An Increase in Same-day Discharge After Total Joint Arthroplasty During the COVID-19 Pandemic Does Not Influence Patient Outcomes: A Retrospective Cohort Analysis.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused major transitions in total joint arthroplasty (TJA), notably with the increased utilization of same-day discharge (SDD) pathways. This study assessed the effect of accelerated discharge pathways following the resumption of elective cases during the COVID-19 pandemic on SDD rates, adverse events, and characteristics associated with successful SDD following total hip and total knee arthroplasty. Methods: This retrospective study split patients into cohorts: TJA prior to COVID-19 (pre-COVID, July 2019-December 2019) and TJA following the resumption of elective surgeries (post-COVID, July 2020-December 2020). Patient characteristics such as age, sex, body mass index, American Society of Anesthesiologists score, and pertinent comorbidities were analyzed, and length of stay, 30-day emergency department (ED) visit rates, readmissions, and reoperations were compared. Results: A total of 1333 patients met inclusion criteria that were divided into pre-COVID (692) and post-COVID (641) cohorts. The pre-COVID group had a median age of 69 years (interquartile range 63-76), and the post-COVID group had a median age of 68 years (interquartile range 61-75) (P = .024). SDD increased from 0.1% to 28.9% (P < .001), and length of stay decreased from 1.3 days to 0.89 days (P < .001). There was no change in 30-day ED visits, readmissions, or reoperations (P = .817, P = .470, and P = .643, respectively). There was no difference in ED visits, readmissions, or reoperations in SDD patients. The odds of SDD were associated with age (P < .001, odds ratio [OR] = 0.94), body mass index (P = .006, OR = 0.95), male sex (P < .001, OR = 1.83), and history of tobacco use (P < .001, OR = 1.87). Conclusions: At our institution, the COVID-19 pandemic accelerated the utilization of SDD pathways without increasing ED visits, readmissions, or reoperations.

Proximal Tibial Osteotomies: Indications, Techniques, and Outcomes.

High tibial osteotomy (HTO) is a surgical procedure that can be used as a primary or as an adjunctive treatment for a variety of knee pathologies, most commonly isolated medial compartment arthrosis in a knee with varus alignment. More recently, indications for HTO have been expanded to include its use in combination with cartilage preserving techniques, to offload the effected compartment, and in conjunction with ligamentous reconstruction. HTO also has utility in delaying total knee arthroplasty (TKA) in select patients with favorable literature on future TKA outcomes. Numerous techniques for HTO have been published, however, medial opening wedge and lateral closing wedge osteotomies remain the most common. The purpose of this article is to summarize HTO patient selection and indications, surgical techniques, common complications, and review outcomes from recent literature. (Journal of Surgical Orthopaedic Advances 32(3):148-155, 2023).

Bone Marrow Edema, Clinical Significance, and Treatment Options: A Review.

Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.

Patient Characteristics and Surgical Start Time Affect Length of Stay Following Anterior Total Hip Arthroplasty.

BACKGROUND: Currently, no consensus exists for selection criteria of appropriate candidates for outpatient total hip arthroplasty (THA). This study evaluates patient characteristics associated with same-day discharge, examined surgical start time's effect on rates of same-day discharge, and compares readmission and reoperation rates between groups. METHODS: All patients who underwent a THA by one surgeon at a single quaternary care hospital between February 2016 and May 2018 were captured. All patients were given the option for same-day discharge. Patient characteristics and perioperative variables were analyzed. RESULTS: A total of 429 patients met inclusion criteria, 153 (36%) were discharged on the day of surgery. In a multivariate analysis, age (P = .000), multiple comorbidities (P = .004), and start time remained statistically significant (P = .000). Patients with start times prior to 9 AM had odds ratio of 11.56 of being discharged same day when compared to those with start times after 12 PM. Patients discharged the day of surgery were less likely to have a 90-day emergency room visit (P = .010), a readmission within 30 days (P = .001) or 90 days (P = .000), or a reoperation (0 vs 14, P = .003). CONCLUSION: Same-day discharge following THA is safe and feasible. Patient's age and number of comorbidities should be considered when developing selection criteria for same-day discharge programs. Patients selected for same-day discharge should receive earlier operating room start times.

Short-Term Outcomes for the Biologic Treatment of Bone Marrow Edema of the Knee Using Bone Marrow Aspirate Concentrate and Injectable Demineralized Bone Matrix.

PURPOSE: To evaluate short-term outcomes for the biologic treatment of bone marrow edema (BME) of the knee using bone marrow aspirate concentrate (BMAC) and injectable demineralized bone matrix (iDBM). METHODS: We performed a review of prospectively collected data from patients who underwent treatment for bone marrow lesions (BMLs) of the knee using BMAC and iDBM (IntraOsseous BioPlasty; Arthrex, Naples, FL) between May 2017 and December 2018. Inclusion criteria included patients aged 18 to 65 years with the presence of BME on T2-weighted magnetic resonance imaging in the subchondral weightbearing region of the tibia or femoral condyle, with pain corresponding to the same compartment. The International Knee Documentation Committee (IKDC), pain visual analog scale (VAS), and 12-Item Short Form Health Survey (SF-12) scores were used to evaluate clinical outcomes. RESULTS: We evaluated 20 patients who were treated at a single academic medical institution over a mean 14.5-month follow-up (median, 14 months; range, 6-25 months). The average patient age was 51.7 years (range 38-62 years). Compared with preoperative values, the visual analog scale decreased from 7.0 to 1.3 (P = .008). The mean International Knee Documentation Committee scores improved from 29.2 to 66.1 (P = .063). Both the Physical and Mental Component Scores of the 12-Item Short Form Health Survey also showed improvement (Physical Component Score, P = .438; Mental Component Score, P = .563). Based on postoperative magnetic resonance imaging, 75% (3 of 4) of the BMLs demonstrated complete healing. The survival rate was 93% at 1-year follow-up. CONCLUSION: Biologic treatment of BME of the knee using BMAC and iDBM is an effective adjunct to arthroscopy that provides short-term pain relief for BMLs associated with degenerative conditions of the knee. This procedure is associated with clinically significant improvements in knee pain and function at a short-term follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Treatment of a chronically infected nasal silicone prosthesis with continuous antibiotic irrigation and gentamicin-impregnated polymethylmethacrylate beads.

Infected nasal alloplasts in revision rhinoplasty can be a complex problem, as timing between implant removal and reconstruction is the major limiting factor. Delaying reconstruction can result in loss of mechanical support, a constricted nose, and in severe cases, complete nasal airway collapse and respiratory compromise. In this case report, we describe a novel surgical approach for the management of a chronically infected nasal implant combining techniques used to treat biomaterial-associated infections: antibiotic-impregnated polymethymethacrylate beads and a continuous catheter-based antibiotic irrigation system. We report a case of a chronic alloplastic-associated infection following nasal reconstruction using a silicone implant. We utilized a two-staged approach. The involved nasal implant was removed and replaced temporarily with gentamicin-impregnated polymethymethacrylate beads and a continuous closed irrigation and drainage system with local and parenteral delivery of antibiotics. Both modalities allowed for complete eradication of the infection. In addition, the gentamicin beads provided sufficient mechanical support in order to minimize the risk of skin contracture. Twelve days after her initial surgery, nasal reconstruction was performed using a cadaver bone graft. The patient was followed for two years postoperatively and has shown good results with no evidence of skin contracture or recurrent infection. This technique may allow for shorter delay in revision surgery and reduce the risk of long-term complications without compromising functional and aesthetic outcomes.

AFAP1 Is a Novel Downstream Mediator of TGF-ß1 for CCN2 Induction in Osteoblasts.

BACKGROUND: CCN2 acts as an anabolic growth factor to regulate osteoblast differentiation and function. CCN2 is induced by TGF-ß1 and acts as a mediator of TGF-ß1 induced matrix production in osteoblasts and Src is required for CCN2 induction by TGF-ß1; however, the molecular mechanisms that control CCN2 induction in osteoblasts are poorly understood. AFAP1 binds activated forms of Src and can direct the activation of Src in certain cell types, however a role for AFAP1 downstream of TGF-ß1 or in osteoblats is undefined. In this study, we investigated the role of AFAP1 for CCN2 induction by TGF-ß1 in primary osteoblasts. RESULTS: We demonstrated that AFAP1 expression in osteoblasts occurs in a biphasic pattern with maximal expression levels occurring during osteoblast proliferation (~day 3), reduced expression during matrix production/maturation (~day 14-21), an a further increase in expression during mineralization (~day 21). AFAP1 expression is induced by TGF-ß1 treatment in osteoblasts during days 7, 14 and 21. In osteoblasts, AFAP1 binds to Src and is required for Src activation by TGF-ß1 and CCN2 promoter activity and protein induction by TGF-ß1 treatment was impaired using AFAP1 siRNA, indicating the requirement of AFAP1 for CCN2 induction by TGF-ß1. We also demonstrated that TGF-ß1 induction of extracellular matrix protein collagen XIIa occurs in an AFAP1 dependent fashion. CONCLUSIONS: This study demonstrates that AFAP1 is an essential downstream signaling component of TGF-ß1 for Src activation, CCN2 induction and collagen XIIa in osteoblasts.

Selective estrogen receptor modulators: tissue specificity and clinical utility.

Selective estrogen receptor modulators (SERMs) are a diverse group of nonsteroidal compounds that function as agonists or antagonists for estrogen receptors (ERs) in a target gene-specific and tissue-specific fashion. SERM specificity involves tissue-specific expression of ER subtypes, differential expression of co-regulatory proteins in various tissues, and varying ER conformational changes induced by ligand binding. To date, the major clinical applications of SERMs are their use in the prevention and treatment of breast cancer, the prevention of osteoporosis, and the maintenance of beneficial serum lipid profiles in postmenopausal women. However, SERMs have also been found to promote adverse effects, including thromboembolic events and, in some cases, carcinogenesis, that have proven to be obstacles in their clinical utility. In this review, we discuss the mechanisms of SERM tissue specificity and highlight the therapeutic application of well-known and emergent SERMs.