Common Orthopedic Surgeries Research Articles

P58. Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery

BACKGROUND CONTEXT 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. PURPOSE Investigate the rates of PD in elective orthopedic procedures. STUDY DESIGN/SETTING Retrospective review of the National Inpatient Database 2007-2013. PATIENT SAMPLE A total of 15,434,393 weighted hospital discharges. OUTCOME MEASURES Rates of PD, post-operative complications, length of stay (LOS), cost to charge (CCR), discharge location, and death. METHODS Inclusion criteria: elective orthopedic surgery procedures from 2007-2013 as defined by ICD-9-CM codes. Exclusion criteria: emergency, trauma, or non-elective surgery. Patients were grouped as shoulder, elbow, hand, spine, hip, knee, or foot/ankle. Descriptive statistics assessed demographics. Rates of DSM-IV PD, as classified by single-level CCS – diagnoses, and perioperative complications, were assessed for each orthopedic group.Logistic regression analysis assessed PD as a predictor of complications, extended LOS (LOS above 75th percentile), higher cost to charge ratio (CCR above 75th percentile), unfavorable discharge (not routine discharge), and death during hospitalization. RESULTS A total of 4,528,121/15,434,393 discharges (age: 61.02 ± 15.48, female: 57%, CCI: 0.91 ± 1.28) included in the analysis had PD. For all elective spine surgery patients, the overall rate of PD increased from 2007-2013 (32.3%, 33.8%, 34.6%, 37.1%, 37.2%, 39.1%, 40.7%, p CONCLUSIONS Psychiatric diagnoses have an immense impact on the treatment and outcomes of patients undergoing elective orthopedic procedures. Afflicted patients are more likely to have higher cost surgeries, extended length of stays, and death during their admission. More discussion is warranted on the possible utility of preoperative mental health treatment for these patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

La prothèse de hanche infectée : le point de vue du médecin

Total hip replacement is one of the most common orthopaedic surgeries, and its most frequent indication is osteoarthritis. Prosthetic Hip infection (PHI) can occur in 1 to 1.5 percent of cases. Some risk factors have been identified (modifiable or not), such as obesity, diabetes, corticosteroids, malnutrition, anemia, or smoking. These risk factors must be screened before surgery, and be corrected preoperatively to decrease the risk. Sometimes surgery must be delayed or abandoned. Prescription of some of our chronic inflammatory rheumatism patients’ immunosuppressive drugs must be modified and steroids prescription must be lowered under 10mg per day. PHI treatment is based on 2 axes: surgery and antibiotic therapy. In this paper we describe the most important molecules the rheumatologist has to know in correlation with the most frequent microorganism found in prosthesis infections, and how to deal with immunosuppressive drugs we usually prescribe to our RA patients.

Comparison of opioid use and prescribing patterns in orthopedic surgery in Japan and the United States: A JOA-AOA Traveling Fellowship Investigation

BackgroundThe US continues to be in the midst of an opioid epidemic. The prescription of narcotics for acute injury or post-operative pain is a common inciting event leading to opioid abuse and addiction. It is eminently important for orthopedic surgeons to lead the charge in changing practice patterns to decrease the prescribing and subsequent use and abuse of opioids. Anecdotally, many surgeons are aware that use of opioids for post-operative pain is substantially less in other countries compared to the US. However, this has not been well quantified and may be useful information to guide practice. MethodsThe 2018 American Orthopedic Association (AOA)– Japanese Orthopedic Association (JOA) traveling fellows developed a survey to compare orthopedic surgeon-reported opioid prescribing patterns after various common orthopedic surgeries in Japan and the US. ResultsWe present here survey data demonstrating significantly less post-operative prescription of opioids in Japan in terms of number of pills provided and duration of prescriptions compared to orthopedic surgeons in the US. ConclusionWe hope this provides meaningful data to motivate orthopedic surgeons in the US to evaluate and potentially alter their own prescription habits to help mitigate the opioid crisis.

Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction: THE GRAFT OF THE FUTURE!

Anterior cruciate ligament (ACL) reconstruction is one of the most common orthopaedic surgeries performed on active people in the world. One of the most important surgical decisions is graft type for use in the reconstruction. Despite extensive research on optimal graft choice for ACL reconstruction, discrepancy exists among practicing surgeons' graft preference. Recently, the quadriceps tendon has gained popularity for use as a graft source for ACL reconstruction.The all soft tissue quadriceps graft offers many advantages over other autograft choices. Histologically it has 20% more collagen fibrils per cross-sectional area than the patellar tendon (PT). Biomechanically, its ultimate load is 70% > than that of a similar width PT graft, while its modulus is more similar to the native ACL than either the PT or hamstring graft. Anatomically the quadriceps tendon has significantly more volume than the PT. Thus, even after harvest of the quadriceps graft, the remaining quadriceps tendon is still 80% stronger than the intact PT!The length and cross-sectional area of the quadriceps tendon graft can be tailored to the needs of the patient. On any patient over 5 feet tall, a graft length of 7 cm can be obtained. Because the thickness of the tendon is almost twice the thickness of the same patient's PT, a graft diameter from 7 to 11 mm can easily be achieved. Thus, this graft can be customized for both primary and revision surgeries.Harvest site morbidity is minimal. An incision less than 2 cm in an area with no significant cutaneous nerves without harvest of any patella bone leads to no significant harvest site pain, numbness, or palpable defect.Clinical outcomes using this graft are excellent. Our prospective data on nearly 1,000 grafts, with a mean patient age of 20 years old, show a 4.2% failure rate. Thus, the all soft tissue quadriceps graft will be the surgical choice for ACL reconstruction for future athletes.

Live Music Therapy During Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial.

Total knee arthroplasty (TKA) is a common orthopedic surgery known to be very painful. Emphasis has been placed on TKA pain management for postoperative care and during rehabilitation. Music therapy is used as a nonpharmacologic intervention for pain management and to promote rehabilitation exercise adherence. The objective of this study was to explore the effects of music therapy/physical therapy co-treatment using live music-supported exercise on pain and exercise adherence during a lower extremity pedaling exercise to facilitate range of motion (ROM). The researcher randomized 32 TKA inpatient rehabilitation participants to an intervention or control group. Following baseline measures, two study intervals occurred with the intervention group receiving live music for the first interval followed by no music during the second interval; the control group received no music during both intervals. Self-reported pain measures, observed pain measures, and observed measures of pedaling adherence were collected for each participant. A mixed analysis of variance (ANOVA) with repeated measures showed no significant effects for self-reported pain perception. For observed pain, ANOVA results did show a significant interaction (p < .05) between group and study interval. There were no statistically significant effects for pedaling adherence. Conclusions show an important role for live music therapy intervention on observed pain while engaged in co-treatment during this lower extremity ROM exercise. Additional implications and limitations are discussed.

Possible Risk Factors for Severe Complications Occurring after Primary Total Knee Arthroplasty

ObjectiveTotal knee arthroplasty is one of the most common orthopedic surgeries. Readmission due to severe complications after total knee arthroplasty is a grave concern to surgeons. In this study, we evaluated the risk factors for severe complications after primary total knee arthroplasty. MethodsWe retrospectively collected clinical data of 2,974 patients who underwent primary total knee arthroplasty from July 2013 to June 2019 in our hospital. Postoperative complication > grade IE was defined as severe complication according to Clavien-Dindo classification system. Binary logistic regression was used to identify the predictive risk factors for severe complications. ResultsThe complication rate after primary total knee arthroplasty was 6.8% and severe complication rate was 2.5%. Male (OR = 2.178, 95%CI: 1.324-3.585, P = 0.002), individuals above 75 years old (OR = 1.936, 95%CI: 1.155-3.244, P = 0.012), arrhythmia (OR = 2.913, 95%CI: 1.350-6.285, P = 0.006) and cerebrovascular disease (OR = 2.804, 95%CI: 1.432-5.489, P = 0.003) were predictive risk factors for severe complications after primary total knee arthroplasty. ConclusionAdvanced age, male, arrhythmia, and cerebrovascular disease might be patients-related risk factors for postoperative severe complications after primary total knee arthroplasty. Special attention should be paid to patients with risk factors.

Appropriateness and pharmacoeconomics of surgical antimicrobial prophylaxis in open reduction internal fixation surgery practiced in a tertiary hospital compared to recommendations in the national center for disease control guidelines.

Context:Surgical site infections are frequently observed despite the availability of national guideline on surgical antimicrobial prophylaxis (SAP). These infections increase patient morbidity, mortality, and direct and indirect health-care costs. Open reduction internal fixation (ORIF) is a common orthopedic surgery for fracture. There is a paucity of Indian data on SAP in ORIF surgery.Aims:The present study was taken up aiming at the evaluation of appropriateness and pharmacoeconomics of SAP in ORIF based on the national guidelines.Subjects and Methods:One-year observational prospective cohort study was conducted among 412 participants, who underwent ORIF in the Department of Orthopedics in a Tertiary Care Hospital. Name, dose, route, timing, frequency, and duration of administration of prophylactic antimicrobials used were recorded.Statistical Analysis Used:Descriptive statistics were used wherever required.Results:The mean age of participants was 39.24 years, majority (60.92%) were male, and 49.52% had fracture of lower-limb bones. The appropriateness of preoperative SAP in terms of indication in ORIF, timing, and route of administration was 100%. Selection and dose of preoperative and postoperative antimicrobials were appropriate in only 13% of cases. Omission of intraoperative dose was appropriate in all participants. Duration of postoperative Antimicrobial agent administration was inappropriately long in all participants. None of the cases received completely appropriate regimen. Cost analysis showed the mean cost of SAP practiced in our hospital was eleven times higher than that with recommended SAP.Conclusions:Considering the inappropriateness of SAP practiced, monitoring of guideline implementation and awareness among health-care professionals are necessary to prevent SSI and to decrease economic burden on the patients.

Performance Outcomes and Return-to-Sport Rate of National Hockey League Athletes Vary After Common Orthopedic Surgical Procedures.

Evaluate performance-based outcomes and return-to-sport rate in National Hockey League (NHL) athletes. Retrospective cohort study. Public records. No direct patient care was provided. National Hockey League athletes who underwent different orthopedic procedures were identified using public records. Three hundred thirty-seven athletes met inclusion criteria. Common orthopedic surgical procedures in NHL athletes. Return-to-play and preoperative and postoperative performance measures were collected to calculate a position-specific performance score. Short-term and medium-term outcomes were defined as 1 and 2 to 3 seasons after surgery, respectively. Three hundred seven athletes (92.6%) successfully returned to play. The number of games played during the first season after surgery compared with baseline was significantly decreased for hip arthroscopy (HA), noninstability shoulder arthroscopy (ie, shoulder arthroscopy procedure to address pathology other than shoulder instability), knee arthroscopy, and sports hernia repair (P = 0.002, 0.009, 0.03, and 0.01, respectively). The number of games played for seasons 2 and 3 after surgery was significantly decreased for both HA and noninstability shoulder arthroscopy (P = 0.01 and 0.001, respectively). Short-term postoperative performance scores were significantly decreased for HA, noninstability shoulder arthroscopy, and anterior cruciate ligament reconstruction (P = 0.00004, 0.02, and 0.02, respectively) while medium-term scores were significantly decreased for HA only (P = 0.009). National Hockey League athletes return to play at a high rate after common orthopedic surgeries. However, certain procedures portend poorer performance scores and game participation than others. In particular, HA and noninstability shoulder arthroscopy have the greatest negative effect on NHL careers after surgery.

Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: results obtained using the RAND/UCLA Appropriateness Method.

BackgroundIndwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use.ObjectiveUsing the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures.MethodsTwo multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness.ResultsAppropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1–4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures.ConclusionWe defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures.

Does the Surgeon-reported Outcome Correlate with Patient-reported Outcome after Total Knee Arthroplasty? A Cohort Study.

Background:Total knee arthroplasty (TKA) has been proved to be a successful and cost-effective treatment for improving pain and function in patients with knee arthritis. Total knee arthroplasty (TKA) is one of the most common orthopaedic surgeries performed worldwide and advancement in surgical techniques and prosthetic designs have improved the patient outcomes. However, concerns and priorities of patients and surgeons relating to joint replacement may differ.Materials and Methods:306 TKAs in 223 patients were evaluated for functional outcome using surgeon reported American Knee Society Knee Score (KS)/Functional Score (FS) and patient-reported Oxford Knee Score (OKS). We have also assessed the correlation between FS and OKS at midterm follow up.Results:The mean preoperative KS, FS, and OKS in 223 patients were 42.76, 42.4, and 38.84 and the midterm mean KS, FS, and OKS were 84.29, 73.40, and 30.26, respectively. There was a statistically significant improvement in the KS, FS, and OKS at midterm follow up in Category A (CAT A) (bilateral TKA or unilateral with asymptomatic contralateral knee), CAT B (unilateral TKA with symptomatic other knee) and CAT C (inflammatory arthritis). Overall, the correlation between the midterm FS and OKS was fair. However, in CAT A and CAT B, there was no significant correlation between FS and OKS, but CAT C had a strong correlation. There was a statistically significant improvement in the KS, FS, and OKS when midterm follow up scores were compared with preoperative scores. However, no significant correlation between the American knee society FS and OKS in osteoarthritic patients at midterm follow up signifies acceptable outcome may vary between patients and physicians.Conclusion:All patients should be counseled preoperatively to assess their expectations and sensitize them to information regarding the expected functional outcome following TKA in their cultural context.

Blood Flow Restriction Training: Current and Future Applications for the Rehabilitation of Musculoskeletal Injuries

Science continues to examine interventions to improve fitness, delay age-related decrements in physical function and facilitate healing and recovery after injury. These factors, or lack thereof, directly affect not only quality of life, but also the overall health care financial burden. With a surging population of seniors 65 years and older, which will swell to over 98 million by 2060, the need for interventions that may mitigate senescent changes could not be timelier. Orthopedic surgeons face many challenges in providing care to not only an aging population, but also to a younger subset that is highly active and engaged in a variety of high-impact sports. Therefore, interventions that can positively affect patient health-related outcomes from the time of injury throughout the rehabilitation process are highly warranted. This special issue will examine a novel but increasingly popular intervention, blood flow restriction (BFR) training. BFR training utilizes an automated pressure cuff placed on the proximal limbs to restrict blood flow and, when combined with light resistance exercise, produces a variety of positive physiological effects. BFR shows potential as an adjunct strategy postinjury or surgery to improve general physical conditioning, target muscle weakness around affected joints and hasten recovery. Moreover, BFR may also benefit the geriatric patient by mitigating age-related decrements in physical function. The following 6 articles will provide the reader with important information about the science, safety, and implementation of BFR training. From a health and safety perspective, Dr Loenneke and colleagues provide a thorough review of the mechanisms and science behind BFR training. Although the mechanisms are not fully understood, this paper serves as a well-crafted summary on current best evidence for the adaptations being seen via BFR. Similarly, Dr Cahalin and colleagues have expanded the review on safety to higher risk patients with hypertension. With the aging baby boomer population likely to continue to seek orthopedic care, this article describes what is currently published and the scientific understanding of applying BFR in the hypertensive patient. A primary concern during periods of disuse is the ensuing muscle atrophy that occurs. Dr Lambert and colleagues describe the potential ability of BFR to upregulate muscle protein metabolism and anabolic signaling to slow or reverse the catabolic postsurgery/injury state. Dr Hackney and colleagues discuss BFR as an intervention to mitigate age-related muscle loss (sarcopenia) and strength (dynapenia) within an aging population that can be implemented both preoperatively and postoperatively to hasten recovery following orthopedic procedures. Anterior cruciate ligament (ACL) reconstruction is a common orthopedic surgery. Dr Patterson and colleagues describe the application of BFR after ACL reconstruction. There are currently multiple clinical trials worldwide assessing the addition of BFR to ACL rehabilitation. This paper describes the rationale for the addition of BFR postsurgically, the state of the current evidence and a sample clinical protocol. Finally, Dr Bradner and colleagues have provided a thorough review on the reported side effects and safety of BFR. As this technique becomes more widespread, it is important for clinicians to understand the current applications, limitations, and safety considerations in order to effectively apply this modality to appropriate patients. Finally, we would like to thank all the authors for their time and contributions to this symposium.

Variability in Case Durations for Common Surgical Procedures.

Under the Merit-based Incentive Payment System, physician payment will be adjusted using a composite performance score that has 4 components, one of which is resource use. The objective of this exploratory study is to quantify the facility-level variation in surgical case duration for common surgeries to examine the feasibility of using surgical case duration as a performance metric. We used data from the National Anesthesia Clinical Outcomes Registry on 404,987 adult patients undergoing one of 6 general surgical or orthopedic procedures: laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram, knee arthroscopy, laminectomy, and total hip replacement. We constructed separate mixed-effects multivariable time-to-event models (survival analysis) for each of the 6 procedures to model surgical case duration. We identified performance outliers, based on surgical case duration, using 2013 data and then quantified the gap between high- and low-performance outliers using 2014 data. After adjusting for patient risk, patients undergoing surgery at high-performance facilities were between 54% and 79% more likely to exit the operating room (OR) per unit time compared to average-performing facilities, depending on the procedure. For example, patients undergoing a laparoscopic appendectomy at high-performance facilities were 68% more likely to exit the OR per unit time (hazard ratio, 1.68; 95% CI, 1.40-2.02; P < .001) compared to average-performing facilities. Patients undergoing a laparoscopic appendectomy at low-performance facilities were 41% less likely to exit the OR per unit time (hazard ratio, 0.59; 95% CI, 0.47-0.74; P < .001) compared to average-performing facilities. The adjusted median surgical case duration for patients undergoing laparoscopic appendectomy was 69 minutes at high-performance centers and 92 minutes at low-performance centers. Similar results were obtained for the other procedures. There was wide variation in surgery case duration for patients undergoing common general surgical and orthopedic surgeries. This variability in care delivery may represent an important opportunity to promote more efficient use of health care resources.

To what extent do current total hip and knee replacement patient information resources adhere to enhanced recovery after surgery principles?

ObjectivesTotal hip replacement (THR) and total knee replacement (TKR) are two of the most common orthopaedic surgeries that occur in the United Kingdom (UK) annually. Enhanced recovery after surgery (ERAS) programmes aim to decrease convalescence across procedures. It has been highlighted that post operative physiotherapy routines may not contain the correct ingredients for promoting acceleration of return to function. This research aims to analyse if current THR and TKR patient information resources adhere to ERAS principles, thus optimising post operative recovery. Data sourcesTwenty hip and knee replacement patient information booklets were sourced using a UK Google search. A flowchart of exercise prescription components was formulated from a review of 5 trial booklets. A content analysis was utilised to assess the information included within the patient information booklets. ResultsForty percent of patient information booklets identified their pathways to be ERAS. Fifty five percent of the hospitals stated their patients would be mobilised on the day of surgery. Ninety percent of THR and 100% of TKR guidelines suggested the use of bed exercises for rehabilitation. Fifteen percent of THR and 35% of TKR booklets suggested functional exercise as a method of rehabilitation. Strength or resistance based exercises were proposed in 40% of THR and 55% of TKR booklets. ConclusionMany patient information booklets do not follow ERAS principles for fast-track rehabilitation and the exercise prescription procedure is non-specific. This must be considered within post operative rehabilitation in order to enhance recovery and reduce length of stay following THR or TKR surgery.

Defining the Key Parts of a Procedure: Implications for Overlapping Surgery

The American College of Surgeons' Statements on Principles requires attending surgeons to be present for the "key parts" of surgical procedures, but the term is not defined. The research question addressed in this study is whether a functional definition of the critical or key steps of common orthopaedic surgical procedures can be reliably constructed. We used the examples of hip and knee arthroplasty because these procedures are highly structured and divisible into distinct subroutines. We surveyed 100 experienced orthopaedic surgeons regarding whether particular steps in knee and hip arthroplasty procedures were considered "key." The patterns of individual surgeons' responses were compared among surgeons for overall reliability. The steps frequently cited as key were also identified. The agreement rates among surgeons for the definitions of the key parts of hip and knee arthroplasty were 3.2% and 8.6%, respectively. For both procedures, five steps were identified as key by >90% of the respondents. The agreement rate on what constitutes the key parts of hip and knee arthroplasty was poor, despite the fact that these are highly structured procedures. Accordingly, defining the key parts for a given procedure must rely on either the operating surgeon's discretion or a consensus definition. Imposing a single surgeon's standard on others is not the optimal approach because such a standard is likely to be idiosyncratic. A consensus standard articulated by the orthopaedic surgery community may be the best means for identifying the key parts of orthopaedic surgical operations. The data presented here suggest a foundation upon which a consensus definition for the key parts of arthroplasty procedures may be built.

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance

With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed. Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared. From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001). Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.

Time to Return to School Following 10 Common Orthopaedic Surgeries Among Children and Adolescents

Time to Return to School Following 10 Common Orthopaedic Surgeries Among Children and Adolescents

Local effect of zoledronic acid on new bone formation in posterolateral spinal fusion with demineralized bone matrix in a murine model.

Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n=10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n=10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10weeks after surgery. The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1-S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. A single local application of zoledronic acid with DBM puttyduring posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our results justify further investigations to potentially use local application of zoledronic acid in future clinical studies.

Evaluation of information available on the internet regarding reverse total shoulder arthroplasty.

Prior studies have analyzed the quality of information available on the Internet regarding common orthopaedic surgical procedures. The purpose of the present study was to evaluate the quality of information available for reverse total shoulder arthroplasty (rTSA). Websites were identified using the search term 'reverse total shoulder arthroplasty' and the first 50 websites from three separate search engines (Google, Yahoo, and Bing) were selected for evaluation of authorship and quality of information using the DISCERN instrument (www.discern.org.uk). After disregarding duplicated or overlapping websites within and among search engines, 90 of the total 150 websites were evaluated. A one-way analysis of variance test was used to compare differences in DISCERN scores between three categories of authorship (academic, private, other). The majority of the websites evaluated were authored by academic (43%) and private institutions (36%). These were the most credible sources, providing overall better quality and reliability than other sources. DISCERN reliable (p = 0.017) and overall scores (p = 0.020) were significantly higher for academic institutions compared to other websites. The information available on the Internet pertaining to reverse total shoulder arthroplasty is highly variable and provides moderate quality information about treatment choices with some limitations based on the DISCERN instrument.

Beneficial Effects of Childhood Selective Dorsal Rhizotomy in Adulthood.

Background: Selective dorsal rhizotomy (SDR) has been used to treat children with spastic cerebral palsy (CP) for over three decades. However, little is known about the outcomes of childhood SDR in adults. Objectives: 1) To study the effects of childhood SDR on the quality of life and ambulatory function in adult life. 2) To determine late side effects of SDR in adults. Methods: Adults (> 17.9 years) who underwent SDR in childhood (2 - 17.9 years) between 1987 and 2013 were surveyed in 2015. Patients completed a survey, including questions on demographic information, quality of life, health, surgical outcomes, motor function, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, work status, and side effects of SDR. Results: In our study population of 294 patients (18.0 - 37.4 years), patients received SDR during the ages of 2.0 - 17.9 years and were followed up 2.2 to 28.3 years after surgery. Eighty-four percent had spastic diplegia, 12% had spastic quadriplegia, and 4% had spastic triplegia. The majority (88%) of patients reported improved post-SDR quality of life and 1% considered the surgery detrimental. Most (83%) would recommend the procedure to others and 3% would not. However, patients who would not recommend SDR to others ambulated with a walker or were not ambulatory at all prior to SDR. The majority (83%) of patients improved (30%) or remained stable (53%) in ambulation. Twenty-nine percent of patients reported pain, mostly in the back and lower limbs, with a mean pain level of 4.4 ± 2.4 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in small areas of the lower limbs was reported by 8% of patients, though this did not affect daily life. Scoliosis was diagnosed in 28%, with 40% of these patients pursuing treatment. Whether scoliosis was related to SDR is not clear, though scoliosis is known to occur in patients with CP and also in the general population. Only 4% of patients underwent spinal fusion. Orthopedic surgeries were pursued by 59% of patients. The most common orthopedic surgeries were hamstring lengthenings (31%), Achilles tendon lengthenings (18%), adductor lengthenings (16%), and derotational osteotomies (16%). Twenty-four percent of all patients later underwent hip surgery and 8% had surgeries on their knees. Conclusion: Results of this study indicate that the beneficial effects of childhood SDR extend to adulthood quality of life and ambulatory function without late side effects of surgery.

Anesthesia for the patient undergoing total knee replacement: current status and future prospects.

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.