How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide Part II: Study Execution.

Systematic reviews are the apex of the evidence-based pyramid, representing the strongest form of evidence synthesizing results from multiple primary studies. In particular, a quantitative systematic review, or meta-analysis, pools results from multiple studies to help answer a respective research question. The aim of this review is to serve as a guide on how to: 1) design; 2) execute, and 3) publish an orthopaedic arthroplasty systematic review. In Part II, we focus on methods to assess data quality through the Cochrane Risk of Bias, Methodological Index for Non-Randomized Studies (MINORS) criteria, or Newcastle-Ottawa scale; enumerate various methods for appropriate data interpretation and analysis; and summarize how to convert respective findings to a publishable manuscript (providing a previously published example). Use of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines is recommended and standard in all scientific literature, including that of orthopaedic surgery. Pooled analyses with forest plots and associated odds ratios and 95% confidence intervals are common ways to present data. When converting to a manuscript, it is important to consider and discuss the inherent limitations of systematic reviews, including their inclusion and/or exclusion criteria and overall quality, which can be limited based on the quality of individual studies (e.g., publication bias, heterogeneity, search/selection bias). We hope our papers will serve as starting points for those interested in performing an orthopaedic arthroplasty systematic review.

The Association of Dental Caries or Dental Implant Placement Within One Year of Primary Total Hip Arthroplasty on Medical and Implant Complications.

INTRODUCTION: Total hip arthroplasty (THA) adverse events among patients who have dental diagnoses remain unclear. We sought to determine if dental caries or dental implant placements increased: 1) 90-day medical complications; 2) 90-day readmissions; and 3) 2-year implant-related complications, including periprosthetic joint infections (PJIs) after THA. METHODS: A nationwide database for primary THAs from 2010 to 2021 was queried to compare three patient cohorts. Patients who had a history of dental implants or caries within 12 months prior to THA (n = 1,179) or 12 months after THA (n = 1,218) were case-matched to patients who did not have dental history (n = 6,090) by age and comorbidities. Outcomes included 90-day complications, 90-day readmissions, and 2-year implant-related complications. Logistic regression models computed the odds ratios (OR) of complications and readmissions. P values less than 0.006 were significant. RESULTS: Patients who had dental caries or implant placement 12 months before or after THA experienced 1.6-fold greater odds of 90-day medical complications compared to case-matched patients. Readmissions within 90 days increased for patients who had a dental history before (11.7 versus 8.3%; OR: 1.49, P < 0.0001) and after (14.2 versus 8.3%; OR: 1.84, P < 0.0001) THA compared to case-matched patients. A dental caries diagnosis or dental implant placement within 12 months following THA increased 2-year implant complications compared to case-matched patients (15.2 versus 9.3%; OR: 1.69, P < 0.0001), including PJIs (5.3 versus 2.8%; OR: 1.98, P < 0.0001), dislocations (4.4 versus 2.7%; OR: 1.63, P = 0.002), and THA revisions (3.9 versus 2.5%; OR: 1.61, P = 0.005). CONCLUSION: Dental diagnoses within 12 months of THA are associated with increased medical complications. Dental diagnoses occurring 12 months after THA are associated with greater implant-related complications, including PJIs. Delaying invasive dental procedures for 12 months after THA may be advisable.

A Nationwide Analysis of the Impact of Socioeconomic Status on Complications and Healthcare Utilizations After Total Knee Arthroplasty Using the Area Deprivation Index: Consideration of the Disadvantaged Patient.

INTRODUCTION: Socioeconomic status (SES) has been demonstrated to be an important prognostic risk factor among patients undergoing total joint arthroplasty. We evaluated patients living near neighborhoods with higher socioeconomic risk undergoing total knee arthroplasty (TKA) and if they were associated with differences in: 1) medical complications; 2) emergency department (ED) utilizations; 3) readmissions; and 4) costs of care. METHODS: A query of a national database from 2010 to 2020 was performed for primary TKAs. The Area Deprivation Index (ADI) is a weighted index comprised of 17 census-based markers of material deprivation and poverty. Higher numbers indicate a greater disadvantage. Patients undergoing TKA in zip codes associated with high ADI (90%+) were 1:1 propensity-matched to a comparison group by age, sex, and Elixhauser Comorbidity Index (ECI). This yielded 225,038 total patients, evenly matched between cohorts. Outcomes studied included complications, ED utilizations, readmission rates, and 90-day costs. Logistic regression models computed the odds ratios (OR) of ADI on the dependent variables. P-values less than 0.003 were significant. RESULTS: High ADI led to higher rates and odds of any medical complications (11.7 versus 11.0%; OR: 1.05, P = 0.0006), respiratory failures (0.4 versus 0.3%; OR: 1.28, P = 0.001), and acute kidney injuries (1.7 versus 1.5%; OR: 1.15, P < 0.0001). Despite lower readmission rates (2.9 versus 3.5%), high ADI patients had greater 90-day ED visits (4.2 versus 4.0%; OR: 1.07, P = 0.0008). The 90-day expenditures ($15,066 versus $12,459; P < 0.0001) were higher in patients who have a high ADI. CONCLUSION: Socioeconomically disadvantaged patients have increased complications and ED utilizations. Neighborhood disadvantage may inform healthcare policy and improve post-discharge care. The SES metrics, including ADI (which captures community effects), should be used to adequately risk-adjust or risk-stratify patients so that access to care for deprived regions and patients is not lost.

Comparison of Patient Demographics and Risk of Surgical Site Infections Following Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures: A Nationwide Analysis of a Private Payor.

Surgical site infections (SSIs) are a notable complication following open reduction and internal fixation (ORIF) for ankle fractures. The purpose of this study was to (1) compare baseline demographics of patients who did and did not develop SSIs within 90 days following ORIF for trimalleolar ankle fractures and (2) identify risk factors associated with SSIs in this setting. A retrospective analysis from 2010 to 2020 was completed using a national administrative database. The study group consisted of patients who underwent ORIF for trimalleolar ankle fractures and developed SSIs within 90 days postoperatively. Patients without SSIs served as the comparison cohort. Baseline demographics of the two cohorts were compared utilizing Pearson's Chi-Square Analyses. A multivariate binomial logistic regression model determined the association of various comorbidities on developing SSIs in this setting. Out of a total sample of 22,118 patients, 1,000 individuals (4.52%) developed SSIs. The study revealed that the SSI cohort exhibited a greater burden of comorbidities, as evidenced by significant differences in various individual comorbidities and average Elixhauser-Comorbidity Indices scores. The most strongly associated risk factors for the development of SSIs following ORIF for trimalleolar ankle fractures were peripheral vascular disease (OR: 1.53, p<0.0001), diabetes mellitus (OR: 1.26, p=0.0010), iron deficiency anemia (OR: 1.24, p=0.0010), male sex (OR: 1.22, p=0.0010), and tobacco use (OR: 1.15, p=0.0010). This study identified several patient risk factors that were associated with developing SSIs after ORIF for trimalleolar ankle fractures, recognizing potential patient-directed interventions that may reduce the rate of SSIs in this setting.

Risk Factors for Undergoing Surgical Intervention for Vertebral Compression Fractures: An Analysis of 703,499 Patients.

STUDY DESIGN: Retrospective Cohort OBJECTIVES: Vertebral compression fractures (VCFs) are typically treated nonoperatively, but can be treated with either kyphoplasty or vertebroplasty when indicated. The decision to treat patients with/without surgical intervention is dependent on the severity of deformity and patient risk profile. The aims of this study were to: 1) compare baseline patient demographics, 2) identify risk factors of patients undergoing operative versus nonoperative management, and 3) identify patient-specific risk factors associated with post-operative re-admissions. METHODS: This retrospective database study used patient information from January 1st, 2010, to October 31st, 2021. Cohorts were identified by patients diagnosed with VCFs through International Classification of Disease, Ninth Revision (ICD-9), ICD-10 codes, identifying those undergoing kyphoplasty/vertebroplasty via Current Procedural Terminology (CPT) codes. The two research domains utilized in this investigation were baseline demographic profiles of patients who underwent kyphoplasty or vertebroplasty for treatment of VCFs, and those who underwent nonoperative management served as the control cohort. RESULTS: Of the 703,499 patients diagnosed with VCFs, 76,126 patients (10.8%) underwent kyphoplasty or vertebroplasty within 90 days of diagnosis of a VCF. Univariate analysis demonstrated female sex was associated with increased risk of undergoing surgical management for VCF (p<0.0001). Several co-morbidities were significantly associated with increased rates of readmission including hypertension, tobacco use, coronary artery disease, and COPD (p <0.0001 for all). CONCLUSIONS: This study highlights specific comorbidities that are significantly associated with higher rates of kyphoplasty or vertebroplasty for the treatment of thoracolumbar wedge compression fractures and increased risk for 90-day post-operative hospital readmission.

Modern Internet Search Analytics: Is There a Difference in What Patients are Searching Regarding the Operative and Nonoperative Management of Scoliosis?

STUDY DESIGN: Observational Study. OBJECTIVES: This study aimed to investigate the most searched types of questions and online resources implicated in the operative and nonoperative management of scoliosis. METHODS: Six terms related to operative and nonoperative scoliosis treatment were searched on Google's People Also Ask section on October 12, 2023. The Rothwell classification was used to sort questions into fact, policy, or value categories, and associated websites were classified by type. Fischer's exact tests compared question type and websites encountered between operative and nonoperative questions. Statistical significance was set at the .05 level. RESULTS: The most common questions concerning operative and nonoperative management were fact (53.4%) and value (35.5%) questions, respectively. The most common subcategory pertaining to operative and nonoperative questions were specific activities/restrictions (21.7%) and evaluation of treatment (33.3%), respectively. Questions on indications/management (13.2% vs 31.2%, P < .001) and evaluation of treatment (10.1% vs 33.3%, P < .001) were associated with nonoperative scoliosis management. Medical practice websites were the most common website to which questions concerning operative (31.9%) and nonoperative (51.4%) management were directed to. Operative questions were more likely to be directed to academic websites (21.7% vs 10.0%, P = .037) and less likely to be directed to medical practice websites (31.9% vs 51.4%, P = .007) than nonoperative questions. CONCLUSIONS: During scoliosis consultations, spine surgeons should emphasize the postoperative recovery process and efficacy of conservative treatment modalities for the operative and nonoperative management of scoliosis, respectively. Future research should assess the impact of website encounters on patients' decision-making.

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs. BACKGROUND: Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression. METHODS: A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P-value<0.001 was considered statistically significant. RESULTS: Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss (P<0.0001). Mean same-day total costs ($17,920 vs. $8204, P<0.001) and mean 90-day costs ($46,050 vs. $15,200, P<0.001) were significantly higher in the readmission group. CONCLUSION: A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.

GPT-4 as a Source of Patient Information for Anterior Cervical Discectomy and Fusion: A Comparative Analysis Against Google Web Search.

STUDY DESIGN: Comparative study. OBJECTIVES: This study aims to compare Google and GPT-4 in terms of (1) question types, (2) response readability, (3) source quality, and (4) numerical response accuracy for the top 10 most frequently asked questions (FAQs) about anterior cervical discectomy and fusion (ACDF). METHODS: "Anterior cervical discectomy and fusion" was searched on Google and GPT-4 on December 18, 2023. Top 10 FAQs were classified according to the Rothwell system. Source quality was evaluated using JAMA benchmark criteria and readability was assessed using Flesch Reading Ease and Flesch-Kincaid grade level. Differences in JAMA scores, Flesch-Kincaid grade level, Flesch Reading Ease, and word count between platforms were analyzed using Student's t-tests. Statistical significance was set at the .05 level. RESULTS: Frequently asked questions from Google were varied, while GPT-4 focused on technical details and indications/management. GPT-4 showed a higher Flesch-Kincaid grade level (12.96 vs 9.28, P = .003), lower Flesch Reading Ease score (37.07 vs 54.85, P = .005), and higher JAMA scores for source quality (3.333 vs 1.800, P = .016). Numerically, 6 out of 10 responses varied between platforms, with GPT-4 providing broader recovery timelines for ACDF. CONCLUSIONS: This study demonstrates GPT-4's ability to elevate patient education by providing high-quality, diverse information tailored to those with advanced literacy levels. As AI technology evolves, refining these tools for accuracy and user-friendliness remains crucial, catering to patients' varying literacy levels and information needs in spine surgery.

How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide Part I: Study Design.

Systematic reviews are conducted through a consistent and reproducible method to search, appraise, and summarize information. Within the evidence-based pyramid, systematic reviews can be at the apex when incorporating high-quality studies, presenting the strongest form of evidence given their synthesis of results from multiple primary studies to level IV evidence, depending on the studies they incorporate. When combined and supplemented with a meta-analysis using statistical methods to pool the results of 3 or more studies, systematic reviews are powerful tools to help answer research questions. The aim of this review is to serve as a guide on how to: (1) design; (2) execute; and (3) publish an orthopaedic arthroplasty systematic review and meta-analysis. In Part I, we discuss how to develop an appropriate research question as well as source and screen databases. To date, commonly used databases to source studies include PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science. Although not all-encompassing, this paper serves as a starting point for those interested in performing and/or critically reviewing lower extremity arthroplasty systematic reviews and meta-analyses.

How-To Create an Orthopaedic Systematic Review: A Step-by-Step Guide. Part III: Executing a Meta-Analysis.

At the top of the evidence-based pyramid, systematic reviews stand out as the most powerful, synthesizing findings from numerous primary studies. Specifically, a quantitative systematic review, known as a meta-analysis, combines results from various studies to address a specific research question. This review serves as a guide on how to: (1) design; (2) perform; and (3) publish an orthopedic arthroplasty systematic review. In Part III, we focus on how to design and perform a meta-analysis. We delineate the advantages and disadvantages of meta-analyses compared to systematic reviews, acknowledging their potential challenges due to time constraints and the complexities posed by study heterogeneity and data availability. Despite these obstacles, a well-executed meta-analysis contributes precision and heightened statistical power, standing at the apex of the evidence-based pyramid. The design of a meta-analysis closely mirrors that of a systematic review, but necessitates the inclusion of effect sizes, variability measures, sample sizes, outcome measures, and overall study characteristics. Effective data presentation involves the use of forest plots, along with analyses for heterogeneities and subgroups. Widely-used software tools are common in this domain, and there is a growing trend toward incorporating artificial intelligence software. Ultimately, the intention is for these papers to act as foundational resources for individuals interested in conducting systematic reviews and meta-analyses in the context of orthopaedic arthroplasty, where applicable.

The real time to surgery: Limited delay after medical optimization does not impact hip fracture surgery outcomes.

INTRODUCTION: Current U.S./Canadian guidelines recommend hip fracture surgery within 48 h of injury to decrease morbidity/mortality. Multiple studies have identified medical optimization as the key component of time to surgery, but have inherent bias as patients with multiple co-morbidities often take longer to optimize. This study aimed to evaluate time from medical optimization to surgery (TMOS) to determine if "real surgical delay" is associated with: 1) mortality and 2) complications for geriatric hip fracture patients. METHODS: A retrospective chart review of geriatric hip fractures treated from 2015-2018 at a single, level-1 trauma center was conducted. Univariate logistic regression was performed to identify association between TMOS and post-operative complication rates. For mortality, the Wilcoxon test was used to compare TMOS for patients discharged following surgery to those who were not. RESULTS: A total of 884 hip fractures were treated operatively, with median TMOS 16.2 h (5.0-22.5, 1st-3rd quartiles). Univariate logistic regression models did not identify an association between TMOS and complication rates. For patients successfully discharged, median TMOS was 16.2 h (5.0-22.3, 1st-3rd quartiles). For the cohort of patients not successfully discharged, median TMOS was 19.1 h (10.1-25.9, 1st-3rd quartiles, p = 0.16). CONCLUSION: "Real surgical delay", or TMOS is not associated with increased complications or with inpatient mortality for geriatric hip fracture patients. With few exceptions, our institution adhered to the 48-hour time window from injury to hip surgery. We maintain the belief timely surgery following optimization plays a crucial role in the geriatric hip fracture patient outcomes.

ChatGPT as a Source of Patient Information for Lumbar Spinal Fusion and Laminectomy: A Comparative Analysis Against Google Web Search.

STUDY DESIGN: Retrospective Observational Study. OBJECTIVE: The objective of this study was to assess the utility of ChatGPT, an artificial intelligence chatbot, in providing patient information for lumbar spinal fusion and lumbar laminectomy in comparison with the Google search engine. SUMMARY OF BACKGROUND DATA: ChatGPT, an artificial intelligence chatbot with seemingly unlimited functionality, may present an alternative to a Google web search for patients seeking information about medical questions. With widespread misinformation and suboptimal quality of online health information, it is imperative to assess ChatGPT as a resource for this purpose. METHODS: The first 10 frequently asked questions (FAQs) related to the search terms "lumbar spinal fusion" and "lumbar laminectomy" were extracted from Google and ChatGPT. Responses to shared questions were compared regarding length and readability, using the Flesch Reading Ease score and Flesch-Kincaid Grade Level. Numerical FAQs from Google were replicated in ChatGPT. RESULTS: Two of 10 (20%) questions for both lumbar spinal fusion and lumbar laminectomy were asked similarly between ChatGPT and Google. Compared with Google, ChatGPT's responses were lengthier (340.0 vs. 159.3 words) and of lower readability (Flesch Reading Ease score: 34.0 vs. 58.2; Flesch-Kincaid grade level: 11.6 vs. 8.8). Subjectively, we evaluated these responses to be accurate and adequately nonspecific. Each response concluded with a recommendation to discuss further with a health care provider. Over half of the numerical questions from Google produced a varying or nonnumerical response in ChatGPT. CONCLUSIONS: FAQs and responses regarding lumbar spinal fusion and lumbar laminectomy were highly variable between Google and ChatGPT. While ChatGPT may be able to produce relatively accurate responses in select questions, its role remains as a supplement or starting point to a consultation with a physician, not as a replacement, and should be taken with caution until its functionality can be validated.

Market resilience of orthopaedic hip/knee arthroplasty sales during COVID-19.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic led to a marked decrease in elective surgical volume and orthopaedic device sales. The aim of this paper was to quantify this decrease and the related financial impact on the largest hip/knee arthroplasty companies by: (1) tracking individual hip/knee company valuations; (2) calculating aggregate changes in overall hip/knee arthroplasty market valuations; and (3) quantifying quarterly hip/knee revenues relative to prior years. MATERIALS AND METHODS: Financial data on the top five hip/knee arthroplasty companies by size between January 1, 2019, and October 1, 2020, was collected from a Wall Street financial database, S&P Capital IQ. Changes in valuation of these companies were compared against benchmark market indices, the S&P500 and Vanguard Healthcare ETF. U.S. hip/knee arthroplasty-specific revenue for Q1 and Q2 of 2019 and 2020 was collected from Securities Exchange Commission 10-Q forms. Quarterly revenue changes were calculated using 1-2Q19 revenues as baselines and aggregate to approximate the overall hip/knee arthroplasty market. RESULTS: The top five hip/knee companies lost $179.2 billion (32.7% loss) in market value from pre COVID-19 market highs to COVID-19 market lows (March 2020), while S&P500 and Vanguard Healthcare ETF decreased 36.1 and 33.2%, respectively. From market lows to October 2020, arthroplasty companies rallied 38.6% while the S&P500 and Vanguard Healthcare ETF regained 43.5 and 56.4% respectively. Notably, this occurred while aggregate 1Q/2Q20 revenue lagged 7.1/41.8% relative to 2019, with an overall decrease of $1.58B (24.8%). CONCLUSIONS: Similar to the overall market and healthcare sector, the top five hip/knee arthroplasty companies have recovered from their COVID market lows. Our results reveal that the valuations of hip/knee companies remained robust during COVID, even as revenues fell, likely due to strong investor confidence in the industry outlook and the greater overall healthcare system utilization.

Preoperative Depression Screening for Primary Total Knee Arthroplasty: An Evaluation of Its Modifiability on Outcomes in Patients Who Have Depression.

INTRODUCTION: Few studies have evaluated preoperative depression screenings in patients who have depression. We studied whether depression screenings before total knee arthroplasty (TKA) were associated with lower: 1) medical complications; 2) emergency department (ED) utilizations and readmissions; 3) implant complications; and 4) costs. METHODS: A nationwide sample from January 1, 2010 to April 30, 2021 was collected using an insurance database. Depression patients were 1:1 propensity-score matched based on those who had (n=29,009) and did not have (n=29,009) pre-operative depression screenings or psychotherapy visits within 3 months of TKA. A case-matched population who did not have depression was compared (n=144,994). A 90-day period was used to compare complications and healthcare utilization and 2-year follow-up for periprosthetic joint infections (PJIs) and implant survivorship. Costs were 90-day reimbursements. Logistic regression models computed odds ratios (OR) of depression screening on dependent variables. P-values less than 0.001 were significant. RESULTS: Patients who did not receive preoperative screening were associated with higher medical complications (18.7 versus 5.2%, OR:4.15, P < 0.0001) and ED utilizations (11.5 versus 3.2%, OR: 3.93, P < 0.0001) than depressed patients who received screening. Patients who had screening had lower medical complications (5.2 versus 5.9%, OR: 0.88, P < 0.0001) and ED utilizations compared to patients who did not have depression (3.2 versus 3.8%, OR: 0.87, P = 0.0001). Two-year PJI incidences (3.0 versus 1.3%, OR: 2.63, P < 0.0001) and TKA revisions (4.3 versus 2.1%, OR: 2.46, P < 0.0001) were greater in depression patients who were not screened preoperatively versus screened patients. Depression patients who had screening had lower PJIs (1.3 versus 1.8%, OR: 0.74, P < 0.0001) compared to non-depressed patients. Reimbursements ($13,949 versus $11,982; P < 0.0001) were higher in depression patients who did not have screening. CONCLUSIONS: Pre-operative screening was associated with improved outcomes in depression patients.

Anterolateral knee complex considerations in contemporary anterior cruciate ligament reconstruction and total knee arthroplasty: a systematic review.

The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament (ACL) tear or a 66-75% chance of a meniscal tear. The purpose of this paper is to provide an updated comprehensive review on the anterolateral ligament complex of the knee focusing on the: (1) anatomy of the ALL/ALC; (2) associated biomechanics/function; and (3) important surgical considerations in contemporary anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). A systematic review of studies on ALL was conducted on Pubmed/MEDLINE and Cochrane databases (May 7th, 2020 to February 1st, 2022), with 20 studies meeting inclusion/exclusion criteria. Studies meeting inclusion criteria were anatomical/biomechanical studies assessing ALL function, cadaveric and computer simulations, and comparative studies on surgical outcomes of ALLR (concomitant with ACL reconstruction). Eight studies were included and graded by MINOR and Newcastle-Ottawa scale to identify potential biases. The anatomy of the ALL is part of the anterolateral ligament complex (ALC), which includes the superficial/deep iliotibial band (including the Kaplan fiber system), iliopatellar band, ALL, and anterolateral capsule. Multiple biomechanical studies have characterized the ALC as a secondary passive stabilizer in resisting tibial internal rotation. Given the role of the ALC in resisting internal tibial rotation, lateral extra-articular procedures including ALL augmentation may be considered for chronic ACL tears, ACL revisions, and a high-grade pivot shift test. In the context of TKA, in the event of injury to the ALC, a more constrained implant or soft-tissue reconstruction may be necessary to restore appropriate knee stability.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

BACKGROUND: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. RESULTS: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. DISCUSSION: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

The Association of Inflammatory Bowel Disease with Postoperative Complications, Re-admissions and Emergency Department Visits Following Primary Total Hip Arthroplasty.

BACKGROUND: Inflammatory bowel disease (IBD) is a systemic inflammatory disorder of the gut. Few studies have evaluated whether patients with a history of IBD have worse outcomes following primary total hip arthroplasty (THA). Therefore, the purpose of this study was to evaluate whether IBD is associated with increased: (1) medical complications; (2) readmissions; and (3) emergency department (ED) visits. METHODS: Using a nationwide claims database, patients with IBD undergoing primary THA were identified and matched to a comparison group according to age, sex and the Charlson Comorbidity Index. Outcomes assessed included the development of 90-day medical complications, 90-day re-admissions and 90-day ED visit rates. A p-value <0.0001 was considered statistically significant. RESULTS: Patients with IBD had a greater incidence and odds ratio of total medical complications (31.90% vs. 11.47%; OR 2.89; p < 0.0001) compared with matched controls. IBD patients had significantly higher incidence and odds ratio of developing acute kidney injury (5.46 vs. 1.46%; OR 3.92; p < 0.0001), cerebrovascular accident (1.32 vs. 0.35%; OR 3.79; p < 0.0001), pneumonia (4.02 vs. 1.30%; OR 3.19; p < 0.0001), respiratory failure (1.21 vs. 0.41%; OR 2.94; p < 0.0001), deep vein thrombosis (0.89% vs. 0.30%; OR 2.93; p < 0.0001), and other adverse events. IBD patients also had higher incidence and odds ratio of 90-day re-admissions (4.20% vs. 3.23%; OR 1.31; p < 0.0001) and ED visits (6.56% vs. 3.99%; OR 1.69; p < 0.0001). CONCLUSIONS: This study found that patients with IBD are at increased risk of 90-day medical complications, re-admissions, and ED visits. Due to its systemic nature, surgeons operating on these patients should be aware of the disease's extra-intestinal manifestations, and the potential postoperative risks in IBD patients. Providers should use this investigation when educating patients on potential risks of elective THA.

The use of machine learning for predicting candidates for outpatient spine surgery: a review.

While spine surgery has historically been performed in the inpatient setting, in recent years there has been growing interest in performing certain cervical and lumbar spine procedures on an outpatient basis. While conducting these procedures in the outpatient setting may be preferable for both the surgeon and the patient, appropriate patient selection is crucial. The employment of machine learning techniques for data analysis and outcome prediction has grown in recent years within spine surgery literature. Machine learning is a form of statistics often applied to large datasets that creates predictive models, with minimal to no human intervention, that can be applied to previously unseen data. Machine learning techniques may outperform traditional logistic regression with regards to predictive accuracy when analyzing complex datasets. Researchers have applied machine learning to develop algorithms to aid in patient selection for spinal surgery and to predict postoperative outcomes. Furthermore, there has been increasing interest in using machine learning to assist in the selection of patients who may be appropriate candidates for outpatient cervical and lumbar spine surgery. The goal of this review is to discuss the current literature utilizing machine learning to predict appropriate patients for cervical and lumbar spine surgery, candidates for outpatient spine surgery, and outcomes following these procedures.

Unicompartmental knee arthroplasty revised to total knee arthroplasty versus primary total knee arthroplasty: A meta-analysis of matched studies.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) offers a less invasive alternative to total knee arthroplasty (TKA), but is accompanied by a high revision risk. The aim of our study was to perform a meta-analysis comparing outcomes of UKA revised to TKA versus primary TKA, to assess if UKA is an effective treatment option, despite its potential need for revision. METHODS: Studies comparing matched cohorts of patients with UKA revised to TKA versus primary TKA were identified via the PubMed, Ovid EMBASE, and Scopus databases. The following outcome measures were compared between treatment modalities: postoperative reoperation or revision, total complications, range of motion, patient-reported outcome measures, and length of stay. RESULTS: Ten studies were included with 1,070 patients: 410 UKA to TKA and 660 primary TKA. At an average follow-up of 5.6 years in the UKA to TKA cohort and 5.7 years in the primary TKA cohort, there were no significant difference in risk of revision (p = 0.81), total complications (p = 0.54), range of motion (p = 0.09), or length of stay (p = 0.31). Both objective and functional Knee Society Score were significantly higher in patients with primary TKA (p < 0.01). However, there was no difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or pain scores (p = 0.13 and p = 0.21, respectively). CONCLUSION: UKA revised to TKA produced comparable clinical and patient-reported outcomes to a primary TKA. UKA may be an effective treatment option in unicompartmental arthritis that would allow for improved functionality and satisfaction without the concern of outcomes deteriorating in patients where a revision becomes necessary.

Sex-Specific Postoperative Outcomes of Primary Total Hip Replacements: The Performance of Total Hip Replacement Procedures Leads to Worse Outcomes in Men.

INTRODUCTION: The demand for primary total hip arthroplasty (THA) is expected to increase significantly in the coming years, and women are expected to account for the greatest proportion of this increased demand. The purpose of this study was to determine, using a national database, the effect of sex on 90-day outcomes in primary THA patients while matching for confounding variables. Specifically, we evaluated: (1) in-hospital lengths of stay; (2) 90-day readmission rates; (3) 90-day medical complications; (4) and total global 90-day episode-of-care (EOC) costs in men and women. MATERIALS AND METHODS: Using the 100% Medicare Standard Analytical Files (SAF), a query from January 1, 2005 to March 31, 2014 from a nationwide database was performed to analyze patients who received a primary THA. The series was divided into two cohorts: men (n=436,737) and women (n=436,737). Male and female patients were matched according to age and Elixhauser-Comorbidity Index (ECI). Uni- and multi-variable regression analyses were performed to analyze the effects of sex on in-hospital lengths of stay, 90-day readmission rates, 90-day medical complications, and total global 90-day EOC costs. RESULTS: Men had greater overall 90-day medical complications compared to women following primary THA (1.28 vs. 1.19%, p<0.001). Men were found to have higher rates of acute kidney failure (0.12 vs 0.05%, p<0.0001), acute pancreatitis (0.02 vs. 0.01%, p<0.0001), cerebrovascular accidents (0.03 vs. 0.01%, p<0.0001), deep vein thromboses (0.06 vs. 0.04%, p<0.0001), and myocardial infarctions (0.02 vs. 0.01%, p<0.0001). Women were found to have higher rates of acute post-hemorrhagic anemiae (0.31 vs. 0.30%, p<0.001) and urinary tract infections (UTI; 0.40 vs. 0.28%, p<0.0001) compared to men. Men had shorter in-hospital lengths of stay (LOS) (3.42 vs. 3.54 days, p<0.001) but greater 90-day readmission rates (7.67 vs. 6.39% p<0.0001). Both cohorts had similar total global 90-day EOC costs ($14,869.85 ± $12,333.50 vs. $14,957.34 ± $10,915.61, p=0.36). CONCLUSION: Men undergoing THA have a greater number of overall 90-day medical complications and readmission rates while women have higher incidence of UTI, post-hemorrhagic anemia, and longer LOS. Understanding sex-based differences in complication rates and outcomes can help surgeons with preoperative counseling and targeted preoperative optimization.