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Association of nausea and length of stay with carbohydrate loading prior to total joint arthroplasty

Blum, Christopher L.; Akerman, Meredith; Callari, Marie; Jordan, Ellen; Capozzi, James D.
Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized approach to the surgical patient that incorporates evidenced-based interventions designed to achieve rapid recovery after surgery by minimizing the patient's stress response. One aspect of ERAS, carbohydrate loading, has been shown in multiple randomized controlled trials to result in postoperative benefits in patients undergoing colorectal surgery, but there appears to be insufficient data to make definitive recommendations for or against carbohydrate loading in joint replacement patients. Objective: To evaluate postoperative nausea and length of stay (LOS) after a preoperative carbohydrate loading protocol was initiated for patients undergoing total joint replacement. Design: Retrospective chart review. Setting and participants: 100 patients who underwent either total knee or hip arthroplasty at Winthrop University Hospital, Mineola, NY, in the past 4 years and either had (n = 50) or had not received preoperative carbohydrate supplements (n = 50). Methods: Using the total joint database, the medical record was reviewed for the patient's demographics, LOS, documentation of postoperative nausea, and number of doses of antiemetic medication given to the patient. Results: The mean LOS for the carbohydrate-loading group and non-carbohydrate group was 1.9 days and 2.6 days. respectively, a difference of 0.70 days (P < 0.0001). The carbohydrate-loaded group received a total of 13 doses of antiemetic medications and the non-carbohydrate group received 21 doses. The average number of antiemetic doses given to a patient postoperatively was 0.26 for the carbohydrate-loaded group and 0.42 for the non-carbohydrate-loaded group. The difference was 0.16 doses (P < 0.7815). Conclusion: The implementation of carbohydrate loading decreased LOS for joint replacement patients by approximately 1 day. Additionally, there was a trend towards decreased antiemetic use and fewer documented cases of postoperative nausea after carbohydrate loading.
ISSN: 1079-6533
CID: 4099552

Hyaluronan Injections Show No Histologic Evidence of Adverse Tissue Effects

Bisogno, Michael; Vojdani, Saman; Aalai, Marriam; Shapiro, Daniel; Moriarty, Meghan; Vigorita, Vincent; Capozzi, James
Background/UNASSIGNED:The safety of hyaluronan intra-articular injections is mostly based on animal studies and clinical evidence rather than histologic studies from human administration. Objective/UNASSIGNED:This study analyzed the histologic effects of viscosupplementation with sodium hyaluronate on the synovium and articular cartilage of human knee specimen status post total knee arthroplasty within 3 years of viscosupplementation. Methods/UNASSIGNED:Twenty-four specimens from total knee arthroplasties from April 2012 to August 2016 at NYU Winthrop Hospital were selected for microscopic analysis. All cases had a diagnosis of end-stage osteoarthritis at the time of surgery. Thirteen of the cases had 3 viscosupplementation injections of the knee with Euflexxa, a hyaluronate-based viscosupplementation agent, within 3 years preceding a total knee replacement. The remaining 11 did not receive viscosupplementation and were incorporated as controls. Upon histologic review, synovium was categorized by degree of hyperplasia and inflammation and the presence or absence of foreign material and giant cell reactions. Residual articular cartilage was categorized by staining intensity, and the presence or absence of crystals, foreign material, and giant cell reactions. Results/UNASSIGNED:= .42). None of the samples displayed evidence of foreign material, crystals, or giant cell reactions. Conclusion/UNASSIGNED:In this cohort of patients, we demonstrated that Euflexxa was administered without any discernible microscopic adverse tissue effects.
PMID: 31392071
ISSN: 2151-4585
CID: 4053982

The Prevalence of Diabetes Mellitus and Routine Hemoglobin A1c Screening in Elective Total Joint Arthroplasty Patients

Capozzi, James D; Lepkowsky, Eric R; Callari, Marie M; Jordan, Ellen T; Koenig, Jan A; Sirounian, Gregory H
BACKGROUND:Diabetes mellitus has been associated with significant perioperative complications in joint arthroplasty. In addition, many patients are unaware of their dysglycemic status, and the prevalence of undiagnosed dysglycemia in joint arthroplasty patients is unknown. METHODS:Several years ago, we began routine hemoglobin A1c (HbA1c) level screening in all our patients planning to undergo elective total hip and total knee arthroplasties. We retrospectively reviewed the HbA1c levels in our initial 663 patients. RESULTS:Forty-eight percent of these patients were found to be nondiabetic; 19% percent had a previous history of some level of dysglycemia. Most significantly, over one third, 33.6% of these patients were previously undiagnosed dysglycemic patients; 31% were diagnosed as prediabetic and 2.6% as diabetic. CONCLUSION:Owing to the high prevalence of prediabetic patients who go on to develop diabetes and to the high correlation of poor glucose control with perioperative complications, we feel that it is imperative to identify this large number of previously undiagnosed dysglycemic patients. We recommend the routine screening of all patients planning to undergo major orthopedic procedures. Likewise, we recommend that identified patients be referred for diabetic counseling. We also recommend that patients with markedly elevated HbA1c levels have their elective surgery postponed until better glycemic control can be achieved.
PMID: 27452137
ISSN: 1532-8406
CID: 3459512

Ethical challenges in orthopedic surgery

Capozzi, James D; Rhodes, Rosamond
Despite our recent attention to ethical issues in orthopedics, we are still faced with multiple conflicts of interest that continue to pose ethical dilemmas to the practicing physician. Using four case scenarios, we review the potential conflicts of interest and the dilemmas posed by these frequently encountered situations. The ethical conflicts confronted in resident training, the introduction of new technology, physician advertising, and the obligations of the sports team physician are reviewed and discussed. The basic principles of medical ethics, including acting for the good of the patients and doing no harm, are discussed in the context of the four case scenarios.
PMID: 25957262
ISSN: 1935-973x
CID: 3459502

Judgments about deservingness

Humbyrd, Casey Jo; Capozzi, James D; Rhodes, Rosamond
A twenty-one-year-old known gang member presented to the emergency room late on a Friday night with multiple gunshot wounds, including one to his hand, with multiple open fractures and extensive soft-tissue injury. After evaluation by the on-call resident, the orthopaedic attending physician was notified and the decision was made to bring the patient to the operating room for surgical treatment.Due to the extensive nature of the trauma, the surgical reconstruction took several hours. In the middle of the operation, one member of the operating-room staff began to complain about the late hour and commented that the surgeon need not be so meticulous as the patient was not going to use the hand to play piano; he would likely be using it to shoot a gun. The attending physician replied that we could not know whether or not the patient played piano, nor whether he might take it up after surgery. The surgery was completed, and the patient was brought to the intensive care unit for postoperative monitoring of his other injuries.
PMID: 24088980
ISSN: 1535-1386
CID: 3459672

Squeaking in third- and fourth-generation ceramic-on-ceramic total hip arthroplasty: meta-analysis and systematic review

Stanat, Scott J C; Capozzi, James D
Postoperative squeaking in ceramic-on-ceramic total hip arthroplasty is a recently emerging phenomenon. We performed a meta-analysis of published data to examine patient and procedural risk factors. Twelve studies (6137 patients, total) were analyzed, with 150 patients (2.4%) complaining of squeaking. The only significant patient risk factor was increasing body mass index (P = .03, n = 2957). There was no significance found with patient age, sex, height, weight, or procedural laterality for squeak incidence. For implant type, the presence of a Stryker Accolade femoral stem (beta-titanium; Stryker Orthopedics, Mahwah, NJ) was significantly found to increase squeak (P < .0001, n = 4654). The presence of a raised metallic lip on the acetabular component was not found to be associated with squeak. Acetabular cup position was also not found to have a significant bearing on the incidence of squeaking.
PMID: 21676580
ISSN: 1532-8406
CID: 3459482

Discussing treatment options with a minor: the conflicts related to autonomy, beneficence, and paternalism [Case Report]

Ross, James R; Capozzi, James D; Matava, Matthew J
A seventeen-year-old male, high-school football player presents to an orthopaedic surgeon because of recurrent right knee pain after having undergone an arthroscopic meniscal repair one year previously. The patient did well initially but now has recurrent medial joint-line pain in the knee, which developed when he planted the right leg to throw a pass during summer training camp. He was evaluated by the team's athletic trainer and by an orthopaedic surgeon, both of whom, on the basis of their physical examination of the boy, believe that he may have sustained a recurrent meniscal tear. A magnetic resonance arthrogram is acquired, which confirms the presence of a large longitudinal tear of the medial meniscus in the "red-red" zone, with no signs of degenerative change, articular cartilage damage, or other ligamentous pathology. The patient had just started summer training camp before his senior year of high-school football, and he is considered to be a potential high-level candidate for a Division-I football scholarship.The orthopaedic surgeon presents the patient and his mother with three treatment options: nonoperative management, arthroscopic partial meniscectomy, and arthroscopic meniscal repair. He also presents the relevant risks and benefits of each choice, including, for meniscectomy, the risk of the future development of osteoarthritis if a large portion of the meniscus were to be excised and, for meniscal repair, the need for an extended (four to six-month) rehabilitation period. Both the patient and his mother are apprised of the limitations of preoperative magnetic resonance imaging (MRI) in determining if a meniscal tear can be repaired1-3. The patient states that, on the basis of his symptoms of pain, intermittent locking, and swelling, he does not believe that he would be able to play football if nonoperative management was chosen. He voices a strong preference for meniscectomy, as this would allow him the most rapid return to play. He states that he is not concerned with the future risk of osteoarthritis but is fearful that missing his senior football season will place his scholarship in jeopardy. His mother states that her son would likely not attend college without a scholarship, considering the family's financial situation. The patient states that he therefore wishes to have a meniscectomy, given the likely quicker recovery and faster return to play.The patient's mother was initially in favor of a meniscal repair, if possible. However, over the course of the patient's visit with the surgeon, she is persuaded by her son to favor a meniscectomy. The surgeon again discusses in detail the risks involved with meniscectomy in an adolescent-primarily the higher risk of future knee osteoarthritis. The patient remains persistent in his choice, mainly due to his desire to avoid the prolonged postoperative course of limited weight-bearing and physical therapy and thus the loss of his final high-school season. The mother, who is the patient's legal guardian for consent, ultimately follows her son's wishes and elects to consent to only an arthroscopic meniscectomy.
PMID: 22218389
ISSN: 1535-1386
CID: 3459652

Moral complexity

Capozzi, James D; Bronson, Wesley; Rhodes, Rosamond
An attending orthopaedic surgeon, an orthopaedic resident, and a spine Fellow are scheduled to perform a multilevel spinal decompression and instrumentation from L3 to S1. The case is delayed for several hours and begins in the late afternoon. The attending orthopaedist chooses not to wait for localization radiographs and proceeds with the decompression and four-level pedicle screw instrumentation with posterior-lateral fusion. The Fellow suggests several times during the procedure that radiographs should be obtained, but the attending surgeon is late for a meeting and declines to obtain radiographs. The attending surgeon leaves the resident and Fellow to close the wound after spinal instrumentation and fusion is complete. Radiographs are obtained prior to closure of the wound, and these indicate that the decompression has been performed at the appropriate levels but that the spinal instrumentation and fusion was from L2 to L5 rather than from L3 to S1. The Fellow notifies the attending surgeon, who has already left the hospital. The Fellow offers to remove the L2 screws, place S1 screws, and reconfigure the instrumentation prior to closing. The attending surgeon forbids the Fellow to do this and tells her, "Everything will be fine." He also states that he will discuss the surgery with the patient and family in the morning. As ordered, the Fellow and the resident close the wound.
PMID: 21915531
ISSN: 1535-1386
CID: 3459492

Catastrophic polyethylene failure diagnosed with magnetic resonance imaging in a painful total knee arthroplasty [Case Report]

Mallo, Gregory C; Stanat, Scott J C; Jones, Jason A; Capozzi, James D; Luchs, Jonathan S
Determining the etiology of a painful knee after arthroplasty can be extremely challenging. Traditionally, orthopedists relied mainly on physical examination, laboratory results, serial radiographs, and 3-phase bone or indium-labeled white blood cell scans; however, recent advances in magnetic resonance imaging (MRI) software have given orthopedists another powerful tool in their diagnostic armamentarium. We provide the MRI software modification technique for metallic artifact reduction as well as present a novel case in which MRI was used to diagnose catastrophic polyethylene postfailure in a posterior cruciate ligament substituting knee. Although the role for MRI in the postarthroplasty knee has yet to be clearly defined, its utility in working up a painful arthroplasty when history, physical examination, and other diagnostic utilities fail to provide answers is clearly demonstrated in this case.
PMID: 20334993
ISSN: 0883-5403
CID: 539552

Examining the ethical implications of an orthopaedic joint registry

Capozzi, James D; Rhodes, Rosamond
R.P., a fifty-seven-year-old man, underwent a total hip replacement with a newly designed, cementless hip system. Within the first several months after surgery, he had persistent thigh pain. Radiographs made at one year indicated progressive radiolucent lines surrounding the femoral component. He required revision surgery for aseptic loosening of the femoral component. Several months following the revision, a single journal article indicating a similar problem at another institution with the same device was published. A year later, two additional articles appeared in the literature. One year later, the femoral device originally implanted in R.P. was removed from the market.
PMID: 20439699
ISSN: 1535-1386
CID: 3459472