Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study.

BACKGROUND: Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS: Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS: Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS: Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Pain-Associated Psychological Distress Is of High Prevalence in Patients With Hip Pain: Characterizing Psychological Distress and Phenotypes.

Purpose: To identify common pain-related psychological factors among patients seeking care for athletic hip pain, as well as characterize psychological distress phenotypes and compare hip-specific quality-of-life measures across those phenotypes. Methods: A total of 721 patients were recruited from hip preservation clinics. The Optimal Screening for Prediction of Referral and Outcome-Yellow Flag Assessment Tool (OSPRO-YF) was used to identify the presence or absence of 11 different pain-associated psychological distress characteristics (yellow flags), while the International Hip Outcome Tool-12 (iHOT-12) was used to assess hip-related quality of life. Latent class analysis identified patient subgroups (phenotypes) based on naturally occurring combinations of distress characteristics. An analysis of variance was used to compare demographics, number of yellow flags, and iHOT-12 scores across phenotypes. Results: The median (interquartile range) number of yellow flags was 6 (3-9), with 13.5% of the sample reporting 11 yellow flags. Latent class analysis (L2 = 543.3, classification errors = 0.082) resulted in 4 phenotypes: high distress (n = 299, 41.5%), low distress (n = 172, 23.9%), low self-efficacy and acceptance (n = 74, 10.3%), and negative pain coping (n = 276, 24.4%). Significant differences in mean yellow flags existed between all phenotypes except low self-efficacy and negative pain coping. There were no differences in demographics between phenotypes. The high distress class had the lowest mean iHOT-12 score (mean [SD], 23.5 [17.6]), with significant differences found between each phenotypic class. Conclusions: There was a high prevalence of pain-associated psychological distress in patients presenting to tertiary hip arthroscopy clinics with hip pain. Furthermore, hip quality-of-life outcome scores were uniformly lower in patients with higher levels of psychological distress. Level of Evidence: Level III, retrospective cohort study.

Influence of running on femoroacetabular joint bone-to-bone distances.

There is limited data quantifying the influence of running on hip cartilage mechanics. The goal of this investigation was to quantify changes in hip joint bone-to-bone distance in response to a 3-mile treadmill run. We acquired magnetic resonance (MR) images of the dominant hip of eight young, asymptomatic runners (five males, three females) before and immediately after they ran 3 miles at a self-selected pace on a level treadmill. The femoral heads and acetabula were semiautomatically segmented from the pre- and post-exercise MR images to generate three-dimensional models of each participant's hip that were used to compute changes in the bone-to-bone distances incurred by the running exercise. We observed a significant 3% decrease in bone-to-bone distance from 3.47 ± 0.20 to 3.36 ± 0.22 mm between the femoral head and acetabulum after a 3-mile treadmill run (mean ± 95% confidence interval; p = 0.03). These findings provide new baseline data describing how running impacts the hip joint in young, asymptomatic runners.

Development and Evaluation of an Enhanced Recovery Protocol to Reduce Length of Stay following Elective Endovascular Aneurysm Repair.

BACKGROUND: Elective endovascular abdominal aortic aneurysm repair (EVAR) can be performed safely with a short postoperative length of stay (LOS). We aimed to develop and assess the impact of an enhanced recovery protocol (ERP) on LOS after elective EVAR. METHODS: Pre-ERP development single center retrospective review of elective EVAR procedures from January 2012 to December 2019. ERP was developed by targeting factors associated with prolonged LOS (>2 days) elucidated from semistructured interviews and Bayesian additive regression tree analysis. Post-ERP development, a subsequent retrospective review of elective EVAR performed from January 2018 to June 2021 was performed to evaluate LOS before and after ERP. Primary outcome was LOS. RESULTS: Two hundred sixteen patients underwent elective infrarenal EVAR from 2012 to 2019. Periprocedural factors identified as associated with LOS >2 days included noncommercial insurance (43.6% vs. 26.5%; P = 0.01), preoperative anemia (hemoglobin 12.56 g/dL vs. 13.57 g/dL; P = 0.001), worse renal function (creatinine 1.31 mg/dL vs. 1.01/dL; P = 0.004), open femoral access (74.4% vs. 26.5%; P < 0.001), intensive care unit (ICU) stay (2.7 days vs. 0.9 days; P < 0.001), postoperative anemia (9.8 g/dL vs. 11.9 g/dL; P < 0.001), postoperative creatinine (1.55 mg/dL vs. 0.97 mg/dL; P < 0.001), and beta blocker need on discharge (45.5% vs. 25%; P = 0.003) as significant between patients with short and prolonged LOS groups. Semistructured interviews revealed postoperative day 1 complete blood count/chemistry, postoperative physical therapy evaluation, ICU admission, urinary retention, patient expectations, and unavailability of transportation home as modifiable factors that delayed early discharge. A 14-component ERP was created to target the factors identified from combined qualitative and quantitative results. Post-ERP development, 74 elective EVAR patients were reviewed from 2018 to 2021 (37 pre-ERP and 37 post-ERP). Following ERP development, the mean LOS was reduced from 2.6 (standard deviation: 1.9) to 1.3 days (standard deviation: 1.3); P < 0.01. There were no significant differences in 30-day readmission, postoperative complications, emergency room visits, or 90-day mortality before and after the ERP was used. CONCLUSIONS: Practice and procedural factors can be modified through an informed and safe process to reduce LOS after elective EVAR. LOS following elective EVAR was safely reduced following the use of a systematically developed ERP.

Design and validation of a semi-automatic bone segmentation algorithm from MRI to improve research efficiency.

Segmentation of medical images into different tissue types is essential for many advancements in orthopaedic research; however, manual segmentation techniques can be time- and cost-prohibitive. The purpose of this work was to develop a semi-automatic segmentation algorithm that leverages gradients in spatial intensity to isolate the patella bone from magnetic resonance (MR) images of the knee that does not require a training set. The developed algorithm was validated in a sample of four human participants (in vivo) and three porcine stifle joints (ex vivo) using both magnetic resonance imaging (MRI) and computed tomography (CT). We assessed the repeatability (expressed as mean ± standard deviation) of the semi-automatic segmentation technique on: (1) the same MRI scan twice (Dice similarity coefficient = 0.988 ± 0.002; surface distance = - 0.01 ± 0.001 mm), (2) the scan/re-scan repeatability of the segmentation technique (surface distance = - 0.02 ± 0.03 mm), (3) how the semi-automatic segmentation technique compared to manual MRI segmentation (surface distance = - 0.02 ± 0.08 mm), and (4) how the semi-automatic segmentation technique compared when applied to both MRI and CT images of the same specimens (surface distance = - 0.02 ± 0.06 mm). Mean surface distances perpendicular to the cartilage surface were computed between pairs of patellar bone models. Critically, the semi-automatic segmentation algorithm developed in this work reduced segmentation time by approximately 75%. This method is promising for improving research throughput and potentially for use in generating training data for deep learning algorithms.

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review.

PURPOSE: To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques. METHODS: A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury. RESULTS: Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively. CONCLUSIONS: The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries. LEVEL OF EVIDENCE: IV, systematic review of Level I-IV evidence.

A Single Center 8 Year Experience of Segmental Arterial Mediolysis Management.

OBJECTIVE: Segmental Arterial Mediolysis (SAM) is a rare, poorly understood vasculopathy that involves vacuolization of the arterial wall, most commonly of the visceral arteries. There are no established therapeutic or monitoring guidelines for SAM, and intervention typically depends on patient presentation. The purpose of this study is to review the management and outcomes of patients with this rare vascular disease METHODS: Single center retrospective review of patients diagnosed with SAM between 2011 and 2019. Included were patients with radiological diagnosis of SAM. Demographic factors, past medical history, presenting symptoms, affected vessels, management, and lesion characteristics over time were collected. Demographic and periprocedural factors, and medical management strategies were compared for those who required operative intervention versus those managed non-operatively. RESULTS: Thirty patients were included, 21 (70%) were male, mean age was 53.5 years (range: 35.7-72.2). Twenty-seven patients were managed non-operatively, 3 patients required surgical intervention. Patients who underwent operative intervention were more likely to present with pain >30 days (P < 0.05), and hemorrhage (P < 0.01). Abdominal pain was the most common presenting symptom (n = 24, 80%). Arterial dissection was the most common radiological finding at time of presentation (n = 20, 67%). The celiac artery and its branches were most often involved (n=22, 73%) followed by the superior mesenteric artery and its branches (n = 15, 50%). Non-operative management most often consisted of anti-hypertensive therapy (n = 13, 43%), antiplatelet agents (n = 17, 57%%), and lipid-lowering agents (n = 13, 43%), with 7 patients receiving all three. Six patients demonstrated confirmed resolution of lesions during surveillance imaging, with average time to resolution of 325.5 days. CONCLUSIONS: Patients who underwent intervention for SAM presented with either mesenteric ischemia or pseudoaneurysm rupture. In patients that present without those conditions, medical management consisting of anti-hypertensives, antiplatelet agents, and lipid-lowering therapy was effective. Non operative management resulted in symptom resolution in all patients and surveillance imaging showed resolution of radiographic abnormalities in 6 patients out of 27 at less than one year.

Axillary pullout syndrome: A novel approach to managing a devastating complication.

OBJECTIVES: Axillary pullout syndrome is a complex, potentially fatal complication following axillary-femoral bypass graft creation. The re-operative nature, in addition to ongoing hemorrhage, makes for a complicated and potentially morbid repair. METHODS: We present the case of a 57-year-old man with history of a previous left axillary-femoral-femoral bypass who presented with acute limb-threatening ischemia as a result of bypass thrombosis managed with a right axillary-femoral bypass for limb salvage. His postoperative course was complicated by an axillary anastomotic dehiscence while recovering in inpatient rehabilitation resulting in acute, life-threatening hemorrhage. He was managed utilizing a novel hybrid approach in which a retrograde stent graft was initially placed across the anastomotic dehiscence for control of hemorrhage. He then underwent exploration, decompression, and interposition graft repair utilizing the newly placed stent graft to reinforce the redo axillary anastomosis. RESULTS AND CONCLUSION: Compared with a traditional operative approach, the hybrid endovascular and open approach limited ongoing hemorrhage while providing a more stable platform for repair and graft revascularization. A hybrid approach to the management of axillary pullout syndrome provides a safe, effective means to the management of axillary anastomotic dehiscence while minimizing the morbidity of ongoing hemorrhage.

Superficial femoral artery stent extrusion.

The superficial femoral artery is a common location for endovascular treatment of occlusive arterial disease. Stent extrusion is an uncommon complication of stent placement. In the present case report, we sought to raise awareness of this rare complication and have described the management of a single unique case. Although rare, the complication of stent extrusion should be considered in patients with abnormal symptoms after endovascular treatment of superficial femoral artery disease.

Opioid legislation and narcotic filling in total hip arthroplasty: descriptive study of time and state-level trends in the United States.

BACKGROUND: The opioid misuse epidemic focused national attention on reducing opioid overprescribing. The purpose of this study is to describe the relationship of time and state-level interventions and opioid filling surrounding total hip arthroplasty (THA) in the United States. METHODS: A national database with diverse insurance constituents was queried for first-prescription and cumulative perioperative opioid filling volumes and rates in oxycodone 5-mg equivalents (OE's) in 487,942 patients undergoing primary THA from 30-days pre-operative to 90-days post-operative. Descriptive statistics evaluated pre-legislative and post-legislative opioid filling by state, legislative type, and surgery year. RESULTS: At the national level, initial opioid filling volumes have remained largely unchanged (56.2 OE's in 2010 to 51.7 OE's in 2018). Meanwhile, cumulative opioid filling volumes (151.9 OE's in 2010 to 111.7 OE's in 2018) have decreased considerably. Rates of initial opioid prescriptions exceeding 90 OE's were similar in 2010 (6.4%) and 2018 (5.6%). States with legislation targeting duration and volume of opioid prescriptions saw the largest decreases in opioid prescription filling. That is, 75% of states with opioid legislation had large (> 10 oxycodone 5-mg equivalents) decreases in cumulative 90-day opioid filling compared to only 20% of states without opioid legislation having large decreases in cumulative 90-day opioid filling. CONCLUSIONS: This descriptive study demonstrates decreases in perioperative opioid filling for THA. Although this study was descriptive in nature, states enacting opioid-limiting legislation had larger decreases. Although causal relationships could not be inferred from this analysis, the results suggest that states without legislation could improve prescriber compliance with national goals of decreased opioid overprescribing by enacting opioid-limiting legislation. LEVEL OF EVIDENCE: Level III, retrospective prognostic cohort study.

Hybrid repair for acute aortic occlusion using aortobifemoral bypass and AngioVac thrombectomy.

Aortic thrombus with multilevel acute ischemia is rare. We report the use of vacuum-assisted thrombectomy of an aortic mural thrombus with superior mesenteric artery involvement causing bilateral lower extremity ischemia and acute mesenteric ischemia, in conjunction with embolectomy and fasciotomy. We describe the novel use of the AngioVac device (AngioDynamics, Latham, NY) for reperfusion in the systemic arterial circulation. This case report demonstrates a feasible and less invasive alternative to the management of aortic thrombi with acute ischemia in patients unfit for open aortic thrombectomy of the visceral segment aorta.

The Impact of State Level Public Policy, Prescriber Education, and Patient Factors on Opioid Prescribing in Elective Orthopedic Surgery: Findings From a Tertiary, Academic Setting.

BACKGROUND: The United States is in the midst of an opioid misuse epidemic. There have been recent changes to North Carolina's public policy leading to institutional education attempting to reduce high-risk opioid prescribing. This study investigated whether state-level and institutional efforts were associated with provider-level changes in opioid prescriptions after common orthopedic surgeries. PATIENTS AND METHODS: Six-week post-operative opioid prescribing in patients 18 years or older undergoing high-volume elective surgeries were reviewed retrospectively. Three patient cohorts from equivalent calendar year periods were included in this analysis; preceding policy implementation (January 1, 2017, to March 31, 2017), immediately after policy implementation (January 1, 2018, to March 31, 2018), and 1 year after policy implementation (January 1, 2019, to March 31, 2019). Multivariable models were constructed to evaluate the effects of public policy and institutional education on postoperative opioid prescribing. RESULTS: The mean (standard deviation) amount of oxycodone 5-mg equivalents prescribed at discharge decreased from 75.6 (53.2) in 2017 to 55.7 (36.2) in 2018 and then 45.6 (32.6) in 2019 (P < .05). Similarly, 6-week postoperative cumulative oxycodone 5-mg equivalents prescribed also significantly decreased from 123.3 (145.8) in 2017 to 84.1 (90.3) in 2018 and to 80.2 (150.1) in 2019. Other outcomes including prescription duration and rates of outlier prescribing showed similar trends. CONCLUSION: In a North Carolina tertiary academic hospital, opioid prescribing decreased after public policy implementation and an institutional response of education for prescribers within a national context of changing practices in opioid prescribing. State-level public policy and prescriber education could be important avenues for decreasing postoperative opioid prescription in orthopedic settings.

Hip Dysplasia.

Acetabular dysplasia represents a structural pathomorphology associated with hip pain, instability, and osteoarthritis. The wide spectrum of dysplasia anatomically refers to a 3-dimensional volumetric- and surface area-based insufficiency in coverage and is classified based on the magnitude and location of undercoverage. Borderline dysplasia has been variably defined and leads to management challenges. In symptomatic dysplasia, treatment addresses coverage with periacetabular osteotomy. Concomitant simultaneous or staged hip arthroscopy has significant advantages to address intra-articular pathology. In nonarthritic individuals, there is evidence PAO alters the natural history of dysplasia and decreases the risk of hip arthritis and total hip arthroplasty.

The Association of Prescriber Awareness of Opioid Consumption Trends with Postoperative Opioid Prescription Volume in Hip Arthroscopy: Prescriber Awareness of Opioid Consumption.

PURPOSE: To evaluate the impact of prescriber knowledge of 6-week postoperative opioid usage trends on postoperative opioid prescribing in hip arthroscopy for femoroacetabular impingement syndrome. METHODS: Two groups of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome with the same 2 surgeons were defined. One group preceded study design and implementation and 1 group was after study completion termed the preawareness group (n = 129) and awareness group (n = 130). Baseline clinical and operative characteristics and cumulative 6-week postoperative opioid prescription amount in oral morphine equivalents (OMEs), initial discharge OMEs, and cumulative 6-week postoperative opioid refills were recorded. Multivariable models were constructed to evaluate the impact of provider awareness of opioid usage along with the other baseline characteristics previously mentioned on the outcomes of postoperative opioid prescribing. RESULTS: Preawareness group (365.8 additional OMEs; 95% confidence interval [CI], 132.6-599; P = .002), preoperative opioid usage (506.2 additional OMEs; 95% CI, 268.0-744.3; P < .001), postoperative nonsteroidal anti-inflammatory drugs (-664.6 additional OMEs; -1002.6 to -326.6; P < .001), and Caucasian race (-597.5 additional OMEs; 95% CI, -914.8 to -280.2; P < .001) were significantly associated with 6-week postoperative opioid prescribing. Caucasian race (odds ratio, 0.4; 95% CI, 0.18-0.86; P = .02) was associated with lower odds of additional postoperative opioid prescriptions whereas preoperative opioid usage (odds ratio, 2.47; 95% CI, 1.4-4.36; P = .002) was associated with increased odds of additional postoperative opioid prescriptions. CONCLUSIONS: Patients in the awareness group received significantly lower opioid volume without an increase in overall prescription numbers. LEVEL OF EVIDENCE: III, prognostic, retrospective comparative study.

Resident perception of fundamental endoscopic skills exam: a single institution's experience.

BACKGROUND: Graduating general surgery residents are required to pass the FES exam for ABS certification. Trainees and surgery educators are interested in defining the most effective methods of exam preparation. Our aim is to define trainee perceptions, performance, and the most effective preparation methods regarding the FES exam. METHODS: General surgery residents from a single institution who completed the FES exam were identified. All participated in a flexible endoscopy rotation, and all had access to an endoscopy simulator. Residents were surveyed regarding preparation methods and exam difficulty. Descriptive statistics and a Kruskal-Wallis test were used. RESULTS: A total of 26 trainees took the FES exam with a first-time pass rate of 96.2%. Of 26 surveys administered, 21 were completed. Twenty trainees (76.9%) participated in a dedicated endoscopy curriculum. Scores were not different among those who received dedicated curricular instruction compared to those who did not (547 [IQR 539-562.5] vs. 516 [484.5-547], p = 0.1484; 535.5 [468.5-571] vs. 519 [464.75-575], p = 0.9514). Written exam difficulty was rated as 5.5 on a 10-point Likert scale, and 85.7% felt it was a fair assessment of endoscopy knowledge; skills exam difficulty was rated as 7, and 71% felt it was a fair assessment of endoscopy skills. Online FES modules, the endoscopy clinical rotation, and an exam preparation session with a faculty member were most effective for written exam preparation. The most effective skills exam preparation methods were independent simulator practice, the endoscopy clinical rotation, and a preparation session with a faculty member. The most difficult skills were loop reduction and retroflexion. Skill decay did not appear to be significant. CONCLUSIONS: A clinical endoscopy rotation, a method for independent skills practice, and faculty-mediated exam instruction appear to be effective exam preparation methods. When these are present, trainees report minimal need for dedicated exam preparation time prior to taking the FES exam.

Assessment of a novel antimicrobial surface disinfectant on inert surfaces in the intensive care unit environment using ATP-bioluminesence assay.

BACKGROUND: Cross-contamination from inanimate surfaces can play a significant role in intensive care unit (ICU)-acquired colonization and infection. This study assessed an innovative isopropyl alcohol/organofunctional silane solution (IOS) to reduce microbial contamination on inert surfaces in a medical ICU. METHODS: Baseline adenosine triphosphate bioluminescence testing (ABT)-measurements (N = 200) were obtained on designated inert ICU surfaces followed by IOS treatment. At 1 and 6 weeks, selective surfaces were randomized to either IOS-treated or nontreated controls for comparison using ABT (N = 400) and RODAC colony counts (N = 400). An ABT value of ≤45 relative light units (RLU) was designated as "clean," whereas >45 was assessed as "dirty." RESULTS: Mean RLU baseline values ranged from 870.3 (computer keyboard) to 201.6 (bed table), and 97.5% of surfaces were assessed as "dirty." At 6 weeks, the mean RLU of surfaces treated with IOS ranged from 31.7 (physician workstation) to 51.5 (telephone handpiece), whereas values on comparative control surfaces were 717.3 and 643.7, respectively (P < .001). Some 95.5% of RODAC cultures from IOS-treated sites at 6 weeks were negative, whereas 90.5% of nontreated sites were culture-positive, yielding multiple isolates including multidrug-resistant gram-positive and gram-negative bacteria. CONCLUSIONS: IOS-treated surfaces recorded significantly lower RLU and RODAC colony counts compared with controls (P < .001). A single application of IOS resulted in a persistent antimicrobial activity on inert ICU surfaces over the 6-week study interval.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database.

BACKGROUND: Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions. METHODS: The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days. RESULTS: We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5). CONCLUSIONS: The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

Achieving Post-Free Distraction in Hip Arthroscopy With a Pink Pad Patient Positioning Device Using Standard Hip Distraction Tables.

Iatrogenic pudendal nerve and groin complications have been reported to occur at rates up to 4.3%. While many of these complications are transient, the hip preservation community is in search of a safe postless distraction technique. Currently available postless distraction tables are expensive, require the surgeon to adopt a different technique, and have a high disposable fee. We present our technique for postless distraction using a standard table and a pink pad positioning device. Using our technique, we have demonstrated safe and cost-effective post-free distraction.

Sex-dependent outcomes following elective endovascular aortic repair.

BACKGROUND: Evidence has shown that women derive less benefit from endovascular aortic repair (EVAR) in large part due to more challenging aortoiliac anatomy. This study sought to examine whether sex-dependent outcomes exist following elective EVAR cases. METHODS: An institutional retrospective review was performed on patients who underwent elective EVAR procedures between 2008 and 2014. Outcome data collected included procedural and hospital morbidity, mortality, and overall EVAR durability based on the incidence of unplanned graft-related secondary interventions (SIs) (e.g., open conversion, proximal or distal extensions, and coil embolizations). RESULTS: One hundred eighty-one patients (150 men, 31 women) met the study inclusion criteria. Median follow-up was 40.3 mo. Women had more challenging anatomy compared to men including smaller overall iliac diameters (6.8 mm versus 8.0 mm, P < 0.001) and more severe iliac angulation (77% moderate to severe versus 44%, P < 0.001). Women had increased risk of postoperative complications compared to men (41.9% versus 11.3%, P = 0.003). There was no perioperative mortality in our series of elective EVAR cases. Median 5-y survival following EVAR was 64.4% for men and 76.3% for women (P = 0.599). Late SI rates following EVAR was 10.5% with 16 (10.7%) men and 3 (9.7%) women needing interventions (P = 0.870). Overall durability of EVAR extrapolated as time to SIs was 91% at 2 y and 85% at 5 y. Factors predisposing SIs were iliac tortuosity (P = 0.046), aortic neck angle (P = 0.022), and endoleak at the follow-up (P = 0.030). CONCLUSIONS: In this study, immediate outcomes following EVAR were different between men and women, with women having increased rates of postoperative complications. Mortality and overall long-term durability of EVAR, however, were the same between sexes despite anatomical differences. EVAR durability was significantly dependent on the severity of iliac tortuosity, aortic neck angulation, and presence of endoleak at the follow-up.

Aortic Graft Infection Secondary to Iatrogenic Transcolonic Graft Malposition.

Aortic graft infections are a rare but devastating complication of aortic revascularization. Often infections occur due to contamination at the time of surgery. Iatrogenic misplacement of the limbs of an aortobifemoral graft is exceedingly rare, and principles of evaluation and treatment are not well defined. We report 2 cases of aortobifemoral bypass graft malposition through the colon. CASE REPORT: Case 1 is a 54-year-old male who underwent aortobifemoral bypass grafting for acute limb ischemia. He had previously undergone a partial sigmoid colectomy for diverticulitis. Approximately 6 months after vascular surgery, he presented with an occult graft infection. Preoperative imaging and intraoperative findings were consistent with graft placement through the sigmoid colon. Case 2 is a 60-year-old male who underwent aortobifemoral bypass grafting due to a nonhealing wound after toe amputation. His postoperative course was complicated by pneumonia, bacteremia thought to be secondary to the pneumonia, general malaise, and persistent fevers. Approximately 10 weeks after the vascular surgery, he presented with imaging and intraoperative findings of graft malposition through the cecum. CONCLUSIONS: Aortic graft infection is usually caused by surgical contamination and presents as an indolent infection. Case 1 presented as such; Case 2 presented more acutely. Both grafts were iatrogenically misplaced through the colon at the index operation. The patients underwent extra-anatomic bypass and graft explantation and subsequently recovered.