Oral cancer patients achieve comparable survival at high safety-net burden hospitals.

PURPOSE: To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma. MATERIALS AND METHODS: We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival. RESULTS: Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals. CONCLUSION: High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.

Interest, Concerns, and Attitudes Among Men Who Have Sex With Men and Health Care Providers Toward Prophylactic Use of Doxycycline Against Chlamydia trachomatis Infections and Syphilis.

BACKGROUND: Prophylactic administration of doxycycline is regarded as a potential new public health strategy to combat the rising rates of Chlamydia trachomatis infections and syphilis among men who have sex with men. We conducted a survey-based study to evaluate how community members and health care providers in Southern California would perceive doxycycline preexposure/postexposure prophylaxis (PrEP/PEP) to predict its acceptability and identify potential areas of concern. METHODS: We conducted an online cross-sectional survey among community members who identify as men who have sex with men and health care providers with prescribing authority in Southern California to investigate the current attitudes toward doxycycline PrEP/PEP, including their willingness to accept. We analyzed the data using descriptive statistics and binary logistic regression. RESULTS: Among 212 enrolled community member participants, 67.5% indicated they would take doxycycline PrEP/PEP if offered by their provider. Higher acceptability was significantly associated with several characteristics, including recent history of bacterial sexually transmitted infection diagnosis and current use of HIV PrEP. For health care providers, 89.5% of 76 enrolled participants expressed willingness to prescribe doxycycline PrEP/PEP to their patients if recommended by the Centers for Disease Control and Prevention, but only 43.4% were willing if not. Both community members and health care providers demonstrated high levels of concern toward possible drug resistance. CONCLUSIONS: Doxycycline PrEP/PEP as a preventive strategy against chlamydial infections and syphilis would likely be accepted among community members and health care providers. Clear guidelines from public health officials and further clarification on the strategy's potential impact on developing drug resistance may be necessary to ensure successful implementation.

A national cancer database analysis on stereotactic body radiation therapy of head and neck cancers.

BACKGROUND: To evaluate demographic, clinicopathological, treatment factors including biological effective radiation dose (BED) that influence overall survival in head and neck cancer (HNC) patients treated with stereotactic body radiation therapy (SBRT). METHODS: Between 2004 and 2015, 591 SBRT-treated HNC patients were identified from the National Cancer Data Base. A BED using an alpha/beta ratio of 10 (BED10), was used to compare dose fractionation of different SBRT regimens. Overall survival was estimated using the Kaplan Meier method, and log-rank tests were used to determine statistical significance. Cox regression modeling was used to compute crude and adjusted hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Median follow-up was 11.9 (interquartile range, 5.5 to 26.7) months. The 5-year overall survival rate was 15.5%. On multivariate analysis, older age, Charlson-Deyo comorbidity score ≥ 1, history of cancer, tumor, nodal and metastatic stage, and receiving treatment at academic/research program were associated with poor survival. Compared to SBRT alone, superior survival was observed with SBRT with chemotherapy, surgery with SBRT, but not surgery with SBRT and chemotherapy. Improved survival was observed with aa BED10 of ≥59.5 Gy (adjusted HR 0.57, 95% CI 0.46-0.70, P < 0.0001). CONCLUSIONS: Factors affecting associated with worse survival in HNC patients treated with SBRT included older age, patient comorbidities, advanced tumor stage, cancer history, and lower biological effective SBRT dose. LEVEL OF EVIDENCE: 2b (individual cohort study).

Visualizing Structure and Vascular Interactions: Macular Nonperfusion in Three Capillary Plexuses.

BACKGROUND AND OBJECTIVE: To assess the relationship between retinal vascular and structural changes in the superficial, middle, and deep capillary plexuses (SCP, MCP, DCP) using optical coherence tomography angiography (OCTA) and en face OCT. PATIENTS AND METHODS: Patients with diabetic retinopathy were imaged using the Cirrus HD-OCT with AngioPlex. Using manual segmentation of the retinal layers, the authors compared OCTA to en face OCT images to examine corresponding patterns in each of the three capillary plexuses. RESULTS: Areas of decreased perfusion and capillary dropout on OCTA were found to be associated with three corresponding lesions on en face OCT: hyporeflectivity, cystic edema, and hard exudates. Vascular changes in individual capillary plexuses corresponded with structural changes in their respective perfused retinal layers. CONCLUSIONS: Using manual segmentation on OCTA, the authors provide a framework to visualize the relationship between vascular pathology on OCTA and structural changes on en face OCT within specific capillary plexuses. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e182-e190.].

Comparison of Zeiss Cirrus and Optovue RTVue OCT Angiography Systems: A Quantitative and Qualitative Approach Examining the Three Capillary Networks in Diabetic Retinopathy.

BACKGROUND AND OBJECTIVES: Construct a method for visualizing the middle capillary plexus (MCP) using Zeiss optical coherence tomography angiography (OCTA) and compare to established segmentation methods using the Optovue system. PATIENTS AND METHODS: Twenty eyes with diabetic retinopathy were imaged. Visualization of the MCP, image artifacts, preservation of pathological changes, foveal avascular zone (FAZ) area, and vessel length density (VLD) were compared between devices. RESULTS: The authors successfully segmented the superficial (SCP), MCP, and deep (DCP) capillary plexuses on both devices. More images artifacts were detected on Optovue. Microaneurysms and telangiectatic vessels were better visualized in the MCP on the Optovue. FAZ area showed a strong correlation between the two instruments (r2= 0.666; P < .0001). The SCP had lower VLD compared to the MCP and DCP on both devices. CONCLUSION: The authors provide an objective and consistent method for manual segmentation using Zeiss OCTA to visualize the three retinal capillary plexuses. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e198-e205.].

Analysis of Postoperative Thoracolumbar Spine Infections in a Prospective Randomized Controlled Trial Using the Centers for Disease Control Surgical Site Infection Criteria.

INTRODUCTION: Wound infections following spinal surgery place a high toll on both the patient and the healthcare system. Although several large series studies have examined the incidence and distribution of spinal wound infection, the applicability of these studies varies greatly since nearly every study is either retrospective and/or lacks standard inclusion criteria for defining surgical site infection. To address this void, we present results from prospectively gathered thoracolumbar spine surgery data for which the Centers for Disease Control (CDC) criteria were stringently applied to define a surgical site infection (SSI). METHODS: A prospective randomized trial of 314 patients who underwent multilevel thoracolumbar spinal surgery with instrumentation followed by postoperative drain placement was completed (Takemoto et al., 2015). The trial consisted of two antibiotic arms: one for 24-hours, and the other for the duration of the drain; no differences were found between the arms. All infections meeting CDC criteria for SSI were included. RESULTS: A total of 40 infections met CDC criteria for SSI, for an overall incidence of 12.7%. Of these, 20 (50%) were culture-positive. The most common organism was Staphylococcus aureus (4 total: methicillin-sensitive=2; methicillin-resistant=2), followed by coagulase-negative Staphylococcus (3 cases), Propionibacterium acnes and Escherichia coli (2 cases each). Six infections grew multiple organisms, most commonly involving coagulase-negative staphylococcus and enterococcus. CONCLUSIONS: Our findings indicate that thoracolumbar SSI occurs at the higher end of the range cited in the literature (2-13%), which is largely based on retrospective data not subjected to the inclusivity of SSI as defined by the CDC. The three most common organisms in our analysis (S. aureus, P. acnes, E. coli) are consistent with previous reports. Staphylococcus aureus continues to be the most common causative organism and continued vigilance and searching for preventive measures need to be a high priority. This study provides Level I evidence.

CHARACTERIZATION OF THE MIDDLE CAPILLARY PLEXUS USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN HEALTHY AND DIABETIC EYES.

PURPOSE: To assess the ability of optical coherence tomography angiography to image the retinal middle capillary plexus (MCP), and to characterize the MCP as a unique vascular network separate from the superficial and deep capillary plexus (DCP). METHODS: Healthy and diabetic eyes were imaged using the Avanti XR optical coherence tomography angiography instrument (Optovue Inc, Fremont, CA). Using manual segmentation of the retinal layers, the authors generated en face angiograms to distinguish the three capillary plexuses (superficial capillary plexus, MCP, DCP). RESULTS: In healthy eyes, arterioles gave rise to distinct branches in the MCP, and venules gave rise to prominent vortex like branches in the DCP. The foveal avascular zone was most well-defined at the level of the MCP, and had a larger area in the DCP. In diabetic eyes, the three capillary plexuses showed varying degrees of nonperfusion, including variable shapes and extent of the foveal avascular zone, with loss of border integrity at the MCP. Microaneurysms appeared in all the three capillary plexuses. CONCLUSION: Using customized segmentation analysis in optical coherence tomography angiography, the authors demonstrate that the MCP is qualitatively and functionally distinct from the superficial capillary plexus and DCP, which may help clarify the pathogenesis of different middle retinal ischemic entities and provide new insights into retinal ischemia in diabetic retinopathy.

A Listeria monocytogenes-based vaccine that secretes sand fly salivary protein LJM11 confers long-term protection against vector-transmitted Leishmania major.

Cutaneous leishmaniasis is a sand fly-transmitted disease characterized by skin ulcers that carry significant scarring and social stigmatization. Over the past years, there has been cumulative evidence that immunity to specific sand fly salivary proteins confers a significant level of protection against leishmaniasis. In this study, we used an attenuated strain of Listeria monocytogenes as a vaccine expression system for LJM11, a sand fly salivary protein identified as a good vaccine candidate. We observed that mice were best protected against an intradermal needle challenge with Leishmania major and sand fly saliva when vaccinated intravenously. However, this protection was short-lived. Importantly, groups of vaccinated mice were protected long term when challenged with infected sand flies. Protection correlated with smaller lesion size, fewer scars, and better parasite control between 2 and 6 weeks postchallenge compared to the control group of mice vaccinated with the parent L. monocytogenes strain not expressing LJM11. Moreover, protection correlated with high numbers of CD4(+), gamma interferon-positive (IFN-γ(+)), tumor necrosis factor alpha-positive/negative (TNF-α(+/-)), interleukin-10-negative (IL-10(-)) cells and low numbers of CD4(+) IFN-γ(+/-) TNF-α(-) IL-10(+) T cells at 2 weeks postchallenge. Overall, our data indicate that delivery of LJM11 by Listeria is a promising vaccination strategy against cutaneous leishmaniasis inducing long-term protection against ulcer formation following a natural challenge with infected sand flies.

Misregulation of the broad-range phospholipase C activity increases the susceptibility of Listeria monocytogenes to intracellular killing by neutrophils.

Listeria monocytogenes is a facultative intracellular bacterial pathogen that tightly regulates the activities of various virulence factors during infection. A mutant strain (the plcBDpro mutant) that has lost the ability to control the activity of a phospholipase C (PC-PLC) is attenuated a hundred fold in mice. This attenuation is not due to a lack of bacterial fitness, but appears to result from a modified host response to infection. The transcriptomic pattern of immune-related genes indicated that PC-PLC did not enhance the innate immune response in infected macrophages. However, it partially protected the cells from bacteria-mediated mitochondrial fragmentation. In mice, the plcBDpro mutant transiently caused an increase in liver pathology, as judged by the size of neutrophil-filled micro-abscesses. Moreover, the plcBDpro mutant was more susceptible to intracellular killing by neutrophils than wild-type L. monocytogenes. Together, these data indicate that in vivo attenuation of the plcBDpro mutant results from its reduced ability to disrupt mitochondrial homeostasis and to resist intracellular killing by neutrophils.

Updates in the use of bone grafts in the lumbar spine.

There has been a rapid increase in the number of lumbar fusion procedures performed in the last 10 years. Many of these procedures involve the use of bone grafts and specifically bone graft extenders and substitutes. Fusion depends on host and surgical factors including the selection of an appropriate graft. Bone grafts have osteoconductive, osteoinductive, and osteogenic properties. Iliac crest autograft has long been considered the gold standard for bone graft procedures as it inherently imparts all three. However, its use is associated with significant disadvantages including donor site pain, increased operative time, and insufficient availability. Allograft has been used to avoid the complications of donor site morbidity but has increased risks of rejection, disease transmission, and slower incorporation into the host bone. The use of alternative bone grafting options, such as demineralized bone matrix, synthetics (ceramics), bone morphogenetic proteins, collagen-based matrices, autogenous growth factors, and bone marrow aspirate, have become routine in some institutions. This review paper highlights the different bone grafting options currently available, discusses their pros and cons, and briefly reviews the relevant literature.

Fusionless surgery for scoliosis.

Scoliosis is a very common condition, affecting approximately 7 million children in the United States. Treatment of this condition in young children can be challenging. A variety of techniques that avoid spinal fusion have been developed to manage scoliosis in this patient population. This review article describes several of these methods, including growing rods, prosthetic ribs, vertebral stapling, and vertebral tethering. Particular attention is given to literature discussing each technique.

Cost analysis of anterior-posterior circumferential fusion and transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Although lumbar interbody fusion has long been a common procedure in the practice of spine surgery, focus on the technological development has produced the relatively new procedure of transforaminal lumbar interbody fusion (TLIF). This procedure is often available to surgeons as an alternative to anterior-posterior circumferential fusion (AP fusion), and both procedures have been demonstrated to be clinically equivalent at up to 5 years after surgery. In the context of clinical equipoise, it is unknown which procedure is more economically advantageous. PURPOSE: To compare the hospital costs, charges, and payments received for surgical treatment with either AP fusion or TLIF. Future directions for health economic research with respect to spine surgery are also considered and discussed. STUDY DESIGN: This is an institutional review board-approved, single-institution retrospective chart review and cost analysis. PATIENT SAMPLE: Our study included patients undergoing either single-level AP fusion or single-level TLIF between 2006 and 2008. All patients were older than 18 years at the time of surgery; the decision of which procedure was performed was entirely at the discretion of the attending surgeon. OUTCOME MEASURES: Hospital costs, charges, and payments received for the treatment of each patient. METHODS: We performed a retrospective review of the medical and financial records of patients undergoing either AP fusion (n=179) or TLIF (n=90) on one operative level between 2006 and 2008. Medical records were evaluated for a history of spine surgery, operative time, estimated blood loss, and length of stay, whereas financial records were reviewed for the hospital costs, charges, and payments received as recorded by the hospital accounting data. Operative materials and service charges were also isolated and compared separately. This study was departmentally sponsored; there were no interest-associated biases for any of the authors involved. RESULTS: AP fusion patients had a longer operative time than TLIF patients, with a mean time of 246.5 versus 202.7 minutes (p<.01). Conversely, TLIF patients had a higher estimated blood loss during surgery (469.8 cm(3)) than AP fusion patients (311.2 cm(3)) (p<.01). The mean hospital cost for AP fusion was $25,165, whereas for TLIF was $23,390 (p=.04). The mean hospital charges and payments received for AP fusion were 1.07 (p=.05) and 1.35 (p<.01) times those received for TLIF, respectively. Therefore, mean hospital charges and payments received for TLIF were 0.93 and 0.76 times those received for AP fusion, respectively. CONCLUSIONS: Our study demonstrates that a single-level AP fusion results in longer operative time, lower blood loss during surgery, higher hospital costs, higher hospital charges, and greater payments received than a single-level TLIF. Although the decision on how best to treat a patient lies solely at the judgment of the attending surgeon, this comparative cost information may be pertinent in cases of clinical equivalence. This study also calls attention to various shortcomings that are found in present spine surgery cost-effectiveness research, as there is an ongoing need for increased standards of quality in the area of health economics research.

Adult Lumbar Degenerative Scoliosis 40° or Less: Outcomes of Surgical Treatment With Minimum 2-Year Follow-up.

STUDY DESIGN: Longitudinal cohort. OBJECTIVE: To determine the outcomes of operative treatment of adult lumbar degenerative scoliosis (ALDS) with Cobb angles of 40° or less. SUMMARY OF BACKGROUND DATA: Some ALDS patients have curves less than 40°. Although these curves may not need correction, the curve may alter the treatment paradigm for associated back and leg pain, requiring fusion to achieve adequate decompression and prevent deformity progression. METHODS: We reviewed hospital records and radiographs of 105 ALDS patients with curves from 10° to 40° who had decompression and instrumented fusion. We collected Oswestry Disability Index (ODI), Short Form-36 Physical (SF36 PCS), Mental Composite Scores (MCS), and back and leg pain scores preoperatively and 2 years postoperatively. RESULTS: The 105 patients had a mean age of 64.0 years and body mass index of 28.8 kg/m2. There were 26 smokers (23%). Preoperative symptoms included both back and leg pain in 94% (mean back pain = 7.8; mean leg pain = 7.0). Mean preoperative Cobb was 22.7° and mean lumbar lordosis was 39.8°. The most common curve apex was L2 (43%) and L3 (39%). An average of 3.0 ± 1.6 levels were decompressed and fused. Mean postoperative Cobb was 17.6° and mean lumbar lordosis was 36.5°. The ODI improved 14.9 points (48.5 vs. 33.6; p < .0001), SF36 PCS improved 6.2 points (27.9 vs. 34.1; p < .0001), and SF36 MCS improved 4.7 points (40.5 vs. 45.1; p < .0001). Back (7.8 vs. 4.1; p < .0001) and leg pain (7.0 vs. 3.1; p < .0001) also improved at 2-year follow-up compared with baseline. CONCLUSIONS: Many ALDS patients present with problems associated with lumbar degenerative disease rather than severe deformity. and may require decompression for leg pain or neurogenic claudication. Even in patients with limited back pain, fusion is often needed, because decompression alone may result in either inadequate decompression or progression of the deformity. Results of this study indicate that ALDS patients with curves less than 40° benefit from decompression and fusion.

Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma.

Management of traumatic soft-tissue injuries remains a challenging and ever evolving field within orthopedic surgery. The basic principle of addressing life before limb in the initial assessment of critically injured patients has not changed. Although arteriography remains the gold standard for vascular injury screening, computed tomography angiography is being used more often to determine limb viability, and its sensitivity and specificity for detecting vascular lesions are reported to be excellent. Thorough debridement and irrigation with early institution of antibiotics are crucial in preventing infection; debridement should be performed urgently once life-threatening conditions have been addressed. Increasing use of vacuum-assisted closure therapy has created a trend down the reconstructive ladder, with improvements in resulting wound closure. Although the orthoplastics approach and new microsurgical techniques have made limb salvage possible in even the most severely injured extremities, it is important to clearly identify the zone of injury and to inform patients and their families of the outcomes of limb salvage versus amputation. Results from the LEAP (Lower Extremity Assessment Project) trials and similar studies should guide orthopedic surgeons in the management of these complex injuries. Nevertheless, it is important to individualize management plans according to patient factors.

Recurrent hemarthrosis in a hemophilic patient after revision total knee arthroplasty.

Recurrent hemarthrosis following a revision total knee arthroplasty is a rare complication. The likelihood of encountering bleeding complications in patients with hemophilia C following major surgery is unpredictable. Although the use of postoperative chemotherapeutic agents to prevent deep venous thrombosis (DVT) is considered the standard of care for most patients, its use in the hemophiliac population is unknown. This case describes a woman with Hemophilia C who presented with recurrent hemarthrosis 9 days after her revision total knee arthroplasty. Initial treatment efforts were directed towards treating the patient's underlying coagulopathy. Repeated transfusions of fresh frozen plasma and desmopressin were given in an attempt to achieve hemostasis. However the hemarthrosis did not resolve and 36 days postoperatively, a pseudoaneurysm of the left superior geniculate artery was found by angiography and percutaneously embolized. This article presents the first case, to our knowledge, of recurrent hemarthrosis in a hemophiliac patient after revision total knee arthroplasty. It further highlights the importance of considering all possible causes of postoperative bleeding to make a timely diagnosis in the face of a confounding clinical picture.

Analysis of segmental cervical spine vertebral motion after prodisc-C cervical disc replacement.

STUDY DESIGN: Retrospective study of patients enrolled in a prospective randomized Food and Drug Administration trial with single level cervical disc replacement (CDR) with the ProDisc-C (Synthes, Paoli, PA). OBJECTIVE: Evaluate the segmental range of motion (ROM) in the cervical spine pre- and postoperative after CDR. SUMMARY OF BACKGROUND INFORMATION: Each cervical level is believed to have its own biomechanical characteristics, ultimately leading to different sagittal and lateral ROM. Our understanding of the factors that influence motion after CDR continues to change and expand. METHODS: One hundred sixty-four patients with single level ProDisc-C arthroplasty were evaluated radiographically using Medical Metrics (QMATM, Medical Metrics, Inc., Houston, TX). Pre- and postoperative disc height and ROM were measured from standing lateral and flexion-extension radiographs. Of these 164 patients, 44 had a CDR at C6/C7, 96 at C5/C6, 18 at C4/C5, and 6 at C3/C4. The mean follow-up was of 24 months. Statistical analysis evaluated the difference in mean ROM between the groups. RESULTS: Before surgery, C4/C5 had more sagittal ROM compared with C3/C4, C5/C6, and C6/C7 (P < 0.001.) Before surgery, C4/C5 also had more lateral ROM compared with C3/C4, C5/C6, and C6/C7 (P = 0.015). After surgery, there were no significant differences in sagittal and lateral ROM between C3/C4, C4/C5, C5/C6, and C6/C7. The delta (difference between pre- and postoperative) proved that the C4/C5 CDR actually lost sagittal ROM (-2.5 degrees ) compared with the other levels, which gained sagittal ROM, C3/C4 (0.9 degrees ), C5/C6 (1.8 degrees ), and C6/C7 (1.6 degrees ); P = 0.037. There was no significant difference in the delta lateral ROM between the segments: C3/C4, C4/C5, C5/C6, and C6/C7. CONCLUSION: CDR approximates the different segmental sagittal and lateral ROM. Although C4/C5 had negative delta ROM in the sagittal and lateral planes, it provided a satisfactory final ROM. Long-term clinical outcome studies are needed to properly evaluate if these differences could ultimately affect the patients everyday life.

Effects of perioperative blood product use on surgical site infection following thoracic and lumbar spinal surgery.

STUDY DESIGN: Retrospective case-control review. OBJECTIVE: This retrospective study explored the hypothesis that the perioperative administration of blood products is an identifiable risk factor of increased surgical site infections (SSIs) after thoracic and lumbar spine surgical procedures. SUMMARY OF BACKGROUND DATA: Surgical site infections are a significant cause of postoperative morbidity and mortality. According to the Center for Disease Control's National Nosocomial Infections Surveillance system, which monitors the rate of hospital-acquired infections in the United States, SSIs represent the third most commonly reported type of nosocomial infection, accounting for 14% to 16% of all nosocomial infections. The incidence of SSIs after spinal surgery is influenced by both preoperative and intraoperative risk factors. The relationship between blood products and SSIs has been a matter of debate for more than 2 decades. Several studies have supported the association between the use of blood products and the development of postoperative surgical site infections. METHODS: A retrospective case-control study was performed. We reviewed the charts of all patients who had undergone thoracic and/or lumbar spinal surgery at the NYU Hospital for Joint Diseases between 2002 and 2007. All patients who had developed surgical site infections following spine surgery in this 5-year period were identified. RESULTS: Data for 61 cases and 71 controls were included in this study. The analysis of the preoperative risk factors was performed for the entire population of patients. Body mass index and blood transfusions were found to be statistically significant risk factors for increased surgical site infections for this population. CONCLUSION: Our findings support current theories that blood transfusions may have modulatory effects on the immune system of the recipients. Our specific study in spine patients may contribute to the expanding literature on allogeneic blood transfusions and the risk of nosocomial infections and encourage surgeons to favor a more restrictive policy with regard to transfusions.

Long-term outcome of surface replacement with comparison to an age- and time-matched primary total hip arthroplasty cohort.

Surface replacement (SR) was introduced as a bone-conserving alternative to total hip arthroplasty (THA) 3 decades ago, then was abandoned due to polyethylene wear, stress shielding, and loosening. Improved bearing surfaces have renewed interest in SR. This study examined long-term SR outcome compared to an age- and time-matched THA cohort. Average age was 47 years at index procedure with 16 years follow-up (range, 5-28). Revision rates were 86% and 40% in SR and THA groups, respectively. However, at 20 years, with an end point of either intact SR or primary THA in the SR group, survivorship was 64% +/- 6% versus 39% +/- 7% unrevised in THA cohort. Contemporary and rapidly changing technology may result in longer-term SR success and improved THA longevity in young patients.