Is Timing of Total Hip Arthroplasty and Lumbar Spine Fusion Associated With Risk of Hip Dislocation?

Background: In patients with concomitant hip and lumbar spine disease, the question of which surgery-total hip arthroplasty (THA) or lumbar spine fusion (LSF)-to address first has not been adequately answered. We aimed to evaluate the risk of dislocation after THA in patients with LSF first or after THA. Methods: Retrospective review utilizing the PearlDiver database querying Current Procedural Terminology codes for LSF in the year prior (LSF first) or in the year after primary or revision THA (THA first). International Classification of Disease codes identified postoperative hip dislocation as our primary outcome variable. Demographic data collected included age, sex, and obesity. Dislocation rates were described as a proportion of the cohort and compared with chi-square tests. Results: We identified 280,857 primary THA and 42,314 revision THA cases from 2012-2019. Of these, 2090 underwent primary THA and LSF, and 283 underwent revision THA and LSF within a year of each procedure. No differences in age, sex, or obesity between groups were noted. No difference in rate of all-time dislocation for primary THA was noted for the LSF first 51/1429 (3.6%) compared to the THA first 30/661 (4.0%) groups (P = .34), or for revision THA with LSF first 48/204 (23.5%) compared to THA first 27/117 (23.1%) groups (P = 1.0). Conclusions: There was no difference in the risk of dislocation after primary or revision THA if LSF occurred prior to or after the THA. These findings can help surgeons as they counsel patients with concomitant lumbar spine and hip degeneration.

It is the Opioids Not the Spine Surgeon; Dislocation After Total Hip Arthroplasty is Associated With Opioid Use in Patients Who Have Prior Lumbar Spine Fusion.

BACKGROUND: Patients who have prior lumbar spine fusion (LSF) have an increased risk for dislocation after total hip arthroplasty (THA). These patients also have elevated rates of opioid use. We aimed to evaluate the associated risk of dislocation after THA in patients who have prior LSF comparing those who have opioid use to those who do not. METHODS: This was a retrospective review using a large national database of 246,617 primary and 34,083 revision THA cases from 2012 to 2019. There were 1,903 primary THA and 288 revision THA cases identified with LSF prior to THA. Postoperative hip dislocation was our primary outcome variable and patients were stratified to use or nonuse of opioid at THA. Demographic data including age, sex, and obesity were collected. Multivariate analyses evaluated association of opioid use and dislocation after adjusting for demographics. RESULTS: There was increased odds of dislocation for opioid use at THA for both primary (adjusted Odds Ratio [aOR] = 2.29, 95% Confidence Interval [CI] 1.46 to 3.57, P < .0003) and revision THA (aOR = 1.92, 95% CI 1.62 to 3.08, P < .0003), in patients who have prior LSF. Prior LSF without opioid use was associated with increased odds of dislocation (aOR = 1.38, 95% CI 1.01 to 1.88, P = .04), but this was lower than the associated risk of opioid use without LSF (aOR 1.72, 95% CI 1.63 to 1.81, P < .001). CONCLUSION: Increased odds of dislocation were noted with opioid use at time of THA in patients who have prior LSF. Associated risk of dislocation was higher for opioid use than prior LSF. This suggests that dislocation risk is multifactorial and we should look to strategies to reduce opioid use prior to THA.

Can we automate spine fusion surgical site infection data capture?

PURPOSE: Spine fusion surgical site infection (SSI) rate is reported to national quality databases and used as a benchmark for orthopedic departments and hospital systems. However, accurate data require resource-heavy administrative review and even this has shown to vary. We aimed to create a passive electronic medical record (EMR) algorithm to automatically capture spine fusion SSI and compared its accuracy against the administrative chart review and self-reported morbidity and mortality (M&M) rates. METHODS: We retrospectively reviewed a single institution's spine fusion records for 7 years for all 90-day post-operative SSIs. We used Centers for Disease Control and Prevention (CDC) SSI definition coupled with intention to treat as an infection by orthopedics/infectious disease service as the gold standard. We compared our gold standard to administrative hand-checked SSI data, anonymously reported departmental M&M, and a passive EMR algorithm (ICD-9 or -10 post-operative SSI diagnosis code entered, or all four of: positive culture, antibiotic prescription between 3-90 days post-op, re-operation/re-admission, and a qualifying diagnosis). RESULTS: Nine hundred and fourteen spine fusions were included, with a 2.8% SSI rate (0.9% superficial and 2.0% deep). Passive EMR algorithm was the most sensitive at 89% (vs 76% administrative review, 73% M&M); all were highly specific at 99-100%. M&M was 100% positively predictive, administrative review 95%, and EMR 79%. CONCLUSION: Our passive EMR algorithm was more sensitive to pediatric spine fusion 90-day SSI than self-reported M&M and hand-checked administrative chart review. Although EMR may over-report, it can be used by others to narrow the initial sample for review, reduce resource burden involved with administrative spine SSI review, and provide a quality check for M&M self-reporting. LEVEL OF EVIDENCE: III.

NSQIP versus institutional morbidity and mortality conference: complementary complication reporting in pediatric spine fusion.

PURPOSE: Other fields of medicine have demonstrated underreported surgical complication rates by institutional M&M compared to NSQIP. However, a study comparing surgical complication rates in the pediatric spine population, using an identical set of patients rather than nationally extrapolated, has not been performed. METHODS: A single institution's ASC-NSQIP Pediatric spine fusion cases and its departmental team-reported M&M database for the same were reviewed for January 1, 2012 to December 31, 2018. Differences in surgical complication reporting between the two databases for the identical patient cohort were recorded. RESULTS: NSQIP identified 50 pediatric spine fusion patients with complications out of 386 NSQIP-algorithm-sampled cases (13%). Of these complications, 23 were not reported in the M&M conference database (6% of NSQIP-sampled cases, 2.5% of all M&M cases). The most common under-reported complication categories include pneumonia (100% under-reported), clostridium difficile (100%), urinary tract infection (83%), and superficial wound disruption (67%). During the same 7 years, M&M covered 924 spine fusions and identified 162 complications. Of these 162 patients, 22 were included in the NSQIP sampling and were not reported as complications (6% of NSQIP sampled patients). CONCLUSION: Recognizing complication rates is central to implement strategies for delivering better quality care. NSQIP data may serve as an important quality check for pediatric spine institutional M&M data, but both may not include all complications even within its sampled patients. In general, NSQIP's protocols identified more medical complications, while M&M has a surgical focus, benefits from the limitless follow-up, and involves timely departmental awareness of complications.

Delayed Postoperative Spinal Cord Ischemia After Posterior Spinal Fusion in a Pediatric Patient with Syrinx and Decompressed Chiari: A Case Report.

CASE: We present a case of delayed postoperative neurologic deficits 1 day after posterior spinal fusion in a pediatric patient with syrinx and previous Chiari decompression, which reversed with urgent rod removal. CONCLUSION: There is limited literature on delayed cord injury occurring after surgery in a patient with scoliosis of neuromuscular origin. Patients with syrinx and a history of Chiari decompression may have spinal cords more sensitive to injury including delayed ischemia after deformity treatment and should be paid extra perioperative attention including considering prolonged mean arterial pressure goals or more conservative deformity correction.

What Should I Wear to Clinic? A National Survey of Pediatric Orthopaedic Patients and Parents.

BACKGROUND: A number of factors have been shown to affect how surgeons are subjectively viewed, including their appearance in clinic. Patient preference for pediatric orthopaedic surgeon attire has not previously been studied, nor has its influence on initial perception of the surgeon. METHODS: At 5 pediatric regional sites across the United States, parents and patients presenting to the pediatric orthopaedic clinic were given anonymous surveys showing 8 photos of surgeons in different clinical dress including in business or scrub dress, each with or without white coat (WC). Subjects reported their demographics, single preferred photo, rated characteristics of the surgeons in each photo on a 5-point Likert scale, and answered specific questions on scrubs and WCs. The first consecutively completed 100 parent and 100 patient surveys were included from each site. RESULTS: One thousand surveys were collected from patients (500) and parents (500). The majority felt a surgeon's clinical dress would not affect how they are cared for (83%), and that it was ok to wear scrubs in clinic (90%). Overall, WC was preferred to those without no matter the age, but there was no difference between scrub and business choices. Of those stating a preference, woman in business and WC (24%) and woman in scrubs and WC (21%) were most selected, with the only geographic difference being the midwest's preference for man in business and WC. Females were more likely to prefer women photographs (P<0.0001). CONCLUSIONS: In general, pediatric orthopaedic patients and parents do not have a strong specific preference toward what their surgeon wears to clinic, including whether or not we are dressed in scrubs, but some initial biases exist. When asked to choose, the traditional WC worn over any attire is preferred, and female patients and parents uncover a preference for a surgeon of their own sex. LEVEL OF EVIDENCE: Level III.

Functionalized magnetic particles for water treatment.

In this study, we have taken the concept of water treatment by functionalized magnetic particles one step forward by integrating the technology into a complete proof of concept, which included the preparation of surface modified beads, their use as highly selective absorbents for heavy metals ions (Zinc, Nickel), and their performance in terms of magnetic separation. The separation characteristics were studied both through experiments and by simulations. The data gathered from these experimental works enabled the elaboration of various scenarios for Life Cycle Analysis (LCA). The LCA showed that the environmental impact of the system is highly dependent on the recovery rate of the magnetic particles. The absolute impact on climate change varied significantly among the scenarios studied and the recovery rates. The results support the hypothesis that chelation specificity, magnetic separation and bead recovery should be optimized to specific targets and applications.