Particulated Juvenile Articular Cartilage Allograft Transplantation for Patellofemoral Defects Shows Favorable Return-to-Sport Rates and Patient-Reported Outcomes.

PURPOSE: To report return-to-sport rates, postoperative patient-reported outcomes (PROs), complication rates, and reoperation rates of a cohort of patients undergoing particulated juvenile articular cartilage (PJAC) allograft transplantation for patellofemoral articular cartilage defects. METHODS: We performed a single-institution retrospective review of all patients with patellofemoral articular cartilage defects who received PJAC allograft transplantation from 2014 to 2022. Baseline demographic characteristics and surgical data, including concomitant surgical procedures, were collected. Clinical outcomes recorded included return-to-sport rates, complications, reoperations, and the following PRO scores: Kujala knee score, Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference score, and PROMIS Physical Function score. RESULTS: Forty-one knees with a mean age of 23.4 ± 9.7 years and mean follow-up period of 30.3 months (range, 12-107 months) were included. The mean postoperative PROMIS Pain Interference, PROMIS Physical Function, and Kujala knee scores were 47.4 ± 7.7, 52.2 ± 10.8, and 81.7 ± 16.1, respectively, reflecting low residual anterior knee pain and a return to normal function. For patients playing organized sports at the high school and collegiate levels, the overall return-to-sport rate was 100% (17 of 17). During follow-up, complications developed in 12 knees (29.3%), the most common of which was anterior-based knee pain, and 6 knees (14.6%) required a total of 8 reoperations, which occurred from 6 to 32 months postoperatively. CONCLUSIONS: The 100% return-to-sport rate and satisfactory PRO scores in our study suggest that PJAC allograft transplantation can effectively address patellofemoral cartilage defects in many patients. The complication and reoperation rates of 29.3% and 14.6%, respectively, are consistent with the challenging and heterogeneous etiology and treatment of patellofemoral articular defects. LEVEL OF EVIDENCE: Level IV, case series.

Telemedicine in Arthroplasty Patients: Which Factors Are Associated With High Satisfaction?

Background: During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown. Methods: All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the "Top Box" response to the survey question "Likelihood of your recommending our video visit service to others," were identified. Results: Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05). Conclusions: Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Telemedicine in Spine Patients: Utilization and Satisfaction Remain High Even After Easing of COVID-19 Lockdown Restrictions.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objectives of the present study were to (1) define telemedicine utilization rates during and after the initial height of the COVID-19 lockdown period and (2) determine patient satisfaction with telemedicine during and after the initial height of the COVID-19 lockdown period for spine patients at an orthopedic specialty hospital. SUMMARY OF BACKGROUND DATA: Previous studies have shown high patient satisfaction with telemedicine during the initial height of the COVID-19 pandemic. However, there exists limited data about spine telemedicine utilization and patient satisfaction after the reopening of in-person office visits and the easing of restrictions on elective surgical care. MATERIALS AND METHODS: All patients who had an in-person or telemedicine visit at an urban tertiary specialty hospital from April 1, 2020 to April 15, 2021 were identified. Rates of overall telemedicine utilization over time were delineated. Patient satisfaction with telemedicine, as assessed through a series of questionnaires, was also evaluated over time. RESULTS: Overall, 60,368 patients were identified. Of these, 19,568 patients (32.4%) had telemedicine visit. During the peak initial coronavirus lockdown period, the rate of overall telemedicine utilization, on average, was greater than 90%. After the peak period, the rate of overall telemedicine utilization on average was at ~29% of all visits per month. The percentage of patients who would have been definitely comfortable if the telemedicine visit had been in-person increased over the entire study period ( P <0.001). Despite this, patient satisfaction based on survey responses remained statistically similar throughout the study period ( P >0.05). CONCLUSION: The rate of telemedicine utilization in spine patients remains high, at ~one-third of all visits, even after the initial peak coronavirus lockdown period. In addition, patient satisfaction with telemedicine remained consistent throughout the study period, regardless of pandemic restrictions on in-person visits. LEVEL OF EVIDENCE: 3.

Opioid prescription trends after ambulatory anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown. PURPOSE: To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. OUTCOME MEASURES: Rate, amount, and type of perioperative opioid prescription. METHODS: Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively). RESULTS: A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066). CONCLUSIONS: Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.

Clinical Outcomes of Arthroscopic Bony Bankart Repair for Anterior Instability of the Shoulder: A Systematic Review.

BACKGROUND: Individual studies reporting the clinical outcomes of arthroscopic bony Bankart repair for anterior shoulder instability have reported excellent results but have been limited by their small sample sizes. No systematic review of the literature has been performed examining the clinical outcomes of arthroscopic bony Bankart repair. PURPOSE: To provide a systematic review of the literature to examine the functional outcomes, recurrence rate, and return to sports rate after arthroscopic bony Bankart repair for anterior instability of the shoulder. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted using the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science. Studies that examined clinical outcomes after arthroscopic bony Bankart repair for anterior shoulder instability were included. Data pertaining to study characteristics and design, patient demographic characteristics, and clinical results, including functional outcomes, recurrence rate, and return to sports, were collected. The results from the studies were pooled, and weighted means and overall rates were calculated. RESULTS: In total, 21 studies with 769 patients were included for analysis. Most patients were male (91.7%), the mean age was 26.7 years (range, 12-71 years), and the mean follow-up was 42.7 months (range, 6-120 months). The most commonly reported functional outcome score was the Rowe score (12 studies), which improved on average from 41.9 preoperatively to 90.8 postoperatively. The rate of recurrent instability was reported by all 21 studies, and the overall recurrence rate was 11.9% (88/738). Return to sports after arthroscopic bony Bankart repair was reported by 11 studies, with a pooled return to sports rate of 91.0% (264/290). CONCLUSION: Arthroscopic bony Bankart repair for anterior shoulder instability resulted in improvements in functional outcomes, a low rate of recurrent instability, and a high rate of return to sports. Although these findings are extremely promising, future prospective studies with larger sample sizes are needed to further evaluate the clinical outcomes of arthroscopic bony Bankart repair.

Boston Carpal Tunnel Questionnaire Scores Alone Do Not Predict Surgical Intervention for Patients With Carpal Tunnel Syndrome.

BACKGROUND: With the expanded indications for telemedicine, there is increased utility for screening methods to determine which patients are likely to progress to surgical intervention, requiring in-person visits. Patient-rated tools such as the Boston Carpal Tunnel Questionnaire (BCTQ) may be one such tool for screening patients with carpal tunnel syndrome (CTS). The aim of the study was to evaluate whether BCTQ scores were predictive of offering conservative treatment or surgical intervention for CTS. METHODS: Patients diagnosed with CTS from January 2017 to February 2020 completed BCTQ questionnaires prior to in-person office visits. Demographics, comorbidities, and highest level of intervention recommended were recorded for each patient as conservative, injection, or surgery. Pearson χ2 and independent-samples t tests were conducted to determine whether BCTQ symptom severity and functional scores were associated with intervention type. RESULTS: A total of 200 patients with CTS were included. Of these, 103 were recommended conservative or injection treatment and 97 were recommended surgery. There were no differences in comorbidities between groups, including other upper extremity pathology (P = .57), previous upper extremity surgery (P = .32), hypertension (P = .17), hypothyroidism (P = .15), rheumatoid arthritis (P = .34), and diabetes (P = .30). Between these groups, there were no differences in BCTQ symptom severity score (symptom severity scale [SSS]; P = .16) or BCTQ functional severity score (functional severity scale [FSS]; P = .96). CONCLUSIONS: There is no correlation between comorbidities and BCTQ SSS or FSS score, and offering surgery for CTS. In an era of minimizing non-essential health care visits, the BCTQ is insufficient in screening patients as potential surgical candidates.

Computer-Assisted Navigation Is Associated With Decreased Rates of Hardware-Related Revision After Instrumented Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To (1) define utilization trends for navigated instrumented posterior lumbar fusion (PLF), (2) compare reasons and rates of revision at 30-day, 60-day, 90-day, and 1-year follow-up, and (3) compare 90-day perioperative complications between navigated versus conventional instrumented PLF. METHODS: Patients who underwent navigated or conventional instrumented PLF were identified from the Humana insurance database using the PearlDiver Patient Records between 2007-2017. Usage of navigation was characterized. Patient demographics and operative characteristics (number of levels fused, interbody usage) were compared between the 2 treatment groups. Propensity score matching was done and comparisons were made for revision rates at different follow-up periods (categorized by reasons) and other 90-day perioperative complications. RESULTS: This study included 1,648 navigated and 23 429 conventional instrumented PLF. Navigated cases increased over the years studied to approximately 10% in 2017. Statistical analysis after propensity score matching revealed significantly lower rates of hardware-related revision at 90-day follow-up in the navigated cohort (0.49% versus 1.15%, P = .033). At 1-year follow-up, the navigated cohort continued to have significantly lower rates of hardware-related revision (1.70% versus 2.73%, P = .044) as well as all cause revision (2.67% versus 4.00%, P = .032). There were no statistical differences between the 2 cohorts in any of the 90-day perioperative complications studied, such as cellulitis and blood transfusion (P > .05 for all). CONCLUSIONS: These findings suggest that navigation is associated with reductions in hardware-related revisions after instrumented PLF. However, these results should be interpreted cautiously in the setting of potential confounding by other unmeasured variables.

Magnetic Resonance Angiography of the Hand Vasculature in Patients With Systemic Sclerosis and Systemic Lupus Erythematosus.

BACKGROUND: When patients with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) develop digital ischemia, conventional angiography (CA) is traditionally used to assess hand vasculature. Recently, Chang et al described an angiographic classification system for patients with SSc. Conventional angiography uses intravascular contrast agents that are nephrotoxic and vasoconstrictive. Owing to these limitations, this study assesses the use of contrast-enhanced magnetic resonance angiography (MRA) as an alternative to CA to evaluate hand vasculature in patients with digital ischemia. METHODS: This retrospective case series reports on 38 contrast-enhanced MRAs of hand vasculature from 30 symptomatic patients with SSc (N = 21) or SLE (N = 9). The radial and ulnar arteries (RA, UA) and the superficial and deep palmar arches were evaluated at standard reference points both quantitatively and qualitatively for their diameter, patency, and Chang classification. RESULTS: In SSc MRAs (n = 26), the UA was significantly smaller than the RA and was occluded in 46%. In SLE MRAs (n = 12), the UA and RA had no difference in diameter and the UA was occluded in 25%. In SSc, the most common Chang classification was type 2 (UA involvement) in 44%. In SLE, the most common Chang classification was type 4 (UA and RA involvement) in 45%, with 18% classified as type 2. CONCLUSIONS: Contrast-enhanced MRA used to assess hand vasculature in SSc patients with digital ischemia shows similar patterns of vascular involvement as previously demonstrated by CA. While vascular involvement in SSc predominantly involves the UA, the RA is also frequently involved in SLE.

Psychological Factors Associated With Return to Play After Ulnar Collateral Ligament Reconstruction: A Systematic Review.

Background: The role of psychological factors in return to play (RTP) after ulnar collateral ligament (UCL) reconstruction remains unclear. Purpose: To perform a systematic review of the literature to (1) identify the specific psychological factors that affect RTP after UCL reconstruction and (2) determine the proportion of failures to RTP after UCL reconstruction because of psychological factors. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted. We queried the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science databases to identify studies examining psychological factors and RTP after UCL reconstruction. Data pertaining to study characteristics and design, clinical and demographic characteristics, and psychological factors were collected. Patients were pooled across included studies, weighted means were calculated, and descriptive statistical analysis was performed. Results: A total of 8 studies consisting of 378 patients were included for analysis. The mean time to RTP was 12.2 months, and the overall RTP rate was 89.4%. Psychological factors affecting RTP included loss of interest, fear of reinjury, individual personality traits, personal reasons, and psychological concerns. While clinical factors accounted for 46.2% (n = 24) of failures to RTP, psychological factors comprised 40.4% (n = 21) of the reasons for failure to RTP. The most commonly cited psychological factors affecting RTP were loss of interest (n = 15 [28.8%]) and fear of reinjury (n = 3 [5.8%]). Conclusion: Psychological factors represented a substantial proportion of failures to RTP after UCL reconstruction, especially in adolescent athletes. Future prospective studies and multicenter initiatives are needed to more thoroughly evaluate the psychological concerns of patients before and after UCL reconstruction.

Contemporary Analysis of Inconsistencies Between Physician-reported Disclosures at the AAOS Annual Meeting and Industry-reported Financial Disclosures in the Open Payments Database.

INTRODUCTION: Healthcare regulators and patients are increasingly interested in financial transparency between physicians and the industry because of concerns of bias. METHODS: Disclosures for every first and last author with a medical degree from the United States associated with a poster or podium presentation at the American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting were identified. Author characteristics were collected. AAOS disclosures were then compared with disclosures from the Open Payments Database to determine whether any inconsistencies existed. RESULTS: In total, 2,503 AAOS presenters were identified, and 1,380 authors met the inclusion criteria. Using AAOS disclosures as the standard comparator, 482 authors (35%) had an inconsistency in any category between AAOS disclosures and the Open Payments Database. Inconsistency rates for each category were 8% for royalties, 10% for speaker's fee, 15% for paid consultant, 16% for research, 14% for stocks, and 1% for other financial support. DISCUSSION: Although the inconsistency rate for each category has improved over the years, the overall inconsistency rate between physician-reported disclosures at a recent AAOS Annual Meeting and industry-reported relationships reported in the Open Payments Database was still 35%.

Return to Play Criteria Following Surgical Management of Osteochondral Defects of the Knee: A Systematic Review.

OBJECTIVE: The objective of this study was to identify and describe the existing literature on criteria used for return to play (RTP) following surgical management of osteochondral defects of the knee. DESIGN: A systematic review was performed to evaluate the surgical management of osteochondral defects of the knee in skeletally mature patients with a minimum of 2-year follow-up using Level I to IV studies in PubMed EMBASE from January 1998 to January 2016. RESULTS: Twelve studies with at least one explicitly stated criterion for RTP were identified from a review of 253 published articles. The majority of included studies were Levels II and IV (33%, respectively). Autologous chondrocyte implantation (ACI) was exclusively evaluated in 33.3% of papers and 16.7% evaluated osteochondral allograft transplantation (OCA). Eight different RTP criteria were used alone or in combination across the reviewed studies and time was the most often utilized criterion (83.3%). Minimum time to RTP ranged from 3 to 18 months. CONCLUSIONS: This systematic review identifies current criteria used in the available literature to dictate RTP. Time from surgery was the most commonly employed criterion across the reviewed studies. Given the complex biological processes inherent to the healing of cartilaginous defects, further research is needed to design more comprehensive guidelines for RTP that are patient-centered and utilize multiple functional and psychological domains relevant to the process of returning to sport.

Early career opportunities and practice characteristics of recent graduates of shoulder and elbow fellowship programs.

BACKGROUND: There exists anecdotal evidence that influential faculty members actively dissuade orthopedic surgery residents from pursuing a fellowship in shoulder and elbow due to a perceived lack of availability of jobs following graduation. The aims of the present study are to evaluate whether this perception is true by characterizing the early career opportunities and practice characteristics of recent graduates of shoulder and elbow fellowship programs through a survey of graduates of the past 5 years. METHODS: An anonymous 39-question survey was designed and approved by the leadership of the American Shoulder and Elbow Surgeons (ASES). The survey was distributed via electronic mail to the fellowship directors and coordinators of the 31 ASES-recognized shoulder and elbow fellowship programs. The fellowship directors and coordinators then sent the survey to the shoulder and elbow fellowship graduates of the last 5 years (2016-2020). Following a total of 4 emails, the survey closed after 8 weeks, and descriptive statistical analysis was performed. RESULTS: Seventy-six of 171 (44.4%) fellows responded. In total, 89.5% were very or somewhat satisfied with their fellowship experience, and 90.8% would pursue a shoulder and elbow fellowship again. Notably, 100% of shoulder and elbow fellowship graduates surveyed in the past 5 years have secured employment. The average number of total orthopedic and shoulder and elbow cases performed annually was 296.7 (SD 141.3) and 173.9 (SD 120.2), respectively. In addition, 62.7% and 89% of respondents were very or somewhat satisfied with the volume and surgical complexity of shoulder and elbow cases, respectively. For the fellows that believed their case experience to be inadequate, the most common reasons were competition from other practices (66.0%) and inadequate patient volume (59.6%). CONCLUSION: Recent graduates of the ASES-recognized shoulder and elbow fellowship programs demonstrate a high level of satisfaction with the fellowship and their subspeciality selection. The majority of fellows believed that completing a shoulder and elbow fellowship enhanced their job opportunities. Altogether, there are ample job opportunities and high satisfaction with the volume and complexity of cases as an early career shoulder and elbow surgeon.

The Role of Advanced Academic Degrees in Orthopaedic Sports Medicine Faculty.

BACKGROUND: Limited knowledge exists on the role of advanced academic degrees within faculty positions in orthopaedic sports medicine. PURPOSE: To 1) provide an assessment of the baseline demographics of advanced degrees among orthopaedic sports medicine faculty and 2) examine the impact of advanced degrees on research productivity and career attainment of orthopaedic sports medicine faculty. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: Orthopaedic sports medicine academics were identified using faculty listings on websites of the 200 orthopaedic surgery residency programs during the 2020-2021 academic year. Advanced degrees were defined as those additional to the primary medical degree (Doctor of Medicine [MD] or Doctor of Osteopathic Medicine [DO]). Outcome measures included timing of advanced degree obtainment, residency program rankings, research productivity, and current academic rank and leadership roles. Statistical analysis was performed using chi-square and Mann-Whitney U tests to determine the association of advanced degrees on outcome measures. RESULTS: In total, 911 orthopaedic sports medicine faculty members were identified, of whom 100 had an advanced degree. The most common advanced degrees were Master of Science (MS/MSc; 38%), Doctor of Philosophy (PhD; 23%), and Master of Business Administration (MBA; 13%). The presence of an advanced degree was associated with greater research productivity, including higher h-index and number of publications, as well as more editorial board positions on orthopaedics journals (P < .001). Advanced degrees were not significantly associated with attending a higher ranked orthopaedic surgery residency program, current academic rank, or leadership roles. At the institutional level, orthopaedic sports medicine programs that employed faculty with an advanced degree had a higher residency program ranking and the presence of a sports medicine fellowship was more likely (P < .05). CONCLUSION: Advanced degrees in orthopaedic sports medicine were associated with greater faculty research engagement and employment at a higher ranked institution; they were not associated with matching to a highly ranked orthopaedic surgery residency program, higher faculty rank, or academic leadership roles.

Insulin-dependent diabetes mellitus is an independent risk factor for postoperative complications in aseptic revision total hip arthroplasty.

INTRODUCTION: Revision total hip arthroplasty (rTHA) is becoming a more common procedure due to the increasing volume of primary total hip arthroplasty. Diabetes mellitus (DM) is currently projected to affect 4.4% of the global population by 2030. Diabetes has been associated with poor outcomes for a variety of surgical interventions. However, the impact of insulin dependence has yet to be fully understood. The aim of this study was to determine the impact of insulin dependence on acute postoperative complications following rTHA. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. All patients who underwent rTHA between 2006 and 2016 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM) or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after rTHA. RESULTS: A total of 7685 patients were evaluated (No DM = 6651, NIDDM = 700, IDDM = 334). Univariate analysis revealed that all patients with DM had significantly higher incidences of postoperative complications (NIDDM: p < 0.001; IDDM: p < 0.001) and extended hospital length of stay (NIDDM: p = 0.015; IDDM: p < 0.0001). NIDDM was associated with increased rates of superficial surgical site infection (SSI) (p = 0.001), deep SSI (p = 0.038), and stroke (p = 0.013), while IDDM was associated with increased rates of pneumonia (p < 0.001), renal failure (p < 0.001), and postoperative transfusion (p < 0.001). On multivariate analysis, insulin-dependence was determined to be an independent risk factor for extended hospital length of stay (OR 1.905; 95% CI, 1.410-2.577; p < 0.001), pneumonia (OR 4.016; 95% CI, 1.799-8.929; p = 0.001), renal failure (OR 7.143; 95% CI, 2.203-23.256; p = 0.001) and postoperative transfusion (OR 1.366; 95% CI, 1.076-1.733; p = 0.01). CONCLUSIONS: Insulin dependence is an independent risk factor for numerous short-term postoperative complications following rTHA. When assessing risk and planning perioperative management, surgeons should consider insulin-dependent diabetics as a sub-cohort within the diabetic population.

Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty.

Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.

Postoperative Patient-reported Pain and Opioid Consumption After Total Hip Arthroplasty: A Comparison of the Direct Anterior and Posterior Approaches.

INTRODUCTION: Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption. METHODS: Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses. RESULTS: A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864). DISCUSSION: The DAA was associated with slightly lower patient-reported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.

Academic Influence as Reflected by h Index Is Not Associated With Total Industry Payments but Rather With National Institutes of Health Funding Among Academic Orthopaedic Sports Medicine Surgeons.

PURPOSE: (1) To compare the total number and dollar amount of industry funding and National Institutes of Health (NIH) funding to academic orthopaedic sports medicine surgeons and (2) to examine the impact of academic influence on industry funding and NIH funding to academic orthopaedic sports medicine surgeons. METHODS: Academic orthopaedic sports medicine surgeons were identified using faculty web pages. Academic influence was approximated by a physician's Hirsch index (h index) and number of publications and obtained from the Scopus database. Total industry payments were acquired through the Open Payments Database, and NIH funding was determined from the NIH website. Statistical analysis was performed using Mann-Whitney U test and Spearman correlations with significance set at P < .05. RESULTS: Physicians who received industry research payments and NIH funding had a significantly higher mean h index and more mean total publications than physicians who did not receive industry research payments and NIH funding. There were no significant differences in h index (P = .374) or number of publications (P = .126) between surgeons receiving industry nonresearch funding and those who did not. h Index and number of publications were both weakly correlated with the amount of industry research and nonresearch funding. CONCLUSION: Although academic influence is associated with industry research funding and NIH funding, there is no association between measures of academic influence and total industry and industry nonresearch payments. Combined with the weak associations between academic influence and the amount of industry payments, academic influence does not appear to be a major determinant of industry funding to academic orthopaedic sports medicine surgeons. CLINICAL RELEVANCE: Surgeons should be cognizant of potential conflicts with industry, but the relationship between academic sports medicine surgeons and industry may be less subject to bias than previously believed.

Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates.

STUDY DESIGN: Retrospective cohort comparison study. OBJECTIVE: The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA: Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF. MATERIALS AND METHODS: Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups. RESULTS: In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%). CONCLUSIONS: The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. LEVEL OF EVIDENCE: Level III.

Neural network prediction of 30-day mortality following primary total hip arthroplasty.

PURPOSE: The purpose is to utilize an artificial neural network (ANN) model to determine the most important variables in predicting mortality following total hip arthroplasty (THA). METHODS: Patients that underwent primary THA were included from a national database. Demographic, preoperative, and intraoperative variables were analyzed based on their contribution to 30-day mortality with the use of an ANN model. RESULTS: The five most important factors in predicting mortality following THA were preoperative international normalized ratio, age, body mass index, operative time, and preoperative hematocrit. CONCLUSION: ANN modeling represents a novel approach to determining perioperative factors that predict mortality following THA.

Industry Payments and Their Association With Academic Influence in Total Joint Arthroplasty.

BACKGROUND: The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding. METHODS: Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations. RESULTS: Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding. CONCLUSION: h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.