Procedures In Orthopaedic Surgery Research Articles

CEMENTED DUAL MOBILITY CUPS IN PRIMARY TOTAL HIP ARTHROPLASTY IN PATIENTS AT HIGH RISK OF DISLOCATION

Background: Although total hip replacement (THR) remains one of the most successful procedures in modern orthopedic surgery, complications may occur. Dislocation is one of the major complications that may increase the hospital length of stay and even lead to a revision arthroplasty. Instability after total hip replacement can occur in 2% to 7% in primary cases and can reach up to 25% to 30% in revision cases and the majority of the dislocating events occur during the first three months after surgery.Aim of the Work: To evaluate DM cups as a treatment option in selected group of patients at an elevated risk for instability after primary THA and will focus on dislocation and early implant survival following surgery.Patients and Methods: In the period between September 2017 to March 2020 a prospective study was conducted involving 20 patients with high risk of dislocation underwent total hip replacement using dual mobility cup either as primary hip arthroplasty or after failed fixation of proximal femoral fractures. The last case was operated at February 2018. All cases were operated upon in Ain Shams University Hospitals and the follow up of the cases was 2 years.Results: There were no case showed dislocation or intra-prosthetic dislocation till the last follow up.Conclusion: In this study 1 case had complication. The complication was peri-prosthetic fracture after a fall while the prosthesis remain stable and was managed with reduction and fixation and the fracture healed with good final results and no intraoperative complication occurred with total complications rate 5%. This study showed that Dual mobility cups are efficient technique in preventing hip arthroplasty instability with good clinical results.

Assessment of Rational use of Antibiotics in Orthopedic Surgery Procedures

Introduction: Appropriate use of antimicrobial agents is important and is essential if the usefulness of antibiotic is to be preserved and the further spread of resistance is to be limited. Antibiotics are one of the pillars of modern medicine are important in prophylaxis and treatment of infectious diseases. Objective: To assess rational use of antibiotics for prophylaxis and treatment among patients in orthopedic department who undergone surgery. Methods: A prospective and observational study was conducted on 300 medical records of orthopedic patients who undergone surgery. Data was collected by using structured questionnaire from Sep2019 to Dec 2019 and then analyzed using SPSS version 20.0 software. Results: Out of 300 patients who undergone surgery 179 patients were male and 121 patients were females. Based on age group classification 30 – 40 years of age i.e. 50 (38.46%) was mostly affected. The most common diagnosis was ORIF(43.07%) followed by THR (20%) of cases. The most frequently prescribed antibiotics for prophylaxis Cefuroxime (67.40%), amikacin (14.91%) and for treatment Cefuroxime (58.17%), amikacin (18.90%). The commonly used antibiotics combination for prophylaxis is Ceftriaxone + Amikacin+ Cefuroxime (20.68%) and treatment includes Ceftriaxone+ Cefuroxime + clavulanic acid (34.04%). It was found that 50% of cases for prophylaxis was inappropriate where as 73.07 % of treatment antibiotics failed to adhere guidelines. Conclusion: Generally, this study indicated that orthopedic patients underwent surgical procedures by majority of patients were ORIF and THR. Mostly prescribed antibiotics were cefuroxime, Amikacin. This study result indicated some level of inappropriateness in antibiotic prescription. Key words: Antibiotics, Surgery, Resistance, Prophylaxis, Treatment.

Fixation of Unstable Osteochondritis Dissecans Lesions and Displaced Osteochondral Fragments Using New Biodegradable Magnesium Pins in Adolescents.

Fixation of unstable osteochondritis dissecans (OCD) lesions and displaced osteochondral fragments are frequently performed procedures in pediatric orthopedic surgery. Since 2018, CE-certified MAGNEZIX pins are used in our institution in these cases. The aim of this study was (1) to analyze safety, efficiency, and limitations of magnesium-pin-based fixation of unstable OCD lesions and displaced osteochondral fragments and (2) to report clinical and radiological outcomes at short-term follow-up (FU). In this prospective cohort study, 19 patients (10 girls and 9 boys) were included. Inclusion criteria were (1) magnetic resonance imaging-confirmed unstable OCD lesion or displaced osteochondral fragment, (2) fixation with magnesium-based pins, and (3) minimum FU of 6 months. X-rays were taken 6 weeks and 6 months after operation and magnetic resonance imaging scans every 4 to 6 months to assess the healing progress. In total 67 pins were used, with a mean of 3.6 ± 1.4 per patient. Average age at surgery was 13.7 years (11-17 years). Mean time of operation was 56 ± 31 minutes, including arthroscopy, fixation, and patellar realignment (n = 6). No intraoperative complications occurred. Average FU was 11.3 ± 4.2 months (6-20 months). No redislocation or new dislocation occurred. Until now a complete radiographic healing occurred in 12 cases. Due to an implant failure in one case 11 weeks after the index surgery a revision became necessary. In short-term FU of 11 ± 4 months MAGNEZIX pins provide high stability after fixation of unstable OCDs and displaced osteochondral fragments leading to uncomplicated and timely healing.

Effect of the surgical exposure on the early postoperative period after total knee arthroplasty

Total knee arthroplasty has become one of the most successful and safest surgical procedures in orthopedic surgery. Of the many different types of surgical exposure, the most common, so-called medial parapatellar (MP) incision is the cut of the quadriceps tendon, which impairs extensor function. In contrast, subvastus (S) exposure, which spares the extensor apparatus, may promise better healing. The purpose of our prospective observational study at the Orthopedic Clinic of Semmelweis University is to compare the effects of the MP and the S excision on the early postoperative period. The 60 patients enrolled were randomly assigned to two different groups according to the type of intervention. In the study, we measured the effects of the two different methods of surgical exposure on homogeneous patient groups in the early postoperative period based on international literature and the parameters we defined. Visual analog scale (VAS) measured resting and active pain levels for the first 10 days, suggesting a more pronounced difference in active VAS values for the S group. In the case of active VAS, patients in the S group also had significantly less pain on days 2, 3, and 10 than in the MP group. Taking into account the results of the other days, it is in favour of preserving the integrity of the extensor apparatus for improved postoperative functionality. Patients' knee joint range of motion was also measured. On day 1, those in the S group were significantly larger. As the days progress, MP group members catch up with S group during their rehabilitation. Group S patients had an average of 1.944 days to extended leg elevation, which is nearly two days shorter compared to the MP group (p<0.0001). After statistical analysis of data, subvastus exposure appears to be more beneficial in the rehabilitation of the early postoperative period. However, large-scale, multicentre observational studies are required to establish evidence. Orv Hetil. 2020; 161(29): 1208-1214.

Declining Orthopaedic Shoulder and Elbow Surgery Medicare Reimbursement Rates from 2000 to 2019

Objectives:In the field of orthopaedics, it has been evident that Medicare reimbursement rates have been relatively stagnant. Although, objective measures of how these financial trends have changed over the past couple of decades has been limited. If orthopaedic practitioners and hospital administrators wish to make progress and advance the degree of satisfactory reimbursement they can expect, a more thorough understanding of these trends is warranted. In this study, the field of orthopaedic shoulder, elbow, and upper arm surgery is being analyzed specifically. The objective of this analysis was to assess the monetary trends in Medicare reimbursement rates for the 10 most commonly utilized shoulder surgical procedures and the 10 most commonly utilized elbow and upper arm surgical procedures from 2000 to 2019.Methods:For this analysis, the current procedural terminology (CPT) code ranges that corresponded to “Surgical Procedures of the Shoulder” and “Surgical Procedures of the Humerus (Upper Arm) and Elbow” were determined. The Medicare Provider Utilization and Payment Data: Physician and Other Suppliers PUF CY 2017 document was then utilized to objectively determine the 10 most common CPT codes fororthopaedic shoulder surgical procedures and orthopaedic elbow and upper arm surgical procedures. The reimbursement data for each of these procedures was then compiled from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services. All monetary data points were adjusted for inflation to 2019 US dollars utilizing changes to the United States consumer price index. The average annual and the total percentage change in reimbursement were based on the adjusted trends for the 10 included shoulder procedures and the 10 included elbow and upper arm procedures.Results:After adjustment for inflation, the average reimbursement for the top 10 orthopaedic shoulder surgery procedures decreased by 25.8% from 2000 to 2019. The greatest mean decrease was observed in the “Repair of ruptured musculotendinous cuff (e.g. rotator cuff) open; chronic (23412)” CPT code (-40.1%). No adjusted reimbursement rates were noted to be positive throughout the study period for surgical shoulder procedures. The procedure with the smallest mean decrease was the “Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation (23600)” CPT code (-5.4%). From 2000 to 2019, the adjusted reimbursement rate for all included shoulder procedures decreased by an average of 1.6% per year. For the top 10 orthopaedic elbow and upper arm surgical procedures, the average reimbursement decreased by 19.5% from 2000 to 2019. The greatest mean decrease was observed in the “Osteoplasty,humerus (e.g., shortening or lengthening) (24420)” CPT code (-32.1%). The procedure with the only positive mean difference was “Closed treatment of humeral shaft fracture; without manipulation (24500)” CPT code (0.34%). From 2000 to 2019, the adjusted reimbursement rate for all included elbow and upper arm procedures decreased by an average of 1.2% per year.Conclusion: To our knowledge, this is the first study to evaluate the orthopaedic shoulder and elbow subspecialtyand its trends in Medicare reimbursement rates. When monetary data is corrected for inflation, Medicare reimbursement rates have shown a steady decline from 2000 to 2019. The 10 most common procedures of or relating to the shoulder have decreased by an average of 25.8% while the 10 most common procedures of or relating to the elbow or upper arm have decreased by an average of 19.5%. Additionally, only one procedure showed a positive increase in reimbursement rate (Closed treatment of humeral shaft fracture; without manipulation (24500)). If access to high quality and sustainable surgicalorthopaedic care is to persist in the United States, increased awareness of these trends is important for stakeholders to take note of.

Robust real-time bone surfaces segmentation from ultrasound using a local phase tensor-guided CNN.

Automatic bone surfaces segmentation is one of the fundamental tasks of ultrasound (US)-guided computer-assisted orthopedic surgery procedures. However, due to various US imaging artifacts, manual operation of the transducer during acquisition, and different machine settings, many existing methods cannot deal with the large variations of the bone surface responses, in the collected data, without manual parameter selection. Even for fully automatic methods, such as deep learning-based methods, the problem of dataset bias causes networks to perform poorly on the US data that are different from the training set. In this work, an intensity-invariant convolutional neural network (CNN) architecture is proposed for robust segmentation of bone surfaces from US data obtained from two different US machines with varying acquisition settings. The proposed CNN takes US image as input and simultaneously generates two intermediate output images, denoted as local phase tensor (LPT) and global context tensor (GCT), from two branches which are invariant to intensity variations. LPT and GCT are fused to generate the final segmentation map. In the training process, the LPT network branch is supervised by precalculated ground truth without manual annotation. The proposed method is evaluated on 1227 in vivo US scans collected using two US machines, including a portable handheld ultrasound scanner, by scanning various bone surfaces from 28 volunteers. Validation of proposed method on both US machines not only shows statistically significant improvements in cross-machine segmentation of bone surfaces compared to state-of-the-art methods but also achieves a computation time of 30 milliseconds per image, [Formula: see text] improvement over state-of-the-art. The encouraging results obtained in this initial study suggest that the proposed method is promising enough for further evaluation. Future work will include extensive validation of the method on new US data collected from various machines using different acquisition settings. We will also evaluate the potential of using the segmented bone surfaces as an input to a point set-based registration method.

A novel self-centring drill bit design for low-trauma bone drilling

Drilling is one of the most common procedures in orthopaedic surgery. However, drilling-induced trauma occurs frequently and affects the processing damage and position accuracy of the holes, which strongly influence the postoperative recovery. Therefore, there is an urgent need to design a dedicated drill bit that can satisfy low-trauma requirements such as low cutting force, low temperature, self-centring, and low surface damage during orthopaedic surgery. In this work, a novel three-step drill structure is proposed to modify the cutting conditions at the entrance and exit of drilling, to effectively reduce the mechanical and thermal damages and improve the position accuracy in bone drilling. As the first step drill, a unique tip with thinned web was adopted by considering the drill skidding mechanisms under a non-perpendicular drilling condition. The second step was achieved by using an optimal point angle for balancing the effects of the cutting force and temperature. Moreover, a transition arc design was proposed as the third step to adjust the point angle during the finishing stage for switching the cutting mechanism from ‘fracture & shear crack’ cutting to ‘shear’ cutting in association with a certain range of feeding rates. This could reduce the mechanical and thermal damages to the finished hole surface. Drilling experiments under various process conditions demonstrated that the proposed drill design significantly reduced the drilling force, temperature, and damage and also improved the position accuracy of the holes compared to the conventional drill design. The proposed design provides an effective tool to achieve low-trauma bone drilling in orthopaedic surgery.

Opioid Prescribing Patterns in Orthopaedic Surgery Patients: the Effect of New York State Regulations and Institutional Initiatives.

The opioid epidemic in the United States is a public health crisis. As a result, regulatory agencies, including state governments, have enacted initiatives to decrease the use of opioids in the perioperative setting. The purpose of this study was to compare opioid utilization in orthopaedic surgery patients at discrete points after implementation of State regulatory and institution/physician-led initiatives to decrease opioid utilization in the perioperative period. We reviewed the electronic medication orders for all patients who underwent orthopaedic surgery procedures between September 2015 and June 2018 at our urban academic medical center. The outcome measures were the number of patients who were prescribed opioid medications, duration of prescription (days), and average milligram morphine equivalents prescribed. Patients were divided into three time cohorts to assess the effect of the NY State (NYS) policy and institutional initiatives to decrease opioid utilization. A total of 20,483 patients met the inclusion criteria over all three time cohorts. After the initiation of the NYS 7-day supply legislation, there was a decrease in the average supply of opioids prescribed from 10.1 to 7.6 days and the average daily milligram morphine equivalent decreased from 67.9 to 56.7 mg (P < 0.0001). However, with the combination of physician education and surgeon-led institutional initiatives, the percentage of patients who were prescribed opioids decreased by over 10% (96% to 84%), with continued decrease in duration of prescription by 1.0 to 6.4 days (P < 0.0001). The addition of institution-led initiatives and education programs to previously established government-led prescription limits produced a substantial reduction in the amount of opioids prescribed to orthopaedic surgery patients in the perioperative period. Although mandatory limits set by the state government resulted in a decreased amount of opioid medications being prescribed per patient, it was only after the introduction of educational programs and institution- and physician-led programs that perioperative patient exposure to opioids decreased. Level III.

The Influence of Preoperative Physical Activity on Postoperative Outcomes of Knee and Hip Arthroplasty Surgery in the Elderly: A Systematic Review.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent two of the most common procedures in orthopedic surgery. The growing need to avoid physical impairment in elderly patients undergoing this kind of surgery puts the focus on the possibility to undertake a preoperative physical activity program to improve their fit and physical health at the time of surgery. A systematic review has been carried out with online databases including PubMed-Medline, Cochrane Central and Google Scholar. The aim was to retrieve available evidence concerning preoperative physical activity and exercise, before total knee or total hip arthroplasty in patients older than 65 years, and to clarify the role of this practice in improving postoperative outcomes. Results of the present systematic analysis showed that, for TKA, most of the studies demonstrated a comparable trend of postoperative improvement of Visual Analogue Scale (VAS), range of movement (ROM) and functional scores, and those of quality of life. There is insufficient evidence in the literature to draw final conclusions on the topic. Prehabilitation for patients undergoing TKA leads to shorter length of stay but not to an enhanced postoperative recovery. Concerning THA, although currently available data showed better outcomes in patients who underwent prehabilitation programs, there is a lack of robust evidence with appropriate methodology.

Determining the Patient Acceptable Symptomatic State for Patients Undergoing Arthroscopic Partial Meniscectomy in the Knee

Background: Arthroscopic partial meniscectomy is one of the most common procedures in orthopaedic surgery. The patient acceptable symptomatic state (PASS), which defines a level of symptoms above which patients consider themselves well, remains to be well-defined in this population. Purpose: Using an anchor-based approach, our goal was to determine the 1-year PASS for the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Marx Activity Scale (MAS) in patients who were treated with partial knee meniscectomy. Study Design: Case series; Level of evidence, 4. Methods: A consecutive series of patients with knee meniscal tears and a Kellgren-Lawrence grade of 0 to 2 treated with arthroscopic partial meniscectomy were eligible. The KOOS (0-100), IKDC (0-100), WOMET (0-100), and MAS (0-16) were administered at baseline and 12 months postoperatively. An external anchor question at 1 year postoperatively was used to determine PASS values. A receiver operating characteristic curve (ROC) analysis was used to determine the PASS value at which patients considered their status to be satisfactory. Results: The study included 110 patients (mean ± SD age, 53.8 ± 12.0 years), 57.3% were male, and the follow-up rate was 82%. In total, 70% of patients had an Outerbridge arthroscopic grade of 2 or lower. Based on ROC analysis, the 1-year postoperative PASS values (sensitivity, specificity) were 64.3 (47.8, 100.0) for KOOS Symptoms, 81.6 (71.6, 100.0) for KOOS Pain, 82.4 (82.1, 86.4) for KOOS Function in Daily Living, 71.0 (62.7, 81.8) for KOOS Function in Sport and Recreation, 51.0 (83.6, 95.5) for KOOS Knee-Related Quality of Life, 56.2 (82.1, 100.0) for IKDC, 58.5 (79.1, 100.0) for WOMET, and 7.0 (44.8, 68.2) for MAS. Baseline scores did not affect the PASS threshold across the different instruments. However, patients with higher baseline scores were more likely to achieve the PASS for the KOOS Symptoms (odds ratio [OR], 2.808; P = .047), IKDC (OR, 4.735; P = .006), and WOMET (OR, 2.985; P = .036). Age, sex, and cartilage status were not significantly related to the odds of achieving the PASS for any of the patient-reported outcome measures. Conclusion: These findings allow researchers and clinicians to determine whether partial meniscectomy is meaningful to patients at the individual level and will be helpful for responder analysis in future trials related to the treatment of meniscal abnormality.

Schirmer Tear Test Value and Corneal Lesions' Incidence during General Anesthesia for Non-Ophthalmic Surgery in Non-Brachycephalic Dogs: A Pilot Study Comparing Three Different Lubricant Eye Drop Formulations.

Aim of this blinded, prospective, randomized clinical study was to compare three different lubricant eye drops (LED) in healthy adult dogs undergoing general anaesthesia (GA) for non-ophthalmic surgery. Tear production rate was monitored by means of Schirmer tear test-1 (STT-1), and incidence of post-operative corneal abrasions/ulcerations was detected by corneal staining. A complete ophthalmic examination was performed before premedication, at extubation time and 24 h after GA in twenty-five non-brachycephalic dogs (fifty eyes) undergoing elective orthopaedic or spinal surgery procedures. Dogs were randomly allocated to one of three groups receiving as prophylactic LED either carmellose sodium (GC), or 1% hyaluronic acid (GH), or 0.25% hyaluronic acid (GL). In each eye STT-1 was repeated every hour during GA, before instilling one drop of the assigned LED. In all groups STT-1 values drastically decreased during GA, while 24 h later nine eyes (18%) had STT-1 values lower than 15 mm/minute. All of the three formulations tested were fully effective in preventing corneal ulceration (0% in all groups), while 10% of eyes reported superficial de-epithelialization. Fluorescein staining demonstrated that hourly prophylactic LED application prevented exposure keratopathy during general anesthesia in 90% of the eyes in non-brachycephalic dogs.

Using radar plots for performance benchmarking at patient and hospital levels using an Australian orthopaedics dataset.

This study will highlight the diagnostic potential that radar plots display for reporting on performance benchmarking from patient admissions to hospital for surgical procedures. Two drawbacks of radar plots - the presence of missing information and ordering of indicators - are addressed. Ten different orthopaedic surgery procedures were considered in this study. Moreover, twelve outcome indicators were provided for each of the 10 surgeries of interest. These indicators were displayed using a radar plot, which we call a scorecard. At the hospital level, we propose a facile process by which to consolidate our 10 scorecards into one. We addressed the ordering of indicators in our scorecards by considering the national median of the indicators as a benchmark. Furthermore, our the consolidated scorecard facilitates concise visualisation and dissemination of complex data. It also enables the classification of providers into potential low and high performers that warrant further investigation. In conclusion, radar plots provide a clear and effective comparative tool for discerning multiple outcome indicators against the benchmarks of patient admission. A case study between two top and bottom performers on a consolidated scorecard (at hospital level) showed that medical provider charges varied more than other outcome indicators.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the "very old" and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007-2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30-1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

Automatic Markerless Registration and Tracking of the Bone for Computer-Assisted Orthopaedic Surgery

To achieve a simple and less invasive registration procedure in computer-assisted orthopaedic surgery, we propose an automatic, markerless registration and tracking method based on depth imaging and deep learning. A depth camera is used to continuously capture RGB and depth images of the exposed bone during surgery, and deep neural networks are trained to first localise the surgical target using the RGB image, then segment the target area of the corresponding depth image, from which the surface geometry of the target bone can be extracted. The extracted surface is then compared to a pre-operative model of the same bone for registration. This process can be performed dynamically during the procedure at a rate of 5-6 Hz, without any need for surgeon intervention or invasive optical markers. Ex vivo registration experiments were performed on a cadaveric knee, and accuracy measurements against an optically tracked ground truth resulted in a mean translational error of 2.74 mm and a mean rotational error of 6.66°. Our results are the first to describe a promising new way to achieve automatic markerless registration and tracking in computer-assisted orthopaedic surgery, demonstrating that truly seamless registration and tracking of the limb is within reach. Our method reduces invasiveness by removing the need for percutaneous markers. The surgeon is also exempted from inserting markers and collecting registration points manually, which contributes to a more efficient surgical workflow and shorter procedure time in the operating room.

Analysis of fracture, force, and temperature in orthogonal elliptical vibration-assisted bone cutting

Bone is a natural composite and its cutting is a common procedure in orthopedic surgery. The processing damage, cutting force, and cutting heat strongly influence postoperative recovery. In this study, a orthogonal elliptical vibration-assisted (EVA) bone cutting system is developed based on semi-brittle behaviors of bone to experimentally investigate fracture, cutting force, roughness and temperature rise. To prevent large-scale fractures during bone cutting, an extended finite element method model incorporating detailed microstructure and material properties of bone is created to understand the crack-propagation mechanism. Both the simulation and the experiments demonstrate that the elliptical vibration could effectively control the direction of crack propagation. The experimental results also demonstrate that the cutting force and surface roughness decreases with an increase in the vibration frequency or amplitude, whereas temperature rise increases with the vibration frequency. These findings prove that the EVA could allow for low-trauma bone cutting in orthopedic surgery.

The Impact of Workman’s Compensation on Recovery After Biceps Tenodesis

The purpose of this study is to compare the postoperative recovery outcomes of after isolated biceps tenodesis in patients with and without workman’s compensation claims. Workman’s compensation (WC) claims have been associated with poor outcomes after a variety of orthopedic surgery procedures, particularly when examining recurrent pain and function. However, the impact of WC on a variety of outcomes after shoulder surgery is not as well understood. Biceps tenodesis is a well-established treatment for isolated biceps or superior labrum pathology. However, the impact of factors, such as workman’s compensation have yet to be examined in depth Using the surgical outcomes system (SOS) database (Arthrex Inc., Naples, FL), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after isolated biceps tenodesis. The time points analyzed included, preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included visual analog score (VAS), American shoulder and elbow score (ASES), VR-12 mental and physical, simple shoulder test (SST), and SANE. Overall, 181 patients with WC claims underwent isolated biceps tenodesis, compared to 1,069 patients without WC claims. There were similar demographics and comorbidities in the two groups, including gender (34% females in WC vs 38% females in non-WC), age (mean 47 years in WC vs. 50 years in non-WC), smokers (15% in WC vs. 10% in non-WC), and diabetes (8% in WC vs. 6% in non-WC). The postoperative recovery curves for VAS, ASES, and SANE are displayed in Figure 1 below. Patients without WC claims had significantly improved VAS, VR-12, ASES, SANE, and SST scores at all times points after 3 months when compared to those with WC claims (p<0.001). However, given many with measures were significantly worse preoperatively in patients with WC claims, we also analyzed the preoperative to postoperative change in all outcomes at each time point. At 1 year when compared to those without WC claims, patients with WC claims had worse VAS (p=0.03), ASES (p=0.007), SANE (p<0.001), and SST (p=0.08) (Figure 2 below). When analyzing the patient’s recovery after isolated biceps tenodesis, workman’s compensation claims lead to significantly worse pain and functional outcomes at every major time point (3, 6, 12, and 24 months). Furthermore, the patients with WC also had worse preoperative to postoperative improvements in most of the outcomes. This information can be used to educate surgeons and patients on postoperative expectations, as well as analyses focused on health economics, value, and policy.

General anesthesia risk across pediatric surgical specialties: Low in otolaryngology

PurposeTo determine the relevance of the Food and Drug Administration (FDA) warning regarding general anesthesia (GA) in children under 3 years of age for procedures lasting longer than 3 h, by surgical specialty and for otolaryngology specifically. MethodsA one-year retrospective review was conducted at a tertiary-care medical center for all children younger than 3 years undergoing surgical procedures with durations greater than 3 h. De-identified data related to age, surgical service, procedure types, American Society of Anesthesiologists (ASA) physical status classification, and general anesthesia time were collected and examined. ResultsDuring 2017, 430 of 11,757 patients (3.7%) met the age and duration of anesthesia criteria. Procedures performed by the cardiothoracic surgery service were mostly likely to result in duration of surgery greater than 3 h (46.6%), followed by neurosurgery (12.9%), cardiology (9.3%), plastic surgery (7.1%), general surgery (6.6%), and urology (5.1%). Less than 2% of patients undergoing ophthalmology (1.9%), orthopedic surgery (1.7%), and otolaryngology (0.5%) procedures required anesthesia greater than 3 h. ConclusionLess than 4% of patients younger than 3 years undergoing surgery required general anesthesia for longer than 3 h. The theoretical risks of general anesthesia per the FDA warning are discussed and must be balanced against the known functional and neurodevelopmental consequences of not performing critical and time-sensitive surgery on children in this age group. A strategy for addressing parental and provider concerns is discussed.

Identifying Technical Procedures in Orthopaedic Surgery and Traumatology That Should Be Integrated in a Simulation-Based Curriculum: A National General Needs Assessment in Denmark.

Simulation-based training is emerging within the orthopaedic field to alleviate the challenges that trainees face such as work-hour restrictions, limited exposure to procedures, and increasing pressures to reduce risk to patients. This training modality has grown increasingly popular over the last 2 decades. However, integration into the curriculum often fails to follow a structured educational plan. The development of simulation-based curricula should follow a structured and stepwise approach that starts with a general needs assessment. This study aimed to identify and prioritize procedures within orthopaedic surgery to be included in a simulation-based curriculum on a national basis. A national needs assessment was conducted using the Delphi method. Ninety-five experts who are involved in the training of orthopaedic surgeons from all orthopaedic departments in Denmark were selected to participate in the assessment. Round 1 was a brainstorming phase to identify technical procedures that are relevant for orthopaedic surgeons in training. Round 2 was performed on a departmental basis; it explored the frequency of procedures, the number of surgeons performing each procedure, the risk and/or discomfort to patients, and the feasibility for simulation-based training to prioritize and eliminate some of the procedures that were determined in round 1. During round 3, the experts eliminated and reprioritized procedures from round 2 to produce a final prioritized list. During the first round, 194 procedures were identified. These were reduced to 62 in round 2, and the final list after round 3 consisted of 33 prioritized procedures that are relevant for simulation-based training in orthopaedic surgery. The response rates were 63 of 95 physicians for round 1, 26 of 26 departments for round 2, and 64 of 97 physicians for round 3. The highest prioritized procedures were basic surgical techniques and principles for osteosynthesis, osteosynthesis of proximal femoral fracture, and surgical exposure of the upper and lower extremities. The prioritized list of technical procedures in orthopaedic surgery that are suitable for simulation-based training can aid in the development of a simulation-based curriculum. This article offers insights into needs assessment and curriculum development of simulation-based training in orthopaedic surgery and traumatology.

Perioperative care of children with sickle cell disease: A systematic review and clinical recommendations.

Children with sickle cell disease (SCD) require specific perioperative care, and clinical practice in this area remains poorly defined. We aimed to conduct a systematic, PRISMA-based review of the literature, available clinical guidelines and practice recommendations. We also aimed to extract any valuable information for the "best of available-evidence"-based prevention of perioperative adverse events in children with SCD, and highlight the most urgent priorities in clinical research. As data sources, US National Library of Medicine, Medline, National Guideline Clearinghouse, International Guideline Network, TRIP databases were searched for any content until January 2019. We also included institutional, consortia and expert group guidelines. Included were reports/guidelines in English, French, German, and Italian. Excluded were reports on obstetrical and fetal management. We identified 202 reports/guidelines fulfilling the criteria outlined above. A majority focused on visceral, cardiovascular and orthopedic surgery procedures, and only five were multicenter randomized controlled trials and two prospective randomized studies. After grading of the quality of the evidence, the extracted data was summarized into clinical recommendations for daily practice. Additionally, we designed a risk-grading algorithm to identify contexts likely to be associated with adverse outcomes. In conclusion, we provide a systematic PRISMA-based review of the existing literature and ancillary practice and delineate a set of clinical recommendations and priorities for research.

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.