An Algorithm for Detection and Correction of Pelvic Tilt in Total Hip Replacement.

Successful joint replacement surgery requires precise preoperative planning and intraoperative placement of implants such that the function of the joint is optimized biomechanically and biologically. The five-step "pelvic tilt algorithm" will enhance the outcome of hip replacement surgery as a result of improved acetabular component alignment. It will solve the problem of pelvic tilt as an unknown variable during hip replacement surgery, and will allow for more consistent and accurate acetabular component placement.

An Update to a Novel Technique for Centering the Femoral Stem in Primary Total Hip Arthroplasty.

Careful surgical technique is a critical component of total hip arthroplasty. Femoral preparation and component positioning are vital to improving outcomes and preventing complications. Femoral preparation begins with creating an entry hole in the proximal femur. Various tools have been used for this purpose which resemble a "cookie cutter." An axial starter reamer, or awl, is then inserted through the entry hole in the proximal femur to aid in opening and centralizing the canal for sequential reaming or broaching. A novel technique was described previously which allows the awl to center itself in the canal with little risk of deviation from midline or cortical perforation. Since describing this technique in 2014, the senior surgeon has further modified the method of preparing the entry hole in the proximal femur. The surgeon now uses a 1/8" drill bit to penetrate the piriformis fossa, instead of a "cookie cutter" or osteotome. A 1/8" entry hole eliminates gaps between the bone and the implant, results in lateralization of the stem, and avoids varus malposition. We evaluated 300 primary hip arthroplasties by a single surgeon using one of the three techniques: traditional clockwise technique (Group 1), our previously published novel counterclockwise technique (Group 2), and our updated novel technique (Group 3). While the deviation from midline of Group 3 did not differ significantly from Group 2, it was significantly less than the deviation from midline of Group 1 (p=00006). This simple updated technique enables the surgeon to avoid potential malalignment during femoral preparation.

Influence of Soft Tissue Preservation in Total Hip Arthroplasty: A 16-Year Experience.

BACKGROUND: Surgical technique in total hip arthroplasty (THA) has been a topic of debate over the last 50 years. Evidence-based studies are needed to compare one technique to another. This study investigated the outcome of the direct superior approach in primary THA as measured by patient perception of pain and recovery over a 16-year period. MATERIALS AND METHODS: We retrospectively reviewed a series of 3,357 consecutive patients who underwent primary THA by a single surgeon using the direct superior approach between 2001 and 2017. The surgical technique was modified twice during this 16-year period. The first modification (2007) consisted of piriformis tendon preservation. The second modification (2012) consisted of iliotibial band (ITB) preservation. These two modifications of the surgical technique created three different patient groups. A telephone interview regarding patient pain and recovery after each THA was conducted with 147 patients who had staged bilateral THA procedures wherein the surgical technique was modified between the first and second (contralateral) THA. RESULTS: Results show the addition of ITB preservation to capsular repair, with or without piriformis preservation, greatly improves the patient's perception of pain and recovery, causing the majority of patients to prefer their ITB-preserving surgery over their ITB-sacrificing surgery. In addition, the dislocation rate over this 16-year period is 0.17%. CONCLUSION: The direct superior approach to the hip results in excellent stability with a dislocation rate of 0.17%. The patient's perception of pain and recovery is dramatically improved with preservation of the iliotibial band.

Nonoperative Treatment of Single-Tendon Proximal Hamstring Avulsions in Recreational Athletes.

The purpose of this study was to evaluate the patient-reported and objective functional outcomes of those patients who underwent nonoperative management of a single-tendon retracted proximal hamstring avulsion. A retrospective case series of consecutive patients with an MRI-confirmed diagnosis of single-tendon proximal hamstring avulsion treated nonoperatively with at least one year of follow-up was performed. Patient-reported outcome measures (PROMs) including SF-12v2, Lower Extremity Functional Score (LEFS), Hip Outcome Score-activities of daily living and sport subscale (HOS-ADL, HOS-SS) were prospectively collected. Objective measurements included strength testing of the affected and unaffected limbs with a handheld dynamometer and single-leg hop test. Student's t-tests were used to determine differences between limbs. Eleven of fourteen patients were available for PROMs (79%); five completed functional testing. Subjective scores revealed a mean SF-12v2 mental component score of 56.53±8.2, and a physical component score of 50.1±12.7. LEFS was 84%±19.8, HOS-ADL 87.9%±17.2, and HOS-SS 80.9%±24. The differences between limbs were not statistically significant for strength at 45 or 90 degrees of knee flexion, nor for single-leg hop distance. Patients in a non-professional athlete population who undergo nonoperative management of single-tendon retracted proximal hamstring avulsions can expect good subjective and objective outcomes.

Evidence for Utilization of Injectable Biologic Augmentation in Primary Rotator Cuff Repair: A Systematic Review of Data From 2010 to 2022.

Background: Biologic healing after rotator cuff repair remains a significant challenge. Injectable biologic augmentation may improve tissue quality at the suture-tendon interface. Purpose: To investigate the effect of injectable biologic supplementation in rotator cuff repair and to assess the quality and adherence to evolving reporting standards. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were 40 studies: 29 preclinical (in vivo animal models) and 11 clinical. Each clinical study was assessed for quality, risk of bias, and adherence to relevant MIBO (Minimum Information for Studies Evaluating Biologics in Orthopaedics) guidelines. The outcomes of interest were reported load to failure, load to gap, gap size, and stiffness in the preclinical studies, and healing rate and any patient-reported outcome measures in the clinical studies. Results: Injectables reported included growth factors (eg, transforming growth factor-beta 3, erythropoietin), bone marrow-derived mesenchymal stem cells and adipose-derived mesenchymal stem cells (ADSCs), and other agents such as platelet-rich plasma (PRP) and hyaluronic acid. The most common findings for preclinical injectables were increased load to failure (16/29 studies; 55.2%) and improved collagen histological quality (11/29 studies; 37.9%). All 11 clinical studies (10 PRP, 1 ADSC) indicated no adverse events, with similar or improved patient-reported outcomes compared with repairs in the control groups. In 1 study utilizing an innovative delivery technique, a concentrated PRP globule with fibrin matrix was shuttled over a suture to maintain concentrated PRP at the repair site and demonstrated a significant decrease in retears (P = .03) at a 31-month follow-up. A matched-cohort study investigating augmentation with ADSCs demonstrated a significantly lower retear rate in the ADSC-augmented group than the control group at a 28-month follow-up (P < .001). On average, the clinical studies adhered to 66% of relevant MIBO reporting guidelines and had a low risk of bias. Conclusion: Approximately 83% of preclinical studies found a positive biomechanical or histological effect, with no studies showing an overall negative effect. Clinically, utilization of innovative delivery techniques may reduce the risk of arthroscopic washout of PRP and improve retear rates. ADSCs were shown to reduce retear rates at a 28-month follow-up.

Anthropometric Measures of the Posterior Condyles: Gender Differences and Correlation to Implant Sizing.

There is abundant data concerning morphological dimensions of the distal femur, particularly in women, which has led to redesign of the femoral component in total knee arthroplasty (TKA). Clinical experience reveals existing asymmetry of the femoral posterior condyles, yet current implant designs have a symmetrical femoral component. The objectives of this study were to analyze the dimensions of posterior condylar bone resection from a group of patients undergoing TKA and correlate the measurements to one prosthetic system. We retrospectively reviewed single surgeon morphological data from the posterior condyles of 105 knees during TKA. The study included 54 males and 51 females. Measurement of the posterior condylar bones was performed with a standard metric metal ruler by one investigator. Known dimensions of a single type of implant design were compared with the resection data. The average difference of posterior medial and lateral condylar width was 5.7 and 5.3 mm in males and females, respectively. The average host posterolateral condylar bone was 5.4 mm less than the trial implant across five sizes in both males and females. Results suggest that the dimension of the posterior lateral condyle is much smaller than the dimension of the implant in both groups of patients. Dimension of the posterior medial is close to dimension of the implant. Overhang of the component posterolaterally can create soft tissue irritation and result in postoperative pain and decreased range of motion. Our results increase awareness of the dimensions of the native posterolateral condyle and may influence future design of femoral implants used in total knee arthroplasty.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears.

PURPOSE: The purpose of this study was (1) to assess the flexion initiation test's (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests. METHODS: We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test. RESULTS: Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears. CONCLUSIONS: The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs. LEVEL OF EVIDENCE: Level IV, diagnostic.

Intraoperative Proximal Tibia Periprosthetic Fractures in Primary Total Knee Arthroplasty.

Intraoperative fracture of the proximal tibia is a rare complication of total knee arthroplasty (TKA) with few studies available reporting risk factors or prognosis. A review of our prospective joint registry was performed to determine the incidence and associated risk factors of intraoperative tibia fractures during primary TKA; 14,966 TKAs of all manufacturers were performed with 9 intraoperative tibia fractures. All fractures occurred in a single TKA design. There were 8,155 TKAs of this design performed with a fracture incidence of 0.110%. All but one fracture occurred on the medial tibial plateau, and all but one occurred during preparation of the tibia with keel punching. A control group of 75 patients (80 knees) with the same TKA design were randomly selected. Baseplates size 3 or smaller were less likely to experience an intraoperative fracture (odds ratio [OR]: 0.864, 95% confidence interval [CI]: 0.785-0.951), as were knees with a polyethylene insert thickness of 13 mm or larger (OR: 0.882, 95% CI: 0.812-0.957). Fractures were treated with a variety of different methods, but every patient had at least one screw placed and most (67%) had postoperative weight-bearing restrictions. At final follow-up, there were no cases of nonunion, component subsidence, or need for reoperation. Intraoperative tibia fractures are a rare complication of this TKA design at 0.11%. Knees with baseplates of size ≤3 and polyethylene thickness ≥13 mm were less likely to experience intraoperative fracture. These findings may be related to the depth of tibial resection, requiring the use of a thicker polyethylene insert, and a change in the keel width in implants size 4 or larger. No fracture patients required reoperation.

Decreasing Incidence of Postoperative Ileus following Total Knee Arthroplasty: A 17-Year Retrospective Review of 38,007 Knee Replacements at One Institution.

Ileus following total knee arthroplasty is a clinically and financially significant postoperative complication that has not been extensively described in the orthopaedic joint literature. Ileus has been found to occur in 0.7 to 4.0% of patients after total joint arthroplasty. In a 17-year period (2001 fiscal year through 2017 fiscal year) at one institution, we found an incidence of 0.500% (190/38,007) following knee arthroplasty. In addition, the incidence of ileus following total knee arthroplasty (TKA) has drastically declined over this 17-year period, from 1.593% (13/816) in 2001 to 0.120% (4/3,332) in 2017. This decrease may be attributed to a reduction in narcotic use postoperatively, earlier ambulation following surgery, and reduction in length of hospital stay. Though postoperative ileus is not yet a preventable complication, recognition of risk factors may permit earlier intervention to ameliorate some of the morbidity associated with this condition.

Total Knee Arthroplasty in Patients of Advanced Age: A Look at Outcomes and Complications.

Total knee arthroplasty (TKA) is one of the most highly successful orthopaedic procedures performed in North America. It is also one of the most common procedures performed, and its incidence continues to increase. Despite this, it is the opinion of many that patients of advanced age groups are not ideal candidates to undergo such procedures secondary to the concern over higher complication rates and poorer functional outcomes. This review article attempts to analyze the current body of literature concerning TKA outcomes and to evaluate some of the issues that are more specific to this population when they undergo TKA. It is our hypothesis that the literature does not support this popular misconception, and that older patients who do not have significant medical comorbidities are good candidates to undergo primary TKA. However, certain cohorts of this population are not ideal candidates to undergo this procedure. Also, certain joint reconstructive procedures, such as simultaneous and staged bilateral TKA, are higher risk procedures in this patient cohort.

Femoral Intramedullary Alignment in Total Knee Arthroplasty: Indications, Results, Pitfalls, Alternatives, and Controversies.

While femoral intramedullary alignment has been found to be the most accurate and reproducible method for proper femoral component orientation in total knee arthroplasty, certain situations preclude the use of intramedullary alignment, such as ipsilateral long-stem total hip arthroplasty, femoral shaft deformity (congenital or post-traumatic), capacious femoral canal, and retained hardware. These cases require alternative alignment guides, that is, extramedullary alignment. The purpose of this study was to determine the accuracy of intramedullary alignment in reproducing the femoral anatomic axis. Using 35 adult cadaveric femora without obvious clinical deformity, and 7 with proximal prosthetic devices blocking the passage of an intramedullary guide, the accuracy of the guide rod was assessed both anatomically and radiographically. In the seven femora with proximal femoral devices, the guide rod could not be completely seated, resulting in a greater degree of flexion of the guide rod compared with the mechanical axis of the femur, and a greater degree of varus compared with the anatomical axis, as compared with 35 femora without obvious deformity. In cases where seating of the intramedullary guide rod is either incomplete or impossible, extramedullary femoral guides allow more accurate determination of the distal femoral cut by referencing directly from the mechanical axis, that is, the center of the femoral head. We present case studies as examples of indications for use of an extramedullary femoral guide. In addition, we demonstrate two different techniques for extramedullary femoral alignment using fluoroscopic guidance in cases incompatible with intramedullary alignment.

Midterm follow-up of total hip arthroplasty in a patient with contralateral Van Nes rotationplasty for congenital proximal femoral focal deficiency.

Total hip arthroplasty is a durable and effective operation in those with normal gait patterns. However, to our knowledge, there is no current literature on longevity in patients who have had a contralateral Van Nes rotationplasty for proximal femoral focal deficiency. We found evidence that patients who underwent rotationplasty have increased demands on the contralateral extremity and higher percentage of their gait cycle on the unaffected extremity. Here, we present a unique case report of a 59-year-old male patient with a 6-year follow-up status after left total hip arthroplasty and a right-sided rotationplasty performed during adolescence. Upon chart and radiograph review, we found no early signs of wear of his hip arthroplasty and a fully functioning lower extremity. In our limited experience, we found that total hip arthroplasty was a safe and durable operation for our patient who underwent a contralateral Van Nes rotationplasty at the 6-year follow-up period.

Incidence and Risk Factors for Posterior Cruciate Ligament Avulsion during Cruciate Retaining Total Knee Arthroplasty.

During cruciate retaining (CR) total knee arthroplasty (TKA), the posterior cruciate ligament (PCL) may avulse at its insertion. The incidence of PCL avulsion fracture has not been previously studied. The aim of this study is to report on the incidence and clinical significance of intraoperative PCL avulsion during primary CR TKA and to identify potential risk factors. Our institutional joint registry was retrospectively reviewed for PCL avulsion occurring during CR TKA implanted between April 2008 and April 2016. Patient demographics, preoperative range of motion (ROM), complications, and revision rate were examined. A control group of 132 patients was used for comparison to identify potential risk factors. Forty-four of 2,457 patients (1.7%) suffered a PCL avulsion fracture during primary CR TKA. No intraoperative repair was performed and no postoperative weight bearing or ROM restrictions were implemented. There was no significant difference in BMI (p = 0.258), mean preoperative ROM (p = 0.763), or femoral and tibial component sizes (p = 0.3069, p = 0.1306) between groups. Logistic regression found female gender (p = 0.0254) to be the only statistically significant risk factor for PCL avulsion. The incidence of intraoperative PCL avulsion fracture during CR TKA is low (1.7%) and does not appear to affect postoperative ROM, subjective stability, or incidence of revision. Female gender was identified as the only patient factor that increased the risk of PCL avulsion fracture.

Efficacy of manipulation under anesthesia beyond three months following total knee arthroplasty.

BACKGROUND: Stiffness after total knee arthroplasty (TKA) is often treated with manipulation under anesthesia (MUA) to improve range of motion (ROM). However, many authors recommend against MUA beyond 3 months after TKA. This study investigates the timing of MUA for stiffness after TKA, focusing on MUA performed at >12 weeks. METHODS: In total, 142 MUAs were retrospectively reviewed. "Early" MUAs were at <12 weeks after TKA; "Late" MUAs were >12 weeks. MUAs were further subdivided into 4 groups: 83 "Group I" cases at <12 weeks, 34 "Group II" between 12 and 26 weeks, 12 "Group III" between 26 and 52 weeks, and 13 "Group IV" at >52 weeks. Gains in ROM were compared between groups. RESULTS: Gains in flexion and overall ROM were statistically equivalent in Early vs Late MUA when controlling for pre-MUA ROM. ROM gains between the early Group I and the later Groups II-IV were also statistically comparable. Overall ROM gain in Group I was 24.1°, 17.9° in Group II, 20.8° in Group III, and 11.1° in Group IV. There were no significant complications. CONCLUSIONS: Early and late MUA resulted in statistically equivalent gains in ROM, regardless of timing after TKA. All groups showed an average improvement in ROM of ≥11°. MUA performed beyond 3 months, and even beyond 1 year, appears to be safe and may improve ROM and allow select patients to avoid revision surgery.

Diagnostic Accuracy of Magnetic Resonance Imaging and Computed Tomography Scan in Young Athletes With Spondylolysis.

The objective of this study was to determine diagnostic accuracy of magnetic resonance imaging (MRI) and computed tomography (CT) scans in young athletes diagnosed with spondylolysis. A cross-sectional study was used. Twenty-two young athletes (14.7 ± 1.5 years) were diagnosed as spondylolysis based on a single-photon emission CT. Following the diagnosis, participants underwent MRI and CT scan imaging tests on the same day. The sensitivity and false-negative rate of the MRI and CT scans were analyzed. MRI test confirmed 13 (+) and 9 (-) results while CT test showed 17 (+) and 5 (-) results. The sensitivity and false-negative rate of MRI were, respectively, 59.1% (95% confidence interval [CI] = 36.7% to 78.5%) and 40.9% (95% CI = 21.5% to 63.3%). Furthermore, the sensitivity and false-negative rate of CT scan were 77.3% (95% CI = 54.2% to 91.3%) and 22.7% (95% CI = 0.09% to 45.8%). Our results indicated that CT scan is a more accurate imaging modality to diagnose spondylolysis compared with MRI in young athletes.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database.

BACKGROUND: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. METHODS: The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05. RESULTS: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001). CONCLUSIONS: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Rates of Mortality in Lumbar Spine Surgery and Factors Associated With Its Occurrence Over a 10-Year Period: A Study of 803,949 Patients in the Nationwide Inpatient Sample.

BACKGROUND: The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database. METHODS: The Nationwide Inpatient Sample database was reviewed from 2003 to 2012. A total of 803,949 patients age 18 years or older were identified by ICD-9CM procedure codes for spinal fusion or decompression of the lumbar spine. Mortality was stratified based on type of procedure (simple or complex fusion, decompression), patient demographics and comorbidities, and in-hospital complications. Binary logistic regression was used to identify the risk of death while controlling for comorbidities, race, sex, and procedure performed. Significance was defined as P < .05 differences relative to the overall cohort. RESULTS: Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51-2.03), black (OR: 1.40; CI: 1.10-1.79), ages 65-74 (OR: 1.46; CI: 1.25-1.70), and age 75+ (OR: 2.70; CI: 2.30-3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76-13.01) and severe (OR: 26.47; CI: 16.03-43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77-5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89-30.56) and pulmonary embolism (OR: 20.15; CI: 14.01-29.00). CONCLUSIONS: From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65-74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality. LEVEL OF EVIDENCE: 3.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study.

BACKGROUND: Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes. METHODS: The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ2 tests were performed to determine differences between groups and impact on outcomes. RESULTS: Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline-2-year Neck Disability Index improvement (P < .05). CONCLUSIONS: Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients. CLINICAL RELEVANCE: These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

Body mass index predicts risk of complications in lumbar spine surgery based on surgical invasiveness.

BACKGROUND CONTEXT: Obesity as a comorbidity in spine pathology may increase the risk of complications following surgical treatment. The body mass index (BMI) threshold at which obesity becomes clinically relevant, and the exact nature of that effect, remains poorly understood. PURPOSE: Identify the BMI that independently predicts risk of postoperative complications following lumbar spine surgery. STUDY DESIGN/SETTING: Retrospective review of the National Surgery Quality Improvement Program (NSQIP) years 2011-2013. PATIENT SAMPLE: A total of 31,763 patients were undergoing arthrodesis, discectomy, laminectomy, laminoplasty, corpectomy, or osteotomy of the lumbar spine. OUTCOME MEASURES: Complication rates. METHODS: The patient sample was categorized preoperatively by BMI according to the World Health Organization stratification: underweight (BMI <18.5), normal overweight (BMI 20.0-29.9), obesity class 1 (BMI 30.0-34.9), 2 (BMI 35.0-39.9), and 3 (BMI≥40). Patients were dichotomized based on their position above or below the 75th surgical invasiveness index (SII) percentile cutoff into low-SII and high-SII. Differences in complication rates in BMI groups were analyzed by Bonferroni analysis of variance (ANOVA) method. Multivariate binary logistic regression evaluated relationship between BMI and complication categories in all patients and in high-SII and low-SII surgeries. RESULTS: Controlling for baseline difference in SII, Charlson Comorbidity Index (CCI) score, diabetes, hypertension, and smoking, complications significantly increased at a BMI of 35 kg/m2. The odds ratios for any complication (odds ratio [OR] [95% confidence interval {CI}]; obesity 2: 1.218 [1.020-1.455]; obesity 3: 1.742 [1.439-2.110]), infection (obesity 2: 1.335 [1.110-1.605]; obesity 3: 1.685 [1.372-2.069]), and surgical complication (obesity 2: 1.622 [1.250-2.104]; obesity 3: 2.798 [2.154-3.634]) were significantly higher in obesity classes 2 and 3 relative to the normal-overweight cohort (all p<.05). CONCLUSION: There is a significant increase in complications, specifically infection and surgical complications, in patients with BMI≥35 following lumbar spine surgery, with that rate further increasing with BMI≥40.

Traumatic Fractures of the Cervical Spine: Analysis of Changes in Incidence, Cause, Concurrent Injuries, and Complications Among 488,262 Patients from 2005 to 2013.

OBJECTIVE: The causes and epidemiology of traumatic cervical spine fracture have not been described with sufficient power or recency. Our goal is to describe demographics, incidence, cause, spinal cord injuries (SCIs), concurrent injuries, treatments, and complications of traumatic cervical spine fractures. METHODS: A retrospective review was carried out of the Nationwide Inpatient Sample. International Classification of Disease, Ninth Revision E-codes identified trauma cases from 2005 to 2013. Patients with cervical fracture were isolated. Demographics, incidence, cause, fracture levels, concurrent injuries, surgical procedures, and complications were analyzed. t tests elucidated significance for continuous variables and χ2 for categorical variables. Level of significance was P < 0.05. RESULTS: A total of 488,262 patients were isolated (age, 55.96 years; male, 60.0%; white, 77.5%). Incidence (2005, 4.1% vs. 2013, 5.4%), Charlson Comorbidity Index (2005, 0.6150 vs. 2013, 1.1178), and total charges (2005, $71,228.60 vs. 2013, $108,119.29) have increased since 2005, whereas length of stay decreased (2005, 9.22 vs. 2013, 7.86) (all P < 0.05). The most common causes were motor vehicle accident (29.3%), falls (23.7%), and pedestrian accidents (15.7%). The most frequent fracture types were closed at C2 (32.0%) and C7 (20.9%). Concurrent injury rates have significantly increased since 2005 (2005, 62.3% vs. 2013, 67.6%). Common concurrent injuries included fractures to the rib/sternum/larynx/trachea (19.6%). Overall fusion rates have increased since 2005 (2005, 15.7% vs. 2013, 18.0%), whereas decompressions and halo insertion rates have decreased (all P < 0.05). SCIs have significantly decreased since 2005, except for upper cervical central cord syndrome. Complication rates have significantly increased since 2005 (2005, 31.6% vs. 2013, 36.2%). Common complications included anemia (7.7%), mortality (6.6%), and acute respiratory distress syndrome (6.6%). CONCLUSIONS: Incidence, complications, concurrent injuries, and fusions have increased since 2005. Length of stay, SCIs, decompressions, and halo insertions have decreased. Indicated trends should guide future research in management guidelines.