Considerations for the care of transgender patients in orthopaedics and sports medicine: a narrative review.

Orthopaedic and sports medicine clinicians can improve outcomes for transgender patients by understanding the physiological effects of gender-affirming hormone therapy (GAHT). This narrative review investigated the role of GAHT on bone mineral density, fracture risk, thromboembolic risk, cardiovascular health and ligament/tendon injury in this population. A search from the PubMed database using relevant terms was performed. Studies were included if they were levels 1-3 evidence. Due to the paucity of studies on ligament and tendon injury risk in transgender patients, levels 1-3 evidence on the effects of sex hormones in cisgender patients as well as basic science studies were included for these two topics. This review found that transgender patients on GAHT have an elevated fracture risk, but GAHT has beneficial effects on bone mineral density in transgender women. Transgender women on GAHT also have an increased risk of venous thromboembolism, stroke and myocardial infarction compared with cisgender women. Despite these elevated risks, studies have found it is safe to continue GAHT perioperatively for both transgender women and men undergoing low-risk operations. Orthopaedic and sports medicine clinicians should understand these unique health considerations for equitable patient care.

Functional Somatic Syndromes Are Associated With Varied Postoperative Outcomes and Increased Opioid Use After Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and clinical outcomes after spine surgery. METHODS: A systematic review of online databases (PubMed and Web of Science) through December 2021 was conducted via PRISMA guidelines to identify all studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches/migraines, interstitial cystitis, chronic fatigue syndrome, multiple chemical sensitivity) on outcomes after spine surgery. Outcomes of interest included patient reported outcome measures (PROMs), postoperative opioid use, cost of care, complications, and readmission rates. RESULTS: A total of 207 records were identified. Seven studies (n = 40,011 patients) met inclusion criteria with a mean MINORS score of 16.6 out of 24. Four studies (n = 21,086) reported postoperative opioid use; fibromyalgia was a strong risk factor for long-term opioid use after surgery whereas the association with chronic migraines remains unclear. Two studies (n = 233) reported postoperative patient reported outcome measures (PROMs) with mixed results suggesting a possible association between fibromyalgia and less favorable PROMs. One study (n = 18,692) reported higher postoperative complications in patients with fibromyalgia. CONCLUSION: Patients with fibromyalgia and possibly migraines are at higher risk for prolonged postoperative opioid use and less favorable PROMs after spine surgery. There is limited research on the relationship between other Functional somatic syndromes (FSSs) and outcomes following spine surgery. Growing evidence suggests the variation in outcomes after spine procedures may be attributed to non-identifiable organic patient factors such as FSSs.

Comparison of Opioid Consumption Patterns of Three Interbody Fusion Surgical Techniques.

STUDY DESIGN: Retrospective review. OBJECTIVES: With increased awareness of the opioid crisis in spine surgery, the focus postoperatively has shifted to managing surgical site pain while minimizing opioid use. Numerous studies have compared outcomes and fusion status of different interbody fusion techniques; however, there is limited literature evaluating opioid consumption postoperatively between techniques. The aim of this study was to assess in-house and postoperative opioid consumption across 3 surgical techniques. METHODS: Patients were stratified by technique: posterior lumbar interbody fusion (PLIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and cortical screw (CS) instrumentation with interbody fusion. Age, ASA, BMI, depression, preoperative opioid use, EBL, and OR time were recorded and compared across surgical groups using Welch's ANOVA and chi-square analysis. Total morphine equivalent dose (MED) was tabulated for both in-house consumption and postoperative prescriptions and was compared across surgical techniques using Welch's ANOVA analysis, Mann Whitney U tests, and linear regression. RESULTS: Two hundred and thirty nine patients underwent one- or two-level posterior lumbar interbody fusion between 2016 and 2020. One hundred and twenty one patients underwent CS instrumentation, 95 underwent PLIF, and 83 underwent MIS-TLIF. There was a significantly higher percentage of patients who had a history of depression and preoperative opioid consumption in the CS group (P = .001, P = .009). CS instrumentation required significantly less total post-op opioids per kilogram bodyweight compared to MIS-TLIF and PLIF surgeries (P = .029). CONCLUSIONS: Patients who underwent CS instrumentation required less opioids postoperatively. CS instrumentation may be associated with less postoperative pain due to the less invasive approach, however, patient education and prescriber practice also play a role in postoperative opioid consumption.

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, P=.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [Orthopedics. 2021;44(5):e668-e674.].

Predictors of Inpatient Morbidity and Mortality After 1- and 2-Level Anterior Cervical Diskectomy and Fusion Based on the National Inpatient Sample Database From 2006 Through 2010.

Spine procedures, including anterior cervical diskectomy and fusion (ACDF), are more commonly being performed in an outpatient setting to maximize value. Early complications after ACDF are rare but can have devastating consequences. The authors sought to determine risk factors for inpatient complications after 1-and 2-level ACDF by performing a retrospective review of the National Inpatient Sample (NIS) administrative database from 2006 through 2010. A total of 78,771 patients were identified. Multivariate logistic regression analysis was performed to identify preoperative risk factors for medical and surgical complications, including mortality, airway compromise, new neurologic deficit, and surgical-site infection. Inpatient mortality and overall complication rates were 0.074% and 3.73%, respectively. The risk of any medical complication was 3.13%. Airway compromise, neurologic deficit, and surgical-site infection occurred in 0.75%, 0.05%, and 0.04% of cases, respectively. Chronic kidney disease was the strongest predictor of mortality, with an odds ratio (OR) of 11.14 (P<.001). Airway complication was associated with age older than 65 years, male sex, myelopathy, diabetes mellitus, anemia, bleeding disorder, chronic obstructive pulmonary disease, obesity, and obstructive sleep apnea (P<.05). Preoperative diagnosis of myelopathy was most strongly associated with an increased rate of neurologic complication (OR, 6.67; P<.001). Anemia was associated with a significantly increased rate of surgical-site infection, with an OR of 14.34 (P<.001). Age older than 65 years; certain medical comorbidities, particularly kidney disease and anemia; and a preoperative diagnosis of myelopathy are associated with increased risk of early complication following ACDF surgery. Surgeons should consider these risk factors when deciding to perform ACDF surgery in an outpatient setting. [Orthopedics. 2021;44(5):e675-e681.].

Impact of body mass index on opioid consumption in lumbar spine fusion surgery.

BACKGROUND: in the United States from 1999 to 2000 through 2017-2018, the prevalence of obesity increased from 30.5 to 42.4%, while the prevalence of severe obesity nearly doubled. In lumbar spine surgery, obesity is associated with increased complications, worse perioperative outcomes, and higher costs. The purpose of this study was to examine the association between body mass index (BMI) and opioid consumption in patients undergoing lumbar spine fusion surgery. We hypothesized that obese patients would require more opioids postoperatively. METHODS: retrospective review of 306 patients who underwent one- or two-level posterior lumbar interbody fusion surgery between 2016 and 2020. Patients were stratified by BMI as follows: normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), and obese II-III (≥ 35.0 kg/m2). Patient demographics and preoperative characteristics were compared across BMI cohorts using one-way ANOVA and chi-square analysis. Patients with prior history of opioid use were excluded. Primary outcome measure was postoperative opioid consumption. Secondary outcomes included operative time, length of stay (LOS), discharge destination, and 30-day re-encounter rates. Outcomes were analyzed using multivariable linear regression adjusted for potential confounders. RESULTS: of 306 total patients, 17.3% were normal weight, 39.9% were overweight, 25.5% were obese I, and 17.3% were obese II-III. Obesity was associated with longer operative times and length of stay (p < 0.001, p = 0.024). For opioid naïve patients, there was no difference in-house opioid consumption when adjusted for kilograms of body mass and LOS (p = 0.083). Classes II-III patients were prescribed more than twice the number of postoperative opioids (p < 0.001) and were on opioids for a longer time postoperatively (p = 0.019). CONCLUSION: obesity is associated with longer operative times, longer LOS, and increased consumption of postoperative opioids. This should be considered when counseling patients preoperatively prior to lumbar spine fusion procedures.

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013.

STUDY DESIGN: Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013. OBJECTIVE: To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU. SUMMARY OF BACKGROUND DATA: The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood. METHODS: Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients. RESULTS: From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87). CONCLUSION: IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes. LEVEL OF EVIDENCE: 3.

Persistent radiculopathy after surgical treatment for lumbar disc herniation: causes and treatment options.

PURPOSE: Lumbar disc surgery is a common procedure in the USA. It is frequently performed with good or excellent results in most patients. This article reviews common causes of persistent radiculopathy after surgical intervention. METHODS: We performed an extensive review of the literature as well as applying our own experience. RESULTS: Common causes of persistent leg pain following operative intervention include re-herniation, epidural fibrosis, biochemical/physiologic changes in the nerve root, and psychosocial issues. CONCLUSIONS: Patients with persistent leg pain after surgical treatment of lumbar disc herniation can pose a challenging clinical problem. Summary of these topics and available treatment options are reviewed.

Exercise stress echocardiography after childhood Ross surgery: functional outcome in 26 patients from a single institution.

Adult studies suggest a better functional outcome after aortic valve replacement with a pulmonary autograft compared with mechanical or homograft valves. Little is known about functional results after Ross surgery in growing children. This study reports formal exercise stress echocardiographic data from 26 pediatric Ross patients. A retrospective cohort study analyzed stress echocardiographic data of patients who underwent Ross surgery as a child (<17 years old). All patients were operated by a single surgeon and underwent a Bruce protocol stress echocardiogram on the treadmill. Twenty-six patients (4 girls) were 9.3 ± 5.0 years at surgery and 14.9 ± 3.5 years (range 6.6-19.7 years) at follow-up. Mean follow-up was 5.4 ± 3.7 years (median 4.2). All were asymptomatic. The exercise time was normal in 87% of cases at 12.8 ± 2.5 min. On stress echocardiography, the mean right-ventricular outflow tract (RVOT) gradient increased from 38 ± 22 mmHg at rest to 82 ± 33 mmHg after exercise, but this did not correlate with exercise times. Stress echocardiography is useful in evaluating patients after childhood Ross surgery for aortic valve disease. In this pediatric cohort, most patients achieved normal exercise capacity. The presence of mild or moderate RVOT obstruction had no significant impact on exercise capacity.

The Ross operation in children and young adults: a fifteen-year, single-institution experience.

BACKGROUND: The optimal operation for aortic valve disease in children and young adults remains controversial. The Ross operation offers avoidance of anticoagulation and the potential for growth but is technically demanding and creates double-valve disease. The goal of this study is to report our experience with the Ross operation and the need for reintervention at intermediate follow-up. METHODS: A retrospective review of Ross operations in a single surgeon experience from 1992 to 2007 was conducted. All echocardiograms were reevaluated by a single cardiologist. RESULTS: The cohort included 54 patients with a mean age of 13.5 years (range 0.5 to 35 years). Pulmonary autograft implantation was accomplished using root replacement (n=43), root inclusion (n=9), and Dacron tube root replacement (n=2). Follow-up was available for 47 patients (87%) at a mean length of 6.4 years. There were no deaths. Kaplan-Meier estimates of freedom from explantation at 10 years were 100% for the autograft and 71% for the homograft. Autograft insufficiency at latest follow-up was trivial in 37 patients (82%), mild in 6 patients (13%), and moderate in 2 patients (4%). Reintervention for the homograft included balloon dilation in 3 children and conduit change in 5 children (all≤2 years old at initial operation). CONCLUSIONS: The Ross operation can be performed in children and adults with low mortality and can provide a durable result for the aortic valve with a low incidence of aortic insufficiency. The need for homograft replacement during follow-up in our series was primarily limited to children who were age 2 years or younger at initial operation.