Difference In Reoperation Research Articles

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and longer-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. MethodsPatients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology (CPT) codes. Exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI).Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. One-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. ResultsIn total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354 respectively.Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (p<0.0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (p<0.0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and ConclusionFibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in one-year revisions.

No Difference in 10-year Clinical or Radiographic Outcomes Between Kinematic and Mechanical Alignment in TKA: A Randomized Trial.

There is continuing debate about the ideal philosophy for component alignment in TKA. However, there are limited long-term functional and radiographic data on randomized comparisons of kinematic alignment versus mechanical alignment. We present the 10-year follow-up findings of a single-center, multisurgeon randomized controlled trial (RCT) comparing these two alignment philosophies in terms of the following questions: (1) Is there a difference in PROM scores? (2) Is there a difference in survivorship free from revision or reoperation for any cause? (3) Is there a difference in survivorship free from radiographic loosening? Ninety-nine patients undergoing primary TKA for osteoarthritis were randomized to either the mechanical alignment (n = 50) or kinematic alignment (n = 49) group. Eligibility for the study was patients undergoing unilateral TKA for osteoarthritis who were suitable for a cruciate-retaining TKA and could undergo MRI. Patients who had previous osteotomy, coronal alignment > 15° from neutral, a fixed flexion deformity > 15°, or instability whereby constrained components were being considered were excluded. Computer navigation was used in the mechanical alignment group, and patient-specific cutting blocks were used in the kinematic alignment group. At 10 years, 86% (43) of the patients in the mechanical alignment group and 80% (39) in the kinematic alignment group were available for follow-up performed as a per-protocol analysis. The PROMs that we assessed included the Knee Society Score, Oxford Knee Score, WOMAC, Forgotten Joint Score, and EuroQol 5-Dimension score. Kaplan-Meier analysis was used to assess survivorship free from reoperation (any reason) and revision (change or addition of any component). A single blinded observer assessed radiographs for signs of aseptic loosening (as defined by the presence of progressive radiolucent lines in two or more zones), which was reported as survivorship free from loosening. At 10 years, there was no difference in any PROM score measured between the groups. Ten-year survivorship free from revision (components removed or added) likewise did not differ between the groups (96% [95% CI 91% to 99%] for the mechanical alignment group and 91% [95% CI 83% to 99%] for the kinematic alignment group; p = 0.38). There were two revisions in the mechanical alignment group (periprosthetic fracture, deep infection) and four in the kinematic alignment group (two secondary patella resurfacings, two deep infections). There was no statistically significant difference in reoperations for any cause between the two groups. There was no difference with regard to survivorship free from loosening on radiographic review (χ2 = 1.3; p = 0.52) (progressive radiolucent lines seen at 10 years were 0% for mechanical alignment and 3% for kinematic alignment). Like the 2-year and 5-year outcomes previously reported, 10-year follow-up for this RCT demonstrated no functional or radiographic difference in outcomes between mechanical alignment and kinematic alignment TKA. Anticipated functional benefits of kinematic alignment were not demonstrated, and revision-free survivorship at 10 years did not differ between the two groups. Given the unknown long-term impact of kinematic alignment with regard to implant position (especially tibial component varus), we must conclude that mechanical alignment remains the reference standard for TKA. We could not demonstrate any advantage to kinematic alignment at 10-year follow-up. Level I, therapeutic study.

Periprosthetic joint infection of the hip.

The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality. Patients undergoing one- or two-stage revision of a primary THA for PJI between January 2008 and January 2021 were identified. Age, sex, BMI, American Society of Anesthesiologists grade, Charlson Comorbidity Index (CCI), McPherson systemic host grade, and causative organism were collated for all patients. PJI was classified as 'confirmed', 'likely', or 'unlikely' according to the 2021 European Bone and Joint Infection Society criteria. Primary outcomes were complications, reoperation, re-revision, and successful treatment of PJI. A total of 37 patients aged 80 years or older and 120 patients aged under 80 years were identified. The octogenarian group had a significantly lower BMI and significantly higher CCI and McPherson systemic host grades compared to the younger cohort. The majority of patients were planned to undergo two-stage revision, although a significantly higher proportion of the octogenarians did not proceed with the second stage (38.7% (n = 12) vs 14.8% (n = 16); p = 0.003). Although there was some evidence of a lower complication rate in the younger cohort, this did not reach statistical significance (p = 0.065). No significant difference in reoperation (21.6% (n = 8) vs 25.0% (n = 30); p = 0.675) or re-revision rate (8.1% (n = 3) vs 16.7% (n = 20); p = 0.288) was identified between the groups. There was no difference in treatment success between groups (octogenarian 89.2% (n = 33) vs control 82.5% (n = 99); p = 0.444). When compared to a younger cohort, octogenarians did not show a significant difference in complication, re-revision, or treatment success rates. However, given they are less likely to be eligible to proceed with second stage revision, consideration should be given to either single-stage revision or use of an articulated spacer to maximize functional outcomes.

Safety of gastric bypass with same-day discharge: a propensity score-matched analysis of the Dutch Audit for treatment of Obesity

BackgroundBariatric surgery with same-day discharge (SDD) is becoming increasingly common. Nevertheless, there is limited data available comparing gastric bypass patients with SDD to those with overnight hospitalization. ObjectiveThe aim of this study was to investigate the short-term outcomes of gastric bypass with SDD compared to overnight hospitalization in The Netherlands. SettingRetrospective database study with the use of the Dutch national registry. MethodsPatients who underwent gastric bypass surgery in 2022 were included and propensity score matching was performed to compare SDD with patients discharged on postoperative days (POD) 1-4. The primary outcome was the occurrence of severe complications within 30 days postoperative. ResultsA total of 775 SDD patients were matched with 1550 patients discharged on POD 1-4. The occurrence of severe complications was .9% in both groups (P = 1.000), and there were no significant differences in reoperations or mortality. A significant difference was observed in the readmission rate, with 3.9% in the SDD group compared to 1.6% in the other group (P = .001). A proportionally small, yet statistically significant difference favored the control group regarding anastomotic leakages (.6% versus 0%, P = .004) and unspecified surgical complications (1.4% versus .5%, P = .028). ConclusionGastric bypass with SDD is safe, with no increased risk of short-term severe complications, reoperations, or mortality. However, SDD is associated with a higher 30-day readmission rate compared to patients who stay overnight in the hospital after surgery.

Does Bone Morphogenetic Protein Use Reduce Pseudarthrosis Rates in Single-Level Transforaminal Lumbar Interbody Fusion Surgeries?

Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown. To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP. This was a retrospective cohort study conducted at a single academic institution. Adults undergoing primary single-level TLIF with a minimum of 1 year of clinical and radiographic follow-up were included. BMP use was determined by operative notes at index surgery. Non-BMP cases with iliac crest bone graft were excluded. Pseudarthrosis was determined using radiographic and clinical evaluation. Bivariate differences between groups were assessed by independent t test and χ 2 analyses, and perioperative characteristics were analyzed by multiple logistic regression. One hundred forty-eight single-level TLIF patients were included. The mean age was 59.3 years, and 52.0% were women. There were no demographic differences between patients who received BMP and those who did not. Pseudarthrosis rates in patients treated with BMP were 6.2% vs 7.5% in the no BMP group (P = 0.756). There was no difference in reoperation for pseudarthrosis between patients who received BMP (3.7%) vs those who did not receive BMP (7.5%, P = 0.314). Patients who underwent revision surgery for pseudarthrosis more commonly had diabetes with end-organ damage (revised 37.5% vs not revised 1.4%, P < 0.001). Multiple logistic regression analysis demonstrated no reduction in reoperation for pseudarthrosis related to BMP use (OR 0.2, 95% CI 0.1-3.7, P = 0.269). Diabetes with end-organ damage (OR 112.6,95% CI 5.7-2225.8, P = 0.002) increased the risk of reoperation for pseudarthrosis. BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis. BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

Total Ankle Arthroplasty Polyethylene Wear Varies with Implant Type and Mode of Failure

Introduction/Purpose: Polyethylene wear is a concern for failure of any joint replacement, including total ankle arthroplasty (TAA). Heterogeneity in bearing surface design among current TAA systems show no clear solution to the competing objectives of function (constraint and kinematics) and wear (contact stresses). Literature has begun to investigate polyethylene wear and damage; however, a comprehensive understanding of polyethylene wear patterns in vivo and location remains unknown. This study aims to quantify the type and severity of differing damage modes on the polyethylene insert from retrieved TAA prostheses following reoperation or revision. We hypothesized that polyethylene wear amount will be greater in TAAs that underwent revisions rather than reoperation, and that wear would vary between implants based on extent of constraint. Methods: This is a retrospective study of TAA patients (2007-2021) who underwent revision (removal of polyethylene and tibial and/or talar components) or reoperation (removal of polyethylene only) following primary TAA with a symmetric bicondylar (SB) implant with more constraint or an asymmetric bicondylar (AB) implant with less constraint. Demographics and surgical data were recorded. Retrieved polyethylene inserts were examined microscopically to characterize wear patterns according to a standardized protocol. Polyethylenes were divided into four regions on both the articular and backside surfaces: 1) lateral anterior, 2) lateral posterior, 3) medial anterior, and 4) medial posterior. Each region was graded by two independent raters on a scale of 0-3 based on severity for each of the following damage modes: 1) burnishing, 2) pitting, 3) scratching, 4) third body debris, 5) abrasion, 6) surface deformation, and 7) delamination. We assessed associations between polyethylene wear pattern and severity with implant type, revision, and reoperation. Results: 55 TAAs underwent revision (n=28) or reoperation (n=27). 30 (55%) ankles had primary TAA with AB implants (Salto Talaris) and 25 (45%) with SB implants (Inbone/Infinity) (Table 1). SB cohort had a shorter mean in-body duration (time from polyethylene implant to polyethylene explant) versus AB cohort (P=0.011). SB cohort had significantly greater overall polyethylene damage severity (P=0.007) and greater damage severity in all articular regions versus AB (P≤0.035 for all). Burnishing was significantly greater in SB versus AB (P &lt; 0.001). TAAs that underwent revision had significantly greater overall damage severity versus reoperation (P=0.005), with significantly greater damage severity on articular medial posterior (P=0.003), lateral anterior (P=0.001), and lateral posterior (P=0.004) regions. Scratching (P=0.005), pitting (P &lt; 0.001), and third body debris (P=0.036) were significantly greater in revision TAAs. Conclusion: While damage modes between SB and AB total ankle implants were similar, ankles with primary SB implants exhibited greater overall polyethylene damage severity in comparison to AB implants, despite being in-body for a shorter duration. In accordance with existing literature for total knee arthroplasty, this may suggest increased polyethylene damage severity with increased constraint. Irrespective of time in-body, failure for revision was associated with greater polyethylene damage than reoperation. This study provides the foundation for additional analyses to investigate radiographic alignment, mode of failure, and, ultimately, the association between polyethylene wear, peri-implant cysts and lucency, and TAA failure. Table 1 Patient demographics, revision, reoperation, and polyethylene in-body duration for the two patient cohorts: Patients with primary TAA with a symmetric bicondylar (SB) implant with more constraint and patients with primary TAA with an asymmetric bicondylar (AB) implant with less constraint. Values are expressed as means ± standard deviation for continuous variables, and frequencies with percentages for categorical variables. P-values reflect chi-square analyses and t tests between the two cohorts for categorical variables and continuous variables, respectively. SB cohort had significantly lower percentage of females, higher body weight, and shorter in-body duration. There was no significant difference in reoperations and revisions between the two groups.

Long-Term Performance of Mechanical and Biological Prostheses in Young Rheumatics aged below 45 years undergoing Combined Mitral and Aortic Valve Replacements: A Propensity-Matched Study

Background and Aim: We compared 23-year composites of valve-related reoperation, morbidity, and mortality following combined mitral and aortic mechanical and bioprostheses in young rheumatics aged &lt;45years. Methods: Retrospective comparative analysis of valve-related reoperations and survival data were performed from 498 consecutive propensity matched patients undergoing either bioprosthetic MVR (Group I, n=249) or mechanical MVR (Group II, n=249) between 1998 and 2022. Results: The median age was 33 (IQR: 27-40) and 33 (IQR: 28-39) years for Group I and II respectively. The median follow-up was 134 months (IQR: 99.5-178.5) with 5281.8 patient-years data in both biological and mechanical arm. Bioprosthetic arm exhibited lesser cumulative mortality (3.6% vs 4.8%, SMD= -0.18, p=0.01). Hazard regression for mortality included (HR, 95% CI) included preoperative CHF on inotropes and ventilator 9.84 (4.54, 18.64), p&lt;0.001, renal failure requiring peritoneal/hemodialysis 11.64, (6.57, 20.64), p&lt;0.001, atrial fibrillation 3.83 (1.63, 8.98), p&lt;0.002, reoperation for thrombosed mechanical and degenerated bioprostheses 5.38, (3.09, 9.35), p&lt;0.001, previous operation 3.53, (1.93, 6.45), p&lt;0.001, poor left ventricular function 4.25, (2.29, 7.88), p&lt;0.001, prolonged aortic clamp time 3.84, (2.19, 6.78), p&lt;0.001, and prolonged CPB time 2.69, (1.84, 8.68), p&lt;0.001. Propensity score matching did not exhibit any difference in reoperation between two groups (Group I vs Group II: 13.6% vs 17.6%, SMD= -0.110, p=0.21). At a median follow-up of 134 months (IQR: 99.5-178.5) months, actuarial survival was 92.3%±0.02% (group I vs 96.6%+0.01%) and there was no difference between the groups (p=0.90). Conclusions: Bioprostheses are an acceptable alternative to mechanical prostheses in young rheumatics aged &lt;45 years undergoing mitral and aortic valve replacements unwilling for mechanical valve, redo surgeries, life-long anticoagulation, and those desirous of pregnancy.

Influence of instrumentation type on outcomes after surgical management of spondylodiscitis: a systematic review and meta-analysis.

Spondylodiscitis refers to infection of the intervertebral disk and neighboring structures. Outcomes based on instrumentation type are not well reported in the literature, but are important in establishing guidelines for surgical management of spondylodiscitis. This study aims to clarify the effect of instrumentation material selection on clinical and radiographic outcomes in patients with spondylodiscitis. Studies that evaluated the use of polyetheretherketone (PEEK), titanium, allograft, and/or autologous bone grafts for spondylodiscitis were identified in the literature. Radiographic and clinical data were analyzed using a meta-analysis of proportions, with estimated risk and confidence intervals reported for our primary study outcomes. Thirty-two retrospective studies totaling 1088 patients undergoing surgical management of spondylodiscitis with PEEK, TTN, allograft, and autologous bone graft instrumentation were included. There were no differences in fusion rates (p-interaction = 0.55) with rates of fusion of 93.4% with TTN, 98.6% with allograft, 84.2% with autologous bone graft, and 93.9% with PEEK. There were no differences in screw loosening (p-interaction = 0.52) with rates of 0.33% with TTN, 0% with allograft, 1.3% with autologous bone graft, and 8.2% with PEEK. There were no differences in reoperation (p-interaction = 0.59) with rates of 2.64% with TTN, 0% with allograft, 1.69% with autologous bone graft, and 3.3% with PEEK. This meta-analysis demonstrates that the choice of instrumentation type in the surgical management of spondylodiscitis resulted in no significant differences in rate of radiographic fusion, screw loosening, or reoperation. Future comparative studies to optimize guidelines for the management of spondylodiscitis are needed.

Intramedullary Nails vs Open Reduction in Internal Fixation for Humeral Shaft Fractures: A Meta-Analysis of Randomized Control Trials.

The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction and internal fixation (ORIF) of humeral shaft fractures. A literature search of three databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using Revman. P value < 0.05 was considered to be statistically significant. Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients with ORIF had a non-union (p = 0.57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs 11.9 weeks , p < 0.05). There was no significant difference in re-operations (11.6% IMN vs 7.6% ORIF, p = 0.26) or radial nerve palsies (2.8% IMN vs 4.2% ORIF, p = 0.58). A lower rate of infection was noted with IMN (1.2% vs 5.3%, p < 0.5). Additionally, there was a lower operative time with IMN (61 minutes vs 88 minutes, p < 0.05). The level I evidence in the literature does not show a significant difference in union rates, re-operations or radial nerve palsies between IMN and ORIF for humerus shaft fractures. Overall, treatment with IMN results in lower infection rates, less operative time, and modestly quicker time to union. Optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.

Longer Screws Decrease the Risk of Radiographic Pseudarthrosis Following Elective Anterior Cervical Discectomy and Fusion.

Retrospective cohort study. In patients undergoing elective anterior cervical discectomy and fusion (ACDF), we sought to determine the impact of screw length on: (1) radiographic pseudarthrosis, (2) pseudarthrosis requiring reoperation, and (3) patient-reported outcome measures (PROMs). A single-institution, retrospective cohort study was undertaken from 2010-21. The primary independent variables were: screw length (mm), screw length divided by the anterior-posterior vertebral body diameter (VB%), and the presence of any screw with VB% < 75% vs all screws with VB% ≥ 75%. Multivariable logistic regression controlled for age, BMI, gender, smoking, American Society of Anesthesiology grade, number of levels fused, and whether a corpectomy was performed. Of 406 patients undergoing ACDF, levels fused were: 1-level (39.4%), 2-level (42.9%), 3-level (16.7%), and 4-level (1.0%). Mean screw length was 14.3 ± 2.3mm, and mean VB% was 74.4 ± 11.2. A total of 293 (72.1%) had at least one screw with VB% < 75%, 113 (27.8%) had all screws with VB% ≥ 75%, and 141 (34.7%) patients had radiographic pseudarthrosis at 1-year. Patients who had any screw with VB% < 75% had a higher rate of radiographic pseudarthrosis compared to those had all screws with VB% ≥ 75% (39.6% vs 22.1%, P < .001). Multivariable logistic regression revealed that a higher VB% (OR = .97, 95%CI = .95-.99, P = .035) and having all screws with VB% ≥ 75% (OR = .51, 95%CI = .27-.95, P = .037) significantly decreased the odds of pseudarthrosis at 1-year, with no difference in reoperation or PROMs (all P > .05). Longer screws taking up ≥75% of the vertebral body protected against radiographic pseudarthrosis at 1-year. Maximizing screw length in ACDF is an easily modifiable factor directly under the surgeon's control that may mitigate the risk of pseudarthrosis.

Outcomes of geriatric periprosthetic distal femur fractures: comparison of fixation versus reconstruction.

Comparing outcomes of periprosthetic distal femur fractures treated with open reduction internal fixation (ORIF) versus distal femoral replacement (DFR). Three major academic hospitals within one metropolitan area. Retrospective. 370 patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs 50 DFR). ORIF with locked plating versus DFR. One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions. No differences were seen between ORIF and DFR cohorts with respect to demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs 9.08 days DFR, p<0.001) and more frequent blood transfusion (12.3% ORIF vs 44.0% DFR, p<0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1-year, or 1-year mortality between the two cohorts. Lastly, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment. Rehospitalization, reoperation, ambulatory status and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

SP9.9 Protocolised Care Pathways in Emergency General Surgery: A systematic review and meta-analysis

Abstract Background Emergency abdominal surgery is associated with significant post-operative morbidity and mortality. The delivery of standardised pathways in this setting may have the potential to transform clinical care and improve patient outcomes. Methods The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. Comparative studies reporting on care pathways in emergency laparotomy in adult patients were included. Risk of bias was assessed using the ROBINS-I for non-randomised studies and the RoB-2 for randomised controlled trials. Meta-analysis was performed using a random effects model. Results Seventeen studies consisting of 20,927 patients were included, with 12,359 patients undergoing protocolised care pathways and 8,568 patients undergoing standard care pathways. Thirteen unique protocolised pathways were identified, with a median of 8 components (range 6 – 15), with variable compliance of 24-100%. Protocolised care pathways were associated with a shorter hospital stay compared to standard care pathways (SMD -2.028, 95% CI -3.28 – -0.88, p = &amp;lt;0.01). Protocolised care pathways were associated with reduced mortality (OR 0.78, 95% CI 0.71 – 0.86, p&amp;lt;0.00001)) and morbidity (OR 0.80, 95% CI 0.649 – 0.94, p=0.005), including post-operative pneumonia (OR 0.43 95% CI 0.29 – 0.64, p&amp;lt;0.0001) and surgical site infection (OR 0.43, 95% CI 0.29 -0.65, p&amp;lt;0.0001). There were no observed differences in re-operation (OR 1.24, 95% CI 0.72 – 2.16, p=0.44) or readmission rates (OR 1.15, 95% CI 0.83 – 1.59, p=0.41). Discussion Protocolised care pathways in the emergency setting currently lack standardisation, however, despite this are associated with short-term clinical benefits.

Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score–Matched Analysis

BackgroundBoth valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. MethodsA consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. ResultsThe CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. ConclusionsBoth valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.

Poster 187: Similar Clinical and Patient Recorded Outcomes Amongst Older Patients over 65 Years of Age Compared to Younger Patients undergoing Arthroscopic Rotator Cuff Repair

Objectives: The purpose of our study was to determine if patients 65 years and over meet the minimally clinical important difference (MCID) for Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS-UE), Depression (PROMIS-D), and Pain Interference (PROMIS-PI) at similar rates compared to a cohort of younger patients. Methods: A retrospective review of a prospectively collected database of patients undergoing RCR was performed. Patients with completed preoperative and 6-month follow up postoperative PROMIS scores were included. A cohort of 65 years and older (65&lt;) was compared to a cohort of 64 years and younger (64&gt;=) in terms of their clinical outcomes and PROMIS scores. A propensity matched analysis was then performed, which matched patients 65+ years old 1:1 to a cohort of 50 years or younger via tear size and body mass index (BMI). Results: A total of 318 patients were included with 79 patients ≥ 65 years (69.2 ± 3.4 years, mean ± SD) and 239 patients &lt;65 years (55.1 ± 3.4 years). No significant differences were found in terms of gender, tear thickness, tear size, reoperation rate, retear rate, preoperative PROMIS-UE, PROMIS-PI, and PROMIS D scores, or change in postoperative PROMIS-UE, PROMIS-PI, and PROMIS D after 6 months. In the sub-analysis, 44 patients over 65 years of age were propensity matched to 44 under 50 years of age. No differences were found in PROMIS-UE change, PROMIS-D change, proportion meeting MCID PROMIS UE, and proportion meeting MCID of PROMIS PI after 6 months. Patients in the 65+ years group experienced larger changes in PROMIS PI scores (12.5 ± 9.6 vs 7.2 ± 7.5, p=0.005) while fewer patients experienced significant declines in PROMIS D scores (26% vs 47%, p=0.03). Conclusions: Patients ≥ 65 years experience no differences in reoperation or retear rate when compared to younger patients. Older patients undergoing RCR were more likely to have a larger improvement in pain scores but were less likely to have significant clinical change in their depression scores. With proper patient selection, patients ≥ 65 years can achieve clinically significant improvements 6 months after RCR that is similar to their younger counterparts. [Table: see text][Table: see text][Table: see text]

Long-Term Outcomes of Bovine versus Porcine Mitral Valve Replacement: A Multicenter Analysis.

Recent national guidelines recommending mitral valve replacement (MVR) for severe secondary mitral regurgitation have resulted in an increased utilization of mitral bioprosthesis. There is a paucity of data on how longitudinal clinical outcomes vary by prosthesis type. We examined long-term survival and risk of reoperation between patients having bovine vs. porcine MVR. Study Design. A retrospective analysis of MVR or MVR + coronary artery bypass graft (CABG) from 2001 to 2017 among seven hospitals reporting to a prospectively maintained clinical registry was conducted. The analytic cohort included 1,284 patients undergoing MVR (801 bovine and 483 porcine). Baseline comorbidities were balanced using 1 : 1 propensity score matching with 432 patients in each group. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity, 30-day mortality, length of stay, and risk of reoperation. In the overall cohort, patients receiving porcine valves were more likely to have diabetes (19% bovine vs. 29% porcine; p < 0.001), COPD (20% bovine vs. 27% porcine; p=0.008), dialysis or creatinine >2 mg/dL (4% bovine vs. 7% porcine; p=0.03), and coronary artery disease (65% bovine vs. 77% porcine; p < 0.001). There was no difference in stroke, acute kidney injury, mediastinitis, pneumonia, length of stay, in-hospital morbidity, or 30-day mortality. In the overall cohort, there was a difference in long-term survival (porcine HR 1.17 (95% CI: 1.00-1.37; p=050)). However, there was no difference in reoperation (porcine HR 0.56 (95% CI: 0.23-1.32; p=0.185)). In the propensity-matched cohort, patients were matched on all baseline characteristics. There was no difference in postoperative complications or in-hospital morbidity and 30-day mortality. After 1 : 1 propensity score matching, there was no difference in long-term survival (porcine HR 0.97 (95% CI: 0.81-1.17; p=0.756)) or risk of reoperation (porcine HR 0.54 (95% CI: 0.20-1.47; p=0.225)). In this multicenter analysis of patients undergoing bioprosthetic MVR, there was no difference in perioperative complications and risk of reoperation of long-term survival after matching.

Rates of reoperation after breast conserving cancer surgery in Western Australia before and after publication of the SSO-ASTRO margins guideline.

A 2014 SSO-ASTRO guideline on surgical margins aimed to reduce unnecessary reoperation after breast conserving surgery (BCS). We investigate whether publication of the guideline was associated with a reduction in reoperation in Western Australia (WA). In this retrospective, population-based cohort study, cases of newly-diagnosed breast cancer were identified from the WA Cancer Registry. Linkage to the Hospital Morbidity Data Collection identified index BCS for invasive cancer between January 2009 and June 2018 (N=8059) and reoperation within 90 days. Pre-guideline (2009-2013) and post-guideline (2014-2018) reoperation proportions were compared, and temporal trends were estimated with generalised linear regression. The pre-guideline reoperation proportion was 25.8% compared with 21.7% post-guideline (difference -4.0% [95% CI -5.9, -2.2, p<0.001], odds ratio [OR] 0.80 [95% CI 0.72, 0.89, p<0.001]). Absolute reductions were similar for repeat BCS (16.3% versus 14.6%; difference -1.8% [95% CI -3.4, -0.2, p=0.03]) and conversion to mastectomy (9.4% versus 7.2%; difference -2.2% [95% CI -3.4, -1.0, p<0.001]). Over the study period, there was an annual absolute change in reoperation of -0.8% (95% CI -1.2, -0.5, p<0.001). Accounting for this linear trend, the difference in reoperation between time periods was -0.5% (95% CI -4.3, 3.3; p=0.81), reflecting a non-significant reduction in conversion to mastectomy. Comparisons of pre- versus post-guideline time periods in WA showed reductions in reoperation that were similar to international estimates; however, an annual decline in reoperation predated the guideline. Analyses that do not account for temporal trends are likely to overestimate changes in reoperation associated with the guideline.

A Multilingual Chatbot Can Effectively Engage Arthroplasty Patients Who Have Limited English Proficiency

BackgroundIn the United States, English language proficiency is widely accepted as a key social determinant of health. For patients with limited English proficiency (LEP), language barriers can make the delivery of perioperative instructions challenging. The purpose of this study was to evaluate whether a multilingual chatbot could effectively engage LEP patients and improve their outcome after total joint arthroplasty (TJA). MethodsWe identified 1,282 TJA patients (705 knees, 577 hips) who enrolled in a short message service (SMS) chatbot from 2020-2022. Forty-seven patients enrolled in the chatbot received their messages in a language other than English. A historical control of 68 LEP patients not enrolled in the chatbot was identified. Chi-squared, Fisher’s exact test, and t-tests were performed to measure the effect that conversational engagement had on emergency department (ED) visits, hospital readmissions, and reoperations. ResultsThere was no difference in the conversational engagement between LEP patients and those with English as their primary language (EPL) (12.3 versus 12.2 text responses, P = .959). The LEP cohort who enrolled in the chatbot had fewer readmissions (0% versus 8.3%, P = .013) and a near significant reduction in ED visits (0.9% versus 8.0%, P = .085) compared to those not enrolled. There was no difference in reoperations between the 2 cohorts. ConclusionLEP and EPL patients engaged equally with the multilingual chatbot. LEP patients who enrolled in the chatbot had fewer readmissions and a near significant reduction in ED visits. Multilingual platforms such as this chatbot may provide more equitable care to our frequently encountered LEP patients.

The cost of a plastic surgery team assisting with cranioplasty

ObjectivesCranioplasty is a commonly performed neurosurgical procedure that restores cranial anatomy. While plastic surgeons are commonly involved with cranioplasties, the cost of performing a cranioplasty with neurosurgery alone (N) vs. neurosurgery and plastic surgery (N + P) is unknown. MethodsA single-center, multi-surgeon, retrospective cohort study was undertaken on all cranioplasties performed from 2012 to 22. The primary exposure variable of interest was operating team, comparing N vs. N + P. Cost data was inflation-adjusted to January 2022 using Healthcare Producer Price Index as calculated by the US Bureau of Labor Statistics. Results186 patients (105 N vs. 81 N + P) underwent cranioplasties. The N + P group has a significantly longer length-of-stay (LOS) 4.5 ± 1.6days, vs. 6.0 ± 1.3days (p < 0.001), but no significant difference in reoperation, readmission, sepsis, or wound breakdown. N was significantly less expensive than N + P during both the initial cranioplasty cost ($36,739 ± $4592 vs. $41,129 ± $4374, p 0.014) and total cranioplasty costs including reoperations ($38,849 ± $5017 vs. $53,134 ± $6912, p < 0.001). Univariable analysis (threshold p = 0.20) was performed to justify inclusion into a multivariable regression model. Multivariable analysis for initial cranioplasty cost showed that sepsis (p = 0.024) and LOS (p = 0.003) were the dominant cost contributors compared to surgeon type (p = 0.200). However, surgeon type (N vs. N + P) was the only significant factor (p = 0.011) for total cost including revisions. ConclusionsHigher costs to N + P involvement without obvious change in outcomes were found in patients undergoing cranioplasty. Although other factors are more significant for the initial cranioplasty cost (sepsis, LOS), surgeon type proved the independent dominant factor for total cranioplasty costs, including revisions.

Comparison of true blood loss between short and long cephalomedullary nail fixation of geriatric hip fractures, a retrospective cohort study.

Existing literature is discrepant on the differences in blood loss and need for transfusion between short and long cephalomedullary nails used for extracapsular geriatric hip fractures. However, prior studies used the inaccurate estimated rather than the more accurate 'calculated' blood loss based on hematocrit dilution (Gibon in IO 37:735-739, 2013, Mercuriali in CMRO 13:465-478, 1996). This study sought to clarify whether use of short nails is associated with clinically meaningful reductions in calculated blood loss and resultant need for transfusion. A retrospective cohort study using bivariate and propensity score-weighted linear regression analyses was conducted examining 1442 geriatric (ages 60-105) patients undergoing cephalomedullary fixation of extracapsular hip fractures over 10years at two trauma centers. Implant dimensions, pre and postoperative laboratory values, preoperative medications, and comorbidities were recorded. Two groups were compared based on nail length (greater or less than 235mm). Short nails were associated with a 26% reduction in calculated blood loss (95% confidence interval: 17-35%; p < 10-14) and a 24-min (36%) reduction in mean operative time (95% confidence interval: 21-26min; p < 10-71). The absolute reduction in transfusion risk was 21% (95% confidence interval: 16-26%; p < 10-13) yielding a number needed to treat of 4.8 (95% confidence interval: 3.9-6.4) with short nails to prevent one transfusion. No difference in reoperation, periprosthetic fracture, or mortality was noted between groups. Use of short compared to long cephalomedullary nails for geriatric extracapsular hip fractures confers reduced blood loss, need for transfusion, and operative time without a difference in complications.

Lateral decubitus single position anterior posterior surgery improves operative efficiency, improves perioperative outcomes, and maintains radiological outcomes comparable with traditional anterior posterior fusion at minimum 2-year follow-up

BACKGROUND CONTEXTThe advantages of lateral single position surgery (LSPS) in the perioperative period has previously been demonstrated, however 2-year postoperative outcomes of this novel technique have not yet been compared to circumferential anterior-posterior fusion (FLIP) at 2-years postoperatively. PURPOSEEvaluate the safety and efficacy of LSPS versus gold-standard FLIP STUDY DESIGN/SETTINGMulticenter retrospective cohort review. PATIENT SAMPLEFour hundred forty-two patients undergoing lumbar fusion via LSPS or FLIP OUTCOME MEASURESLevels fused, operative time, estimated blood loss, perioperative complications, and reasons for reoperation at 30-days, 90-days, 1-year, and 2-years. Radiographic outcomes included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, and segmental lumbar lordosis. METHODSPatients were grouped as LSPS if anterior and posterior portions of the procedure were performed in the lateral decubitus position, and FLIP if patients were repositioned from supine or lateral to prone position for the posterior portion of the procedure under the same anesthetic. Groups were compared in terms of demographics, intraoperative, perioperative and radiological outcomes, complications and reoperations up to 2-years follow-up. Measures were compared using independent samples or paired t-tests and chi-squared analyses with significance set at p<.05. RESULTSFour hundred forty-two patients met inclusion, including 352 LSPS and 90 FLIP patients. Significant differences were noted in age (62.4 vs 56.9; p≤.001) and smoking status (7% vs 16%; p=.023) between the LSPS and FLIP groups. LSPS demonstrated significantly lower Op time (97.7min vs 297.0 min; p<.001), fluoro dose (36.5mGy vs 78.8mGy; p<.001), EBL (88.8mL vs 270.0mL; p<.001), and LOS (1.91 days vs 3.61 days; p<.001) compared to FLIP. LSPS also demonstrated significantly fewer post-op complications than FLIP (21.9% vs 34.4%; p=.013), specifically regarding rates of ileus (0.0% vs 5.6%; p<.001). No differences in reoperation were noted at 30-day (1.7%LSPS vs 4.4%FLIP, p=.125), 90-day (5.1%LSPS vs 5.6%FLIP, p=.795) or 2-year follow-up (9.7%LSPS vs 12.2% FLIP; p=.441). LSPS group had a significantly lower preoperative PI-LL (4.1° LSPS vs 8.6°FLIP, p=.018), and a significantly greater postoperative LL (56.6° vs 51.8°, p = .006). No significant differences were noted in rates of fusion (94.3% LSPS vs 97.8% FLIP; p=.266) or subsidence (6.9% LSPS vs 12.2% FLIP; p=.260). CONCLUSIONSLSPS and circumferential fusions have similar outcomes at 2-years post-operatively, while reducing perioperative complications, improving perioperative efficiency and safety.