Faculty Bibliography

OBJECTIVE:Our study aimed to determine the duration of pain relief from intraarticular hip corticosteroid injections and identify patient predictive factors on injection response. We also sought to determine the subsequent rate of hip surgery and whether severity of hip osteoarthritis or injection response correlated with the decision to undergo surgery. MATERIALS AND METHODS/METHODS:All intraarticular hip steroid injections performed for osteoarthritis under fluoroscopic guidance at a single institution between January 2010 to December 2012 were retrospectively reviewed. Response was divided into three groups: no relief, immediate (≤ 2 weeks of pain relief), and continued (> 2 weeks of pain relief). Presence of hip surgery for osteoarthritis performed within 2 years following injection was obtained. Correlation between patient characteristics with injection outcome and hip surgery was analyzed. RESULTS:Of 78 patients, a total of 82 injections were analyzed. For injections, 19.5% (16/82) showed no response, 47.6% (39/82) showed immediate response, and 32.9% (27/82) showed continued response. There was no significant correlation between injection outcome with age, Tönnis grade, BMI, or duration of symptoms. In total, 48.7% had hip surgery within 2 years after initial injection. There was a significant association between Tönnis grade and surgery, with higher Tönnis grades correlating with decision to undergo surgery (p = 0.002). CONCLUSIONS:Gender, age, BMI, duration of symptoms, and radiographic severity of disease do not predict injection response. Due to high surgical rates and poor response, intraarticular hip steroid injections may be less effective in the long term, and surgical management may be considered earlier.

STUDY DESIGN/METHODS:A retrospective case-control study. OBJECTIVE:The aim of this study was to determine the nationwide trends and complication rates associated with outpatient posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA/BACKGROUND:Outpatient lumbar spine fusion is now possible secondary to minimally invasive techniques that allow for reduced hospital stays and analgesic requirements. Limited data are currently available regarding the clinical outcome of outpatient lumbar fusion. METHODS:The Humana administrative claims database was queried for patients who underwent one to two-level PLF (CPT-22612 or CPT-22633 AND ICD-9-816.2) as either outpatients or inpatients from Q1 2007 to Q2 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients undergoing PLF. RESULTS:Cohorts of 770 patients who underwent outpatient PLF and 26,826 patients who underwent inpatient PLF were identified. The median age was in the 65 to 69 years age group for both cohorts. The annual relative incidence of outpatient PLF remained stable across the study period (R = 0.03, P = 0.646). Adjusting for age, gender, and comorbidities, patients undergoing outpatient PLF had higher likelihood of revision/extension of posterior fusion [(OR 2.33, confidence interval (CI) 2.06-2.63, P < 0.001], anterior fusion (OR 1.64, CI 1.31-2.04, P < 0.001), and decompressive laminectomy (OR 2.01, CI 1.74-2.33, P < 0.001) within 1 year. Risk-adjusted rates of all other postoperative surgical and medical complications were statistically comparable. CONCLUSION/CONCLUSIONS:Outpatient lumbar fusion is uncommonly performed in the United States. Data collected from a national private insurance database demonstrate a greater risk of postoperative surgical complications including revision anterior and posterior fusion and decompressive laminectomy. Surgeons should be cautious in performing PLF in the outpatient setting, as the risk of revision surgery may increase in these cases. LEVEL OF EVIDENCE/METHODS:3.

The purpose of this study was to determine the relative incidence of postoperative complications in 25-hydroxyvitamin D (25D)-deficient and -sufficient patients undergoing total knee arthroplasty (TKA). Patients who were either serum 25D deficient (25D <20 ng/mL) or 25D sufficient (25D ≥20 ng/mL) 90 days prior to primary TKA from 2007 to 2016 were identified using the Humana administrative claims registry. The incidence of postoperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Risk-adjusted odds ratios (ORs) were calculated using multivariate logistic regression with age, sex, and Charlson Comorbidity Index as covariates. In total, 868 of 6593 patients who underwent TKA from 2007 to 2016 were 25D deficient, corresponding to a 13.2% prevalence rate. On adjustment for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had a higher incidence of postoperative stiffness requiring manipulation under anesthesia (OR, 1.69; 95% confidence interval [CI], 1.39-2.04; P<.001), surgical site infection requiring irrigation and debridement (OR, 1.76; 95% CI, 1.25-2.48; P=.001), and prosthesis explantation (OR, 2.97; 95% CI, 2.04-4.31; P<.001) at 1 year. Patients who were 25D deficient also had higher rates of postoperative deep venous thrombosis (OR, 1.80; 95% CI, 1.36-2.38; P<.001), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.15; P<.001), and cerebrovascular accident (OR, 1.73; 95% CI, 1.17-2.57; P=.006). Thus, serum 25D levels below 20 ng/mL are associated with a higher incidence of postoperative complications and may be a perioperative modifiable risk factor in TKA. [Orthopedics. 2018; 41(4):e489-e495.].

BACKGROUND CONTEXT:With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population. PURPOSE:The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF. STUDY DESIGN/SETTING:This is a large-scale retrospective case control study. PATIENT SAMPLE:The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery. MATERIALS AND METHODS:A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF. RESULTS:=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable. CONCLUSIONS:Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.

Outpatient arthroplasty is an appealing option among select patient populations as a mechanism for reducing health care expenditure. The purpose of this study was to determine the nationwide trends and complication profile of outpatient total shoulder arthroplasty (TSA). The authors reviewed a national administrative claims database to identify patients undergoing TSA as outpatients and inpatients from 2007 to 2016. The incidence of perioperative surgical and medical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Multivariate logistic regression adjusted for age, sex, and Charlson Comorbidity Index was used to calculate odds ratios of complications among outpatients relative to inpatients undergoing TSA. The query identified 1555 patients who underwent outpatient TSA and 15,987 patients who underwent inpatient TSA. The median age was in the 70 to 74 years age group in both the outpatient and the inpatient cohorts, and the age distribution was comparable between the 2 cohorts (P=.287). The incidence of both outpatient (P<.001) and inpatient (P<.001) TSA increased during the study period. On adjustment for age, sex, and comorbidities, patients undergoing outpatient TSA had significantly lower rates of stiffness requiring manipulation under anesthesia (outpatient, 1.09%; inpatient, 2.35%; odds ratio, 0.52; 95% confidence interval, 0.38-0.71; P<.001) and higher rates of postoperative surgical site infections requiring reoperation (outpatient, 0.90%; inpatient, 0.65%; odds ratio, 1.65; 95% confidence interval, 1.15-2.35; P<.001) at 1 year. Rates of all other postoperative complications were comparable. Ambulatory TSA is increasing in incidence nationwide and is associated with an overall favorable postoperative complication profile. [Orthopedics. 2018; 41(3):e400-e409.].

Objective To perform a systematic review of clinical outcomes following microfracture augmented with biological adjuvants (MFX+) compared with microfracture (MFX) alone. Design The MEDLINE, Scopus, and Cochrane databases were searched for clinical studies on MFX+ for chondral defects of the knee. Study characteristics and clinical outcome score data were collected. Subjective synthesis was performed using data from randomized controlled studies to determine effect size of MFX+ procedures performed with either injectable or scaffold-based augmentation compared with MFX alone. Results A total of 18 articles reporting on 625 patients (491 MFX+, 134 MFX) were identified. Six studies were level II evidence and 1 study was level I evidence. Mean patient age range was 26 to 51 years, and mean follow-up ranged from 2 to 5 years. All studies demonstrated significant improvement in reported clinical outcome scores at follow-up after MFX+ therapy, and 87% of patients reported satisfaction with treatment. The most commonly reported treatment complication was postoperative stiffness (3.9% of patients). Subjective synthesis on randomized controlled trials demonstrated that 2/2 injectable MFX+ interventions had significantly greater improvements in International Knee Documentation Committee Subjective Knee Form (IKDC; P = 0.004) and Knee injury and Osteoarthritis Outcome Score (KOOS; P = 0.012) scores compared with MFX alone, while 2/2 trials on scaffolding MFX+ adjuvants showed comparable postoperative improvements. Conclusions MFX+ biological adjuvants are safe supplements to marrow stimulation for treating cartilage defects in the adult knee. Early literature is heterogenous and extremely limited in quality. Individual trials report both equivalent and superior clinical outcomes compared with MFX alone, making definitive conclusions on the efficacy of MFX+ difficult without higher quality evidence.

OBJECTIVES:To describe the incidence and determinants of survival of patients with verrucous carcinoma (VC) of the oral cavity between the years of 1973 and 2012 using the Surveillance, Epidemiology, and End Results (SEER) database. STUDY DESIGN:Retrospective cohort study using a national database. METHODS:The SEER registry was utilized to calculate survival trends for patients with VC of the oral cavity between 1973 and 2012. Patient data was then analyzed with respect to histopathology, age, sex, race, stage, grade, and treatment modalities (surgery and radiation therapy). Overall survival (OS) and disease-specific survival (DSS) were calculated. RESULTS:A total of 1,481 cases of VC of the oral cavity were identified. The cohort was composed of 50.5% males. The mean age at diagnosis was 69.5 years. The oral tongue was the most common primary site (28.9%), followed by the alveolar ridge (21.4%) and buccal mucosa (19.0%). The vast majority of cases (79.1%) presented with stage I and stage II disease. Nodal disease was present in only 1.6% of cases. The median OS was 94.6 months. Eighty-seven percent of cases underwent surgery, and 11.5% received both surgery and radiation therapy. Overall survival at 2, 5, and 10 years was 83%, 64%, and 42%, respectively. On multivariate analysis, advanced age (P < 0.001) and stage (P < 0.001) were associated with worse OS, whereas surgery improved OS (P = 0.047). CONCLUSION:We provide the first population-based analysis of prognostic factors affecting survival outcomes in patients with oral cavity VC. Verrucous carcinoma of the oral cavity is associated with a generally favorable prognosis. Age, stage, nodal status, and surgical therapy are independent predictors of OS. LEVEL OF EVIDENCE:4. Laryngoscope, 128:393-397, 2018.

INTRODUCTION/BACKGROUND:Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients. METHODS:We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium. RESULTS:< 0.001). DISCUSSION/CONCLUSIONS:Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes. CONCLUSIONS:Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.

BACKGROUND:As concerns regarding health-care expenditure in the U.S. remain at the national forefront, outpatient arthroplasty is an appealing option for carefully selected patient populations. The purpose of this study was to determine the nationwide trends and complication rates associated with outpatient total knee arthroplasty (TKA) in comparison with standard inpatient TKA. METHODS:We performed a retrospective review of the Humana subset of the PearlDiver Patient Record Database to identify patients who had undergone TKA (Current Procedural Terminology [CPT] code 27447) as either outpatients or inpatients from 2007 to 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision (ICD-9) and CPT codes. Multivariate logistic regression analysis adjusted for age, sex, and Charlson Comorbidity Index (CCI) was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients treated with TKA. RESULTS:Cohorts of 4,391 patients who underwent outpatient TKA and 128,951 patients who underwent inpatient TKA were identified. The median age was in the 70 to 74-year age group in both cohorts. The incidence of outpatient TKA increased across the study period (R = 0.60, p = 0.015). After adjustment for age, sex, and CCI, outpatient TKAs were found to more likely be followed by tibial and/or femoral component revision due to a noninfectious cause (OR = 1.22, 95% confidence interval [CI] = 1.01 to 1.47; p = 0.039), explantation of the prosthesis (OR = 1.35, CI = 1.07 to 1.72; p = 0.013), irrigation and debridement (OR = 1.50, CI = 1.28 to 1.77; p < 0.001), and stiffness requiring manipulation under anesthesia (OR = 1.28, CI = 1.17 to 1.40; p < 0.001) within 1 year. Outpatient TKA was also more frequently associated with postoperative deep vein thrombosis (OR = 1.42, CI = 1.25 to 1.63; p < 0.001) and acute renal failure (OR = 1.13, CI = 1.01 to 1.25; p = 0.026). CONCLUSIONS:With the potential to minimize arthroplasty costs among healthy patients, outpatient TKA is an increasingly popular option. Nationwide data from a private insurance database demonstrated a higher risk of perioperative surgical and medical complications including component failure, surgical site infection, knee stiffness, and deep vein thrombosis. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

With significant advancements over recent decades, magnetic resonance imaging (MRI) and shoulder arthroscopy are important complementary tools in guiding orthopedic surgeons to diagnosis, decision making, and treatment of rotator cuff pathology. The objective of this article is to review the basic principles and pearls of MRI-arthroscopy correlation of the rotator cuff through an overview of our approach to reading shoulder MRI followed by a case-based review of selected conditions. By understanding and comparing the subtleties of these modalities, radiologists and clinicians can better appreciate both the utility and limitations of MRI in predicting operative findings.