated amongst treatment groups using analysis of variance and chi square where appropriate. Statistical significance was determined as p < 0.05. RESULTS: Eighty-four patients were followed. 26 (30.1%) were normal BMI, 35 (41.7%) were overweight and 23 (27.4%) were obese. Patients with increasing BMI had correspondingly greater American Society of Anesthesiologist (ASA) scores. There were no significant differences in VAS Back, VAS Leg, and ODI scores, or postoperative complications among the cohorts. There were no cases of surgical site infections in the cohort. All cohorts demonstrated significant improvement up to 1 year postoperatively. CONCLUSIONS: This study demonstrates that obesity is not a risk factor for increased perioperative complications with biportal spinal endoscopy and has similar clinical outcomes and safety profile as compared to patients with normal BMI. Biportal spinal endoscopy is a promising alternative to traditional techniques to treat common lumbar pathology.

Similar Medium-Term Revision Rates Following Acute Total Hip Arthroplasty Versus Open Reduction and Internal Fixation for Acetabular Fractures in the Elderly.

BACKGROUND: The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA. METHODS: The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA. RESULTS: A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22). CONCLUSIONS: No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively. LEVEL OF EVIDENCE: III.

Does the use of tranexamic acid intraoperatively reduce postoperative blood loss and complications following biportal endoscopic lumbosacral decompression?

Background: Biportal endoscopic spine surgery is an effective minimally invasive technique for treating common lumbar pathologies. We aim to evaluate the impact of intraoperative tranexamic acid (TXA) use on postoperative blood loss in biportal endoscopic decompression surgery. Methods: Patients undergoing biportal endoscopic lumbar discectomies and decompressions either by same day surgery or overnight stay at a single institution beginning in October 2021 were prospectively enrolled. This study was non-randomized, non-blinded with the first cohort of consecutive patients receiving 1 g of intravenous TXA intra-operatively before closure and the second cohort of consecutive patients receiving no TXA. Exclusion criteria included any revision surgery, any surgery for the diagnosis of spinal instability, infection, tumor, or trauma, any contraindication for TXA. Results: Eighty-four patients were included in the study, with 45 (54%) receiving TXA and 39 (46%) not receiving TXA. Median follow-up was 168 days [interquartile range (IQR), 85-368 days]. There were no differences in patient or surgical characteristics between cohorts. Estimated blood loss (EBL) was similar (P=0.20), while post-operative drain output was significantly lower in the TXA cohort (P=0.0028). Single level discectomies had significantly less drain output as compared to 2 level unilateral laminotomy, bilateral decompression (ULBD) cases (P<0.005). Post-operative complications were similar, with low rates of wound complication (1.2%) and transient postoperative weakness (2.4%, P>0.99 for both). Oswestry disability index (ODI), visual analog scale (VAS) back and VAS leg scores decreased significantly; the absolute decrease in scores did not differ between groups (P=0.71, 0.22, 0.86, respectively). Conclusions: Systemic intraoperative TXA administration is associated with a significant decrease in post-operative blood loss in biportal spinal endoscopy, with no impact on the improvement in patient-reported outcomes (PROs) or rate of post-operative complications. Single level biportal discectomies had significantly less postoperative drainage with TXA and may not need drains postoperatively. Larger, randomized studies are necessary to evaluate the cost-effectiveness of TXA use in biportal spinal endoscopy.

Compliant Intramedullary Stems for Joint Reconstruction.

The longevity of current joint replacements is limited by aseptic loosening, which is the primary cause of non-infectious failure for hip, knee, and ankle arthroplasty. Aseptic loosening is typically caused either by osteolysis from particulate wear, or by high shear stresses at the bone-implant interface from over-constraint. Our objective was to demonstrate feasibility of a compliant intramedullary stem that eliminates over-constraint without generating particulate wear. The compliant stem is built around a compliant mechanism that permits rotation about a single axis. We first established several models to understand the relationship between mechanism geometry and implant performance under a given angular displacement and compressive load. We then used a neural network to identify a design space of geometries that would support an expected 100-year fatigue life inside the body. We additively manufactured one representative mechanism for each of three anatomic locations, and evaluated these prototypes on a KR-210 robot. The neural network predicts maximum stress and torsional stiffness with 2.69% and 4.08% error respectively, relative to finite element analysis data. We identified feasible design spaces for all three of the anatomic locations. Simulated peak stresses for the three stem prototypes were below the fatigue limit. Benchtop performance of all three prototypes was within design specifications. Our results demonstrate the feasibility of designing patient- and joint-specific compliant stems that address the root causes of aseptic loosening. Guided by these results, we expect the use of compliant intramedullary stems in joint reconstruction technology to increase implant lifetime.

Postoperative Care and Outcomes in Solid-Organ Transplant Patients Undergoing Lower Extremity Fracture Treatment.

OBJECTIVES: To determine the postoperative outcomes in solid-organ transplant (SOT) patients undergoing operative treatment of lower extremity fractures. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who underwent SOT and operative treatment of lower extremity fracture from 2013 to 2021 were identified, excluding pathologic fractures. OUTCOME MEASURES AND COMPARISONS: Postoperative complications, length of stay, time to death, 90-day and 1-year readmission rates, readmission causes, discharge location, and immunosuppressive regiments. RESULTS: Sixty-one patients with an average age of 67 years (range 29-88) were included. The mortality rate was 37.7%. The average follow-up was 15.2 months (range of 2 weeks-10 years). The majority of patients (32.8%) had received a liver transplant, and femoral neck fractures constituted the largest fracture group. The average length of stay was 10 days, with the shortest being 1 day and the longest being 126 days (SD 18). The majority of patients (57.3%) were not discharged home. Only 2 suffered from a postoperative complication requiring another procedure: hardware removal and liner exchange for periprosthetic joint infection, respectively. There was a 27.9% 90-day readmission rate with 2 deaths within that period with the most common being altered mental status (29.4%), genitourinary infections (17.6%), repeat falls (11.8%), and low hemoglobin requiring transfusion (11.8%). The longest average time to death analyzed by transplant type was found among lung transplant patients (1076 days, 62.5% mortality), followed by liver transplant patients (949 days, 35.0% mortality), and then kidney transplant patients (834 days, 38.9% mortality). The shortest time to death was 71 days from index procedure. CONCLUSIONS: Family members of SOT patients undergoing operative treatment of lower extremity fractures should be made aware of the high risk for 90-day readmission postoperatively (27.9%) and overall mortality (12.5%). Providers should be aware of the need for multidisciplinary involvement for inpatient care, monitoring postoperative complications, and facilitating discharge planning. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

MELD score predicts short-term outcomes after surgical management of proximal humerus fractures: a matched analysis.

Objective: We aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10. Design: This was a retrospective database review. Setting: All centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients/Participants: Patients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included. Intervention: Open reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment. Main outcome measurements: Thirty-day complications, mortality, readmission, and reoperation rates were measured. Results: Of the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications. Conclusions: A MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty. Level of Evidence: Prognostic Level III.

Biportal Endoscopic Approach for Lumbar Degenerative Disease in the Ambulatory Outpatient vs Inpatient Setting: A Comparative Study.

BACKGROUND: Biportal spinal endoscopy is increasingly utilized for lumbar disc herniations and lumbar stenosis. The objective was to investigate the safety and effectiveness of the technique in the outpatient vs inpatient setting. METHODS: This is a comparative study of consecutive patients who underwent biportal spinal endoscopy by a single surgeon at a single institution. Demographics, surgical complications, and patient-reported outcomes were prospectively collected and retrospectively analyzed. Statistics were calculated among treatment groups using unpaired t test and χ 2 analysis where appropriate. Statistical significance was determined as P < 0.05. RESULTS: Eighty-four patients were included, 58 (69.0%) as outpatient, 26 (31.0%) as inpatient. Mean follow-up was 7.5 months. Statistically significant differences in age, American Society of Anesthesiologists classification, and Charleston Comorbidity Index scores were reported between cohorts, with younger and healthier patients undergoing outpatient surgery (P < 0.0001). Outpatients were more likely to have discectomies while inpatients were more likely to have decompressions for stenosis. No significant differences in postoperative complications were found between groups.Both cohorts demonstrated significant improvement in visual analog scale (VAS) back and leg pain scores and Oswestry Disability Index scores (P < 0.001). Outpatients had significantly lower postoperative VAS back pain (P = 0.001) and Oswestry Disability Index scores (P = 0.004) at 5-8 weeks compared with inpatients, but there was no significant difference for VAS leg pain scores at all time points between the cohorts. CONCLUSIONS: Early results demonstrate that biportal spinal endoscopy can safely and effectively be performed in both inpatient and outpatient settings. CLINICAL RELEVANCE: Outpatient biportal spinal endoscopy can be performed successfully in well selected patients, which may reduce the financial burden of spine surgery to the U.S. healthcare system.

Short-Term Outcomes and Long-Term Implant Survival After Inpatient Surgical Management of Geriatric Proximal Humerus Fractures.

Introduction: The most common surgical options for geriatric proximal humerus fractures are open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty. We used a longitudinal inpatient discharge database to determine the cumulative incidence of conversion to arthroplasty after ORIF of geriatric proximal humerus fractures. The rates of short-term complications and all-cause reoperation were also compared. Patients and Methods: All patients 65 or older who sustained a proximal humerus fracture and underwent either ORIF, HA, or shoulder arthroplasty (SA) as an inpatient from 2000 through 2017 were identified. Survival analysis was performed with ORIF conversion to arthroplasty and all-cause reoperation as the endpoints of interest. Rates of 30-day readmission and short-term complications were compared. Trends in procedure choice and outcomes over the study period were analyzed. Results: A total of 27 102 geriatric patients that underwent inpatient surgical management of proximal humerus fractures were identified. Among geriatric patients undergoing ORIF, the cumulative incidence of conversion to arthroplasty within 10 years was 8.2%. The 10-year cumulative incidence of all-cause reoperation was 12.1% for ORIF patients and less than 4% for both HA and SA patients. Female sex was associated with increased risk of ORIF conversion and younger age was associated with higher all-cause reoperation. ORIF was associated with higher 30-day readmission and short-term complication rates. Over the study period, the proportion of patients treated with ORIF or SA increased while the proportion of patients treated with HA decreased. Short-term complication rates were similar between arthroplasty and ORIF patients in the later cohort (2015-2017). Conclusion: The 10-year cumulative incidence of conversion to arthroplasty for geriatric patients undergoing proximal humerus ORIF as an inpatient was found to be 8.2%. All-cause reoperations, short-term complications, and 30-day readmissions were all significantly lower among patients undergoing arthroplasty, but the difference in complication rate between arthroplasty and ORIF was attenuated in more recent years. Younger age was a risk factor for reoperation and female sex was associated with increased risk of requiring conversion to arthroplasty after ORIF.

Cementless Compared to Cemented Total Knee Arthroplasty is Associated With More Revisions Within 1 Year of Index Surgery.

Background: Cementless total knee arthroplasties (TKAs) have gained renewed interest due to improved implant designs and lower rates of revision than its cemented counterparts. The purpose of this study was to compare revision rates between cemented vs cementless TKAs within 1 year of primary arthroplasty. Methods: This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone cemented and cementless TKAs and subsequent surgical revisions. An unadjusted univariate analysis of patient demographics, Charlson Comorbidity Index score, and surgical revisions at 90 days and 1 year after TKA was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for 1-year surgical complications requiring revision. Results: Of 324,508 patients, 312,988 (96.45%) underwent cemented TKAs, and 11,520 (3.55%) underwent cementless TKAs. Patients undergoing cementless TKA tended to be younger than patients undergoing cemented TKA (63.67 ± 9.15 cementless vs 66.22 ± 8.85 cemented, P < .001). Univariate chi-squared testing showed that cementless patients were more likely to require 1-component femoral or tibial revision at 90 days and 1 year, irrigation and debridement at 90 days and 1 year, and arthroscopy with lysis of adhesions at 1 year only. Similar findings were observed for these 3 revision procedures at 1 year after correcting for age, gender, and Charlson Comorbidity Index score using multivariate logistic regression analysis as cementless TKA patients had higher odds ratios for each of the revisions. Conclusions: Small but significant differences were found in surgical revisions among cementless TKAs when compared to cemented TKAs within 1 year of the index procedure.

Renal Transplant Patients Have a Lower Risk of Complications and Mortalities After Total Knee Arthroplasty Compared to Those on Hemodialysis: A Large National Database Study.

BACKGROUND: Total knee arthroplasty (TKA) in end-stage renal disease is associated with complications. Controversy exists whether elective TKA should be performed while patients are on hemodialysis (HD) or following renal transplant (RT). This study compares TKA outcomes in HD versus RT patients. METHODS: A national database was retrospectively reviewed using International Classification of Diseases codes to identify HD and RT patients who underwent primary TKA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared using Wald and Chi-squared tests. The primary outcome was in-hospital mortalities while secondary outcomes included quality outcomes and medical/surgical complications. Multivariate regressions were used to determine independent associations. Significance was determined with a 2-tailed P value of .05. There were 13,611 patients who underwent TKA (61.1 HD and 38.9% RT). Patients who had RT were younger, had fewer comorbidities, and more likely to have private insurance. RESULTS: The RT patients had a lower rate of mortality (odds ratio (OR) 0.23, P < .01)), complications (OR 0.63, P < .01), cardiopulmonary complications (OR 0.44, P = .02), sepsis (OR 0.22, P < .001), and blood transfusion (OR 0.35, P < .001) during the index hospitalization. This cohort was also found to have decreased length of stay (-2.0 days, P < .001), non-home discharge (OR 0.57, P < .001), and hospital cost (-$5,300, P < .001). Patients who had RT had a lower rate of readmission (OR 0.54, P < .001), periprosthetic joint infection (OR 0.50, P < .01), and surgical site infection (OR 0.37, P < .001) within 90 days. CONCLUSION: These findings suggest that HD patients are a high-risk population in TKA compared to RT patients and warrant stringent perioperative monitoring.

Impact of the COVID-19 Pandemic Hiatus From Sports Activities on Injuries Observed Among Division I NCAA Athletes.

Background: The coronavirus disease 2019 (COVID-19) pandemic significantly disrupted athletic activities, including those in the Pacific 12 (Pac-12) Conference of the National Collegiate Athletic Association. It is currently unknown how the disruption in training and competition impacted athletes' risk of injury upon resumption of activities. Purpose: To describe and compare the rate, timing, mechanism, and severity of injuries among collegiate athletes across multiple sports in the Pac-12 Conference before and after the COVID-19 pandemic-associated hiatus of intercollegiate athletic activities. Study Design: Descriptive epidemiology study. Methods: Descriptive and injury data among intercollegiate athletes from both the season before the hiatus and the season after the hiatus were acquired from the Pac-12 Health Analytics Program database. Injury elements (timing of injury onset, injury severity, mechanism, recurrence, outcome, need for procedural intervention, and event segment during which the injury took place) were compared by time using the chi-square test and a multivariate logistic regression model. Subgroup analyses were performed on knee and shoulder injuries among athletes participating in sports with traditionally high rates of knee and shoulder injuries. Results: A total of 12,319 sports-related injuries across 23 sports were identified, with 7869 pre-hiatus injuries and 4450 post-hiatus injuries. There was no difference in the overall incidence of injury between the pre-hiatus and post-hiatus seasons. However, the proportion of noncontact injuries was higher in the post-hiatus season for football, baseball, and softball players, and the proportion of nonacute injuries in the post-hiatus season was higher among football, basketball, and rowing athletes. Finally, the overall proportion of injuries sustained by football players in the final 25% of competition or practice was higher in the post-hiatus season. Conclusion: Athletes competing in the post-hiatus season were observed to have higher rates of noncontact injuries and injuries sustained in the final 25% of competition. This study demonstrates that the COVID-19 pandemic has had varied effects on athletes from different sports, suggesting that many factors must be considered when designing return-to-sports programs for athletes after an extended absence from organized training.

Clinical outcomes and complications after biportal endoscopic spine surgery: a comprehensive systematic review and meta-analysis of 3673 cases.

PURPOSE: Current literature suggests that biportal spinal endoscopy is safe and effective in treating lumbar spine pathology such as lumbar disc herniation, lumbar stenosis, and degenerative spondylolisthesis. No prior study has investigated the postoperative outcomes or complication profile of the technique as a whole. This study serves as the first comprehensive systematic review and meta-analysis of biportal spinal endoscopy in the lumbar spine. METHODS: A PubMed literature search provided over 100 studies. 42 papers were reviewed and 3673 cases were identified with average follow-up time of 12.5 months. Preoperative diagnoses consisted of acute disc herniation (1098), lumbar stenosis (2432), and degenerative spondylolisthesis (229). Demographics, operative details, complications, and perioperative outcome and satisfaction scores were analyzed. RESULTS: Average age was 61.32 years, 48% male. 2402 decompressions, 1056 discectomies, and 261 transforaminal lumbar Interbody fusions (TLIFs) were performed. Surgery was performed on 4376 lumbar levels, with L4-5 being most common(61.3%). 290 total complications occurred, 2.23% durotomies, 1.29% inadequate decompressions, 3.79% epidural hematomas, and < 1% transient nerve root injuries, infections, and iatrogenic instability. Significant improvement in VAS-Back, VAS-Leg, ODI, and Macnab Scores were seen across the cohort. CONCLUSION: Biportal spinal endoscopy is a novel method to address pathology in the lumbar spine with direct visualization through an endoscopic approach. Complications are comparable to previously published rates. Clinical outcomes demonstrate effectiveness. Prospective studies are required to assess the efficacy of the technique as compared to traditional techniques. This study demonstrates that the technique can be successful in the lumbar spine.

Spondylolisthesis and mismatch deformity affect outcomes after total knee arthroplasty.

BACKGROUND: Little published data currently exist regarding the potential relationships between spondylolisthesis, mismatch deformity, and clinical outcomes following total knee arthroplasty (TKA). We hypothesize that preexisting spondylolisthesis will result in decreased functional outcomes after TKA. METHODS: This retrospective cohort comparison of 933 TKAs was performed between January 2017 and 2020. TKAs were excluded if they were not performed for primary osteoarthritis (OA) or if preoperative lumbar radiographs were unavailable/inadequate to measure the degree of spondylolisthesis. Ninety-five TKAs were subsequently available for inclusion and divided into two groups: those with spondylolisthesis and those without. Within the spondylolisthesis cohort, pelvic incidence (PI) and lumbar lordosis (LL) were calculated on lateral radiographs to determine the difference (PI-LL). Radiographs with PI-LL > 10° were then categorized as having mismatch deformity (MD). The following clinical outcomes were compared between the groups: need for manipulation under anesthesia (MUA), total postoperative arc of motion (AOM) both pre-MUA or post-MUA/revision, incidence of flexion contracture, and a need for later revision. RESULTS: Forty-nine TKAs met the spondylolisthesis criteria, while 44 did not have spondylolisthesis. There were no significant differences in gender, body mass index, preoperative knee range of motion (ROM), preoperative AOM, or opiate use between the groups. TKAs with spondylolisthesis and concomitant MD were more likely to have MUA (p = 0.016), ROM < 0-120 (p < 0.014), and a decreased AOM (p < 0.02) without interventions. CONCLUSION: Preexisting spondylolisthesis by itself may not have adverse effect clinical results following TKA. However, spondylolisthesis increases the likelihood of developing MD. In those with both spondylolisthesis and concomitant mismatch deformities, patients had statistically and clinically significantly decreased in postoperative ROM/AOM and increased need for MUA. Surgeons should consider clinical/radiographic assessments of patients with chronic back pain who present for total joint arthroplasty. LEVEL OF EVIDENCE: Level 3.

Higher Rates of Readmission After Acute Total Hip Arthroplasty Versus Open Reduction Internal Fixation for Elderly Acetabular Fractures, a National Study From 2010 to 2019.

OBJECTIVES: To evaluate the initial complications and short-term readmissions and reoperations after open reduction internal fixation (ORIF) versus acute total hip arthroplasty (THA) for elderly acetabular fractures. DESIGN: Retrospective database review. SETTING: All hospitalizations in the National Readmissions Database and National Inpatient Sample. PATIENTS/PARTICIPANTS: Patients 60 years of age or older with closed acetabular fractures managed surgically identified from the National Readmissions Database or National Inpatient Sample between 2010 and 2019. INTERVENTION: Acute THA with or without ORIF. MAIN OUTCOME MEASUREMENTS: 30-, 90-, and 180-day readmissions and reoperations and index hospitalization complications. RESULTS: An estimated 12,538 surgically managed acetabular fractures in elderly patients occurred nationally between 2010 and 2019, with 10,008 (79.8%) undergoing ORIF and 2529 (20.2%) undergoing THA. Length of stay was 1.7 days shorter ( P < 0.001) and probability of nonhome discharge was reduced (OR 0.68, P = 0.009) for THA patients than for ORIF patients. THA was associated with lower rates of pneumonia (4.6 vs. 9.1%, P < 0.001) and other respiratory complications (10.2 vs. 17.6%) when compared with ORIF. At 30 days, THA patients had higher rates of readmission (13.9 vs. 10.1%, P = 0.007), related readmission (5.4 vs. 1.2%, P < 0.001), readmission for dislocation (3.1 vs. 0.3%, P < 0.001), and reoperations (2.9 vs. 0.9%, P = 0.002). At 180 days, THA patients had higher rates of related readmission (10.1% vs. 3.9%, P < 0.001), readmission for dislocation (5.1% vs. 1.3%, P < 0.001), and readmission for SSI (3.4 vs. 0.8%, P = 0.005). CONCLUSIONS: Acute THA is associated with lower length of stay and certain index hospitalization complications, but higher rates of readmissions for related reasons and specifically for dislocation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Distal Femur Fractures: Equivalent Long-Term Reoperation Rates Between Fixation and Primary Arthroplasty.

OBJECTIVE: Our primary objectives were to (1) determine the rate of requiring conversion to arthroplasty after open reduction internal fixation (ORIF) of geriatric distal femur fractures and (2) compare 10-year reoperation rates after ORIF versus primary arthroplasty for geriatric distal femur fractures. DESIGN: Propensity-matched retrospective cohort study. SETTING: All centers participating in the California Office of Statewide Health Planning and Development (OSHPD) database. PATIENTS/PARTICIPANTS: All patients 65 years of age or older who underwent operative management of a distal femur fracture between 2000 and 2017. INTERVENTION: ORIF, total knee arthroplasty (TKA), or distal femur replacement (DFR). MAIN OUTCOME MEASUREMENTS: Reoperation. RESULTS: A total of 16,784 patients with geriatric distal femur fracture were identified, of which 16,343 (97.4%) underwent ORIF. The cumulative incidence of conversion to arthroplasty within 10 years of ORIF was found to be 3.5%, with young age and female sex identified as risk factors for conversion. There was no significant difference in 10-year reoperation-free survival rate between propensity-matched patients undergoing ORIF versus primary arthroplasty (94.5% vs. 96.2%, P = 0.659). There were no differences in short-term complication or readmission rates between matched treatment cohorts, but arthroplasty was associated with a higher rate of wound infection within 90 days (2.0% vs. 0.2%, P = 0.011). CONCLUSIONS: The 10-year cumulative incidence of conversion to arthroplasty after ORIF was found to be low. There was no significant difference in long-term reoperation-free survival rates between patients undergoing ORIF versus primary arthroplasty. Primary arthroplasty was associated with significantly higher rates of acute wound or joint infection. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development and External Validation of a Risk Calculator for Prediction of Major Complications and Readmission After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: A retrospective, case-control study. OBJECTIVE: We aim to build a risk calculator predicting major perioperative complications after anterior cervical fusion. In addition, we aim to externally validate this calculator with an institutional cohort of patients who underwent anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: The average age and proportion of patients with at least one comorbidity undergoing ACDF have increased in recent years. Given the increased morbidity and cost associated with perioperative complications and unplanned readmission, accurate risk stratification of patients undergoing ACDF is of great clinical utility. METHODS: This is a retrospective cohort study of adults who underwent anterior cervical fusion at any nonfederal California hospital between 2015 and 2017. The primary outcome was major perioperative complication or 30-day readmission. We built standard and ensemble machine learning models for risk prediction, assessing discrimination, and calibration. The best-performing model was validated on an external cohort comprised of consecutive adult patients who underwent ACDF at our institution between 2013 and 2020. RESULTS: A total of 23,184 patients were included in this study; there were 1886 cases of major complication or readmissions. The ensemble model was well calibrated and demonstrated an area under the receiver operating characteristic curve of 0.728. The variables most important for the ensemble model include male sex, medical comorbidities, history of complications, and teaching hospital status. The ensemble model was evaluated on the validation cohort (n=260) with an area under the receiver operating characteristic curve of 0.802. The ensemble algorithm was used to build a web-based risk calculator. CONCLUSION: We report derivation and external validation of an ensemble algorithm for prediction of major perioperative complications and 30-day readmission after anterior cervical fusion. This model has excellent discrimination and is well calibrated when tested on a contemporaneous external cohort of ACDF cases.

The Utility of IR-Guided Biopsy in the Treatment of Pediatric Osteomyelitis.

BACKGROUND: Accurate and efficient diagnosis, as well as a consistent and effective treatment of acute hematogenous osteomyelitis, are paramount to ensure successful clinical outcomes. Noninvasive measures of isolating the causative pathogen from blood cultures have low sensitivity, with published rates often <50%. The use of interventional radiology (IR)-guided percutaneous biopsy has gained traction as a nonsurgical means of obtaining tissue cultures with a reported increased sensitivity of >90%. This study aims to determine the utility of IR-guided biopsy in the management of pediatric patients with acute hematogenous pediatric osteomyelitis (OM). METHODS: An IRB-approved retrospective review was completed of children younger than 18 years admitted to a single institution for treatment of magnetic resonance imaging or culture/biopsy-proven acute hematogenous OM. Patients were excluded for the diagnosis of chronic recurrent multifocal OM, incomplete documentation, treatment initiation at an outside institution, open surgical debridement, and concomitant septic arthritis. Patients who underwent IR-guided biopsy were compared with those treated empirically without biopsy. RESULTS: Fifty patients were included for analysis. Fifteen (30%) had IR-guided biopsies; 35 (70%) were treated empirically. The average age at diagnosis was 11.8 years old (SD: 4.9). Of the 15 patients who underwent IR-guided biopsy, a pathogen was identified in 12 cases (80%); 14 of these patients had concomitant blood cultures with only 1 (7%) positive result ( P <0.01). Of the 11 patients with positive IR-guided biopsy results in the setting of negative blood cultures, 9 (82%) had alterations in their antibiotic regimen as a result of the biopsy. The average time from blood sample collection to definitive antibiotic initiation was nearly double that of time from IR-guided biopsy collection to definitive antibiotic initiation (70.8 vs. 36 h; P <0.01). CONCLUSION: IR-guided biopsy increased pathogen identification by 47% over blood cultures alone and decreased the time to definitive antibiotics. As such, IR-guided biopsy is an effective and safe diagnostic tool for pathogen identification and appropriate antibiotic selection. Orthopaedic surgeons are encouraged to incorporate IR-guided biopsy early in the treatment pathway for patients with acute OM without an indication for open surgical intervention. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty, a National Registry Study.

BACKGROUND: The purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry. METHODS: Adult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA. RESULTS: On multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions. CONCLUSION: Black, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.

Reduced Costs, Complications, and Length of Stay After Arthroscopic Versus Open Irrigation and Débridement for Knee Septic Arthritis.

BACKGROUND: In the treatment of native knee bacterial septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival, complications, and resource utilization between these approaches. METHODS: The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D), if any, were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: A total of 14,365 patients with native knee septic arthritis undergoing I&D were identified, 8,063 arthroscopic (56.1%) and 6,302 open (43.9%). The mean follow-up was 148 days (interquartile range 53 to 259). A total of 2,156 patients (15.0%) underwent revision I&D. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $5,674 and length of stay of 1.46 days (P < 0.001 for both). Arthroscopic I&D was associated with lower overall complications (odds ratio [OR] 0.63, P < 0.001), need for blood transfusion (OR 0.58, P < 0.001), and wound complications (OR 0.32, P < 0.001). Revision-free survival after index I&D was 95.3% at 3 days, 91.0% at 10 days, 88.3% at 30 days, 86.0% at 90 days, and 84.5% at 180 days. No statistically significant difference was observed between surgical approaches on Cox modeling. DISCUSSION: Risk of revision I&D did not differ between arthroscopic and open I&D; however, arthroscopy was associated with decreased costs, length of stay, and complications. Additional study is necessary to confirm these findings and characterize which patients require an open I&D. LEVEL OF EVIDENCE: III.