Robotic Arm-Assisted versus Manual Total Knee Arthroplasty: A Propensity Score-Matched Analysis.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal-Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p < 0.001), and fewer PT visits (median [interquartile range] = 10.0 [8.0-13.0] vs. 11.5 [9.5-15.5] visits, p = 0.014). RA-TKA had shorter LOS (0.48 ± 0.59 vs.1.2 ± 0.59 days, p < 0.001) and higher proportion of home discharges (p < 0.001). RA-TKA and manual TKA had similar postoperative complications and 1-year PROMs. Although RA-TKA patients had longer operative times, they had shorter LOS and higher propensity for home discharge. In an era of value-based care models and the steady shift to outpatient TKA, these trends need to be explored further. Long-term and randomized controlled studies may help determine potential added value of RA-TKA versus manual TKA. This study reflects level of evidence III.

Neighborhood Socioeconomic Disadvantages Associated With Prolonged Lengths of Stay, Nonhome Discharges, and 90-Day Readmissions After Total Knee Arthroplasty.

BACKGROUND: Low socioeconomic status and neighborhood context has been linked to poor health care outcomes after total knee arthroplasty (TKA). The area deprivation index (ADI) addresses this relationship by ranking neighborhoods by socioeconomic disadvantage. We examined the following relationships of the ADI among TKA recipients: (1) patient demographics, (2) lengths of stay (LOS), (3) nonhome discharges, and (4) 90-day readmissions, emergency department visits, and reoperations. METHODS: We reviewed a consecutive series of primary TKAs from 2018 through 2020 at a tertiary health care system. A total of 3928 patients who had complete ADI data were included. A plurality of patients (14.9%) were categorized within ADI 31-40, below the national median ADI of 47. Associations between the national ADI decile and 90-day postoperative health care utilization metrics were evaluated using multivariate regressions (adjusted for patient demographics and comorbidities). RESULTS: The 91-100 ADI cohort was disproportionately African American, female, younger, and smokers. Compared with ADI 31-40 (reference), the ADI 61-70 cohort was associated with higher odds of LOS ≥3 days (odds ratio [OR] = 1.6 [1.08-2.36], P = .019) and nonhome discharges (OR = 1.73 [1.08-2.75], P = .021). The ADI 91-100 cohort was associated with the highest odds of prolonged LOS (OR = 2.27; [1.47-3.49], P < .001), nonhome discharges (OR = 3.49 [2.11-5.78], P < .001), and all-cause readmissions (OR: 1.79, [1.02-3.14], P = .044). No significant associations were found between the ADI and 90-day emergency department visits or reoperations (P > .05). CONCLUSION: A higher ADI was associated with prolonged LOS, nonhome discharge status, and 90-day readmissions after TKA. This index highlights potential areas of intervention for assessing health care outcomes.

The Cost-Effectiveness of Robotic-Assisted Versus Manual Total Knee Arthroplasty: A Markov Model-Based Evaluation.

INTRODUCTION: The purpose of this study was to investigate the cost-effectiveness of robotic-assisted total knee arthroplasty (TKA) versus conventional manual TKA in patients with knee osteoarthritis. METHODS: A Markov model simulated the lifetime outcomes of TKA of patients at average age 60 years. Costs of robotic-assisted TKA included a preoperative CT scan and the costs for acquisition and use of robotic equipment (average $706,250). We used three institutional case volumes to generate average per-case robotic costs: low volume (10 cases, $71,025 per case), mid volume (100 cases, $7,463 per case), and high volume (200 cases, $3,931 per case). Systematic reviews were used to determine early (≤1 year) and late (> 1 year) revision rates after robotic-assisted TKA (0.3 and 0.6%, respectively) and conventional TKA (0.78% and 1.5%, respectively). Outcomes were total costs and health outcomes measured in quality-adjusted life-years (QALYs). Costs and QALYs were organized into incremental cost-effectiveness ratios (ICERs). A procedure was considered cost-effective if its ICER fell below willingness-to-pay (WTP) thresholds of $50,000 and $100,000/QALY. Sensitivity analyses evaluated the effect of data uncertainty. RESULTS: Robotic-assisted TKA produced 13.55 QALYs versus 13.29 QALYs for conventional TKA. Total costs per case for robotic-assisted TKA were $92,823 (low volume), $29,261 (mid volume), and $25,730 (high volume) compared with $25,113 for conventional. The ICERs for robotic-assisted TKAs were $256,055/QALY (low volume), $15,685/QALY (mid volume), and $2,331/QALY (high volume). ICERs for mid- and high-volume institutions were below WTP. Average number needed to treat was >42 and >24 robotic-assisted TKAs for cost-effectiveness at the $50,000 and $100,000/QALY WTP. Robotic-assisted TKAs remained cost-effective when annual revision rates <1.6% and quality of life values were >0.85. CONCLUSION: With lower annualized revision rates and higher postoperative quality of life, robotic-assisted TKAs potentially offer improved health outcomes, especially when annual institutional case volume >24 cases per year. Continued prospective investigation will be crucial to demonstrate the value of this new technology.

Robotic-arm assisted versus manual total hip arthroplasty: Systematic review and meta-analysis of radiographic accuracy.

BACKGROUND: We systematically reviewed the radiological outcomes of studies comparing robotic-assisted (RA-THA) and manual total hip arthroplasty (mTHA). METHODS: The PubMed, Embase, and Cochrane databases were queried from 1994-2021 for articles comparing radiographic outcomes between RA-THA and mTHA cohorts. A meta-analysis was conducted whenever sufficient data was present for common outcomes. RESULTS: Our analysis included 20 articles reporting on 4140 patients (RA-THA: n = 1228; mTHA: n = 2912). No differences were demonstrated for acetabular inclination or anteversion. However, RA-THA demonstrated higher rates of cup orientation within the Lewinnek and Callanan safe zones, improved femoral stem alignment, and lower global offset difference (GOD) and limb length discrepancy (all p-values <0.05). Superior femoral canal fill and combined offset were seen among RA-THA patients. CONCLUSION: Our review found that the use of RA-THA yields superior radiographic outcomes compared to mTHA counterparts. This information can inform healthcare systems considering investing in and implementing these technologies.

The Olerud Extensile Anterior Approach for Complex Distal Femoral Fractures: A Systematic Review.

The management of AO/OTA (AO Foundation/Orthopaedic Trauma Association) 33-C3 complex distal femoral fractures presents challenges for orthopaedic surgeons. The extensile anterior approach may be an appropriate alternative treatment technique. The purpose of this systematic review is to (1) evaluate the Olerud approach (extensile anterior approach) for the treatment of 33-C3 complex distal femoral fractures and (2) evaluate postoperative patient outcomes. A systematic literature search was performed to retrieve studies that evaluated the treatment of 33-C3 complex distal femoral fractures. The PubMed database query resulted in 429 studies. Two reviewers independently reviewed the studies, of which six were identified. Patient demographics, AO/OTA fracture, surgical intervention, follow-up duration, clinical outcomes, and postoperative complications were collected and analyzed. The systematic review included six studies reporting on 85 patients (43 males and 42 females); the mean patient age was 45 years (range: 16-101 years). The most common cause of injury was road/traffic accident (51 patients). The mean follow-up time was 26 months (range: 3-72 months). In five studies, the mean time for union was 5.8 months (range: 2-9 months). The three most commonly reported complications were infection (seven [8.2%] patients), failure/malunion (three [3.5%] patients), and delayed tibial tuberosity osteotomy healing (three [3.5%] patients). Seventy (82.4%) patients did not suffer any postoperative complications. Out of 72 patients, 7 (9.7%) had resultant varus/valgus deformity. Overall, 57.1% had excellent/good functional outcomes. Based on the systematic literature review, the extensile anterior approach may be a viable alternative surgical option for 33-C3 complex distal femoral fractures. Given the current literature, more comprehensive and extensive studies need to be performed to ensure the best possible outcome.

The Impact of Malnutrition on 30-Day Postoperative Complications following Surgical Fixation of Distal Radius Fractures.

Introduction Distal radius fractures (DRFs) are increasingly managed surgically among fragility fractures due to prolonged life expectancy and surgical advancements. Yet, malnutrition can impact postoperative outcomes and complications. We sought to determine the impact of malnutrition on open reduction and internal fixation (ORIF) of DRFs during the perioperative and 30-day postoperative periods. Materials and Methods Using the National Surgical Quality Improvement Program database, all patients who underwent ORIF of a DRF between January 1, 2008, and December 31, 2016, were identified and stratified by preoperative serum albumin levels: normal (≥3.5 g/dL; n = 2,546) or hypoalbuminemia (<3.5 g/dL; n = 439). Demographical and perioperative data were compared. Operative complications were stratified into major and minor complications, and data were analyzed using descriptive statistics and multivariate regression models. Results Compared with patients with normal levels, a higher proportion of hypoalbuminemia patients had ASA scores > 3 (9.1 vs. 2%) and a longer mean length of stay (3.16 vs. 0.83 days). Hypoalbuminemia patients also had 625% greater odds for developing major complications during the 30-day postoperative period (odds ratio = 7.25; 95% confidence interval: 1.91-27.49). Conclusion Malnutrition significantly affected outcomes and complications of distal radius ORIF. This study highlights the importance of prevention and treatment of malnutrition in the setting of fragility fractures.

Liposomal Bupivacaine Is Both Safe and Effective in Controlling Postoperative Pain After Spinal Surgery in Children: A Controlled Cohort Study.

STUDY DESIGN: Retrospective comparative cohort study. OBJECTIVE: To evaluate: (1) pain relief efficacy; (2) opioid consumption; (3) length of stay (LOS); (4) discharge disposition (DD); and (5) safety and adverse effects of liposomal bupivacaine (LB) in pediatric patients who underwent spinal deformity correction. SUMMARY OF BACKGROUND DATA: LB is a long-acting, locally injectable anesthetic. Previous orthopedic studies investigating its use have been limited to adult patients. The use of LB as part of postoperative pain management in pediatric patients undergoing spine deformity correction surgery is yet to be evaluated. MATERIALS AND METHODS: A total of 195 patients that received LB as part of their postoperative pain management regimen were compared with 128 patients who received standard pain management without LB. Pain intensity, opioid consumption, LOS, and DD were recorded. Potential LB-related complications were reported as frequencies and statistically compared for superiority. Noninferiority tests were performed using the Farrington-Manning score test. Multivariate tests based on generalized estimating equations were performed to determine the common and average treatment effects. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The LB cohort demonstrated lower pain scores [postoperative day 1 (POD 1)-median=2, interquartile range (IQR)=(0-5) vs. 5 (2.5-7); POD 2-3 (0-5) vs. 4 (3-6); P<0.001], lower overall opioid consumption (78.2 vs. 129 morphine milligram equivalents; P=0.0001) and consistently from POD 0 to 3 (mean differences; 7.47, 9.04, 17.2, and 17.3 morphine milligram equivalents, respectively; P<0.01), shorter LOS (median=3 d, IQR=3-4 vs. 4 d, IQR=4-6; P<0.001), and similar to-home DD (98% vs. 97%). Complications were similar among the cohorts in superiority and 10% noninferiority analyses. Patients in the LB cohort had lower odds for complications (odds ratio=0.77; 95% CI, 0.64-0.93; P=0.009 and 0.67; 95% CI, 0.50-0.90; P=0.008). CONCLUSIONS: This study demonstrated the safety and efficacy of LB when added to the current multimodal postoperative pain management regimens after pediatric spinal surgery. LEVEL OF EVIDENCE: Level III.

Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up.

PURPOSE: No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA). METHODS: Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty-one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft-tissue release procedure. Mean age at intervention was 60 years (range 46-78 years). Mean preoperative knee range of motion (ROM) was - 27° extension (range - 20° to - 40°) to 100° flexion (range 90°-115°). All radiographs were evaluated for proper component sizing and signs of loosening. RESULTS: Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow-up of 31 months (range 24-49 months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70-90) when compared with preoperative KSS (mean 45, range 25-65) (p = 0.008). CONCLUSION: The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2-year follow-up. LEVEL OF EVIDENCE: IV, retrospective case series.

The effect of body mass index on 30-day complications after total hip arthroplasty.

BACKGROUND: Evaluating body mass index (BMI) as a continuous variable eliminates the potential pitfalls of only considering BMI as a binary or categorical variable, as most studies do when correlating BMI and total hip arthroplasty (THA) outcomes. Therefore, the objective of this study was to correlate the effect of continuous BMI on 30-day complications post-THA. Specifically, we correlated BMI to: (1) 30-day readmissions and reoperations; (2) medical complications; and (3) surgical complications in: (a) normal-weight; (b) over-weight; (c) obese; and (d) morbidly obese patients. METHODS: Using the NSQIP database, 93,598 primary THAs were identified. 30-day rates of readmissions, reoperations, and medical/surgical complications as well as patient BMI data were extrapolated. A comparative analysis using univariate, multivariate, and spline regression models adjusting for demographics and comorbidities were created to study the continuous effect of BMI on different outcomes. RESULTS: Readmission (p < 0.001), reoperation (p = 0.007), superficial infection (p = 0.003), prosthetic joint infection (p < 0.001), and sepsis (p = 0.026) had a J-shaped relationship with BMI, with the lowest rates seen in patients with BMI around 28 kg/m2. The risks of mortality (p = 0.007) and transfusion (p < 0.001) had a reverse J-shaped relationship, with the risk steadily decreasing for BMIs in the normal weight and overweight range, and then flattening afterwards. CONCLUSION: This data proposes a multifactorial effect of BMI on post-THA complications. Considering BMI as a continuous variable allows for a better assessment when considering the interplay between modifiable risk factors, such as smoking or alcohol use, as well as multiple comorbidities.

Survivorship and Functional Outcomes of Cementless versus Cemented Total Knee Arthroplasty: A Meta-Analysis.

The purpose of this meta-analysis was to assess the evidence supporting the use of cementless versus cemented total knee arthroplasties (TKAs). Specifically, we evaluated (1) all-cause survivorship, (2) aseptic survivorship, and (3) functional outcomes (Knee Society Scores [KSS], Oxford Knee Scores, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores, and ranges of motion [ROMs]). A literature search was performed for studies that evaluated cementless versus cemented TKAs published between 2000 and 2017. Selected studies included three randomized controlled trials, three retrospective observational studies, and one prospective observational study that met the following criteria: (1) primary TKAs, (2) compared cementless and cemented TKAs, (3) implant survivorship that described the causes of failure, and (4) at least one functional outcome. To compare the two cohorts, pooled odds ratios (OR) and 95% confidence intervals (95% CI) were used to calculate tibial and femoral implant survivorship, and pooled mean differences (MD) and 95% CI calculated the functional scores and ROMs. Based on pooled data from the few number of studies, cementless TKAs had a better all-cause survivorship (OR = 0.37; 95% CI, 0.15-0.92) and tended to have a better aseptic survivorship (OR = 0.44; 95% CI, 0.17-1.14). However, this is likely due to the 83.3% weight of the single cementless study potentially influencing the analysis. There were no differences in terms of KSS knee (MD = 1.03; 95% CI, -1.13-3.20) or function scores (MD = 5.36; 95% CI, -3.75-14.51), Oxford knee scores (MD = 0.36; 95% CI, -3.84-4.56), or WOMAC scores (MD = 0.62; 95% CI, -0.87-2.11). Moreover, there was no difference in ROMs (MD = 1.47; 95% CI, -0.11-3.05). Cementless TKA had a better all-cause survivorship when compared with cemented fixation, and similar functional outcomes were demonstrated. However, these findings are based on only a few number of studies (n = 7). Therefore, additional prospective, randomized control trials need to be performed to best compare cementless versus cemented outcomes.

Results of a Phase II Study to Determine the Efficacy and Safety of Genetically Engineered Allogeneic Human Chondrocytes Expressing TGF-ß1.

Genetically engineered chondrocytes virally transduced with a transforming growth factor (TGF)-ß1 (TG-C [TissueGene-C]) expression vector have been shown to have potential benefits in the nonoperative management of knee osteoarthritis. Previous literature has reported on safe dosages of TG-C. Therefore, the purpose of this study was to evaluate the Phase II results and a 24-month efficacy of this injectable mixture compared with placebo in patients with Kellgren-Lawrence (K-L) grade III knee osteoarthritis. Specifically, we assessed (1) functional outcomes, (2) pain scores, (3) adverse events (AEs), and (4) magnetic resonance imaging (MRIs) findings. We performed a multicenter, double-blinded, placebo-controlled, and randomized study of adults who had K-L grade III knee osteoarthritis. A total of 102 patients were 2:1 randomized to TG-C at a dose of 3.0 × 107 cells, or placebo injections between May 1, 2011 and October 31, 2012. Outcomes analyzed were knee joint function, pain, quality of life, adverse events, and MRI findings using the whole-organ magnetic resonance imaging score (WORMS) system. There were significant improvements in the International Knee Documentation Committee (IKDC) and visual analogue scale (VAS) scores in the TG-C cohort, when compared with the placebo cohort at weeks 12, 52, 72, and 104 (p < 0.05). No severe AEs were observed. Common AEs were arthralgia, joint inflammation, and joint effusion which were similar between both cohorts. Whole-knee MRIs at 12 months showed less progression of cartilage damage, infrapatellar fat pad-synovitis, and effusion-synovitis in the TG-C cohort. Patients who received TG-C had significant improvements in IKDC and VAS scores. These patients also reported less severe and frequent pain. Additionally, fewer patients treated with TG-C showed progression of cartilage damage, as well as less progression of infrapatellar fat pad synovitis and effusion-synovitis. Furthermore, treatment with TG-C was generally well tolerated with minor AEs. Therefore, based on these results, TG-C appears to be a safe and effective modality for the management of K-L grade III osteoarthritis.

Patient-Reported Functional and Satisfaction Outcomes after Robotic-Arm-Assisted Total Knee Arthroplasty: Early Results of a Prospective Multicenter Investigation.

The purpose of this study was to perform a 3-month interim comparative analysis on outcomes between robotic-arm-assisted total knee arthroplasty (RATKA) and manual TKA patients. Specifically, we evaluated (1) patient self-reported symptoms, (2) expectations and satisfaction, and (3) functional activities, based on the 2011 Knee Society Scoring System. Between June 1, 2016, and March 31, 2018, 252 patients (102 manual and 150 robotic) were enrolled into a prospective, nonrandomized, open-label, multicenter comparative cohort study. Functional activity scores, patient-reported symptoms, as well as satisfaction and expectation scores were obtained from the 2011 Knee Society Scoring System preoperatively, at 4 to 6 weeks, and at 3 months postoperatively. Student's t-tests, Wilcoxon rank-sum tests, and chi-square tests with α set at 0.05 were used to compare between-group mean improvements from baseline. At 4 to 6 weeks postoperatively, RATKA patients were found to have significantly larger improvements in walking and standing (1.4 vs. -1.2 points; p = 0.019). RATKA patients were also found to have larger improvements in advanced activities (1.3 vs. 2.3 points), pain with walking (3.3 vs. 3.2 points), satisfaction score (12.4 vs. 12 points), and expectations score (5.1 vs. 4.4 points) when compared with manual TKA patients. At 3 months, RATKA patients were also found to have larger improvements in walking and standing (6.0 vs. 4.8 points), standard activities (11.4 vs. 10.1 points), advanced activities (6.2 vs. 4.6 points), functional activities total score (22.8 vs. 21.2 points), pain with walking (4.3 vs. 4.1 points), total symptoms score (10.5 vs. 10.3 points), satisfaction score (17.0 vs. 15.5 points), expectations score (4.8 vs. 4.0 points) when compared with manual TKA patients. The data indicate RATKA patients to have equal or greater improvements in 9 out of 10 of the Knee Society Scoring System components assessed at 3 months postoperatively, though not all findings were statistically significant. Since this is an early results report, this study will be continued for a longer follow-up, but we are encouraged by these interim results.

Malnutrition increases the 30-day complication and re-operation rates in hip fracture patients treated with total hip arthroplasty.

INTRODUCTION: This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates. METHODS: The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates. RESULTS: Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43-2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31-3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42-2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20-3.23). CONCLUSIONS: The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk.

Comparison of a Posterior versus Anterior Approach for Lumbar Interbody Fusion Surgery Based on Relative Value Units.

INTRODUCTION: The current value-driven healthcare system encourages physicians to continuously optimize the value of the services they provide. Relative value units (RVUs) serve as the basis of a reimbursement model linking the concept that as the effort and value of services provided to patient's increases, physician reimbursement should increase proportionately. Spine surgery is particularly affected by these factors as there are multiple ways to achieve similar outcomes, some of which require more time, effort, and risk. Specifically, as the trend of spinal interbody fusion has increased over the past decade, the optimal approach to use-posterior versus anterior lumbar interbody fusion (PLIF vs. ALIF)-has been a source of controversy. Due to potential discrepancies in effort, one factor to consider is the correlation between RVUs and the time needed to perform a procedure. Therefore, the purpose of this study was to compare: 1) mean RVUs; 2) mean operative time; and 3) mean RVUs per unit of time between PLIF and ALIF with the utilization of a national surgical database. We also performed an individual surgeon cost benefit analysis for performing PLIF versus ALIF. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify 6,834 patients who underwent PLIF (CPT code: 22630) and 6,985 patients who underwent ALIF (CPT code: 22558) between 2008 and 2015. The mean operative times (in minutes), mean RVUs, and RVUs per minute were calculated and compared using the Student's t-tests. In addition, the reimbursement amount (in dollars) per minute, case, day, and year for an individual surgeon performing PLIF versus ALIF were also calculated and compared. A p-value of less than 0.05 was used as the threshold for statistical significance. RESULTS: Compared to ALIF cases, PLIF cases had longer mean operative times (203 vs. 212 minutes, p<0.001). However, PLIF cases were assigned lower mean RVUs than ALIF cases (22.08 vs. 23.52, p<0.001). Furthermore, PLIF had a lower mean RVU/minutes than ALIF cases (0.126 vs. 0.154, p<0.001). The reimbursement amounts calculated for PLIF versus ALIF were: $4.52 versus $5.53 per minute, $958.66 versus $1,121.95 per case, and $2,875.98 versus $3,365.86 per day. The annual cost difference was $78,380.92. CONCLUSION: The data from this study indicates a potentially greater annual compensation of nearly $80,000 for performing ALIF as opposed to PLIF due to a higher "hourly rate" for ALIF as is noted by the significantly greater RVU per minute (0.154 vs. 0.126 RVU/minutes). These results can be used by spine surgeons to design more appropriate compensation effective practices while still providing quality care.

Current Concepts in Osteoarthritis of the Ankle: Review.

Ankle osteoarthritis constitutes a large burden to society and is a leading cause of chronic disability in the United States. Most commonly, it is post-traumatic, occurs in younger individuals, and is associated with obesity. This entity presents similarly to osteoarthritis of the other joints, with the typical nonspecific symptoms of stiffness, swelling, and pain. Radiographic investigation includes four weight-bearing standard views: antero-posterior and lateral foot, mortise view of the ankle, and a specialized view of the hindfoot. In this review, we covered epidemiology, anatomy and biomechanics, etiology, pathology, differential diagnoses, symptoms, physical examination, appropriate radiological investigation, as well as current treatment options and algorithms. Non-operative treatment options include weight loss, physical therapy, bracing, orthoses, pharmacologic treatments, corticosteroid injections, viscosupplementation, and biologic modalities. Viscosupplementation with hyaluronic acid has the most evidence-based support and has been shown to be safe and efficacious. For patients who have moderate to severe disease, surgery may be indicated. However, current surgical options are either associated with high rates of complications or restrict ankle range of motion (ROM). Early stages of the ankle osteoarthritis should be treated with the above-mentioned non-surgical methods, and once the disease progresses, surgical options can be utilized.

Difficult Revision Total Hip Arthroplasty Cases Treated with an Offset Head Center Acetabular Shell.

Acetabular bone loss is common during revision total hip arthroplasty (THA). A new acetabular shell was developed with a goal of maintaining native hip center-of-rotation (COR) while achieving good fixation with standard instrumentation and technique. Previous radiographic studies have demonstrated the efficacy of this shell in lowering hip COR. In this case series, we demonstrate the use of this shell in patients undergoing difficult revision THAs. Based on these cases, we have presented how this offset COR acetabular shell may help bring down the hip COR in patients who undergo revision total hip arthroplasty with severe bone loss.

Patient satisfaction and outcomes of static progressive stretch bracing: a 10-year prospective analysis.

BACKGROUND: Multiple surgical and non-surgical modalities are available for patients suffering from shoulder elbow, forearm, wrist, knee and ankle stiffness. For most patients, bracing can provide optimal therapy to restore functional range of motion (ROM). Three commonly used bracing mechanisms include static progressive stretch (SPS), turnbuckle, and dynamic bracing. However, although, in general, these three brace types have been shown to have successful outcomes, there are a number of different manufacturers, and company specific designs might affect outcomes. Therefore, the purpose of this study was to analyze 10 years of prospectively collected patient satisfaction and outcomes data from a single brace company. Specifically, we evaluated: (I) mobility, (II) pain, (III) stiffness, (IV) swelling, and (V) any adverse events of patients treated with an SPS brace. METHODS: From 2007 to 2017, data from a total of 167,751 patients treated with a JAS Brace (Joint Active Systems Inc., Effingham, IL, USA) were prospectively collected through a cross-sectional survey addressing various outcomes such as pain, stiffness, swelling and mobility. More specifically, patients were asked "Are you having pain?", "Do you have any stiffness?", "Do you have any swelling?", and "Do you feel your mobility has improved?" Patients who answered "yes" were then asked to categorize their response as either worse, same, or better (or improvement) for pain, stiffness, and swelling. For mobility, patients answered either "yes", "no", or "undecided". This data was then graphed and a yearly trends analysis was performed. We also assessed the number of complaints as well as any device related adverse events. RESULTS: In 2008, 59% of patients reported no pain, 45% no stiffness, and 79% no swelling after device use. Those numbers increased by 2013, to 70% of patients reporting no pain, 79% reporting no stiffness, and 84% reporting no swelling after brace use. A consistent positive trend was also seen for mobility, with at least 90% of patients reporting improved mobility after orthosis use. The number of complaints decreased from 38 in 2007 to 3 in 2017. No patients experienced any device related serious injuries. CONCLUSIONS: Overall, to the best of the author's knowledge, this study is the first to demonstrate a brace designed to improve ROM also has significant effect on pain, stiffness, and swelling. These results are of particular importance, since no other study reports prospective data on thousands of patients showing that a bracing system substantially reduces pain and stiffness. These data indicate that not only or these SPS braces effective in improving functional ROM with high rate of success and no significant complications, but this bracing system has a significant effect on improving pain and stiffness. Based on the results from this study, patients suffering from shoulder, elbow, forearm, wrist, knee and/or ankle pathology can expect excellent clinical outcomes by using one of the above braces.

Astym® therapy: a systematic review.

Soft tissue dysfunction can result from the degeneration of tissues as in the case of degenerative tendinopathy or from the build-up of problematic scar tissue, which can be the result of several aggravating factors, including overuse injuries, acute or chronic trauma, or as a result of surgery. This dysfunction often results in impaired movement, pain, and swelling of the affected area, which can lead to patient dissatisfaction and a lower quality of life. These soft tissue dysfunctions also have a marked economic impact. Although a number of traditional treatments attempt to address these issues, no optimal treatment choice has emerged. Traditional treatments are not always successful, can be invasive, and can consume many medical resources. A relatively new treatment approach, Astym therapy, is a potentially useful, non-invasive, more cost-effective option. This therapy was developed to address soft-tissue dysfunctions by stimulating the regeneration of soft tissues and the resorption of inappropriate scar tissue/fibrosis. It has been reported to help with the resorption and remodeling of abnormal tissue, thereby leading to improved motion, function and pain relief. The purpose of this analysis was to review the published literature related to Astym therapy on various musculoskeletal disorders. Specifically, we evaluated the effectiveness of this therapeutic method on disorders related to the: (I) knee; (II) upper extremity; (III) hamstring muscles; and (IV) ankle and Achilles tendon injuries.

Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper's knee due to the high prevalence seen in the athletic community. In many published reports, the name "patellar tendinopathy" is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Quadriceps tendinopathy: a review, part 2-classification, prognosis, and treatment.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy in the non-athlete population. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the previous part we reviewed: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In this part we discuss: (I) classification; (II) prognosis; and (III) treatment results.