Distal Femoral Osteotomies Improves Recurrent Patellar Instability in Patients with Genu Valgum: A Systematic Review.

IMPORTANCE: Coronal plane malalignment can contribute to recurrent patellar instability, a common knee pathology particularly in adolescents that can negatively impact knee function and stability. OBJECTIVE: To systematically review the literature in order to summarize the clinical and radiologic outcomes of the surgical treatment of recurrent lateral patellar instability in patients with genu valgum using varus-producing distal femoral osteotomies (DFOs). EVIDENCE REVIEW: A systematic review was conducted using PubMed, Cochrane Library, and OVID Medline databases from 1990 to present. Inclusion criteria were: outcomes of lateral opening- and medial closing-DFO's performed for treatment of recurrent patellar instability with associated genu valgum, minimum 90-days follow-up, English language articles, and human studies. Data extracted included demographic information, type of osteotomy and concomitant procedures, radiological outcomes, patient reported outcome scores, and incidence of complications. FINDINGS: Nine studies, with a total of 147 knees, were available for review. All included studies were retrospective case series, with a weighted mean follow-up of 2.75 ± 0.75 years. 6 of 147 (4.08%) knees demonstrated recurrent patellar instability. All studies reported good to excellent patient-reported outcomes postoperatively, with improvement from pre-operative measures. All studies reported relative normalization of measurements of mechanical axis and/or lateral distal femoral angle (LDFA) postoperatively. 63 of 147 (42.86%) knees underwent re-operation, with hardware removal [53 of 147 (36.05%) knees] being the most commonly performed procedure. CONCLUSIONS: Varus-producing DFO's are an efficacious procedure to improve functionality and radiographic malalignment, and address recurrent patellar instability in patients with associated valgus deformity. Additional higher-level of evidence studies utilizing matched control groups, such as patients undergoing conservative treatment, with standardized reporting of outcomes should be performed in order to better understand clinical and radiographic outcomes of varus-producing DFO's for this indication. STUDY DESIGN: Systematic Review; Level of evidence, 4.

Curve progression following selective and nonselective spinal fusion for adolescent idiopathic scoliosis: are selective fusions stable?

PURPOSE: The purpose of this study is to compare postoperative outcomes between selective and non-selective fusions longitudinally over the first five postoperative years. METHODS: Patient parameters were retrieved from a multicenter, prospective, database. Patients with Lenke 1-6, B and C deformities were included. Patients were stratified into 2 groups: selective fusion (SF), if the last instrumented vertebra (LIV) was at or cranial to the lumbar apex, or non-selective fusion (NSF). Differences in coronal and sagittal radiographic outcomes were assessed with generalized linear models (GLMs) at 1-, 2- and 5- year postoperative outcomes. Five-year postoperative categorical radiographic outcomes, flexibility, scoliosis research society scores (SRS), and reoperation rates were compared between groups. Matched cohorts were created for subgroup analysis. RESULTS: 416 (SF:261, NF:155) patients, including 353 females were included in this study. The mean preoperative thoracic and lumbar Cobb angles were 57.3 ± 8.9 and 45.3 ± 8.0, respectively. GLMs demonstrated greater postoperative coronal deformity in the SF group (p < 0.01); however, the difference between groups did not change overtime (p > 0.05) indicating a relatively stable postoperative deformity correction. The SF group had a greater incidence of lumbar Cobb ≥ 26 degrees (p < 0.01). The NSF group demonstrated worse forward and lateral flexibility at 5-year postoperative outcome (p < 0.05). There was no difference in postoperative SRS scores between the SF and NSF groups. Reoperation rates were similar between groups. CONCLUSION: Selective fusion results in greater coronal plane deformity; however, this deformity does not progress significantly over time compared to non-selective fusion. Selective spinal fusion may be a beneficial option for a larger subset of patients than previously identified. LEVEL OF EVIDENCE: III.

Total Hip Arthroplasty Outcomes before or after Renal Transplant: A Retrospective Large Cohort Analysis.

Background: While it is known that patients with end-stage renal disease (ESRD) are at an increased risk of complications following total hip arthroplasty (THA), there is a gap in the literature in comparing patients with ESRD to patients who undergo renal transplant (RT) before or after THA. This study is to address this gap by analyzing outcomes of THA in ESRD patients, RT patients, and RT candidates. Methods: Using the PearlDiver Mariner database, ESRD patients, RT patients, and RT candidates undergoing primary THA were identified and compared. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. Ninety-day emergency department (ED) visits and inpatient readmission were also documented. Results: A total of 7,868 patients were included: 5,092 had ESRD, 2,520 had RT before THA, and 256 were candidates for RT. Compared to patients with ESRD, RT patients demonstrated lower rates of medical complications such as pneumonia (3.61% vs. 5.99%, p = 0.039) and transfusion (4.60% vs. 7.66%, p < 0.001). Additionally, RT patients displayed decreased rates of surgical complications, including wound complications (2.70% vs. 4.22%, p = 0.001), periprosthetic joint infection (PJI) at 1 year (2.30% vs. 4.81%, p < 0.001) and 2 years (2.58% vs. 5.42%, p < 0.001), and aseptic loosening at 2 years (0.79% vs. 1.43%, p = 0.006). Similarly, when compared to RT candidates, RT patients demonstrated a lower incidence of postoperative complications, including 1-year PJI (2.30% vs. 5.08%, p = 0.013), 2-year PJI (2.58% vs. 5.08%, p = 0.028), 1-year aseptic loosening (0.56% vs. 2.73%, p < 0.001), and 2-year aseptic loosening (0.79% vs. 2.73%, p = 0.005). RT patients also had lower rates of ED visits and hospital readmissions. Conclusions: Compared to ESRD patients and RT candidates, patients with RT have a significantly lower likelihood of medical complications, PJI, aseptic hardware loosening, ED visits, and hospital readmission. Patients with ESRD on the RT waiting list should delay THA until after RT surgery. For those not eligible for RT, it is vital to take extra precautions to reduce the risk of complications.

Combined tibial deflexion osteotomy and anterior cruciate ligament reconstruction improves knee function and stability: A systematic review.

IMPORTANCE: Patients with excessive posterior tibial slope (PTS) may have higher risks of anterior cruciate ligament (ACL) reconstruction (ACL-R) failure, and clinical outcomes after revision of ACL-R procedures are typically poor. OBJECTIVE: This study aimed to perform a systematic review of the literature summarizing the clinical and radiological outcomes of the surgical treatment of ACL insufficiency in the setting of excessive PTS using a tibial deflexion osteotomy combined with ACL-R. EVIDENCE REVIEW: A systematic review of the literature was performed using PubMed, Cochrane Library, and OVID Medline databases from 1990 to present. Inclusion criteria were studies of outcomes of isolated tibial deflexion osteotomies performed with primary or revision ACL-R in the English language. Data extracted included study demographic information, type of tibial deflexion osteotomy and concomitant procedures, radiological outcomes, patient-reported outcome scores, and postoperative complications. FINDINGS: Six studies, with 133 knees were identified. All included studies were retrospective case series, with a weighted mean follow-up of 3.39 years. In 106 of 133 (79.7%) knees, tibial deflexion osteotomy was performed concomitantly with an ACL-R, whereas in 27 of 133 (20.3%) knees, the procedures were staged. 22, 45, and 66 of 133 knees (16.5%, 33.8%, and 49.6%) underwent primary, first revision, and second or greater revision ACL-R, respectively. Three of 133 (2.25%) knees demonstrated recurrent ACL graft failure at the final follow-up. On average, PTS decreased from 15.2° preoperatively to 7.1° postoperatively. The mean International Knee Documentation Committee, Lysholm, and Tegner scores increased from 42.5, 46.4, and 4.2 preoperatively to 71.8, 89.0, and 6.7 postoperatively. CONCLUSIONS: The results of this review suggest that combined ACL-R and tibial deflexion osteotomy may be effective in decreasing PTS and improving knee function and stability. STUDY DESIGN: Systematic Review; Level of evidence 4.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI. METHODS: The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05. RESULTS: Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003). CONCLUSIONS: Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Polymyositis.

BACKGROUND: Polymyositis (PM) is a systemic connective tissue disorder that can lead to early onset degenerative joint disease and a need for total knee arthroplasty (TKA). Outcomes of TKA in patients who have PM are not well documented in the literature. The purpose of this study was to evaluate PM as a risk factor for complications after TKA. METHODS: Using a national private payer insurance database from 2010 to 2022, PM patients undergoing primary TKA were compared to 10:1 matched controls based on age, sex, and comorbidities. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department visits and inpatient readmissions were also documented. A total of 25,039 patients undergoing primary TKA were queried, of which 2,290 had PM. RESULTS: Compared to the matched controls, patients who had PM demonstrated higher rates of medical and surgical complications, including pulmonary embolism (1.0% versus 0.5%, P = .001), cerebrovascular accident (1.3% versus 0.7%, P = .002), wound complications (3.4% versus 2.1%, P < .001), and periprosthetic joint infection at 1 year (1.7% versus 1.3%, P = .042) and 2 years (2.6% versus 1.9%, P = .006). Patients who had PM displayed elevated 90-day emergency department (14.9% versus 13.3%, P = .032) and hospital readmission rate (7.1% versus 4.8%, P < .001). CONCLUSIONS: Patients who have PM are at higher risks of postoperative medical and surgical complications, including pulmonary embolism, cerebrovascular accident, wound complication, and periprosthetic joint infection. Given these results, it is helpful for orthopedic surgeons and patients to consider these risks when considering TKA for patients who have PM.

Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Marfan Syndrome.

BACKGROUND: Outcomes of Marfan syndrome (MFS) patients after total knee arthroplasty (TKA) are poorly documented in the literature. The purpose of this study was to evaluate MFS as a potential risk factor for complications after TKA. METHODS: Using a national private payer insurance database from 2010 to 2022, MFS patients undergoing primary TKA were identified and compared to 10:1 matched controls based on age, sex, obesity, diabetes mellitus, and a comorbidity index. A total of 4,092 patients undergoing primary TKA were analyzed, of which 372 had MFS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department-visits and inpatient readmissions were also documented. RESULTS: Compared to the matched controls, patients who have MFS displayed elevated rates of surgical complications, including prosthetic instability (1-year, odds ratio (OR) 3.88, 95% confidence interval (CI) [1.58 to 8.66]; 2-year, OR 4.39, 95% CI [2.16 to 8.44]), and revision surgery (2 year, OR 1.79, 95% CI [1.05 to 2.91]). Additionally, patients who have MFS demonstrated significant higher rates of medical complications, including aortic dissection (2.15 versus 0%) and transfusion (OR 2.63, 95% CI [1.31 to 4.90]). CONCLUSIONS: Patients who have MFS are at higher risks of postoperative complications after TKA, encompassing both medical and surgical complications. Specifically, patients who have MFS have a significantly higher likelihood of experiencing prosthetic instability and requiring revision surgery. Given these results, it is crucial for orthopedic surgeons and patients alike to consider these risks when determining a course of TKA for patients who have MFS.

A Matched-Cohort Analysis of Outcomes in Patients with Hereditary Hemochromatosis After Anterior Cervical Discectomy and Fusion.

BACKGROUND: Hereditary hemochromatosis (HH) is a common autosomal recessive disorder. This disease affects gut iron transport, leading to iron overload, which affects immune function, coagulation mechanics, and bone health. Within the spine, HH contributes to decreased bone mineral density and accelerated intervertebral disc degeneration. The purpose of this study was to discover the differences in the rates of common 90-day postoperative complications and 1-year and 2-year surgical outcomes in patients with and without HH after anterior cervical discectomy and fusion (ACDF). METHODS: Using the PearlDiver database, patients with active diagnoses of HH before ACDF were matched to patients without HH using a 1:5 ratio on the basis of age, sex, body mass index, and comorbidities. Postoperative complications were assessed at 90 days, and 1-year and 2-year surgical outcomes were assessed. All outcomes and complications were analyzed using multivariate logistic regression with significance achieved at P < 0.05. RESULTS: Patients with HH had significantly higher rates of 1-year and 2-year reoperation rates compared with patients without HH (29.19% vs. 3.94% and 37.1% vs. 5.93%, respectively; P < 0.001). The rates of 90-day postoperative complications significantly increased in patients with HH including dysphagia, pneumonia, cerebrovascular accident, deep vein thrombosis, acute kidney injury, urinary tract infection, hyponatremia, surgical site infection, iatrogenic deformity, emergency department visit, and hospital readmission. CONCLUSIONS: Patients with HH undergoing ACDF showed increased 90-day postoperative complications and significantly increased rates of 1-year and 2-year reoperation compared with patients without HH. These findings suggest that iron overload may contribute to adverse outcomes in patients with HH undergoing 1-level and 2-level ACDF.

Effect of Patient Age on Total Hip Arthroplasty Outcomes in Patients Who Have Osteonecrosis of the Femoral Head Compared to Patients Who Have Hip Osteoarthritis.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) affects both young and old patients. However, outcomes following total hip arthroplasty (THA) for these patients may vary with age. This study aimed to examine the effect of age on THA outcomes for non-traumatic ONFH patients, an area currently lacking research. METHODS: Patients who had non-traumatic ONFH undergoing THA with at least 2 years of follow-up were identified using a database and divided into four groups by age. Then, 4 matched control groups of patients who had hip osteoarthritis (OA) were created. Multivariate logistic regression analyses were used to evaluate the rates of medical and surgical complications. Additionally, cohorts with a minimum 5-year follow-up were filtered to obtain further data on surgical outcomes. The study analyzed 85,462 non-traumatic ONFH and 80,120 hip OA patients undergoing THA. RESULTS: Multiple medical complications in ONFH patients increased with age. Periprosthetic fracture within 2 years increased with age, while 90-day wound complications, 2-year periprosthetic joint infections, dislocations, and revisions decreased. The trends for complications continued at the 5-year follow-up. Compared to OA patients, those who had ONFH had higher risks of most complications, but this discrepancy decreased with age. CONCLUSIONS: In ONFH patients undergoing THA, medical complications generally rise with age, while most surgical complications, including revisions, decrease. It is notable that ONFH patients experienced more complications than those who had OA, but this difference diminished with age.

Increased rate of complications following total knee arthroplasty in patients with systemic sclerosis.

PURPOSE: Outcomes after total knee arthroplasty (TKA) for patients with systemic sclerosis (SSc) are poorly documented in the literature. The purpose of this study was to evaluate SSc as a potential risk factor for increased rate of complications after TKA. METHODS: Using the PearlDiver Mariner database, 2,002 patients with SSc undergoing primary TKA were identified and compared to matched controls of 19,892 patients without SSc. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. 90-day ED-visit and inpatient readmission were also documented. RESULTS: Compared to the matched controls, patients with SSc demonstrated higher rates of medical complications such as cerebrovascular accident (1.5% vs 0.6%, p < 0.001), myocardial infarction (1.3% vs 0.3%, p < 0.001), and sepsis (1.1% vs 0.4%, p < 0.001). Additionally, patients with SSc displayed elevated rates of surgical complications, including wound complications (3.9% vs 2.2%, p < 0.001) and aseptic loosening at 90 days (0.2% vs 0.1%; OR 3.53 [1.13-9.28]), one year (0.7% vs 0.4%; OR 1.78 [0.96-3.05]), and two years (1.4% vs 0.9%; OR 1.68 [1.10-2.45]). Patients with SSc also had higher rates of emergency department visits (21.2% vs 11.4%, p < 0.001). CONCLUSIONS: Patients with SSc are at higher risks of postoperative complications, encompassing both medical and surgical complications. Specifically, patients with SSc have a significantly higher likelihood of experiencing wound complications, cerebrovascular accident, and myocardial infarction. It is crucial for orthopaedic surgeons and patients alike to consider the elevated risks when determining a course of TKA for patients with SSc.

The impact of Behcet syndrome on total knee arthroplasty outcomes: a retrospective matched cohort study.

PURPOSE: Articu lar involvement is a common manifestation of Behcet syndrome (BS), which can eventually result in significant arthralgia and necessitate total knee arthroplasty (TKA). However, outcomes of BS patients after TKA are still poorly documented in the literature. The purpose of this study was to evaluate BS as a potential risk factor for complications after TKA. METHODS: BS patients undergoing primary TKA were identified from the PearlDiver Mariner database from 2010 to 2021 and compared to 10:1 matched controls. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. Ninety-day emergency department (ED) visit and inpatient readmission were also documented. RESULTS: A total of 4286 patients undergoing primary TKA were queried, of which 390 had BS. Patients with BS demonstrated significantly higher rates of medical complications, including deep venous thrombosis. The rates of surgical complications were similar between the two groups with the exception of periprosthetic instability, aseptic loosening, and wound complications in BS patients. Additionally, a significantly higher rate of ED visits but markedly lower rates of 90-day readmissions were noted in patients with BS. CONCLUSION: Patients with BS undergoing TKA are at higher risks of medical and surgical complications. Special considerations for a unique postoperative course with the higher complications should be made. It is crucial for orthopedic surgeons and patients alike to consider these risks when determining the expected course after TKA for patients with BS.

The Ratings Game: Demographic and Practice Factors Affecting Yelp Ratings of Plastic Surgeons.

BACKGROUND: Review platforms such as Yelp are increasingly used by patients establishing care and may contain substantial information regarding patient preferences and potential biases. The authors' aims were to (1) analyze patient satisfaction through identifying factors associated with positive and negative patient reviews for plastic surgery providers across the United States, and (2) investigate the association between overall rating and different physician and practice factors based on gender and race. METHODS: Reviews of plastic surgery provider practices from cities across seven different regions within the United States were obtained from Yelp. Quantitative and qualitative analyses were performed. Chi-square tests were used to determine whether race or sex was associated with overall rating (of five stars) and qualitative themes. RESULTS: A total of 5210 reviews met inclusion criteria; 80.3% received a five-star rating and 13.5% received a one-star rating. Positive Yelp reviews and higher ratings were associated with positive comments regarding surgical and injectable outcomes, physical examination, communication, competency/knowledge base, temperament, scheduling, and staff interactions. When the following factors were mentioned negatively, the practice was more likely to receive a lower rating: temperament, communication, cost consciousness, surgical and injectable outcomes, physical examination, billing/insurance, scheduling, interactions with staff, and wait times. No association was identified in terms of overall physician rating based on sex or race; however, there were differences noted in distribution of positive and negative themes. CONCLUSIONS: Patient reviews on Yelp indicate that several physician and practice factors influence patient satisfaction. The themes reported in this study may be used by plastic surgery providers to identify areas for practice improvement to enhance the overall patient experience.

The Association between Weather and Emergency Department Visitation for Diabetes in Roanoke, Virginia.

Diabetes mellitus imposes a significant and increasing health burden on the US population. Our objective is to determine if weather is related to daily variations in emergency department (ED) visits for diabetes mellitus in Roanoke, Virginia. A time series of daily ED visits for diabetes mellitus at the Carilion Clinic in southwestern Virginia is associated with daily minimum temperature from 2010-2017. Associations between ED visits (through a 14-day lag period) and temperature are examined using generalized additive models and distributed lag nonlinear models. Heat and cold waves are identified at low and high thresholds, and ED visitation during these events is compared to prior control periods using a time-stratified case crossover approach. ED visits for diabetes exhibit a U-shaped relationship with temperature, with a higher relative risk (RR) during cold events (RR = 1.05) vs. warm events (RR = 1.02). When minimum temperatures are below freezing, ED visitation peaks starting 2 days afterward, with RRs approaching 1.04. The RR on warm days (minimum temperature > 10 °C) approaches 1.02 but peaks on the day of or the day following the elevated temperatures. Cold waves increase the odds of ED visits by up to 11% (p = 0.01), whereas heat waves exhibit no significant effect (p = 0.07). The increasing health burden linked to diabetes requires new research on environmental factors that might exacerbate related illness. When examined in the context of climate change impacts on local weather variations, these kinds of linkages between environment and disease can aid in facility staffing and public health messaging during extreme weather events.