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1.
Artigo em Inglês | MEDLINE | ID: mdl-32011546

RESUMO

INTRODUCTION: There has been a burgeoning interest for implementing bundled payments for hip fractures being treated with hemiarthroplasty, percutaneous pinning, and/or open reduction and internal fixation. Concerns exist about how hip fracture bundles may impede access to care for patients who require more resources, such as those with pathologic/neoplastic fractures. METHODS: The 2011 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify patients undergoing percutaneous pinning, hemiarthroplasty, plate/screw, and intramedullary nail for hip fractures. Multivariate regression analyses were used to identify notable differences in 30-day complications, readmissions, reoperations, mortality, length of stay, and nonhome discharges between native and pathologic/neoplastic hip fractures. RESULTS: A total of 67,548 patients were included-of which 378 (0.6%) had a pathologic/neoplastic hip fracture. Pathologic fractures (versus native hip fractures) had significantly higher odds of experiencing a prolonged length of stay >5 days (odds ratio [OR] 1.57), pulmonary embolism (OR 3.67), deep vein thrombosis (OR 2.03), 30-day readmissions (OR 1.43), and 30-day mortality (OR 2.66). DISCUSSION: Patients sustaining a pathologic/neoplastic hip fracture have a worse adverse event profile. Risk adjustment based on facture etiology will be necessary to ensure that providers taking care of pathologic/neoplastic fractures are appropriately reimbursed to minimize barriers to access of care for this vulnerable cohort.

2.
J Arthroplasty ; 35(2): 313-317.e1, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31601455

RESUMO

BACKGROUND: The majority of the cost analysis literature on total hip arthroplasties (THAs) has been focused around the perioperative and postoperative period, with preoperative costs being overlooked. METHODS: The Humana Administrative Claims database was used to identify Medicare Advantage (MA) and Commercial beneficiaries undergoing elective primary THAs. Preoperative healthcare resource utilization in the year prior to a THA was grouped into the following categories: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid injections, physical therapy, and pain medications. Total 1-year costs and per-patient average reimbursements for each category have been reported. RESULTS: Total 1-year preoperative costs amounted to $21,022,883 (average = $512/patient) and $4,481,401 (average = $764/patient) for MA and Commercial beneficiaries, respectively. The largest proportion of total 1-year costs was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA). Conservative treatments (steroid injections, hyaluronic acid injections, physical therapy, and pain medications) alone accounted for 40%-44% of the total 1-year costs prior to a THA. A high healthcare utilization within the last 3 months prior to surgery was noted for opioids and steroid injections. CONCLUSION: On average, $500-$800/patient is spent on hip osteoarthritis-related care in the year prior to a THA. Despite their potential risks, opioids and steroid injections are often utilized in the last 3 months prior to surgery.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31714413

RESUMO

BACKGROUND: Centralization of cancer care to high-volume facilities has been shown to improve the overall survival of patients with soft-tissue sarcomas. Current evidence regarding the impact of increased hospital volume on treatment patterns and survival rates for patients with primary malignant bone tumors remains limited. Understanding the facility volume-outcome relationship for primary malignant bone tumors will further discussion on ways to promote delivery of quality cancer care across the nation. QUESTIONS/PURPOSES: (1) Is there a difference in overall survival for patients with primary malignant bone tumors undergoing treatment at a high-volume facility (at least 20 patients per year) versus those treated at a low-volume facility (less than 20 patients per year)? (2) Do surgical treatment patterns (limb-salvage versus amputation) and margin status (positive versus negative) vary between high-volume and low-volume facilities? METHODS: The 2004 to 2015 National Cancer Database was queried using International Classification of Disease for Oncology topographical codes to identify patients undergoing treatment (surgery, chemotherapy, and/or radiation therapy) for primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) or pelvis (C41.4). Histologic codes were used to group the tumors into the following categories: osteosarcomas, Ewing's sarcomas, chondrosarcomas, chordomas, and other or unspecified. Patients who did not receive any treatment (surgery, chemotherapy, and/or radiotherapy) at the reporting facility were excluded from the study. Facility volume was calculated based on the average number of patients per year for the entire study period. A preliminary stratified Cox regression model was used to identify evidence-based thresholds or cutoffs for high-volume and low-volume facilities, while adjusting for differences in patient, tumor, and treatment characteristics. We identified high-volume facilities as those treating at least 20 patients per year and low-volume facilities as those treating fewer than 20 patients per year. A Kaplan-Meier survival analysis was used to report overall unadjusted 5-year survival rates at high-volume and low-volume facilities. Multivariate Cox regression analyses were used to assess whether undergoing treatment at a high-volume facility was associated with a lower risk of overall mortality, after controlling for differences in baseline demographics, tumor presentation, and treatment characteristics. For patients undergoing surgery, multivariate regression models were used to evaluate whether patients receiving care in a high-volume facility were more likely to receive resections with limb salvage surgery than to receive amputation and whether facility volume was associated with a patient's likelihood of having a positive or negative surgical margin. RESULTS: A total of 14,039 patients were included, 15% (2115) of whom underwent treatment in a high-volume facility. Patients undergoing treatment at a high-volume facility were more likely to be white, have tumors involving the pelvis, have larger tumor sizes, and have a higher tumor grade at presentation than those undergoing treatment at a low-volume facility. Unadjusted 5-year overall survival rates were greater for high-volume facilities than for low-volume facilities (65% versus 61%; p = 0.003). After controlling for differences in patient demographics, tumor characteristics (including histologic type, grade, stage, size, and location) and treatment factors, we found that patients treated at high-volume facilities had a slightly lower overall mortality risk than those treated at low-volume facilities (hazard ratio 0.85 [95% CI 0.77 to 0.93]; p < 0.001). Patients treated at high-volume facilities were also slightly more likely to undergo resection with limb-salvage surgery to than to undergo amputation (odds ratio 1.34 [95% CI 1.14 to 1.59]; p = 0.001). Patients undergoing surgical treatment at high-volume facilities also had a lower odds of having positive resection margins than those undergoing treatment at low-volume facilities (OR 0.56 [95% CI 0.44 to 0.72]; p < 0.001). CONCLUSIONS: Patients undergoing treatment for primary malignant bone tumors at high-volume facilities experience a slightly better overall survival than those receiving treatment at low-volume facilities. Further research questioning the value of care at high-volume facilities is required before sweeping changes in regionalization can be considered. LEVEL OF EVIDENCE: Level III, therapeutic study.

4.
J Bone Joint Surg Am ; 2019 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-31596798

RESUMO

BACKGROUND: Standardized letters of recommendation (SLORs) were introduced to provide a more objective method of evaluating applicants for orthopaedic surgery residency positions. We sought to establish whether there exists an association between the SLOR summative rank statement (SRS), which is a question that asks the letter-writing authors where they would rank a student relative to other applicants, and success in matching into orthopaedic surgery residency. METHODS: We reviewed 858 applications to an orthopaedic surgery residency program from 2017 to 2018. Data on 9 assessment categories, SRSs, and written comments in the SLORs were extracted. The match success of applicants was determined by an internet search algorithm. Logistic regression was used to evaluate the association between the SRSs and match success. The Spearman correlation was performed between the SRSs and other variables. RESULTS: Only 60% of all LORs were SLORs. With 24% of the SLORs, a supplemental letter was used. Median percentile rank ranged from 90% to 100% for the 9 categories in the SLORs. Recommendations of "high rank" or higher were found in 88% of the SRSs. The mean of the SLOR SRSs was associated with match success. CONCLUSIONS: The mean of the SLOR SRSs was associated with match success. However, the SLOR is not uniformly used. Future efforts should be devoted to improving question design and validity in order to better discriminate among applicants, increase adherence to the rating scale, and quantify the strength of the written comments in the SLOR.

5.
J Cancer Educ ; 2019 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-31625019

RESUMO

The objective of this study was to determine the characteristics and logistics of orthopedic oncology rotations at various residency programs across the USA and determine the effect of orthopedic oncology rotations on Orthopedic In-Training Examination (OITE) scores. An eight-question survey was sent to 162 orthopedic surgery residency programs obtained from the Accreditation Council for Graduate Medical Education public database. Pre-oncology rotation and post-oncology rotation OITE scores for 24 residents at a major academic medical center were collected and analyzed. The response rate was 43.8%. Survey results were as follows: 90.1% responded positively to having a dedicated orthopedic oncology rotation in their curriculum; 49.3% carried out their oncology rotation at a hospital outside of their home institution; 70.4% of programs had only one dedicated orthopedic oncology rotation throughout residency; 42.3% indicated that residents experience 6-10 weeks of dedicated orthopedic oncology training during the 5-year residency program; 42.2% indicated that residents experience oncology rotations during post-graduate year 4; and 80.3% of programs had orthopedic oncology trained surgeons on their faculty. The mean increase in OITE oncology scores after the rotation was 12.1% (p = 0.005). There are variations in orthopedic oncology curricula across residency programs, most notably in the number of weeks residents participate in a dedicated oncology rotation, the post-graduate year that residents rotate on an oncology service, and the location where residents obtain their orthopedic oncology training. Participating in a dedicated orthopedic oncology rotation resulted in significant improvement in scores on the oncology domain of the OITE.

6.
J Shoulder Elbow Surg ; 28(11): 2147-2152, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31405716

RESUMO

BACKGROUND: Tumors may necessitate resection of a substantial portion of the proximal humerus and surrounding soft tissues, making reconstruction challenging. We evaluated outcomes in patients undergoing treatment of tumors of the proximal humerus with reverse total shoulder arthroplasty (rTSA) or shoulder hemiarthroplasty. METHODS: Patients who underwent rTSA (n = 10) or shoulder hemiarthroplasty (n = 37) for tumors of the proximal humerus in 2009 to 2017 were reviewed. Of these patients, 27 had died, leaving 20 for review. The mean follow-up period of the survivors was 27.1 months. They were evaluated clinically and contacted to determine the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale score. RESULTS: Postoperative complications occurred in 13 hemiarthroplasty patients (34%). Tumor recurrence occurred in 3 hemiarthroplasty patients (7.9%), whereas in the rTSA group, 1 patient (10%) had a postoperative complication, with no recurrences. One hemiarthroplasty patient required revision surgery with rTSA to improve shoulder function. Six dislocations and two subluxations occurred in the hemiarthroplasty group, whereas no subluxations occurred in the rTSA group (P = .14). Mean range of motion was 85° of forward flexion for rTSA patients (n = 10) compared with 28° for hemiarthroplasty patients (P < .001). The mean American Shoulder and Elbow Surgeons score was 63 for hemiarthroplasty patients (n = 5) and 59 for rTSA patients (n = 4). The mean Simple Shoulder Test scores were 3.8 and 2.4, respectively. The mean visual analog scale pain scores were 2.4 and 2.5, respectively. CONCLUSION: Reverse total shoulder arthroplasty can reproducibly reconstruct the shoulder in patients requiring oncologic proximal humerus resection. Patients have good outcomes, better range of motion, and no increase in instability rates compared with hemiarthroplasty.


Assuntos
Artroplastia do Ombro/métodos , Neoplasias Ósseas/cirurgia , Hemiartroplastia , Recidiva Local de Neoplasia/etiologia , Articulação do Ombro/fisiopatologia , Idoso , Artroplastia do Ombro/efeitos adversos , Neoplasias Ósseas/patologia , Epífises/cirurgia , Feminino , Seguimentos , Hemiartroplastia/efeitos adversos , Humanos , Úmero/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Amplitude de Movimento Articular , Reoperação , Luxação do Ombro/etiologia , Articulação do Ombro/cirurgia , Resultado do Tratamento
7.
J Surg Oncol ; 120(3): 348-358, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31197851

RESUMO

BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.


Assuntos
Cotos de Amputação/inervação , Amputação/métodos , Amputação/reabilitação , Músculo Esquelético/inervação , Neoplasias/cirurgia , Transferência de Nervo/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Ósseas/reabilitação , Neoplasias Ósseas/cirurgia , Estudos de Coortes , Continuidade da Assistência ao Paciente , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/reabilitação , Osteossarcoma/reabilitação , Osteossarcoma/cirurgia , Equipe de Assistência ao Paciente , Membro Fantasma/prevenção & controle , Sarcoma/reabilitação , Sarcoma/cirurgia , Adulto Jovem
8.
J Knee Surg ; 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-30861538

RESUMO

Relative value units (RVUs) are used for ensuring that physicians are appropriately reimbursed based on case complexity. While past research has elucidated that surgeons are reimbursed at a higher rate for primary total knee arthroplasty (TKA) versus revision TKA, no study has explored differences in reimbursements between single-component and double-component revisions, considering a double-component revision is likely to require more effort/skill as compared with single-component revision. The 2015 to 2016 American College of Surgeons National Surgical Quality Improvement Program files were queried using Current Procedural Terminology (CPT) codes for single-component revision TKA (CPT-27486) and double-component revision TKA (CPT-27487). A total of 1,962 single-component and 4,184 double component revisions were performed during this period. Total RVUs, RVU/min, and dollar amount/min were calculated for each case. The mean RVU was 21.12 and 27.11 for single-component and double-component revision TKAs, respectively. A statistically significant difference was noted in mean operative time (single component = 100.44 vs. double component = 144.29; p < 0.001) between the two groups. Single-component revision had a significantly higher mean RVU/min (0.267) versus double-component revision (0.223). The reimbursement amounts calculated for single-component versus double-component revisions were per minute ($9.58/min vs. $8.00/min), per case ($962.22 vs. $1,154.32), and per day ($5,773.32 vs. $4,617.28) with a projected annualized cost difference of $184,966. Orthopaedic surgeons are reimbursed at a higher rate for single-component revision TKAs as compared with double-component revision TKAs, despite the higher complexity and longer operative times required in the latter. The study highlights the need for a change in the RVUs for either double-component or single-component revision to ensure reimbursement per unit time is adequate for performing a complex case such as double-component revision TKA.

9.
Am J Med Qual ; 34(6): 561-568, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30654622

RESUMO

Operating room (OR) traffic and door openings increase potential for air contamination in the OR and create distractions for surgical teams. A multidisciplinary intervention was developed among OR staff, surgical staff, vendors, radiology, and anesthesia and approved by the hospital system's patient and quality safety department for implementation. Interventions included education, OR signage, and team-based accountability and behavioral interventions. After interventions were implemented, a second prospective, observational data collection was performed and compared to preintervention OR traffic. A total of 35 cases were observed over the 3-month period in the preintervention group; 42 cases were observed in the postintervention group. Average door openings per minute decreased by 22% (P = .0011) after intervention. All surgical groups excluding anesthesia had significant reductions in OR traffic following the intervention. Behavioral interventions that focus on education, awareness, and efficiency strategies can decrease overall OR traffic for orthopedic cases.

10.
J Surg Oncol ; 118(6): 867-872, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30151889

RESUMO

BACKGROUND AND PURPOSE: Both malignant and benign tumors of the proximal humerus may necessitate resection of a substantial portion of the proximal humerus, making reconstruction options challenging. While hemiarthroplasty has been a classic treatment, reverse total shoulder replacement may provide better pain relief and function for these patients. METHODS: We utilize a two-surgeon approach for these challenging cases. The orthopedic oncologist resects the tumor. A shoulder-trained surgeon implants the reverse shoulder replacement. Modern implants, with large glenospheres and modular components, can allow reliable, straightforward reconstructions for these patients. We prefer 6 weeks of postoperative immobilization to decrease the risk of instability. RESULTS: We have completed 13 reverse total shoulder replacements for oncologic shoulder resections, with acceptable clinical outcomes and no complications to date. CONCLUSION: Reverse total shoulder replacement with long-stem, modular components can reliably and reproducibly reconstruct the shoulder in patients with oncologic resections of the proximal humerus.


Assuntos
Artroplastia do Ombro/métodos , Neoplasias Ósseas/cirurgia , Úmero/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Artroplastia do Ombro/instrumentação , Humanos , Úmero/patologia , Procedimentos Cirúrgicos Reconstrutivos/instrumentação
11.
Clin Neurol Neurosurg ; 172: 1-7, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29936298

RESUMO

OBJECTIVES: Sepsis is a rare but potentially devastating complication when it occurs after surgery for spinal tumors. Given the morbidity associated with sepsis, we sought to collate evidence using a large national surgical database to identify the incidence, pre-operative predictors and post-operative factors associated with sepsis following spinal tumor surgery. PATIENTS AND METHODS: The 2005-2014 ACS-NSQIP database was queried for patients undergoing surgery for spinal tumors using ICD-9 codes for primary (170.2, 170.6, 213.2, 213.6) or secondary (198.3, 198.4 and 198.5) spinal tumor. Data were then filtered to include patients who underwent a laminectomy, corpectomy and/or spinal fusion for the tumor. A total of 1468 patients were included in the final cohort. Pre-operative risk factors were assessed using univariate regression models while adjusting for the occurrence of missing variables. Post-operative infectious sources such as urinary tract infection (UTI), pneumonia and surgical site infection were assessed for any association with the occurrence of sepsis. RESULTS: A total of 44 patients (3.0%) had an episode of sepsis within 30 days after surgery. Independent pre-operative factors significantly associated with the occurrence of sepsis were history of prior systemic inflammatory response syndrome (SIRS) (OR 2.89 [95% CI 1.3-6.2]), presence of Insulin-dependent Diabetes Mellitus (IDDM) (OR 3.52 [95% CI 1.4-8.7] and a length of stay>8 days (OR 2.5 [95% CI 1.0-6.2]). Independent infectious sources associated with occurrence of sepsis were surgical site infection (SSI) (OR 23.3 [95% CI 8.6-63.7]), pneumonia (OR 5.8 [95% CI 2.2-15.2]) and urinary tract infection (UTI) (OR 14.7 [95% CI 5.96-36.1]). Up to 52% of the cases of sepsis were associated with at least one source of infection (UTI, pneumonia or SSI) with UTI being the most common (29.5%) followed by pneumonia (22.7%) and SSI (18%). CONCLUSION: Three percent of patients following surgery for spinal tumor experience an episode of sepsis within 30 days. The most likely sources of sepsis include UTI, pneumonia and SSI. Pre- and post-operative targeted interventions in these high risk patients will be most beneficial in reducing the incidence, morbidity and mortality from sepsis after surgery for spinal tumors.


Assuntos
Sepse/etiologia , Neoplasias da Medula Espinal/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Infecção da Ferida Cirúrgica/etiologia , Infecções Urinárias/etiologia , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Fatores de Risco , Sepse/complicações , Neoplasias da Coluna Vertebral/complicações , Infecção da Ferida Cirúrgica/epidemiologia , Infecções Urinárias/complicações
12.
J Arthroplasty ; 33(10): 3329-3342, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29921502

RESUMO

BACKGROUND: Surgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty. METHODS: PubMed (MEDLINE) and Google Scholar databases were queried for articles using the following search criteria: ("Surgeon Volume" OR "Provider Volume" OR "Volume Outcome") AND ("THA" OR "Total hip replacement" OR "THR" OR "Total hip arthroplasty"). Studies investigating total hip arthroplasty being performed for malignancy or hip fractures were excluded from the review. Twenty-eight studies were included in the final review. All studies underwent a quality appraisal using the GRADE tool. The systematic review was performed in accordance with the PRISMA guidelines. RESULTS: Increasing surgeon volume was associated with a shorter length of stay, lower costs, and lower dislocation rates. Studies showed a significant association between an increasing surgeon volume and higher odds of early-term and midterm survivorship, but not long-term survivorships. Although complications were reported and recorded differently in studies, there was a general trend toward a lower postoperative morbidity with regard to complications following surgeries by a high-volume surgeon. CONCLUSION: This systematic review shows evidence of a trend toward better postoperative outcomes with high-volume surgeons. Future prospective studies are needed to better determine long-term postoperative outcomes such as survivorship before healthcare policies such as regionalization and/or equal-access healthcare systems can be considered.


Assuntos
Artroplastia de Quadril/mortalidade , Complicações Pós-Operatórias/epidemiologia , Reoperação/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Artroplastia de Quadril/efeitos adversos , Humanos , Ortopedia , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Resultado do Tratamento
14.
J Bone Joint Surg Am ; 100(4): 288-294, 2018 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-29462032

RESUMO

BACKGROUND: Perioperative allogeneic red blood-cell transfusion is a suspected risk factor for surgical site infection (SSI) after total joint arthroplasty (TJA), but the interrelationships among SSI risk, transfusion dose, preoperative anemia, and the presence of coagulopathies have not been well described. METHODS: Data on SSI within 1 year after surgery as well as on transfusion with blood products within 30 days after surgery were obtained for 6,788 patients who had undergone primary or revision total hip or knee arthroplasty from 2000 to 2011 in a single hospital system. Multivariate logistic regression modeling was used to determine the independent association between allogeneic red blood-cell transfusion and SSI. RESULTS: There was a dose-dependent association between allogeneic red blood-cell transfusion and SSI, with the infection rate increasing as the transfusion dose increased from 1 unit (odds ratio [OR] = 1.97; 95% confidence interval [CI] = 1.38, 2.79; p < 0.001), to 2 units (OR = 2.20; CI = 1.37, 3.44; p = 0.002), to 3 units (OR = 3.66; CI = 1.72, 7.16; p = 0.001), and to >3 units (OR = 7.40; CI = 4.91, 11.03; p < 0.001) after controlling for medical comorbidities, planned procedure, preoperative anemia, and preexisting coagulopathies. A preexisting bleeding disorder (OR = 2.09; CI = 1.57, 2.80; p < 0.001) and clotting disorder (OR = 1.37; CI = 1.14, 1.64; p = 0.001) and preoperative anemia (OR = 3.90; CI = 3.31, 4.61; p < 0.001) were all independent risk factors for transfusion after adjusting for the planned procedure. CONCLUSIONS: We found a dose-dependent relationship between allogeneic red blood-cell transfusion and SSI risk after total hip or knee arthroplasty. Additionally, preoperative anemia or a known bleeding or clotting disorder were risk factors for the need for allogeneic red blood-cell transfusion. Our findings underscore the need for preoperative risk assessment, methods to limit surgical tissue injury, and optimized blood conservation strategies. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
15.
J Patient Saf ; 2017 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-29112032

RESUMO

OBJECTIVE: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic. METHODS: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement. Operative cases were observed and categorized into 3 periods (6:00-9:59, 10:00-13:59, and 14:00-17:59) to assess if time of day affected room traffic. RESULTS: Forty-six cases were observed for the present study. Among all cases, the mean room traffic rate was 35.2 openings per hour (SD, 10; range, 13.2-60.8). One-way analysis of variance revealed no statistically significant difference among groups (6:00-9:59 [n = 29], 10:00-13:59 [n = 10], and 14:00-17:59 [n = 7]) as it relates door openings per minute (room traffic rate) (P = 0.9237) or mean number of people in the OR (P = 0.3560). Pearson correlation revealed no correlation between case start time and room traffic rates (P = 0.6129, r = 0.0059) or between case start time and mean number of people in the OR (P = 0.3435, r = 0.0214). CONCLUSIONS: Room traffic rates and mean number of people in the OR do not correlate with time of day of case in orthopedic implant procedures.

16.
J Surg Oncol ; 116(8): 1132-1140, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28793180

RESUMO

BACKGROUND: Malignant hip lesions can be managed operatively by intramedullary (IM) nail fixation and hemiarthroplasty. METHODS: A retrospective review was performed on 86 patients who underwent hemiarthroplasty (n = 22) or IM nail fixation (n = 64) for prophylactic treatment of impending pathologic fracture due to malignant lesions of the hip. Cox proportional hazards and logistic regression modeling were performed to determine risk of death, fixation failure, pain relief, and return to ambulation without gait aids. RESULTS: Median survival time after surgery was 8.8 months (with no difference in survival between hemiarthroplasty and IM nail [adjusted Hazard Ratio 1.40, CI 0.72, 2.53; P = 0.31]). Hemiarthroplasty was associated with lower risk of pathologic fracture, fixation failure, or reoperation (adjusted HR 0.02, CI < 0.001, 0.48; P = 0.01). Hemiarthroplasty did not increase odds of unassisted ambulation compared to IM nail fixation (adjusted Odds Ratio [OR] 2.23, CI 0.56, 9.71; P = 0.26). The strongest predictor of postoperative ambulation was preoperative ambulation without aids (adjusted OR 28.9, CI 7.37, 161; P < 0.001). CONCLUSIONS: There is no difference in survival or likelihood of unassisted ambulation after prophylactic femoral fixation with IM nails versus hemiarthroplasty in patients with metastatic disease of proximal femur.


Assuntos
Neoplasias Ósseas/cirurgia , Fêmur/cirurgia , Fixação Intramedular de Fraturas/métodos , Hemiartroplastia , Adulto , Idoso , Feminino , Marcha , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos
17.
Cancer ; 123(18): 3434-3440, 2017 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-28493547

RESUMO

More than half of all sarcomas occur in adolescents and young adults (AYAs) aged 15 to 39 years. After the publication of the AYA series in the April 1, 2016 issue of Cancer, several leaders in the field of sarcoma across disciplines gathered to discuss the status of sarcoma clinical research in AYAs. They determined that a focused effort to include the underrepresented and understudied AYA population in current and future sarcoma clinical trials is overdue. Trial enrichment for AYA-aged sarcoma patients will produce more meaningful results that better represent the disease's biology, epidemiology, and treatment environment. To address the current deficit, this commentary outlines changes believed to be necessary to expediently achieve an increase in the enrollment of AYAs in sarcoma clinical trials. Cancer 2017;123:3434-40. © 2017 American Cancer Society.


Assuntos
Neoplasias Ósseas/terapia , Ensaios Clínicos como Assunto , Osteossarcoma/terapia , Seleção de Pacientes , Adolescente , Adulto , Fatores Etários , American Cancer Society , Neoplasias Ósseas/mortalidade , Neoplasias Ósseas/patologia , Feminino , Humanos , Masculino , Osteossarcoma/mortalidade , Osteossarcoma/patologia , Sarcoma de Ewing/mortalidade , Sarcoma de Ewing/patologia , Sarcoma de Ewing/terapia , Análise de Sobrevida , Estados Unidos , Adulto Jovem
18.
J Arthroplasty ; 32(8): 2381-2385, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28392132

RESUMO

BACKGROUND: The development of acute kidney disease (AKD) following total joint arthroplasty has not been well characterized in the literature. We sought to calculate the incidence and identify risk factors associated with postoperative AKD for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: A total of 1000 consecutive cases (860 unique patients, including revisions) of TKA or THA performed between January 2010 and May 2016 were identified. Seventy-nine cases were excluded due to pre-existing kidney dysfunction and 23 additional cases were excluded due to incomplete data, resulting in 898 cases included in the study. There were 492 females and 406 males with a mean age of 58.1 years (range, 14-93 years). The Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria and serum creatinine values were used to determine AKD status. Multiple logistic regression modeling was used to identify postoperative AKD risk factors. RESULTS: Overall incidence of postoperative AKD was 6.8% (n = 61). Use of perioperative angiotensin receptor blocker (ARBs) or angiotensin-converting enzyme inhibitors (ACEi) (odds ratio [OR] = 2.09; P = .030), increasing body mass index (BMI) (OR = 1.58 per 10 kg/m2; P = .014), and use of vancomycin perioperatively (OR = 1.91; P = .021) were associated with increased odds of development of postoperative AKD. CONCLUSION: A 6.8% incidence rate of postoperative AKD was noted in patients undergoing TKA or THA. Perioperative use of ARBs/ACEi, perioperative vancomycin use, and increased BMI were associated with increased odds of postoperative AKD.


Assuntos
Lesão Renal Aguda/complicações , Lesão Renal Aguda/epidemiologia , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Vancomicina , Adulto Jovem
19.
J Bone Joint Surg Am ; 98(18): 1522-32, 2016 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-27655979

RESUMO

BACKGROUND: Surgical site infection (SSI) is a major complication following total joint arthroplasty. Host susceptibility to infection has emerged as an important predictor of SSI. The purpose of this study was to develop and validate a preoperative SSI risk-assessment tool for primary or revision knee and hip arthroplasty. METHODS: Data for 6,789 patients who underwent total joint arthroplasty (from the years 2000 to 2011) were obtained from a single hospital system. SSI was defined as a superficial infection within 30 days or deep infection within 1 year. Logistic regression modeling was utilized to create a risk scoring system for a derivation sample (n = 5,789; 199 SSIs), with validation performed on a hold-out sample (a subset of observations chosen randomly from the initial sample to form a testing set; n = 1,000; 41 SSIs). RESULTS: On the basis of logistic regression modeling, we created a scoring system to assess SSI risk (range, 0 to 35 points) that is the point sum of the following: primary hip arthroplasty (0 points); primary knee (1); revision hip (3); revision knee (3); non-insulin-dependent diabetes (1); insulin-dependent diabetes (1.5); chronic obstructive pulmonary disease (COPD) (1); inflammatory arthropathy (1.5); tobacco use (1.5); lower-extremity osteomyelitis or pyogenic arthritis (2); pelvis, thigh, or leg traumatic fracture (2); lower-extremity pathologic fracture (2.5); morbid obesity (2.5); primary bone cancer (4); reaction to prosthesis in the last 3 years (4); and history of staphylococcal septicemia (4.5). The risk score had good discriminatory capability (area under the ROC [receiver operating characteristic] curve = 0.77) and calibration (Hosmer-Lemeshow chi-square test, p = 0.34) and was validated using the independent sample (area under the ROC curve = 0.72). A small subset of patients (5.9%) had a >10% estimated infection risk. CONCLUSIONS: The patient comorbidities composing the risk score heavily influenced SSI risk for primary or revision knee and hip arthroplasty. We believe that infection risk can be objectively determined in a preoperative setting with the proposed SSI risk score.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infecções Estafilocócicas/etiologia , Infecções Estreptocócicas/etiologia
20.
J Surg Oncol ; 114(3): 385-91, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27238092

RESUMO

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine the pattern and timing of major wound complications (MWCs) in patients at our institution who received multimodality treatment for lower extremity soft tissue sarcoma (LE-STS) and to evaluate the impact of MWCs on tumor control and patient outcomes. METHODS: The medical records of 102 LE-STS patients treated with limb-sparing surgery and radiation therapy were reviewed. MWCs were defined as secondary operations with anesthesia, seroma/hematoma aspiration, admission for IV antibiotics, or persistent deep packing. RESULTS: MWCs occurred in 22% of patients, with 45% of events occurring >120 days after resection. On multivariate analysis, preoperative external beam radiation therapy (EBRT) (OR 4.29, 95% CI 1.06-17.40, P = 0.042) and skin graft placement (OR 6.39, 95% CI 1.37-29.84, P = 0.018) were found to be independent predictors of MWCs. MWC occurrence did not predict for chronic toxicity and did not impact tumor control or survival. CONCLUSIONS: A considerable proportion of MWCs occur >120 days from surgical resection with preoperative EBRT and skin graft placement independent predictors for MWCs. While an additional source of morbidity, MWC occurrence did not impact tumor control, nor did it predict for chronic toxicity. J. Surg. Oncol. 2016;114:385-391. © 2016 Wiley Periodicals, Inc.


Assuntos
Extremidade Inferior , Complicações Pós-Operatórias/epidemiologia , Sarcoma/terapia , Neoplasias de Tecidos Moles/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Sarcoma/mortalidade , Neoplasias de Tecidos Moles/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
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