The James A. Rand Young Investigator's Award: Keeping It Simple: Are all Musculoskeletal Infection Society Tests Useful to Diagnose Periprosthetic Joint Infection?

BACKGROUND: Current data evaluating the clinical value and cost-effectiveness of advanced diagnostic tests for periprosthetic joint infection (PJI) diagnosis, including alpha-defensin and synovial C-reactive protein (CRP), is conflicting. This study aimed to evaluate the adequacy of preoperative and intraoperative PJI workups without utilizing these tests. METHODS: This retrospective analysis identified all patients who underwent revision total knee or hip arthroplasty (rTKA and rTHA, respectively) for suspected PJI between 2018 and 2020 and had a minimum follow-up of 2 years. Perioperative data and lab results were collected, and cases were dichotomized based on whether they met the 2018 Musculoskeletal Infection Society (MSIS) criteria for PJI. In total, 204 rTKA and 158 rTHA cases suspected of PJI were reviewed. RESULTS: Nearly 100% of the cases were categorized as "infected" for meeting the 2018 MSIS criteria without utilization of alpha-defensin or synovial CRP (rTKA: n = 193, 94.6%; rTHA: n = 156, 98.7%). Most cases were classified as PJI preoperatively by meeting either the major MSIS or the combinational minor MSIS criteria of traditional lab tests (rTKA: n = 177, 86.8%; rTHA: n = 143, 90.5%). A subset of cases was classified as PJI by meeting combinational preoperative and intraoperative MSIS criteria (rTKA: 16, 7.8%; rTHA: 13, 8.2%). Only 3.6% of all cases were considered "inconclusive" using preoperative and intraoperative data. CONCLUSIONS: Given the high rate of cases satisfying PJI criteria during preoperative workup using our available tests, the synovial alpha-defensin and synovial CRP tests may not be necessary in the routine diagnostic workup of PJI. We suggest that the primary PJI workup process should be based on a stepwise algorithmic approach with the most economical testing necessary to determine a diagnosis first. The use of advanced, commercialized, and costly biomarkers should be utilized only when traditional testing is indeterminate.

Changes in Pitch Velocity and Selection in Major League Baseball Pitchers Following the Ulnar Collateral Ligament Reconstruction.

BACKGROUND: The ulnar collateral ligament (UCL) is a soft-tissue stabilizer of the elbow, that is commonly injured among baseball pitchers due to excess valgus stress in overhead throwing motions. The location of a UCL tear typically ranges from the central aspect of the ligament to an avulsion-type injury at its proximal insertion site on the medial epicondyle of the humerus, or its distal insertion site on the ulna. The effect of UCL reconstruction on pitching performance has become a well-studied topic in medical literature. In our study, we aimed to identify general performance patterns amongst those having undergone UCL reconstruction surgery. METHODS: Data for patients with UCL reconstruction performed between 2010 and 2020 were extracted from publicly available databases. Pitching data was extracted from Brooks Baseball, a publicly available database for Major League Baseball (MLB) player statistics. We identified patients who played at least one full season after surgery and rehabilitation. Patient characteristics were evaluated for intergroup differences. RESULTS: Of 109 patients with UCL reconstruction, 87 were included in the final analysis. Compared to the preoperative group, the average postoperative fastball usage rate was less despite there being an increase in the off-speed usage rate. Velocity analysis demonstrated shifts of less than 1% for all three pitch groups compared to preoperative velocity average values (all P-values <0.05). Earned Run Average (ERA)+ demonstrates a decrease in the postoperative group; this finding was not significant (P=0.61). CONCLUSIONS:  Patients treated surgically demonstrated a throwing tendency for their secondary and tertiary pitches and a decreased usage of fastballs. Further studies are needed to explore the factors contributing to the change in pitching performance.

Survey of ophthalmic imaging use to assess risk of progression of choroidal nevus to melanoma.

BACKGROUND/OBJECTIVES: The aim of this study was to ascertain the use of ocular imaging and the updated screening criteria in the evaluation of choroidal nevus across the United States. METHODS: Sixty ophthalmologists completed an anonymous 21-question survey addressing their use of the screening criteria for evaluating choroidal nevi, as well as their use of ultrasonography (US), optical coherence tomography (OCT), and autofluorescence (AF) in daily practice. RESULTS: The majority of respondents were from the Northeast (55%), worked in private practice (83%), and practiced general ophthalmology (42%). The 2009 criteria TFSOM-UHHD was used by 39 (65%) respondents, while the 2019 criteria TFSOM-DIM was used by 29 (48%) respondents. Compared to anterior segment ophthalmologists, posterior segment ophthalmologists were more likely to use the TFSOM-UHHD criteria (94% vs. 53%, OR = 13.9, p = 0.014), the TFSOM-DIM criteria (88% vs. 33%, OR = 15.5, p < 0.001), fundus AF (82% vs. 19%, OR = 20.4, p < 0.001), and US (94% vs. 42%, OR = 22.2, p = 0.004) in daily practice. CONCLUSIONS: From the survey of current practice patterns, we learned that there is a general trend of underutilization of the proper imaging modalities - and thus the criteria - in evaluating choroidal nevus. More education about ocular cancer and its screening could improve patient outcomes in the future.

Temporal, Seasonal, and Monthly Effects on Total Knee Arthroplasty Surgical Site Infection Rates.

BACKGROUND: Deep surgical site infections (dSSI) following total knee arthroplasty (TKA) are associated with morbidity and poor outcomes. Although numerous patient and non-patient factors have been correlated with dSSI development, the temporal and seasonal variability of dSSI is unclear. The purpose of this study was to investigate the monthly and seasonal variability of dSSI rates following TKA. METHODS: The dSSI database at a single large, urban, academic medical center was reviewed for TKAs performed between January 2009 and August 2018. The monthly and seasonal variability of dSSI was evaluated using a Poisson regression. Additionally, the change in dSSI rate was calculated over the entire study period. RESULTS: We reviewed 15,230 consecutive TKAs. The average dSSI rate following TKA was 1.11% (SD: 0.91). The rate of dSSI decreased over the study period (r = 0.94, 95% CI: 0.85-1.05) but did not reach statistical significance. With summer as the reference season, there were no significant differences in the dSSI rate in fall, winter, or spring. With July as the reference season, there were no differences in the dSSI rate in any other months of the year. CONCLUSION: Although non-significant, this analysis found a decreasing rate of dSSI after TKA over a nearly 10-year period. Interestingly, there was no difference in the dSSI rate following TKA in July as compared to other months or in summer as compared to other seasons. This conflicts with previous reports that have found an increased incidence of dSSI and other complications in July when the graduate medical education calendar begins.

Are there avoidable causes of early revision total knee arthroplasty?

INTRODUCTION: Surgeons can improve their practice by understanding potentially avoidable reasons for early revision total knee arthroplasty (rTKA). The purpose of this study is to describe potentially avoidable indications for rTKA within 5 years of the index procedure. METHODS: This retrospective observational analysis utilized the rTKA database at a large, academic orthopedic specialty hospital to identify 167 consecutive rTKA from 2014 to 2019 performed within 5 years after primary TKA (pTKA). Two fellowship-trained arthroplasty surgeons reviewed the cases to classify them as potentially avoidable or unavoidable. Unavoidable indications for rTKA included infection/wound complication, arthrofibrosis, instability due to underlying collagen disease or significant weight loss, and any traumatic event leading to pTKA failure. Potentially avoidable indications included atraumatic instability, intraoperative fracture, metal allergy, and atraumatic patellar instability or maltracking. Aseptic loosening was considered avoidable if it occurred in the presence of component malpositioning or poor cementation technique. RESULTS: There were 112 (67.1%) unavoidable cases and 55 avoidable cases (32.9%). Of the unavoidable cases, there were 68 rTKA for infection or wound complications (60.7%), 23 for arthrofibrosis (20.5%), 6 for instability (5.4%), 6 for postoperative fracture (5.4%), 6 for aseptic loosening (5.4%), and 3 for extensor mechanism pathology following trauma (2.6%). Of the potentially avoidable rTKA, 24 were for aseptic loosening (43.7%), 23 for atraumatic instability (41.8%), 6 for atraumatic extensor mechanism pathology (10.9%), 1 for nickel allergy (1.8%), and 1 for intraoperative fracture (1.8%). CONCLUSION: These findings indicate that over 30% of early rTKA are potentially avoidable. Interventions should focus on addressing potentially avoidable causes such as short-term aseptic loosening and instability to reduce the need for costly and resource-intensive rTKA. Level of evidence III, retrospective observational analysis.

The Temporality of Deep Surgical Site Infection Rates Following Spinal Laminectomy and Fusion.

BACKGROUND: Deep surgical site infections (dSSI) following spinal laminectomy and fusion are serious complications associated with poor patient outcomes. The objective of this study is to investigate the monthly and seasonal variability of dSSI rates following common spinal surgeries to investigate the "July effect," which refers to the alleged increase in adverse health outcomes due to new hospital trainees at the beginning of the academic year. METHODS: We performed a retrospective analysis of patients who had a dSSI following laminectomy (without fusion) or spinal fusion (with or without laminectomy) at a single large urban academic medical center between January 2009 and August 2018. The change in dSSI rate over the entire study period was calculated. The monthly and seasonal variability of dSSI were assessed using a Poisson regression model to assess for the presence of the July effect. RESULTS: A total of 7931 laminectomies and 14,637 spinal fusions were reviewed. The average dSSI rates following laminectomy and spinal fusion were 0.46 (SD, 0.47) and 1.26 (SD, 0.86) per 100 patients, respectively. The rate of dSSI following spinal fusion significantly decreased over the study period (rate ratio [RR] = 0.89, 95% CI 0.84-0.94, P < 0.01). With summer as the reference season, there were significantly lower dSSI rates following spinal fusions performed in the fall (RR = 0.62, 95% CI 0.39-0.98, P = 0.04 ). With July as the reference month, there was a significantly higher dSSI rate in April following spinal fusions. CONCLUSION: The overall decrease in dSSI rate over the study period is consistent with previous reports. The monthly analysis revealed no significant differences in either procedure, calling into question the July effect. CLINICAL RELEVANCE: This study is relevant to practicing spinal surgeons and can inform surgeons about seasonal data regarding dSSIs.

Clinical Outcome of Nerve Decompression Surgery for Migraine Improves with Nerve Wrap.

BACKGROUND: Chronic migraine headaches affect nearly 30 million Americans every year and are responsible for roughly 1.2 million emergency department visits annually. Many of the standard therapies commonly used to treat migraines are often unsuccessful and may furthermore introduce unwanted side effects. The purpose of this study was to identify independent predictors of clinical improvement in patients undergoing surgical nerve decompression for migraine. METHODS: A retrospective chart review between 2010 and 2020 was conducted. The primary endpoint was clinical improvement at 1-year follow-up, defined as an independence from prescription medications. Patients were stratified into two groups: clinical improvement and treatment failure. Backward multivariable logistic regression was used to examine the associations between migraine improvement and different patient characteristics. RESULTS: A total of 153 patients were included. In total, 129 (84.3%) patients improved and 24 (15.7%) did not. Significant associations with clinical improvement at multivariable logistic regression were found with acellular dermal matrix nerve wrap (OR = 10.80, 95%CI: 6.18-16.27), and operation of trigger sites four (OR = 37.96, 95%CI: 2.16-73.10) and five (OR = 159, 95%CI: 10-299). CONCLUSION: The use of acellular dermal matrix nerve wraps in surgery was significantly associated with clinical migraine improvement, as was operation at trigger sites four and five.

Importance of Pharmacy Partnerships in Effective COVID-19 Vaccine Distribution.

The goal of vaccinating the majority of Americans against coronavirus disease 2019 (COVID-19) in a timely manner requires a robust federal vaccine distribution plan involving pharmacy partnerships. Previously, the 2009 Centers for Disease Control and Prevention (CDC) H1N1 Vaccine Pharmacy Initiative resulted in approximately 10% of adults who received a vaccine during the 2009 pandemic reporting they were vaccinated at a pharmacy. This proportion has already largely increased for COVID-19 vaccinations, with the US Department of Health and Human Services (HHS) using similar channels for vaccination as existing partnerships with national pharmacy and grocery retail chains for the COVID-19 Community-Based Testing Program. It continues to prove crucial that the Biden administration's national COVID-19 vaccine distribution plan, including the Federal Retail Pharmacy Program, focus on ensuring equitable vaccine distribution and access in medically underserved areas and to vulnerable populations, enabling maximum uptake of COVID-19 vaccines.