The Geriatric Nutritional Risk Index Is an Independent Predictor for Adverse Outcomes After Anterior Cervical Discectomy and Fusion.

BACKGROUND: Malnutrition frequently is associated with increased complications and worse outcomes after surgery. The purpose of this study was to determine whether malnutrition status determined using the Geriatric Nutritional Risk Index (GNRI) can serve as an independent risk factor for complications in patients undergoing anterior cervical discectomy and fusion (ACDF). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2016 for patients age ≥65 years who underwent ACDF. Patients were categorized into 3 groups based on the GNRI: >98, normal nutritional status; 92-98, moderately malnourished; and <92, severely malnourished. Multivariate logistic regression models adjusted for covariates of demographics, comorbidities, and operative metrics were used to evaluate GNRI as an independent risk factor for postoperative outcomes. RESULTS: A total of 3148 patients who underwent ACDF were analyzed, of whom 78.9% had normal nutrition, 16.1% were moderately malnourished, and 5.0% patients were severely malnourished. On multivariate analysis, moderate and severe malnutrition were found to be independent risk factors for any complication, pulmonary complications, pneumonia, unplanned intubation, and hospital length of stay >6 days (P < 0.05 for all). In addition, moderate malnutrition was a risk factor for failure to wean from ventilation for >48 hours and 30-day readmission. Severe malnutrition was an independent risk factor for septic shock and nonhome discharge. CONCLUSIONS: In elderly patients after ACDF, malnutrition determined using GNRI is an independent risk factor for 30-day complications, readmissions, prolonged hospital length of stay, and nonhome discharge.

Motion capture evaluation of sagittal spino-pelvic biomechanics after lumbar spinal fusion.

PURPOSE: The spine and pelvis coexist as a dynamic linked system in which spinal and pelvic parameters are correlated. Investigation of this system can inform the understanding and treatment of spinal deformity. Here, we demonstrate the use of motion capture technology to measure spine biomechanical parameters using a novel testing apparatus. METHODS: Three complete cadaveric spines with skull and pelvis were mounted into a biomechanical testing apparatus. Each lumbar vertebra was monitored by motion capture cameras as the spines underwent maximal anterior and posterior pelvic tilts about two sagittal axes at a controlled speed and applied force. These axes were defined as the sacral axis which passes transversely through the ilium and S1, and the acetabular axis which passes transversely through both acetabula. The experiments were repeated after L4-L5 fusion, and then, after both L4-L5 and T12-S1 fusion with pedicle screw instrumentation. Data were collected for total range of motion and for coupled translation at each functional spinal unit (FSU). RESULTS: Total range of motion and coupled translation within functional spinal units (FSUs) was decreased after spinal fusion. The displacement of each individual FSU was captured and summarized along with the observed patterns under each experimental condition. CONCLUSION: Lumbar fusion decreases spinal motion in the sagittal plane in both overall ROM and individual coupled translations of lumbar vertebrae. This was demonstrated using motion capture technology which is useful for quantifying the translations of individual FSUs in a multisegmental spinal model.

Performing Lumbosacral Transdiscal Fixation: The Boachie Screw Technique.

Transdiscal screw fixation through the Boachie screw technique at the lumbosacral junction is a well-accepted procedure in the treatment of high-grade spondylolisthesis. This technique allows for partial reduction of the spondylolisthesis, decompression of the neural elements, and reliable posterior lumbosacral fixation. When performed properly, this procedure produces reliable results and high rates of arthrodesis with relief of preoperative neurological symptoms.

Cervical Alignment and Proximal and Distal Junctional Failure in Posterior Cervical Fusion: A Multicenter Comparison of 2 Surgical Approaches.

STUDY DESIGN: This was a multicenter retrospective cohort study. OBJECTIVE: The purpose of this study was to compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2 to T2 to patients with constructs extending from C3 to T1. SUMMARY OF BACKGROUND DATA: Limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. METHODS: A multicenter retrospective cohort study of patients who underwent PCF between 2012 and 2020 was performed. Surgical and radiographic outcomes were compared between those who had C3-T1 or C2-T2 constructs. RESULTS: A total of 155 patients were included in the study (C2-T2: 106 patients, C3-T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2-T2 (93%) than the C3-T1 (80%, P=0.040) cohort. When comparing the C2-T2 to the C3-T1 cohort, the C3-T1 cohort had a significantly greater rate of proximal junctional failure (2% vs. 10%, P=0.006), distal junctional failure (1% vs. 20%, P<0.001) and distal screw loosening (4% vs. 15%, P=0.02). Although ∆C2-C7 sagittal vertical axis increased significantly in both cohorts (C2-T2: 6.2 mm, P=0.04; C3-T1: 8.4 mm, P<0.001), correction did not significantly differ between groups (P=0.32). The C3-T1 cohort had a significantly greater increase in ∆C2 slope (8.0 vs. 3.1 degrees, P=0.03) and ∆C0-C2 Cobb angle (6.4 vs. 1.2 degrees, P=0.04). CONCLUSION: In patients undergoing PCF, a C2-T2 construct demonstrated lower rates of pseudarthrosis, distal junctional failure, proximal junctional failure, and compensatory upper cervical hyperextension compared with a C3-T1 construct.

Multilevel cervical laminectomy and fusion with posterior cervical cages.

CONTEXT: Cervical spondylotic myelopathy (CSM) is a progressive disease that can result in significant disability. Single-level stenosis can be effectively decompressed through either anterior or posterior techniques. However, multilevel pathology can be challenging, especially in the presence of significant spinal stenosis. Three-level anterior decompression and fusion are associated with higher nonunion rates and prolonged dysphagia. Posterior multilevel laminectomies with foraminotomies jeopardize the bone stock required for stable fixation with lateral mass screws (LMSs). AIMS: This is the first case series of multilevel laminectomy and fusion for CSM instrumented with posterior cervical cages. SETTINGS AND DESIGN: Three patients presented with a history of worsening neck pain, numbness in bilateral upper extremities and gait disturbance, and examination findings consistent with myeloradiculopathy. Cervical magnetic resonance imaging demonstrated multilevel spondylosis resulting in moderate to severe bilateral foraminal stenosis at three cervical levels. MATERIALS AND METHODS: The patients underwent a multilevel posterior cervical laminectomy and instrumented fusion with intervertebral cages placed between bilateral facet joints over three levels. Oswestry disability index and visual analog scores were collected preoperatively and at each follow-up. Pre- and post-operative images were analyzed for changes in cervical alignment and presence of arthrodesis. RESULTS: Postoperatively, all patients showed marked improvement in neurological symptoms and neck pain. They had full resolution of radicular symptoms by 6 weeks postoperatively. At 12-month follow-up, they demonstrated solid arthrodesis on X-rays and computed tomography scan. CONCLUSIONS: Posterior cervical cages may be an alternative option to LMSs in multilevel cervical laminectomy and fusion for cervical spondylotic myeloradiculopathy.

What Protects Certain Nerves from Stretch Injury?

The human tibial nerves is less prone to injury following joint arthroplasty compared with the peroneal nerves. Besides the anatomical distribution, other features may confer protection from stretch injury. We therefore examined the size, shape and connective tissue distribution for the two nerves. The tibial and peroneal nerves from each side of nine fresh human cadavers we reharvested mid-thigh. Proximal segments manually stretched 20%-25% were fixed in aldehyde, while the adjacent distal segments were fixed in their natural length. Paraffin sections stained by Masson's trichrome method for connective tissue were examined by light microscopy. Tibial nerves had 2X more fascicles compared with the peroneal, but the axonal content appeared similar. Analysis showed that neither nerve had a significant reduction in cross sectional area of the fascicles following stretch. However, fascicles from stretched tibial nerves become significantly more oval compared with those from unstretched controls and peroneal nerves. Tibial nerves had a greater proportion that was extrafascicular tissue (50-55%) compared with peroneal nerves (38%-42%). This epineurium was typically adipose tissue. Perineurial thickness in both nerves was directly related to fascicular size. Tibial nerves have several unique histological features associated with size, shape and tissue composition compared with the peroneal nerve. We suggest that more fascicles with their tightly bound perineurium and more robust epineurium afford protection against stretch injury. Mechanical studies should clarify how size and shape contribute to nerve protection and/or neurapraxia.

Arthroscopic Resection of a Bilateral Calcaneonavicular Coalition in a Child.

Calcaneonavicular coalition is a congenital anomaly characterized by a connection between the calcaneus and the navicular. It can manifest as lateral foot pain, peroneal spastic flatfoot, and repeated ankle sprains. Surgery is required in the case of chronic pain and after failure of conservative treatment. The aim of surgical intervention is pain relief and preventing recurrence. Arthroscopic resection is a minimally invasive alternative that has the advantages of quicker recovery and better aesthetic results. This technique has shown significant symptomatic improvement and no recurrence at early follow-up points in a small number of reported cases. The present report presents the case of a child with bilateral calcaneonavicular coalition. This is the first report to our knowledge that describes the outcome of simultaneous bilateral arthroscopic resection of calcaneonavicular coalition in a child with a 2-year follow-up period.

Ultrasound and fluoroscopy are unnecessary for injections into the arthritic hip.

PURPOSE: We investigated the effectiveness of non-image-guided hip injections. METHODS: We retrospectively evaluated 369 intra-articular hip injections in 331 patients using anatomical landmarks. The percentage and duration of pain relief was documented. Hip injections were grouped in responders and nonresponders (50 % maximum pain relief as a cut off). RESULTS: In 82% (n = 304) of hip injections, patients responded positively and experienced >50 % pain relief. Nonresponders had a significantly higher body mass index (p = 0.007). CONCLUSIONS: Hip injections using anatomical landmarks are an effective treatment option for patients with osteoarthritis of the hip.

Achilles tendon allograft for augmentation of the Hanssen patellar bone grafting.

PURPOSE: Severe patellar bone loss precludes the insertion of another patellar implant in revision total knee arthroplasty (TKA) and weakens the attachment of the patella to the quadriceps tendon. Hanssen described securing a tissue flap to the patellar rim allows the delivery of cancellous bone graft into the patellar bone defect. The purpose of this study is to describe the surgical technique and early clinical results of a modified Hanssen patelloplasty with an Achilles tendon allograft. METHODS: The modified technique described in three patients undergoing revision TKA aims to augment the extensor mechanism by securing an Achilles tendon allograft to the proximal part of the patellar tendon and the distal quadriceps tendon using mattress sutures. This serves to reinforce the extensor mechanism and decrease the risk of a tear of its patellar attachment. The patellar bone defect is grafted using corticocancellous bone chips. RESULTS: Over a 12- to 48-month follow-up, all reconstructions healed with an increase in patellar bone thickness. No patient had any extensor lag, and all patients achieved 110°-125° of flexion. The Western Ontario and McMaster University knee scores improved from 53 (23-88) preoperatively to 88.5 (66-100) at last follow-up, with no reported complications. CONCLUSIONS: Augmentation of the extensor mechanism with an Achilles tendon allows for early mobilization and excellent postoperative range of motion in patients with large patella bone defects and imminent patella fracture. LEVEL OF EVIDENCE: IV.

Blood management may have an impact on length of stay after total hip arthroplasty.

BACKGROUND: The steady rise in demand for total hip arthroplasty constitutes a significant and increasing burden on health care resources. The biggest contributors to the total cost of hip replacement procedures other than the price of the implant are hospital stay and postoperative rehabilitation. Blood management is one of the most adjustable factors that can impact length of stay and cost-efficiency while improving patient safety. QUESTIONS/PURPOSES: The primary purpose of this retrospective study was to assess the potential impact of blood management interventions on length of hospital stay after primary unilateral total hip arthroplasty. This was achieved by first identifying which patient and surgical factors are associated with an increased risk of prolonged hospital stay. Subsequently, the significant factors were controlled for through a multivariate regression analysis to quantify the association between blood transfusions and increased hospital stay. METHODS: Retrospectively, the study included 2,104 primary total hip replacements. Eight hundred eighty-eight procedures were performed on males and 1,216 on females, with a mean age of 64 years at the time of the surgery (range 18-94 years) and BMI of 28.6 kg/m(2) (range 12-51.5 kg/m(2)). The correlation between each factor and length of stay was analyzed separately using univariate regression analysis. Those variables with p ≤ 0.05 in the univariate model were selected for inclusion in the multivariate logistic regressions. Multiple linear regression was used to analyze the effect of each significant factor and derive odds ratios with adjustment for the other variables. RESULTS: Multivariate Poisson regression revealed that increased length of stay was significantly correlated to patient age (p = 0.05), the use of coumadin (p = 0.02) or lovenox/heparin (p = 0.007) as opposed to aspirin for anticoagulation, and allogeneic blood transfusion (p < 0.0001). The data shows that allogeneic blood transfusion is associated with a longer hospital stay regardless of absolute drop in hemoglobin level postoperatively or at discharge or the number of units transfused (OR = 1.18, 95% CI = 1.09 to 1.28, p < 0.001). CONCLUSION: Transfusion of allogeneic blood is independently associated with increased hospital stay after total hip arthroplasty. Blood management modalities that can significantly reduce transfusion risk could impact length of stay as well as the total cost of hip replacement procedures.

Targeted pre-operative autologous blood donation: a prospective study of two thousand and three hundred and fifty total hip arthroplasties.

PURPOSE: Pre-operative donation of autologous blood has been widely used in elective joint replacement procedures to avoid the risks of allogeneic blood transfusions. However, the high percentage of wasted autologous blood questions the general efficacy of pre-operative autologous blood donation (PABD) for all patients undergoing hip replacement. This study prospectively investigates the impact of a targeted pre-operative autologous blood donation protocol for anaemic patients on allogeneic and overall transfusion rates in 2,350 unilateral primary total hip arthroplasty procedures. METHODS: Patients with pre-operative haemoglobin less than 12.5 g/dL were advised to donate one unit of autologous blood seven to 15 days prior to the date of surgery. The targeted protocol was followed by 2,251 patients: 280 out of 367 anaemic patients donated while 1,971 out of 1,983 non-anaemic patients did not donate. RESULTS: Results showed a significantly lower rate of allogeneic transfusion for anaemic patients who predonated than anaemic patients who did not (13 % vs. 37% respectively, p < 0.001). Overall transfusion rates for patients who followed the protocol (n = 2,251) were found to be 0.17 units/patient compared to previously reported numbers of 0.75 units/patient when routine donation was used. Among the 2,251 patients who followed the protocol, only 140 patients (6%) had their autologous blood wasted, in contrast to values reported in the literature ranging from 14% up to 50%. CONCLUSIONS: Targeted PABD reduces the need for allogeneic blood transfusion in anaemic patients and significantly reduces the overall number of transfusions compared to routine pre-operative autologous donation.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty.

INTRODUCTION: Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions. MATERIALS AND METHODS: 176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements. RESULTS: All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005). CONCLUSIONS: While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Targeted preoperative autologous blood donation in total knee arthroplasty reduces the need for postoperative transfusion.

BACKGROUND: Preoperative donation of autologous blood has been widely used to minimize the potential risk of allogeneic transfusions in total knee arthroplasty. A previous study from our center revealed that preoperative autologous donation reduces the allogeneic blood exposure for anemic patients but has no effect for non-anemic patients. QUESTIONS/PURPOSES: The current study investigates the impact of a targeted blood donation protocol on overall transfusion rates and the incidence of allogeneic blood transfusions. METHODS: Prospectively, 372 patients undergoing 425 unilateral primary knee replacements were preoperatively screened by the Blood Preservation Center between 2009 and 2012. Anemic patients with a hemoglobin level less than 13.5 g/dL were advised to donate blood, while non-anemic patients did not donate. RESULTS: Non-anemic patients who did not donate blood required allogeneic blood transfusions in 5.9% of the patients. The overall rate of allogeneic transfusion was significantly lower for anemic patients who donated autologous blood (group A, 9%) than those who did not donate (group B, 33%; p < 0.001). Donating autologous blood did increase the overall transfusion rate of anemic patients to 0.84 per patient in group A compared to 0.41 per patient in group B (p < 0.001). CONCLUSION: This investigation confirms that abandoning preoperative autologous blood donation for non-anemic patients does not increase allogeneic blood transfusion rates but significantly lowers overall transfusion rates.

The value of valgus stress radiographs in the workup for medial unicompartmental arthritis.

BACKGROUND: High tibial osteotomy and unicompartmental knee arthroplasty are surgical treatment options for unicompartmental knee arthritis; these procedures are indicated for patients who do not have severe arthritis in the lateral compartment. Valgus stress radiographs sometimes are used to make this evaluation, but this test has not been critically evaluated. QUESTIONS/PURPOSES: We sought to determine (1) whether valgus stress radiographs help to evaluate the integrity of the cartilage in the lateral compartment in patients undergoing TKA for noninflammatory arthritis, and (2) whether valgus stress radiographs can identify patients whose varus deformity is correctable. METHODS: We reviewed preoperative hip-to-ankle standing radiographs, AP standing radiographs, and valgus stress radiographs of 84 patients (91 knees) who underwent TKA for varus knee arthritis between July 2010 and January 2012. Valgus stress radiographs were obtained with the patient supine with the knee 20° flexed and a firm manual valgus force was applied through the knee. On valgus stress radiographs, the lateral compartment joint space width and the corrected mechanical alignment were measured. Intraoperative cartilage assessment (Outerbridge grade) was compared with lateral compartment joint space width. Knees with mechanical leg alignment of 3° varus to 3° valgus on valgus stress radiographs were considered correctable deformities. RESULTS: The lateral compartment joint space width on valgus stress radiographs did not correlate with the intraoperative Outerbridge grading of the lateral compartment cartilage (rs = -0.154; p = 0.146). The majority of knees (93%; 55 of 59) with 10° or less mechanical varus on hip-to-ankle standing radiographs were correctable within the range of 3° varus to 3° valgus. CONCLUSIONS: Valgus stress radiographs provided no added benefit to the radiographic assessment of the lateral compartment cartilage and regarding the correctability of the varus deformity.

HLA population genetics: a Lebanese population.

Human leukocyte antigen (HLA) typing was done in 426 Lebanese subjects of 88 families, in which 347 haplotypes were identified. The A, B, C, DRB1, DRB3/4/5, DQB1 and DPB1 loci were typed at high resolution. This study shows that information theory, as originally developed by Claude Shannon in 1948, provides a promising theoretical foundation to study the population genetics of a genetic system like HLA. Although Lebanese carry HLA alleles found in other populations, the association of these alleles into haplotypes is quite unique. Comparisons are made with the main ethnic groups. Two haplotypes well represented in the Lebanese population are not identified in any global population: L1 = {A*26:01:01 - B*35:01:01:01- C*04:01:01:01- DRB1*16:01:01 - DRB5*02:02 - DQB1*05:02:01} and L2 = {A*02:02 - B*41:01- C*17:01:01:01 -DRB1*11:04:01 - DRB3*02:02:01:01- DQB1*03:01:01:01}. By studying linkage disequilibrium in two blocks at a time, with the division of the blocks at different levels in consecutive cycles, conserved haplotypes in full linkage disequilibrium come to light, such as {A*26:01:01- B*35:01:01:01 - C*04:01:01:01 - DRB1*16:01:01 - DRB5*02:02 - DQB1*05:02:01- DPB1*03:01:01} and {A*33:01:01 - B*14:02:01 - C*08:02:01 - DRB1*01:02:01- DQB1*05:01:01:01 - DPB1*04:01:01:01}.

Nonanemic patients do not benefit from autologous blood donation before total knee replacement.

A retrospective analysis of 221 patients undergoing unilateral total knee arthroplasty between January 2007 and April 2008 was performed to look at rates of total transfusions, allogenic transfusions, and autogenic transfusions. Two senior surgeons performed all the surgeries. During that period, patients in group A (129 patients) all donated one unit of autologous blood and patients in group B (92 patients) did not donate. Within both groups, patients were further divided by preoperative hemoglobin level as either anemic or non-anemic. A hemoglobin of 12.5 g/dL was used as the cutoff. Ninety-eight patients in group A (76%) required autologous blood. Patients in group A received a higher total number of transfusions (0.93 per patient) than those in group B (0.33 per patient; p < 0.001). The rate of allogenic transfusion was lower for group A (14%) than for group B (25%; p < 0.033). The reduction of allogenic transfusions associated with preoperative autologous blood donation was confined to anemic patients (29% in group A vs 72% in group B; p = 0.0006). There was no difference in allogenic blood transfusions in non-anemic patients between group A (8%) and group B (9%; p = 0.91). Limiting autologous blood donation to anemic patients decreased cost compared to routine autologous blood donation (US $256.63/patient versus US $511.44/patient) without exposing patients to increased allogenic blood transfusions. Targeted blood management in total knee replacement surgery decreases transfusion rates and reduces cost.