The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

BACKGROUND: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated. PURPOSE AND CLINICAL RELEVANCE: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery. METHODS: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated. RESULTS: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment. CONCLUSION: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes.

PURPOSE AND HYPOTHESIS: The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair. METHODS: Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS). RESULTS: Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001). CONCLUSION: Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission. LEVEL OF EVIDENCE: IV.

Functional outcomes after removal of hardware in patellar fracture: are we helping our patients?

PURPOSE: Functional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee pain, limited range of motion and symptomatic hardware. The purpose of this study was to evaluate if removal of hardware is beneficial to symptomatic patients after patellar fracture fixation. METHODS: Patients who presented to our institution between December 2006 and November 2014 with patella fractures treated with ORIF were eligible for inclusion. Patella ORIF was performed using (1) K-wires (KW) with a tension band construct or (2) Cannulated Screws (CS) with a tension band construct. Radiological analyses included (1) AO classification and (2) measurements of prominent hardware length. Patient medical charts were reviewed for demographic and intraoperative data as well as peri/postoperative complications. All patients completed the SF-12 score, visual analog scale, Kujala score, Lysholm score and questionaries' regarding return to previous activity levels. RESULTS: Forty-seven patients met the inclusion criteria. The average time from fracture fixation to removal of hardware was 15.8 (SD ± 14.9) months. The mean follow-up was 43.1 (SD ± 27.1) months. Patella fixation was accomplished using tension band constructs with KW in 28 patients (59.5%) or with CS in 19 patients (40.5%). Patient reported quality of life and pain outcomes improved significantly after removal of hardware (p = 0.001, and p = 0.002 respectively). Functional outcome scores (Kujala and Lysholm) did not improve significantly after hardware removal in the KW or CS groups. Significantly more patients in the KW group returned to pre-injury activity (p = 0.005). CONCLUSIONS: Hardware removal after patella ORIF significantly improves patient reported pain and quality of life outcomes but not functional outcomes. Patients should be counseled regarding the expected outcome of hardware removal following patella ORIF and diabetic patients should be given special consideration before undergoing this procedure.

Rivaroxaban significantly inhibits the stimulatory effects of bone-modulating hormones: In vitro study of primary female osteoblasts.

BACKGROUND: Anticoagulant therapy is a mainstay of treatment subsequent to major orthopedic surgeries. Evidence linking anticoagulant therapy, osteoporosis, and delayed fracture healing is not conclusive. We have previously reported that rivaroxaban significantly inhibited cell growth and energy metabolism in a human osteoblastic cell line. This study analyzed the response of primary female osteoblast cells to rivaroxaban in combination with various bone-modulating hormones. METHODS: Bone samples were taken from both premenopausal (pre-Ob) and postmenopausal (post-Ob) women. Cells were isolated from each sample and cultured to sub-confluence. Each sample was then treated with Rivaroxaban (10 µg/ml) in combination with the following hormones or with the hormones alone for 24 hours: 30nM estradiol-17ß (E2), 390nM estrogen receptor α (ERα) agonist PPT, 420nM estrogen receptor ß (ERß) agonist DPN, 50nM parathyroid hormone (PTH), and 1nM of vitamin D analog JKF. RESULTS: No effects were observed after exposure to rivaroxaban alone. When pre-Ob and post-Ob cells were exposed to the bone-modulating hormones as a control experiment, DNA synthesis and creatine kinase (CK)-specific activity was significantly stimulated with a greater response in the pre-Ob cells. When the cells were exposed to rivaroxaban in combination with bone-modulating hormones, the increased DNA synthesis and CK-specific activity previously observed were completely attenuated. CONCLUSIONS: Rivaroxaban significantly inhibited the stimulatory effects of bone-modulating hormones in both pre-Ob and post-Ob primary human cell lines. This finding may have clinical relevance for patients at high risk of osteoporosis managed with rivaroxaban or other factor Xa inhibitors.

Biomechanical evaluation of two arthroscopic techniques for biceps tenodesis: triple loop suture versus simple suture.

BACKGROUND: Several techniques and procedures have been described to treat long head of the biceps pathology; however, tenodesis and tenotomy are the 2 most common procedures performed. This study evaluated the initial fixation strength of the biceps tenodesis triple loop suture (TLS) technique and compared it with that of the simple suture technique (SST). METHODS: Twenty fresh frozen cadaveric human shoulders (humeral head and neck with attached biceps tendons) were harvested. The biceps tendon was tenotomized proximally before reattachment to the bicipital groove of the matching humerus using suture anchors. Tenodesis was performed using the SST or the TLS technique. Specimens were tested biomechanically for load to failure, stress, and stiffness. The mechanism of failure was evaluated and compared between the 2 suture techniques. RESULTS: Maximal load to failure was significantly greater using the TLS technique (122.2 ± 26.73 N) than the SST (46.12 ± 14.37 N, P < .001). There was no difference in the mean stiffness (SST: 7.33 ± 4.41 N/mm, TLS: 7.46 N/mm ± 2.67, P = .94). The failure mechanism in all SST samples occurred by suture cutout through the longitudinal fibers of the tendon. In all TLS samples, the failure occurred by suture slippage. CONCLUSION: This study demonstrated superior load to failure of the TLS compared with the SST technique for biceps tenodesis. Furthermore, this study provides the first description of the TLS technique as a possible application in biceps tenodesis. Clinical application of the TLS must be carefully considered, because although it achieved a superior biomechanical profile, experience with this stitch is limited.

The response of cells derived from the supraspinatus tendon to estrogen and calciotropic hormone stimulations: in vitro study.

PURPOSE: The most frequent complications after rotator cuff repair (RCR) are non-healing and re-tear. Age and gender are both proven risk factors for faulty RCR. This study analyzed the effects of female sex steroids and calciotropic hormones on tendon-derived cell characteristics. METHODS: Tendon-derived cells from rat supraspinatus were treated with estradiol-17ß (E2); soy isoflavones (daidzein, genistein, biochainin A); raloxifene and estrogen receptors α and ß agonists and antagonists; and less-calcemic vitamin-D analog, parathyroid hormone, and vehicle control for 24 h. Cell proliferation and mRNA expression of estrogen receptor α and ß, vitamin-D receptor (VDR), scleraxis, and collagen-1 were assessed. RESULTS: E2, Biochainin A, raloxifene, and vitamin-D significantly increased tendon-derived cell proliferation. Estrogen receptor α antagonists neutralized tendon-derived cells response to estradiol 17-ß; however, estrogen receptor ß antagonists did not have an effect. Scleraxis expression decreased following estradiol 17-ß and vitamin-D treatments. Vitamin-D significantly reduced collagen-1 expression, while estradiol 17-ß had no effect. Vitamin-D and estradiol 17-ß upregulated VDR expression. CONCLUSIONS: Significant tendon-derived cell proliferation can be achieved with commonly prescribed female sex and calciotropic hormones. However, collagen-1 expression remained constant or decreased following the administration of these hormones. Female sex steroids and vitamin-D promoted tendon-derived cell proliferation via estrogen receptor α and VDR, not estrogen receptor ß. Amplified cell proliferation was not associated with increased scleraxis and collagen-1 expression. These results have important implications to the properties of healing tendon and possible pharmaceutical therapies for patients with torn RC. Further research is warranted to expose the underling mechanisms of these effects.

Hip Arthroscopy for Femoral-Acetabular Impingement: Do Active Claims Affect Outcomes?

PURPOSE: To compare outcomes of 3 patient groups undergoing hip arthroscopy. METHODS: This study included 138 consecutive hip arthroscopies (106 analyzed) for femoral-acetabular impingement (FAI) with or without labral tear in patients with a minimum 1-year follow-up. Inclusion criteria included patients older than 18 with clinical or radiologic manifestation of FAI with or without labral tear. Exclusion criteria included previous hip surgery and various hip pathologies. Patients were classified into 3 study groups. Group 1 included work-related injuries with active claims ACs (n = 33); mean age, 32 (range, 19 to 63); group 2 included sports injuries with no ACs (n = 35); mean age, 32 (range, 18 to 69); and group 3 included non-sports-related injuries without pending ACs (NAS; n = 38); mean age, 45 (range, 20 to 68). Outcomes were assessed using modified Harris hip scores (mHHS) and hip outcome scores (HOS) preoperatively and during the final evaluation. RESULTS: Baseline score for all groups did not significantly differ (P = .210 for mHHS, P = .176 for HOS). All groups significantly improved from preoperative to final evaluation (group 1: mHHS P = .42, HOS P = .001; group 2: mHHS P < .001, HOS P < .001; group 3 NAS: mHHS P = .001, HOS P = .007). AC patients had the lowest final evaluation scores, while the sports group had the highest. The NAS group did not differ from either group at final evaluation. Preoperative and final evaluation scores inversely correlated with age (r range, -24 to -28; P < .05). CONCLUSIONS: This study has shown that patients may benefit from arthroscopic repair of FAI and labral tears regardless of ACs. The level of improvement, however, is not constant across patients with different characteristics. Moreover, it appears that age may impact perceived improvement after hip arthroscopy. Hip arthroscopy as an intervention in patients with ACs provided positive outcomes, corroborating that an AC is not a contraindication for this procedure. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Balancing Thromboprophylaxis and Bleeding in Total Joint Arthroplasty: Impact of Eliminating Enoxaparin and Predonation and Implementing Pneumatic Compression and Tranexamic Acid.

BACKGROUND: Venous thromboembolic disease (VTED) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) poses substantial risk. Pharmacologic prophylaxis against VTED can cause bleeding, transfusion, and associated complications. The ActiveCare+SFT is a portable, intermittent pneumatic compression device (IPCD), providing equivalent VTED prophylaxis to pharmacologic agents without associated bleeding. Tranexamic acid (TXA) is an antifibrinolytic that reduces blood loss after THA and TKA. Our objective was to measure blood transfusion and VTED after eliminating enoxaparin, introducing an IPCD, eliminating autologous blood transfusion, and administering TXA during primary TKA and THA. METHODS: Four consecutive cohorts of THA and TKA patients were studied. Group A, the historical control, received enoxaparin VTED prophylaxis. Group B received IPCD VTED prophylaxis. Group C received IPCD VTED prophylaxis along with TXA (1 g intravenous at incision and closure). Groups A, B, and C predonated 1 unit of autologous blood. Group D received IPCD VTED prophylaxis, TXA as above, but did not donate blood preoperatively. RESULTS: Seventeen of 50 patients (34%) in Group A, 7 of 47 (14.9%) patients in Group B, 4 of 43 (9.3%) patients in Group C, and 0 of 46 patients in Group D received transfusions. There were no major symptomatic VTED events. CONCLUSION: Using an IPCD and TXA and discontinuing enoxaparin and preoperative autologous blood donation eliminated blood transfusion in primary THA and TKA without any increase in VTED. Using an IPCD instead of enoxaparin, adding TXA, and eliminating preoperative autologous donation each had an incremental dose response effect. This protocol provides effective VTED prophylaxis equivalent to pharmacologic methods and eliminates transfusion risk in the primary THA and TKA population.

Bicycle-Related Shoulder Injuries: Etiology and the Need for Protective Gear.

BACKGROUND: The popularity of bicycle riding for recreation, exercise and transportation has grown enormously in recent years, which has led to an increased incidence of bicycle-related injuries. While these injuries involve mainly the musculoskeletal system, data on shoulder-specific injuries incurred while bike riding are lacking. Classifying these shoulder injuries may provide insight and assistance in the creation and implementation of effective protective gear and measures. OBJECTIVES: To investigate the types and mechanisms of shoulder injuries among cyclists. METHODS: This study retrospectively examined all cyclists who incurred shoulder injuries while riding and were admitted to the emergency department and shoulder clinic between January 2008 and November 2013. The study included 157 subjects with various bicycle-related shoulder injuries treated with either conservative or surgical measures. RESULTS: Eighty-four percent of injuries were caused by a direct blow to the shoulder, 7% by falling on an outstretched hand, 6% were traction injuries, and 3% were due to hyperabduction. Nine different clinical types of injury were observed; the most common injuries were clavicle fractures (32%), followed by acromioclavicular joint dislocations (22%), rotator cuff tears (22%), and humeral fractures (8%). Fifty-one percent of subjects were managed with conservative care and the remaining patients required surgical interventions. CONCLUSIONS: Shoulder injuries incurred while riding a bicycle span the entire spectrum of shoulder injuries and often result in debilitating conditions. Although the use of helmets is increasing, there is currently no effective protective gear or measures to prevent riders from suffering shoulder injuries.

Pathological findings in patients with low anterior inferior iliac spine impingement.

PURPOSE: Femoroacetabular impingement (FAI) has been well described in recent years as one of the major causes of hip pain potentially leading to acetabular labral tears and cartilage damage, which may in turn lead to the development of early degenerative changes. More recently, extra-articular patterns of impingement such as the anterior inferior iliac spine (AIIS)/subspine hip impingement have gained focus as a cause of hip pain and limitation in terminal hip flexion and internal rotation. The purpose of this study was to evaluate the prevalence of low AIIS in patients undergoing hip arthroscopy and to characterize the concomitant intra-articular lesions. METHODS: Between November 2011 and April 2013, 100 consecutive patients underwent hip arthroscopy for various diagnoses by a single surgeon. After intra-operative diagnosis of low AIIS was made, a comprehensive review of the patients' records, preoperative radiographs, and intra-operative findings was conducted to document the existence and location of labral and chondral lesions. RESULTS: Twenty-one (21 %) patients had low AIIS. There were 13 males (mean age 38.4 years) and eight females (mean age 35.5 years). Eight patients had pre-operative radiographic evidence of low AIIS. All patients had a labral tear anteriorly, at the level of the AIIS; 17 had chondrolabral disruption and 17 had chondral lesions in zone two (antero-superior); and four patients had lesion in zones two and three. CONCLUSIONS: Low AIIS is a common intra-operative finding in hip arthroscopy patients. Characteristic labral and chondral lesions are routinely found in a predictable location that effaces the low AIIS. Level of Evidence-Level IV, Case Series.

Coronal Alignment in Adult Spine Surgery.

Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.

Proximal Junctional Kyphosis and Failure: Strategies for Prevention.

Proximal junctional kyphosis (PJK) and proximal junctional failure/fractures (PJF) are common complications following long-segment posterior instrumented fusions for adult spinal deformity. As progression to PJF involves clinical consequences for patients and requires costly revisions that may undermine the utility of surgery and are ultimately unsustainable for health care systems, preventative strategies to minimize the occurrence of PJF are of tremendous importance. In this article, the authors present a detailed outline of PJK and PJF with a focus on surgical strategies aimed at preventing their occurrence..

Development of a New Model of Humeral Hemiarthroplasty in Rats.

PURPOSE: In vivo models are anatomically comparable to humans allowing to reproduce the patterns and progression of the disease and giving the opportunity to study the symptoms and responses to new treatments and materials. This study aimed to establish a valid and cost-effective in vivo rat model to assess the effects of implanted shoulder hemiarthroplasty materials on glenoid articular cartilage wear. METHODS: Eight adult male Wistar rats underwent right shoulder hemi-arthroplasty. A stainless steel metal bearing was used as a shoulder joint prosthesis. X-rays were performed one week after surgery to verify correct implant position. Additional X-rays were performed 30 and 60 days post-implantation. Animals were sacrificed 24 weeks after implantation. All specimens were evaluated with micro-CT for cartilage and bone wear characteristics as well as histologically for signs of osteoarthritis. Samples were compared to the non-operated shoulders. RESULTS: All animals recovered and resumed normal cage activity. All X-rays demonstrated correct implant positioning except for one in which the implant was displaced. Histologic evaluation demonstrated arthritic changes in the implanted shoulder. Decreased Trabecular thickness and Trabecular Spacing were documented among the implanted parties (p < .05). Bone Mineral Density and Tissue Mineral Density were reduced in the operated shoulder although not significantly (p = .07). CONCLUSIONS: This study demonstrated significant glenoid cartilage wearing in the operated shoulder. Furthermore, the presence of an intra-articular hemiarthroplasty implant diminished underlying glenoid bone quality. This novel, in vivo-model will enable researchers to test implant materials and their effects on cartilage and bone tissue in a cost-effective reproducible rat model.

The Value of 2 Orthopaedic Learning Platforms from the Learners' and Educators' Point of View.

Online learning platforms are a staple of orthopaedic resident education. These platforms typically address a user's knowledge base, aiming to improve OITE and AAOS Board Examination scores. Orthopaedic residents often use these platforms as their primary educational resource. However, an orthopaedic surgeon is more than an orthopaedic knowledge base; acquisition of clinical acumen is integral as well. We sought to investigate the following: From a learner's and educator's perspective, do Orthobullets (OB) and Clinical Classroom (CC) contribute to both knowledge base and clinical acumen? Methods: Thirty residents and 16 attending surgeons at a single institution were assigned to review topics and complete questions on either the OB and CC platform. Participants then filled out surveys regarding the platform they were assigned, switched platforms, and completed a final survey. Independent-samples Student t tests and χ2 tests were used to analyze differences in continuous and categorical data. Results: Residents and attendings reported a preference for OB for fact acquisition, relevance to the OITE, and explanation of answers. Senior residents (PGY5) and attending surgeons reported that CC had a greater impact on their clinical acumen. Junior residents (PGY1, PGY2, and PGY3) reported the opposite. Participants responded that both platforms expand a learner's knowledge base and clinical acumen. Conclusions: Learners and educators felt both platforms addressed knowledge base and clinical acumen. Junior residents reported a preference for OB to CC to advance their knowledge base and clinical acumen, but senior residents and attendings felt the opposite was true. Based on survey responses, these platforms were found to be additive, complementary, and that their value to the learner changes during the course of residency education. Level of Evidence: III.

Did we do the right thing? The appropriateness of orthopedic operative interventions during the height of the coronavirus disease 2019 pandemic.

PURPOSE: During the coronavirus disease (COVID) pandemic elective surgeries were cancelled and operative indications curtailed to counteract shortages in resources. We aimed to review each orthopedic operative indication at an urban Level 1 Trauma Center inundated with COVID. We aimed to classify the appropriateness of each operative intervention and determine if exposure to COVID impacted morbidity or mortality. METHODS: All orthopedic procedures between March 16, 2020 and May 16, 2020 were reviewed. The most urgent surgical indication for each procedure was classified by 2 fellowship trained orthopedic trauma surgeons and 2 senior residents. The appropriateness of the operative intervention was determined. The American Academy of Orthopedic Surgery (AAOS) and American College of Surgeons (ACS) guidelines for surgery during the pandemic were considered. RESULTS: Seventy-six surgical encounters were performed on 71 inpatients including 99 total procedures. No outpatient procedures were performed. Fifty-four of 71 patients were male. There was a mean age of 51.6 years. Of 71 patients, 41 presented to the emergency department without trauma activation with a mean time to presentation of 2.7 days post injury. The most urgent surgical indications included 18 hip fractures, 18 periarticular fractures, 17 open fractures, 7 severe infections, 5 pelvic fractures, 5 femoral shaft fractures, 3 spinal injuries, 1 tibial fracture, 1 tendon injury, and 1 clavicle fracture. Four procedures could have been delayed for conservative management without causing significant harm. Upon discharge 13/71 patients had tested positive for COVID, 41/71 had remained negative throughout their hospital stay, and 17/71 patients never were tested. Four patients contracted COVID in the hospital. There were 4 in hospital deaths, 2 attributed to hypoxemic respiratory failure secondary to COVID pneumonia. CONCLUSION: It was determined that 72/76 cases were considered appropriate in following guidelines of the AAOS and ACS. This highlights the value of halting outpatient procedures and limiting patient exposure to COVID. Comprehensive patient/provider discussions addressing the risks, benefits, alternatives to surgery, and the risk of exposure to respiratory illness are vital. It behooves the surgical team to follow established guidelines such as those of the AAOS and ACS when triaging orthopedic patients for a surgical admission.

Age-Adjusted Normative Values for Hip Patient-Reported Outcome Measures.

BACKGROUND: Patient-reported outcome measures (PROMs) are essential clinical instruments used for assessing patient function, assisting in clinical decision making, and quantifying outcomes of surgical and nonsurgical management. However, PROMs are often designed using patients with preexisting pathology and typically assume that a patient without the pathology would have a perfect or near perfect score. This may result in unrealistic expectations or falsely underestimate how well a patient is doing after treatment. The influence of age on PROMs about the hip of healthy individuals has not been studied. HYPOTHESIS: We hypothesize that in asymptomatic individuals hip-specific PROM scores will decrease in an age-dependent manor. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: In this multicenter survey study, volunteers who denied preexisting hip pathology and previous hip surgery completed 3 PROMs online or as traditional paper questionnaires. The International Hip Outcome Tool (iHOT), the modified Harris Hip Score (mHHS), and the Hip Outcome Score-Activities of Daily Living (HOS-ADL) and HOS-Sport were completed. Analysis of variance with a Tukey post hoc test was used to analyze differences in PROMs among subgroups. An independent-samples Student t test and a χ2 test were used to analyze differences in continuous and categorical data, respectively. RESULTS: In total 496, 571, 534, and 532 responses were collected for the iHOT, mHHS, HOS-ADL, and HOS-Sport, respectively. Respondents' PROMs were scored and arranged into 3 groups by age: <40 years, 40 to 60 years, and >60 years. The iHOT, mHHS, HOS-ADL, and HOS-Sport of these asymptomatic respondents all decreased in an age-dependent manner: iHOT (<40, 94.1; 40-60, 92.4; >60, 87.0), mHHS (<40, 94.8; 40-60, 91.3; >60, 89.1), HOS-ADL (<40, 98.4; 40-60, 95.0; >60, 90.9), and HOS-Sport (<40, 95.7; 40-60, 82.9; >60, 72.9) (analysis of variance between-group differences, P < .05). CONCLUSION: This study demonstrated that the iHOT, mHHS, and HOS-ADL and HOS-Sport scores in asymptomatic people decrease in an age-dependent manner. It is important to compare a patient's outcome scores with the age-normalized scores to establish an accurate reference frame with which to interpret outcomes.

Do racial disparities exist in a spine surgery practice that serves a predominately minority population? Outcomes of transforaminal lumbar interbody fusion: A retrospective review.

Background: Racial minority status is associated with inferior peri-operative outcomes following spinal fusion. Findings have largely been reported within institutions serving few minority patients. This study aimed to identify if racial disparities exist for transforaminal lumbar interbody fusion (TLIF) procedures within an urban academic medical center which serves a majority non-White population. Methods: This is a retrospective review of patients who underwent a TLIF procedure at our institution between 06/2016-10/2019. Primary outcome measures included length of stay (LOS), discharge disposition, 30-day return to the emergency department (ED), 30-day readmission rate, and 30-day complication rates. One-hundred-fifty-six patients (female: male, 99: 57) met inclusion criteria. Demographic and clinical data (body mass index (BMI), comorbidities, preoperative lab values) were compared. Results: The mean LOS was 6.2, 5.9, and 6 days in the White, Hispanic, and Black cohorts, respectively (p = 0.92). There were no differences in discharge disposition between groups (p = 0.52). Thirty-day post-operative complication rates did not differ between groups (p > 0.07). Readmission rates did not differ between groups (p > 0.05). ED visits were more prevalent in the Hispanic group with 16 visits as compared to 8 and 4 in the White and Black groups respectively (p = 0.01). Conclusions: We found no racial disparities in terms of LOS, discharge disposition, or 30-day readmission rates. Hispanic patients demonstrated an increased utilization of the ED in the early post-operative period. Efforts to overcome language barriers, communicate instructions clearly, and outline post-operative expectations and plans may prevent the need for post-operative ED visits.

Cigarette smoking and complications in elective thoracolumbar fusions surgery: An analysis of 58,304 procedures.

Study Design: This was retrospective cohort study. Purpose: The current investigation uses a large, multi-institutional dataset to compare short-term morbidity and mortality rates between current smokers and nonsmokers undergoing thoracolumbar fusion surgery. Overview of Literature: The few studies that have addressed perioperative complications following thoracolumbar fusion surgeries are each derived from small cohorts from single institutions. Materials and Methods: A retrospective study was conducted on thoracolumbar fusion patients in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2016). The primary outcome compared the rates of overall morbidity, severe postoperative morbidity, infections, pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), transfusions, and mortality in smokers and nonsmokers. Results: A total of 57,677 patients were identified. 45,952 (78.8%) were nonsmokers and 12,352 (21.2%) smoked within 1 year of surgery. Smokers had fewer severe complications (1.6% vs. 2.0%, P = 0.014) and decreased discharge to skilled nursing facilities (6.3% vs. 11.5%, P < 0.001) compared to nonsmokers. They had lower incidences of transfusions (odds ratio [OR] = 0.9, confidence interval [CI] = 0.8-1.0, P = 0.009) and DVT (OR = 0.7, CI = 0.5-0.9, P = 0.039) as well as shorter length of stay (LOS) (OR = 0.9, CI = 0.9-0.99, P < 0.001). They had a higher incidence of postoperative pneumonia (OR = 1.4, CI = 1.1-1.8, P = 0.002). There was no difference in the remaining primary outcomes between smoking and nonsmoking cohorts. Conclusions: There is a positive correlation between smoking and postoperative pneumonia after thoracolumbar fusion. The incidence of blood transfusions, DVT, and LOS was decreased in smokers. Early postoperative mortality, severe complications, discharge to subacute rehabilitation facilities, extubation failure, PE, SSI, and return to OR were not associated with smoking.

Preemptive analgesia in hip arthroscopy: intra-articular bupivacaine does not improve pain control after preoperative peri-acetabular blockade.

INTRODUCTION: Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures. METHODS: 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively. RESULTS: Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, p = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period. CONCLUSIONS: This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.

Black and Hispanic Patients Do Not Stay Longer After Primary Total Knee Arthroplasty: Results From an Urban Center Serving a Predominantly Minority Cohort.

INTRODUCTION: Previous reports identified minority race/ethnicity to be an independent risk factor for prolonged length of stay (LOS); however, these cohorts consisted of predominantly White patients. This study sought to evaluate minority status as an independent risk factor for prolonged LOS after primary total knee arthroplasty (TKA) in a predominantly Hispanic and Black cohort. METHODS: This was a retrospective study using an institutional database of patients who underwent primary TKA between the years 2016 and 2019. Demographic and socioeconomic data, smoking, body mass index (BMI), medical comorbidities, discharge disposition, and 30-day readmission rates were collected. Patients were first categorized into racial/ethnic groups (Hispanic, Black, or White). An univariate analysis was performed comparing patient characteristics between racial/ethnic groups using the Wilcoxon rank sum, chi-squared, and Fisher exact tests. We then categorized patients into two groups-normal LOS (discharged on postoperative day 1 to 2) and prolonged LOS (discharged after postoperative day 2). An univariate analysis was again performed comparing patient characteristics between LOS groups using Wilcoxon rank sum, chi-squared, and Fisher exact tests. After identifying risk factors markedly associated with LOS, a multivariate logistic regression analysis was performed to identify independent risk factors for prolonged LOS. RESULTS: A total of 3,093 patients were included-47.9% Hispanic and 38.3% Black. Mean LOS was 2.9 ± 1.6 days. An univariate analysis found race/ethnicity, age, low socioeconomic status (SES), discharge disposition, insurance type, weekday of surgery, BMI >40, smoking, increased American Society of Anesthesiologists (ASA)/Charlson Comorbidity Index (CCI) and several medical comorbidities to be associated with prolonged LOS (P < 0.05). A multivariate logistic regression analysis found Black and Hispanic patients were less likely to have prolonged LOS after adjusting for associated risk factors. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, and increased ASA and CCI were identified as independent risk factors for prolonged LOS (P < 0.05). The overall 30-day readmission rate was 3.6%, with no notable difference between racial/ethnic and LOS groups (P = 0.98 and P = 0.78). CONCLUSION: In contrast to previous reports, our study found that after adjusting for associated risk factors, minority patients do not have prolonged LOS after primary TKA in an urban, socioeconomically disadvantaged, predominantly minority patient cohort. White race/ethnicity, nonhome discharge, low SES, weekday of surgery, smoking, BMI >40, increased CCI, and ASA were all found to be independent risk factors for prolonged LOS. These findings highlight the need to further investigate the role of race/ethnicity on LOS after primary TKA using large-scale, randomized controlled trials with equally represented patient cohorts.