Faculty Bibliography

Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).

PURPOSE/OBJECTIVE:To determine the association between labral width as measured on preoperative MRI with hip-specific validated patient self-reported outcomes at a minimum of 2 years follow-up. METHODS:An IRB-approved retrospective review of prospectively gathered hip arthroscopy patients from 2010 to 2017 was performed. Inclusion criteria was defined as patients >18 years old with radiographic evidence of femoroacetabular impingement who underwent a primary labral repair and had a minimum of 2 years clinical follow-up. Exclusion criteria was defined as inadequate preoperative imaging, prior hip surgery, Tonnis grade ≥2 or lateral central edge angle <25 degrees. An a-priori power analysis was performed. MRI measurements of labral width were conducted by two blinded, musculoskeletal fellowship-trained radiologists at standardized "clockface" locations using a previously validated technique. Outcomes were assessed using the Harris Hip Score (HHS), Modified HHS (mHSS), and NonArthritic Hip Score (NAHS). For mHHS, a minimal clinically important difference (MCID) and Patient Acceptable Symptomatic State (PASS) of 8 and 74 were used, respectively. Patients were divided into groups by labral width of < (hypoplastic) and ≥ 1 standard deviation below the mean. Statistical analysis was performed using linear and polynomial regression, Mann-Whitney U, chi-square, Fischer exact, and interclass-correlation coefficients (ICC) testing. RESULTS:=0.26, p<0.001). CONCLUSION/CONCLUSIONS:Hip labral width < 1 standard deviation below the mean measured via preoperative MRI was associated with significantly worse functional outcomes following arthroscopic labral repair and treatment of FAI. The negative relationship between labral width and outcomes may be non-linear.

BACKGROUND:The purpose of this study is to evaluate the value and efficacy of rapid response teams (RRTs) for different triggering events in total hip arthroplasty (THA) patients. METHODS:A retrospective review of all RRT events at a single, tertiary referral center from 2014 to 2016 was performed. Inclusion criteria were defined as patients >18 years old that underwent primary or revision THA. Information queried included demographics, primary reason for RRT, Charlson Comorbidity Index (CCI), underlying etiology, whether any changes in management occurred, and whether the patient was uptriaged. RESULTS:In total, 168 RRTs were called on 153 hip arthroplasty patients (mean age 65.2 ± 14.1 years; mean body mass index 32.3 ± 4.8, 66% female). Length of stay in RRT for primary and revision THA was 3.4 and 6.2 days, respectively. This was significantly longer than the length of stay for primary THA patients (2.4 days, P < .001) and revision THA patients (4.6 days, P = .005) that did not require an RRT. There were no mortalities. RRTs for hypotension/presyncope (11%) and for syncope (11%) resulted in significantly fewer changes in management (P < .01) than tachycardia (77%), hypoxia (57%), AMS (79%), and other (47%). RRTs for hypotension/presyncope (28%), syncope (15%), and hypoxia (30%) resulted in significantly fewer patients being uptriaged (P < .001) than tachycardia (81%). Hypotension/presyncope was found to be significantly more commonly due to volume depletion (67%) (P < .001) than other etiologies. Hypoxia was significantly more commonly due to atelectasis (57%) and opioids/oversedation (30.4%) (P = .037). AMS/delirium was also significantly more commonly caused by opioids/over-sedation (71%) (P < .001). CONCLUSION/CONCLUSIONS:In patients undergoing THA, RRTs for hypotension/presyncopal symptoms and syncope were significantly less likely to result in changes in management or uptriaging compared to tachycardia. The most common etiologies were potentially preventable, including volume depletion and opioid use.

BACKGROUND/UNASSIGNED:Previous research has demonstrated a statistically significant relationship between hip arthroscopy outcomes and age. PURPOSE/UNASSIGNED:To investigate the link, if any, between hip arthroscopy outcomes and intraoperative pathology as well as with patient age and sex. STUDY DESIGN/UNASSIGNED:Cohort study; Level of evidence, 3. METHODS/UNASSIGNED:< .05. RESULTS/UNASSIGNED:< .0004). CONCLUSION/UNASSIGNED:Surgical treatment of femoroacetabular impingement in females led to improved functional outcomes at 2 years of follow-up, although older female patients did worse after hip arthroscopy as compared with their younger counterparts. There may be an age-dependent decrease in incidence of cam-type lesions in female patients.

There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00-2.63], 2.33 [2.08-2.61], 2.35 [2.11-2.61], 2.27 [2.06-2.49], 2.33 [2.14-2.54], all p < 0.001).

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

In recent years, the use of three-dimensional printing (3DP) technology has gained traction in orthopedic spine surgery. Although research on this topic is still primarily limited to case reports and small cohort studies, it is evident that there are many avenues for 3DP innovation in the field. This review article aims to discuss the current and emerging 3DP applications in spine surgery, as well as the challenges of 3DP production and limitations in its use. 3DP models have been presented as helpful tools for patient education, medical training, and pre-surgical planning. Intraoperatively, 3DP devices may serve as patient-specific surgical guides and implants that improve surgical outcomes. However, the time, cost, and learning curve associated with constructing a 3DP model are major barriers to widespread use in spine surgery. Considering the costs and benefits of 3DP along with the varying risks associated with different spine procedures, 3DP technology is likely most valuable for complex or atypical spine disorder cases. Further research is warranted to gain a better understanding of how 3DP can and will impact spine surgery.

BACKGROUND:To determine if preoperative characteristics and postoperative outcomes of a first total knee arthroplasty (TKA) were predictive of characteristics and outcomes of the subsequent contralateral TKA in the same patient. METHODS:Retrospective administrative claims data from (SPARCS) database were analyzed for patients who underwent sequential TKAs from September 2015 to September 2017 (n = 5,331). Hierarchical multivariable Poisson regression (length of stay [LOS]) and multivariable logistic regression (all other outcomes), controlling for sex, age, and Elixhauser comorbidity scores were performed. RESULTS:The cohort comprised 65% women, with an average age of 66 years and an average duration of 7.3 months between surgeries (SD: 4.7 months). LOS was significantly shorter for the second TKA (2.6 days) than for the first TKA (2.8 days; P < .001). Patients discharged to a facility after their first TKA had a probability of 76% of discharge to facility after the second TKA and were significantly more likely to be discharged to a facility compared with those discharged home after the first TKA (odds ratio [OR]: 63.7; 95% confidence interval [CI]: 52.1-77.8). The probability of a readmission at 30 and 90 days for the second TKA if the patient was readmitted for the first TKA was 1.0% (OR: 3.70; 95% CI: 0.98-14.0) and 6.4% (OR: 9; 95% CI: 5.1-16.0), respectively. Patients with complications after their first TKA had a 27% probability of a complication after the second TKA compared with a 1.6% probability if there was no complication during the first TKA (OR: 14.6; 95% CI: 7.8.1-27.2). CONCLUSION/CONCLUSIONS:The LOS, discharge disposition, 90-day readmission rate, and complication rate for a second contralateral TKA are strongly associated with the patient's first TKA experience. The second surgery was found to be associated with an overall shorter LOS, fewer readmissions, and higher likelihood of home discharge. LEVEL OF EVIDENCE/METHODS:Level 3-retrospective cohort study.

PURPOSE/OBJECTIVE:To determine if magnetic resonance angiography (MRA) and/or magnetic resonance imaging (MRI) could accurately determine the width of the labrum. METHODS:Consecutively enrolled patients between the ages of 18 and 65 indicated for hip arthroscopy for femoroacetabular impingement were included between December 2017 and June 2018. Inclusion criteria for preoperative MRIs included: MRI availability in picture archiving and communication system; performance on a 1.5T or 3T MRI or 3T MRA; and adequate quality and lack of labrum ossification. Intraoperative labral width measurements were taken at standardized locations using an established acetabular "clockface" paradigm. Measurement was performed using a calibrated probe. The labral width was defined as the distance from the labrum extended laterally from the acetabular rim. MRI measurements were taken by 2 blinded musculoskeletal fellowship-trained radiologists at the same positions. Measurements were made at the 11:30 o'clock position (indirect rectus) on coronal proton density (PD) sequence, at 3 o'clock position (psoas-U) on axial oblique PD sequence, and at 1:30 (a point halfway between the 2) on sagittal fat-suppressed PD. The surgeons were blinded to the radiologists' measurements and vice versa. Intraoperative and radiographic labral width measurements were compared using an intraclass correlation coefficients (ICC), absolute agreement, and 2-way random effects model. The 2 radiologists' measurements were compared for interrater reliability using the same ICC model. RESULTS:Fifty-one patients were included (30 females, 26 right hips). Average labrum width at the 3:00, 11:30, and 1:30 o'clock positions by arthroscopic measurement were 5.8 mm (range; standard deviation, 2-8; ±1.4), 6.3 mm (2-10; ±1.5) and 6.0 mm (2-9; ±1.5), and by MRI were 6.3 mm (2-10; ±1.5), 6.7 mm (3-10; ±1.4), and 6.1 mm (2-9; ±1.6), respectively. When including all MRI modalities, ICC agreement between intraoperative assessment, and radiologist assessment at the 3:00 o'clock, 11:30, and point halfway between was 0.82 (P < .001), 0.78 (P < .001), 0.84 (P < .001), respectively. Radiologist interrater ICC agreement at the same points was 0.88 (P < .001), 0.93 (P < .001), and 0.88 (P < .001). CONCLUSIONS:Strong agreement was found between radiologic and arthroscopic measurement of labrum width when using MRI, suggesting MRI is an accurate way to measure labral width. There was not a significant difference between different MRI modalities. Accurately measuring labral width preoperatively with MRI may aid in surgical decision making. LEVEL OF EVIDENCE/METHODS:Level II, diagnostic study.