Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids.

BACKGROUND: Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared with patients using traditional opioids and those who were opioid naïve. METHODS: Using the IBM Watson Health MarketScan databases, a retrospective cohort study was performed for patients who underwent TSA from 2009 to 2018. Filled pain prescriptions were collected, and prescribing trends were analyzed. Outcomes were compared between 4 patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1 and 3 years postoperatively were also compared. RESULTS: A total of 29,454 TSA patients were studied, with 8959 available for 3-year postoperative follow-up. Of these, 10,462 (35.5%) were prescribed traditional opioids and 2214 (7.5%) tramadol only. From 2009 to 2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas the number of patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared with opioid-naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared with both opioid-naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid-naïve patients at 1 and 3 years, whereas the tramadol cohort did not. CONCLUSION: Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. Although tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable with opioid-naïve patients.

Trends in Costs and Professional Reimbursements for Revision Total Hip and Knee Arthroplasty.

BACKGROUND: With increasing numbers of revision total hip and total knee arthroplasties (rTHAs and rTKAs), understanding trends in related out-of-pocket (OOP) costs, overall costs, and provider reimbursements is critical to improve patient access to care. METHODS: A large database was used to identify 92,116 patients who underwent rTHA or rTKA between 2009 and 2018. The OOP costs associated with the surgery and related inpatient care were calculated as the sum of copayment, coinsurance, and deductible payments. Professional reimbursement was calculated as total payments to the principal physician. All monetary data were adjusted to 2018 dollars. Multivariate regressions evaluated the associations between costs and procedure type, insurance type, and region of service. RESULTS: From 2009 to 2018, overall costs for rTHA significantly increased by 35.0% and overall costs for rTKA significantly increased by 32.3%. The OOP costs for rTHA had no significant changes, while OOP costs for rTKA increased by 20.1%, with patients on Medicare plans having the lowest OOP costs. Professional reimbursements, when measured as a percentage of overall costs, decreased significantly by 4.4% for rTHA and 4.0% for rTKA, with the lowest reimbursements from Medicare plans. CONCLUSION: From 2009 to 2018, total costs related to rTHA and rTKA significantly increased. The OOP costs significantly increased for rTKA, and professional reimbursements for both rTHA and rTKA decreased relative to total costs. Overall, these trends may combine to create greater financial burden to patients and the healthcare system, as well as further limit patients' access to revision arthroplasty care.

Overexpression of the base excision repair NTHL1 glycosylase causes genomic instability and early cellular hallmarks of cancer.

Base excision repair (BER), which is initiated by DNA N-glycosylase proteins, is the frontline for repairing potentially mutagenic DNA base damage. The NTHL1 glycosylase, which excises DNA base damage caused by reactive oxygen species, is thought to be a tumor suppressor. However, in addition to NTHL1 loss-of-function mutations, our analysis of cancer genomic datasets reveals that NTHL1 frequently undergoes amplification or upregulation in some cancers. Whether NTHL1 overexpression could contribute to cancer phenotypes has not yet been explored. To address the functional consequences of NTHL1 overexpression, we employed transient overexpression. Both NTHL1 and a catalytically-dead NTHL1 (CATmut) induce DNA damage and genomic instability in non-transformed human bronchial epithelial cells (HBEC) when overexpressed. Strikingly, overexpression of either NTHL1 or CATmut causes replication stress signaling and a decrease in homologous recombination (HR). HBEC cells that overexpress NTHL1 or CATmut acquire the ability to grow in soft agar and exhibit loss of contact inhibition, suggesting that a mechanism independent of NTHL1 catalytic activity contributes to acquisition of cancer-related cellular phenotypes. We provide evidence that NTHL1 interacts with the multifunctional DNA repair protein XPG suggesting that interference with HR is a possible mechanism that contributes to acquisition of early cellular hallmarks of cancer.

Current Trends in Clinical Practice for the Direct Anterior Approach Total Hip Arthroplasty.

BACKGROUND: Despite increased popularity of the direct anterior approach (DAA) for total hip arthroplasty (THA), current practice trends and specific driving factors leading to adoption are not well established. METHODS: We conducted an electronic e-mail survey of members of the American Association of Hip and Knee Surgeons inquiring into the choice of THA surgical approach, perceptions of clinical outcomes, and economic implications associated with the DAA. RESULTS: Of 996 total respondents (44.3% American Association of Hip and Knee Surgeons member response rate), 56.2% currently perform the DAA. DAA performers have been in practice for statistically less time than non-performers (17.0 years vs 20.9 years, P < .001). Similarly, high-volume DAA surgeons have been in practice for less time than low-volume surgeons. DAA performers felt that revision case status (79.3%), complex anatomy (65.0%), and body habitus (53.0%) were factors leading to preferential use of the posterior approach. We also provide comprehensive data for perceived outcomes comparing the DAA and posterior approach. For current non-performers, the top reasons for not utilizing the DAA were feelings of worse outcomes, no clinical benefit, and concern for the learning curve. Economically, 76.1% of DAA performers reported increased patient market share by performing the DAA while 65.8% of non-performers endorsed lost patient market share. Only 3.0% of current non-performers plan to adopt the DAA in the future. CONCLUSION: This is the first study of its kind to highlight current trends and clinical practices from a surgeon perspective regarding the DAA. Specifically, it provides comprehensive data regarding perceptions of clinical outcomes, practice economics, and driving factors for choice of surgical approach for surgeons who do and do not perform the DAA.

Pathologic Peri-Implant Proximal Femur Fracture: Takeaways from Our Experience.

Pathologic fractures of the distal femur secondary to bone metastases are not as common as those in the proximal femur, and they are rarely reported on in the literature. Even in the absence of current metastatic lesions in the femoral neck, traditional orthopaedic teaching has stressed the importance of protecting the entire femur, while recent studies have shown that it may not be necessary to stabilize the entire femur in the event of future metastases. Thus, there is no consensus regarding optimal surgical treatment, making the choice of fixation often based on the experience of the surgeon. In this paper, we reported on a patient who presented with a pathologic fracture of the distal femur who was stabilized with a retrograde intramedullary nail and then subsequently suffered a pathologic fracture of the proximal femur. To our knowledge, there have been no cases reported on a peri-implant pathologic fracture proximal to a retrograde intramedullary nail in the setting of metastatic bone disease. We would like to share our experience on how to surgically manage this and discuss the literature around management of distal femoral bone metastases.

Projections and Epidemiology of Total Ankle and Revision Total Ankle Arthroplasty in the United States to 2030.

Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.

Spontaneous Spinal Epidural Hematoma: An Atypical Clinical Presentation and Discussion of Management.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is a rare but potentially devastating condition if not appropriately identified and managed. A few case series exist regarding SSEH and certain risk factors have been described; however, much continues to be unknown regarding the pathophysiology and optimal management. CASE PRESENTATION: We present the case of SSEH in a healthy 33-year-old African American woman with no identifiable risk factors who initially presented with significant neurologic compromise. This case reports discusses pertinent clinical presentation, imaging findings, and surgical management. The patient demonstrated near-complete neurologic recovery, highlighting the need for prompt identification and intervention. CONCLUSIONS: We believe this case adds to the limited literature surrounding the topic, particularly in regard to diagnosis and surgical management. It is essential for clinicians to be cognizant of SSEH for timely diagnosis and treatment, even in patients without obvious risk factors.

Are Geriatric Patients Who Sustain High-Energy Traumatic Injury Likely to Return to Functional Independence?

OBJECTIVES: To evaluate physical function and return to independence of geriatric trauma patients, to compare physical function outcomes of geriatric patients who sustained high-energy trauma with that of those who sustained low-energy trauma, and to identify predictors of physical function outcomes. DESIGN: Retrospective. SETTING: Urban Level I trauma center. PATIENTS: Study group of 216 patients with high-energy trauma and comparison group of 117 patients with low-energy trauma. INTERVENTION: Injury mechanism (high- vs. low-energy mechanism). MAIN OUTCOME MEASUREMENT: Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) patient-reported outcome measure, and change in living situation and mobility. RESULTS: Physical function outcomes and return to independence differed between patients with high-energy and low-energy injuries. High-energy geriatric trauma patients had significantly higher PROMIS PF scores compared with low-energy geriatric trauma patients (PROMIS PF score 42.2 ± 10.4 vs. 24.6 ± 10.4, P < 0.001). High-energy geriatric trauma patients were able to ambulate outdoors without an assistive device in 67% of cases and were living independently 74% of the time in comparison with 28% and 45% of low-energy geriatric trauma patients, respectively (P < 0.001, P < 0.001). Multivariate linear regression analysis demonstrated that low-energy mechanism injury was independently associated with a 13.2 point reduction in PROMIS PF score (P < 0.001). CONCLUSIONS: Geriatric patients greater than 1 year out from sustaining a high-energy traumatic injury seem to be functioning within the expected range for their age, whereas low-energy trauma patients seem to be functioning substantially worse than both age-adjusted norms and their high-energy cohorts. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Thrombotic Thrombocytopenic Purpura after Total Hip Arthroplasty: A Case Report and Review of the Literature.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon and potentially lethal microangiopathy that carries a >90% mortality rate if not treated urgently and appropriately. Postoperative TTP after orthopaedic procedures is particularly rare with only four case reports existing in the literature. We present the case of postoperative TTP in a 57-year-old female who underwent elective total hip arthroplasty. We believe this case adds to the limited literature surrounding the topic. While rare, TTP after orthopaedic procedures poses a real and potentially fatal condition if not managed appropriately. Therefore, it is essential for orthopaedic surgeons to be cognizant of postoperative TTP for timely diagnosis and treatment.

Experience of families during cardiopulmonary resuscitation in a pediatric intensive care unit.

OBJECTIVES: Having parents present during cardiopulmonary resuscitation is becoming a common practice in pediatrics. This study aimed to determine parents' perception of the effects of their presence during the resuscitation efforts of their child and whether they would recommend the experience to other families. METHODS: This study included parents or guardians of children who underwent cardiopulmonary resuscitation, and died at least 6 months before the interview. After telephone consent was obtained, a survey questionnaire was completed. The interviewees answered whether they were asked to be present, whether they had physical contact with their child, and whether the experience frightened them or gave them and their child comfort. The interviewees were asked to express their feelings about what was helpful to them and what could be done to improve the experience. RESULTS: A total of 41 interviews were conducted, and responders were divided into 2 groups: 21 in the present group and 20 in the not-present group for cardiopulmonary resuscitation. Twelve (60%) of those in the not-present group believed that their presence would have comforted the child, and 50% (10 of 20) believed that it would have helped them accept the child's death. Of those in the present group, 67% (8 of 12) believed that touching their child brought comfort, 29% (6 of 21) felt scared during cardiopulmonary resuscitation, 71% (15 of 21) believed that their presence comforted their child, and 67% (14 of 21) believed that their presence helped them adjust to the loss of the child. The majority in both groups (63% [26 of 41]) would recommend being present during cardiopulmonary resuscitation. CONCLUSIONS: This study supports encouraging family presence during cardiopulmonary resuscitation. The majority of parents who had been present and those who had not been present believed that all families should be given the option to be present.