Preoperative Patient Education May Decrease Postoperative Opioid Use After Meniscectomy.

PURPOSE: To identify the current opioid prescribing and use practices after arthroscopic meniscectomy and to evaluate the role of preoperative patient education in decreasing postoperative opioid consumption. METHODS: Patients undergoing arthroscopic meniscectomy were prospectively identified for inclusion. They were placed into 1 of 2 groups: Group 1 received no education regarding opioid use after surgery, whereas group 2 received a standardized overview on postoperative opioid use. Patients were assigned to the groups consecutively: Patients treated at the beginning of the study were assigned to group 1, and patients treated at the end of the study were assigned to group 2. Data from group 1 were used to identify "normal" opioid prescribing and use practices and to guide patients in group 2 regarding normal postoperative opioid use. Patients were surveyed weekly for 4 weeks after surgery to determine the number of opioids taken. Postoperative opioid consumption was analyzed and compared between the 2 groups. RESULTS: A total of 62 patients completed the study (32 in group 1 and 30 in group 2). Patients in group 1 were prescribed an average of 42.0 opioid pills (95% confidence interval [CI], 34.0-51.0 pills) and used an average of 15.84 pills (95% CI, 9.26-22.4 pills) after surgery, whereas patients in group 2 used an average of 4.00 pills (95% CI, 2.12-5.88 pills) after surgery. Patients in group 2 used 11.84 fewer opioid pills (P = .001), a 296% decrease in postoperative opioid consumption. The number of patients who continued to take opioid pills 4 weeks after surgery was 7 patients (21.9%) in group 1 and 1 patient (3.3%) in group 2. CONCLUSIONS: Preoperative patient education regarding opioids may decrease postoperative opioid consumption and the duration for which patients take opioid pills after arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Quantifying Surgeon Work in Total Hip and Knee Arthroplasty: Where Do We Stand Today?

BACKGROUND: Physician work is a critical component in determining reimbursement for total joint arthroplasty (TJA). The purpose of this study is to quantify the time spent during the different phases of TJA care relative to the benchmarks used by the Centers for Medicare and Medicaid Services. METHODS: We retrospectively reviewed all patients captured in our institutional joint database between January 1, 2014, and December 31, 2018. Four phases of care were assessed: (1) preoperative period following the decision to proceed with TJA and leading to the day before surgery, (2) immediate 24 hours preceding surgery (preservice time), (3) operative time from skin incision to dressing application (intraservice time), and (4) postoperative work including day of surgery and the following 90 days. RESULTS: A total of 666 procedures were analyzed (379 total hip arthroplasties and 287 total knee arthroplasties). The mean preoperative care coordination, preservice, intraservice, immediate postservice, and 91-day global period times were 21.9 ± 10, 84.1, 114 ± 24, 35, and 150 ± 37 minutes, respectively. Except for a slightly higher preoperative time associated with Medicare coverage (P = .031), there were no differences in the other phases of care by payer type. There were no temporal differences between 2014 and 2017. However, in 2018, there were significant increases in preoperative and intraservice times (6 and 20 minutes, respectively, P < .001) which were accompanied with a significant decrease in postoperative service time (34 minutes, P < .001). CONCLUSION: Even when performing TJA under the most optimal conditions, the overall time has remained stable over the past 5 years and consistent with current benchmarks.

Comparison of Anterior Cervical Discectomy and Fusion With a Stand-Alone Interbody Cage Versus a Conventional Cage-Plate Technique: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Compare the clinical and radiographic outcomes of anterior cervical discectomy and fusion (ACDF) with a stand-alone interbody cage versus a conventional cage and anterior cervical plate technique. METHODS: A systematic Medline search was conducted using PubMed, EMBASE, and Cochrane Library Database of Systematic Reviews. Search terms included "anterior cervical discectomy and fusion," "cage," and "bone plates," or variations thereof. Only studies involving a direct comparison of ACDF with a stand-alone cage versus a cage and plate were included. From the selected studies, we extracted data on patient demographics, comorbidities, surgical risk factors, and pre- and postoperative radiographic findings. A meta-analysis was performed on all outcome measures. The quality of each study was assessed using the Downs and Black checklist. RESULTS: Nineteen studies met the inclusion and exclusion criteria. Patients who underwent ACDF with a cage-only technique had significantly lower rates of postoperative dysphagia and adjacent segment disease compared with patients who underwent ACDF with a cage-plate technique. However, patients who underwent ACDF with a cage-plate technique had better radiographic outcomes with significantly less subsidence and better restoration of cervical lordosis. There were no other significant differences in outcomes or postoperative complications. CONCLUSIONS: ACDF with a cage-only technique appears to have better clinical outcomes than the cage-plate technique, despite radiographic findings of increased rates of subsidence and less restoration of cervical lordosis. Future randomized controlled trials with longer term follow-up are needed to confirm the findings of this meta-analysis.

Outcomes and Complications Following Laminectomy Alone for Thoracic Myelopathy due to Ossified Ligamentum Flavum: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Examine the functional outcomes and complications following laminectomy for thoracic myelopathy due to ossification of the ligamentum flavum (OLF). SUMMARY OF BACKGROUND DATA: OLF is a rare condition that can cause thoracic myelopathy. Laminectomy is a procedure that can be performed to decompress the spinal cord in patients with thoracic myelopathy due to OLF. Few studies have examined postoperative outcomes and complications following laminectomy for thoracic myelopathy secondary to OLF. METHODS: A systematic review and meta-analysis was performed. Literature search yielded six studies that met our selection criteria. Study characteristics and baseline patient demographics were extracted from each study. Primary outcomes included pre- and postoperative Japanese Orthopedic Association (JOA) scores and perioperative complications including dural tears, cerebrospinal fluid (CSF) leaks, neurological deficits, surgical site infections, and other complications. We calculated pooled proportion estimates for JOA scores and complications using a random effects model. RESULTS: A total of 137 patients were included. The pooled pre- and postoperative JOA scores were 5.08 (95% confidence interval [CI], 2.70-7.47; I = 98%) and 8.29 (95% CI, 7.73-8.85; I = 18%), respectively, with a mean improvement of +3.03 points (95% CI, 1.08-4.98; I = 88%). Pooled proportion estimates for dural tears, CSF leaks, infections, and early neurological deficits were 18.4% (95% CI, 12.6-26.1; I = 0%), 12.1% (95% CI, 6.6-21.2; I = 0%), 5.8% (95% CI, 2.1-15.4; I = 0%), and 5.7% (95% CI, 2.2-14.3; I = 0%), respectively. CONCLUSION: Thoracic myelopathy secondary to OLF can be treated with laminectomy. However, despite some improvement in JOA score, functional status remains poor postoperatively. Perioperative complications are common, with dural tears and CSF leaks occurring most frequently. OLF is an uncommon condition and more research is needed to better understand how we can improve the outcomes of laminectomy alone for the treatment of thoracic myelopathy due to OLF. LEVEL OF EVIDENCE: 3.

Examining the Ability of Artificial Neural Networks Machine Learning Models to Accurately Predict Complications Following Posterior Lumbar Spine Fusion.

STUDY DESIGN: A cross-sectional database study. OBJECTIVE: The aim of this study was to train and validate machine learning models to identify risk factors for complications following posterior lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Machine learning models such as artificial neural networks (ANNs) are valuable tools for analyzing and interpreting large and complex datasets. ANNs have yet to be used for risk factor analysis in orthopedic surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent posterior lumbar spine fusion. This query returned 22,629 patients, 70% of whom were used to train our models, and 30% were used to evaluate the models. The predictive variables used included sex, age, ethnicity, diabetes, smoking, steroid use, coagulopathy, functional status, American Society for Anesthesiology (ASA) class ≥3, body mass index (BMI), pulmonary comorbidities, and cardiac comorbidities. The models were used to predict cardiac complications, wound complications, venous thromboembolism (VTE), and mortality. Using ASA class as a benchmark for prediction, area under receiver operating curves (AUC) was used to determine the accuracy of our machine learning models. RESULTS: On the basis of AUC values, ANN and LR both outperformed ASA class for predicting all four types of complications. ANN was the most accurate for predicting cardiac complications, and LR was most accurate for predicting wound complications, VTE, and mortality, though ANN and LR had comparable AUC values for predicting all types of complications. ANN had greater sensitivity than LR for detecting wound complications and mortality. CONCLUSION: Machine learning in the form of logistic regression and ANNs were more accurate than benchmark ASA scores for identifying risk factors of developing complications following posterior lumbar spine fusion, suggesting they are potentially great tools for risk factor analysis in spine surgery. LEVEL OF EVIDENCE: 3.

Pioneer transcription factors target partial DNA motifs on nucleosomes to initiate reprogramming.

Pioneer transcription factors (TFs) access silent chromatin and initiate cell-fate changes, using diverse types of DNA binding domains (DBDs). FoxA, the paradigm pioneer TF, has a winged helix DBD that resembles linker histone and thereby binds its target sites on nucleosomes and in compacted chromatin. Herein, we compare the nucleosome and chromatin targeting activities of Oct4 (POU DBD), Sox2 (HMG box DBD), Klf4 (zinc finger DBD), and c-Myc (bHLH DBD), which together reprogram somatic cells to pluripotency. Purified Oct4, Sox2, and Klf4 proteins can bind nucleosomes in vitro, and in vivo they preferentially target silent sites enriched for nucleosomes. Pioneer activity relates simply to the ability of a given DBD to target partial motifs displayed on the nucleosome surface. Such partial motif recognition can occur by coordinate binding between factors. Our findings provide insight into how pioneer factors can target naive chromatin sites.