Preoperative Patient Functional Status Is an Independent Predictor of Outcomes After Primary Total Hip Arthroplasty

The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review

BACKGROUND

 When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.

METHODS

 A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.

RESULTS

 A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.

CONCLUSION

 This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

The five times sit-to-stand test predicts same-day discharge for outpatients undergoing total joint arthroplasty

PURPOSE

To examine whether a patient's pre-operatively administered five times sit-to-stand (FTSTS) test score, when used alone or when combined with previously established predictors, relates to same-day discharge (SDD) after total knee or hip arthroplasty.

METHODS

This study utilized a multivariate, retrospective, observational design. Electronic medical record data for included participants were used to analyze the relationship between the patient factors (including the novel FTSTS variable) and the SDD outcome. Univariate and multiple variable regression modeling was undertaken to understand the strength of the relationship between the independent variables with the dependent variable. Receiver operating curve (ROC) analysis was performed to determine the area under the curve (AUC) for the novel model. Cut score analysis was performed to establish the score which has the greatest utility for stratifying patients based upon their likelihood of achieving SDD.

RESULTS

All independent variables related to the SDD outcome with varying effect sizes. The dichotomized FTSTS score related to the SDD outcome with medium effect (Exp(B) = 2.56). The score of 13.6 s was established as the point where the test was most highly sensitive and specific. The combined model including all included patient characteristics had a classification accuracy of 64.7% and an area under the curve score of .724.

CONCLUSION

The FTSTS score had higher predictive accuracy than all other stand-alone patient characteristics for the SDD outcome.

Better Before-Better After: A Qualitative Phenomenology Study of Older Adults' Experiences With Prehabilitation Before Total Hip Replacement

Total hip replacement is considered a successful intervention for pain relief and improved function. However, poor presurgery physical function may increase the likelihood of delayed postsurgery recovery. The purpose of this study was to describe community-dwelling older adults' experiences with a prehabilitation program (preoperative exercise) before total hip replacement. Four participants were interviewed 13 and 15 weeks postsurgery. The interviews were recorded, transcribed, and analyzed with systematic text condensation. Physical, mental, and social limitations were, to a higher or lesser degree, part of the participants' life presurgery. The results indicate that tailored close supervised training presurgery increased the participants' amount of and adherence to exercise, confidence, and sense of control. The participants had a positive experience of increased strength during the training period and gained motivation to perform progressive training. The exercise program helped the participants be physically and mentally prepared. The results indicate that close supervised prehabilitation in community-dwelling older adults undergoing total hip replacement can contribute to improved function and increase the level of activity and self-efficacy postsurgery.

Pediatric and Adult Patients Have Similar Functional Improvement After Endoprosthetic Reconstruction of Lower-Extremity Tumors

BACKGROUND

Although the treatment of lower-extremity bone tumors is similar between adult and pediatric patients, differences in outcomes are unknown. Outcomes for lower-extremity oncologic reconstruction have been challenging to study because of the low incidence and heterogeneity in disease and patient characteristics. The PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) trial is the largest prospective data set assembled to date for patients with lower-extremity bone tumors and presents an opportunity to investigate differences in outcomes between these groups.

METHODS

Patient details were acquired from the prospectively collected PARITY trial database. The 1993 Musculoskeletal Tumor Society (MSTS-93) and Toronto Extremity Salvage Score (TESS) questionnaires were administered preoperatively and at 3, 6, and 12 months postoperatively. Continuous outcomes were compared between groups with use of the Student t test, and dichotomous outcomes were compared with use of the Pearson chi-square test.

RESULTS

A total of 150 pediatric and 447 adult patients were included. Pediatric patients were more likely than adult patients to have a primary bone tumor (146 of 150 compared with 287 of 447, respectively; p < 0.001) and to have received adjuvant chemotherapy (140 of 149 compared with 195 of 441, respectively; p < 0.001). Reoperation rates were not significantly different between age groups (45 of 105 pediatric patients compared with 106 of 341 adult patients; p ≤ 0.13). Pediatric patients had higher mean MSTS-93 scores (64.7 compared with 53.8 among adult patients; p < 0.001) and TESS (73.4 compared with 60.4 among adult patients; p < 0.001) at baseline, which continued to 1 year postoperatively (mean MSTS-93 score, 82.0 compared with 76.8 among adult patients; p = 0.02; mean TESS, 87.7 compared with 78.6 among adult patients; p < 0.001). Despite the differences in outcomes between cohorts, pediatric and adult patients demonstrated similar improvement in MSTS-93 scores (mean difference, 17.4 and 20.0, respectively; p = 0.48) and TESS (mean difference, 14.1 and 14.7, respectively; p = 0.83) from baseline to 1 year postoperatively.

CONCLUSIONS

Pediatric patients had significantly better functional outcomes than adult patients at nearly all of the included postoperative time points; however, pediatric and adult patients showed similar mean improvement in these outcomes at 1 year postoperatively. These findings may be utilized to help guide the postoperative expectations of patients undergoing oncologic reconstruction.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty

BACKGROUND

There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty.

METHODS

A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts.

RESULTS

There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort.

CONCLUSION

SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Time trends in use of non-steroidal anti-inflammatory drugs and opioids one year after total hip arthroplasty due to osteoarthritis during 1996-2018: a population-based cohort study of 103,209 patients

OBJECTIVE

To examine time trends in the use of NSAIDs and opioids for patients with osteoarthritis undergoing total hip arthroplasty (THA) during 1996-2018.

METHOD

Using Danish population-based medical databases, we identified 103,209 THA patients. Prevalence rates of NSAID and opioid use among preoperative users and non-users were calculated in four quarters (Q1-Q4) after THA by calendar periods (1996-2000, 2001-2006, 2007-2012 and 2013-2018). Prevalence rate ratios (PRR) were adjusted for age and gender.

RESULTS

Among preoperative NSAID users and non-users, NSAID use in Q1 increased from 32.6% in 1996-2000 to 48.0% in 2013-2018 (PRR = 1.49, 95% CI: 1.42-1.55) and from 12.9% to 32.0% (PRR = 2.49 (2.32-2.67)), respectively. Among preoperative opioid users and non-users, opioid use in Q1 increased from 42.7% in 1996-2000 to 76.9% in 2013-2018 (PRR = 1.81 (1.73-1.89)) and from 15.2% to 58.2% (PRR = 3.85 (3.65-4.05)), respectively. NSAID use in Q4 decreased from 24.5% in 1996-2000 to 21.4% in 2013-2018 (PRR = 0.88 (0.83-0.93)) and from 6.9% to 5.6% (PRR = 0.81 (0.73-0.91)) in preoperative NSAIDs users and non-users, respectively. Opioid use in Q4 increased from 26.6% in 1996-2000 to 28.6% (PRR = 1.08 (1.02-1.15)) in 2013-2018 and from 4.1% to 5.0% (PRR = 1.25 (1.11-1.40)) in preoperative opioid users and non-users, respectively.

CONCLUSION

We observed up to a 4-fold increase in NSAID and opioid use in Q1 during 1996-2018, while usage in Q4 did not change substantially. However, 5-6% of the preoperative non-users of NSAIDs and opioids were users in Q4, which might relate to inaccurate indication for or timing of THA and the post-surgical phasing out of analgesics use.

Patient characteristics predicting prolonged length of hospital stay following robotic-assisted radical prostatectomy

Objective:

The objective of this study is to determine the preoperative patient characteristics predicting prolonged length of hospital stay (pLOS) following robotic-assisted radical prostatectomy (RARP).

Methods:

The National Surgical Quality Improvement Program (NSQIP) database was used to select patients who underwent RARP without other concomitant surgeries between 2008 and 2016. Patients’ demographics, comorbidities, and laboratory markers were collected to evaluate their role in predicting pLOS. The pLOS was defined as length of stay (LOS) >2 days. A multinomial logistic regression was constructed adjusting for postoperative surgical complications to assess for the predictors of pLOS.

Results:

We obtained data for 31,253 patients of which 20,774 (66.5%) patients stayed ⩽1 day, 6993 (22.4%) patients stayed for 2 days, and 3486 (11.2%) patients stayed for >2 days. Demographic variables – including body mass index (BMI) <18.5: odds ratio (OR) = 2.8, 95% confidence interval (CI) = [1.7–4.8]; smoking: OR = 1.2, 95% CI = [1.1–1.4]; and dependent functional status: OR = 3.1, 95% CI = [1.6–6.0] – were predictors of pLOS. Comorbidities – such as heart failure: OR = 4.6, 95% CI = [2.0–10.8]; being dialysis dependent: OR = 2.7, 95% CI = [1.4–5.0]; and predisposition to bleeding: OR = 2.0, 95% CI =  [1.5–2.7] – were the strongest predictors of extended hospitalization. In addition, pLOS was more likely to be associated with postoperative bleeding, renal, or pulmonary complications.

Conclusion:

Preoperative patient characteristics and comorbidities can predict pLOS. These findings can be used preoperatively for risk assessment and patient counseling.

Use of Patient-Reported Outcomes Measurement Information System (PROMIS) measures to characterise health status for patients seeking care from an orthopaedic provider: a retrospective cohort study

OBJECTIVES

Characterise the health status of patients newly consulting an orthopaedic specialist across eight clinical subspecialties.

DESIGN

Retrospective cohort.

SETTING

18 orthopaedic clinics, including 8 subspecialties (14 ambulatory and 4 hospital based) within an academic health system.

PARTICIPANTS

14 910 patients consulting an orthopaedic specialist for a new patient consultation who completed baseline Patient-Reported Outcomes Measurement Information System (PROMIS) measures associated with their appointment from 17 November 2017 to 13 May 2019. Patients were aged 55.72±5.8 years old, and 61.3% were female and 79.3% were Caucasian and 13.4% were black or African American. Patients who did not complete PROMIS measures or cancelled their appointment were excluded from the study.

PRIMARY OUTCOME

PROMIS domains of physical function, pain interference, pain intensity, depression, anxiety, fatigue, sleep disturbance and the ability to participate in social roles.

RESULTS

Mean PROMIS scores for physical function were (38.1±9.2), pain interference (58.9±8.1), pain intensity (4.6±2.5), depression (47.9±8.9), anxiety (49.9±9.5), fatigue (50.5±10.3), sleep disturbance (51.1±9.8) and ability to participate in social roles (49.1±10.3) for the entire cohort. Across the clinical subspecialties, neurosurgery, spine and trauma patients were most profoundly affected across almost all domains and patients consulting with a hand specialist reported the least limitations or symptoms across domains. There was a moderate, negative correlation between pain interference and physical functioning (r=-0.59) and low correlations between pain interference with anxiety (r=0.36), depression (r=0.39) as well as physical function and anxiety (r=-0.32) and depression(r=-0.30) and sleep (r=-0.31).

CONCLUSIONS

We directly compared clinically meaningful PROMIS domains across eight orthopaedic subspecialties, which would not have been possible with legacy measures alone. These results support PROMIS's utility as a common metric to assess and compare patient health status across multiple orthopaedic subspecialties.

Development of a Machine Learning Algorithm to Predict Nonroutine Discharge Following Unicompartmental Knee Arthroplasty

BACKGROUND

Reliable and effective prediction of discharge destination following unicompartmental knee arthroplasty (UKA) can optimize patient outcomes and system expenditure. The purpose of this study is to develop a machine learning algorithm that can predict nonhome discharge in patients undergoing UKA.

METHODS

A retrospective review of a prospectively collected national surgical outcomes database was performed to identify adult patients who underwent UKA from 2015 to 2019. Nonroutine discharge was defined as discharge to a location other than home. Five machine learning algorithms were developed to predict this outcome. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis.

RESULTS

Overall, of the 7275 patients included, 263 (3.6) patients were unable to return home upon discharge following UKA. The factors determined most important for identification of candidates for nonroutine discharge were total hospital length of stay, preoperative hematocrit, body mass index, preoperative sodium, American Society of Anesthesiologists classification, gender, and functional status. The extreme boosted model achieved the best performance based on discrimination (area under the curve = 0.875), calibration, and decision curve analysis. This model was integrated into a web-based open access application able to provide both predictions and explanations.

CONCLUSION

The present model can, following appropriate external validation, be used to augment clinician decision-making in patients undergoing elective UKA. Patients with high preoperative probabilities of nonroutine discharge based on nonmodifiable risk factors should be counseled to start the insurance authorization process with case management to avoid unnecessary inpatient stay, and those with modifiable risk can attempt prehabilitation to optimize these parameters before surgery.

Insurance Payer Type and Patient Income Are Associated with Outcomes after Total Shoulder Arthroplasty

OBJECTIVE

To assess the independent association of insurance and patient income with total shoulder arthroplasty (TSA) outcomes.

METHODS

We used the 1998-2014 US National Inpatient Sample. We used multivariable-adjusted logistic regression to examine whether insurance type and the patient's median household income (based on postal code) were independently associated with healthcare use (discharge destination, hospital stay duration, total hospital charges) and in-hospital complications post-TSA based on the diagnostic codes (fracture, infection, transfusion, or revision surgery). We calculated the OR and 95% CI.

RESULTS

Among the 349,046 projected TSA hospitalizations, the mean age was 68.6 years, 54% were female, and 73% white. Compared to private insurance, Medicaid and Medicare (government insurance) users were associated with significantly higher adjusted OR (95% CI) of (1) discharge to a rehabilitation facility, 2.16 (1.72-2.70) and 2.27 (2.04-2.52); (2) hospital stay > 2 days, 1.65 (1.45-1.87) and 1.60 (1.52-1.69); and (3) transfusion, 1.35 (1.05-1.75) and 1.39 (1.24-1.56), respectively. Medicaid was associated with a higher risk of fracture [1.74 (1.07-2.84)] and Medicare user with a higher risk of infection [2.63 (1.24-5.57)]; neither were associated with revision. Compared to the highest income quartile, the lowest income quartile was significantly associated with (OR, 95% CI): (1) discharge to a rehabilitation facility (0.89, 0.83-0.96); (2) hospital stay > 2 days (0.84, 0.80-0.89); (3) hospital charges above the median (1.19, 1.14-1.25); (4) transfusion (0.73, 0.66-0.81); and (5) revision (0.49, 0.30-0.80), but not infection or fracture.

CONCLUSION

This information can help to risk-stratify patients post-TSA. Future assessments of modifiable mediators of these complications are needed.