Breaking the "law of diminishing returns" with novel, staged, unilateral magnetically controlled growing rods to guided growth surgery for severe, progressive infantile scoliosis.

PURPOSE: Infantile scoliosis presents a significant challenge due to high risk of pulmonary complications and morbidity. While dual growing rod constructs are often utilized, they are not always feasible in a young patient with a severe curve. In this study, we present a series of eight patients treated with a unilateral magnetically controlled growing rod (uMCGR) construct later converted to guided growth surgery (GGS). METHODS: A multicenter database was queried for patients with progressive infantile scoliosis treated with uMCGR before later conversion to GGS. A minimum of 2 year follow-up was required for inclusion. Curve magnitude, trunk growth, revisions, and complications were tracked at all time points. RESULTS: Eight patients were included in the study. Mean age at index surgery was 4.1 years, while conversion to GGS occurred at average 7.9 years and final follow-up was at 10.5 years of age. At index procedure, major curve averaged 77.1°, which improved to 45.4°. Major curve increased to 48.4° prior to conversion, then improved to 30.9°. Major curve averaged 36.8° at final follow-up, for a maintained curve correction of 52.3%. T1-12 height and T1-S1 height averaged 15.4 and 21.5 cm at index procedure and increased to 20.6 and 32.7 cm at final follow-up. Nine revisions were performed in 6 patients, and no patient showed evidence of premature fusion. CONCLUSIONS: Treatment of severe progression infantile scoliosis with this staged protocol provided excellent curve correction with continued trunk growth through treatment, without evidence of the "Law of Diminishing Returns".

An Anatomically Placed Tibial Tunnel does not Completely Surround a Simulated PCL Reconstruction Graft in the Proximal Tibia.

INTRODUCTION: It is hypothesized that anatomic tunnel placement will create tunnels with violation of the posterior cortex and subsequently an oblique aperture that is not circumferentially surrounded by bone. In this article, we aimed to characterize posterior cruciate ligament (PCL) tibial tunnel using a three-dimensional (3D) computed tomography (CT) model. METHODS: Ten normal knee CTs with the patella, femur, and fibula removed were used. Simulated 11 mm PCL tibial tunnels were created at 55, 50, 45, and 40 degrees. The morphology of the posterior proximal tibial exit was examined with 3D modeling software. The length of tunnel not circumferentially covered (cortex violation) was measured to where the tibial tunnel became circumferential. The surface area and volume of the cylinder both in contact with the tibial bone and that not in contact with the tibia were determined. The percentages of the stick-out length surface area and volume not in contact with bone were calculated. RESULTS: The mean stick-out length of uncovered graft at 55, 50, 45, and 40 degrees were 26.3, 20.5, 17.3, and 12.7 mm, respectively. The mean volume of exposed graft at 55, 50, 45, and 40 degrees were 840.8, 596.2, 425.6, and 302.9 mm3, respectively. The mean percent of volume of exposed graft at 55, 50, 45, and 40 degrees were 32, 29, 25, and 24%, respectively. The mean surface of exposed graft at 55, 50, 45, and 40 degrees were 372.2, 280.4, 208.8, and 153.3 mm2, respectively. The mean percent of surface area of exposed graft at 55, 50, 45, and 40 degrees were 40, 39, 34, and 34%, respectively. CONCLUSION: Anatomic tibial tunnel creation using standard transtibial PCL reconstruction techniques consistently risks posterior tibial cortex violation and creation of an oblique aperture posteriorly. This risk is decreased with decreasing the angle of the tibial tunnel, though the posterior cortex is still compromised with angles as low as 40 degrees. With posterior cortex violation, a surgeon should be aware that a graft within the tunnel or socket posteriorly may not be fully in contact with bone. This is especially relevant with inlay and socket techniques.

Intramural hematoma of the thoracic aorta: A single-institution, 12-year experience.

OBJECTIVE: The natural history and management of intramural hematoma (IMH) has varied significantly worldwide. From the present retrospective analysis of our institutional database, we have reported the long-term results from medical and surgical management of types A and B IMH. METHODS: Computed tomography reports completed at our tertiary care hospital from July 2007 to July 2020 were used to identify patients with IMH with a thickness of ≥7 mm. Those with IMH directly related to trauma, previous aortic surgery, penetrating atheromatous ulcer, dissection flap, or an iatrogenic source and those who had never received any treatment of IMH at presentation were excluded. RESULTS: A total of 54 patients with IMH had met the inclusion and exclusion criteria. Of the 54 patients, 24 had presented with Stanford type A. Of these 24 patients, 10 had initially undergone surgery and 14 had initially received medical treatment. Two patients in the medical group had subsequently undergone surgery. In addition, 30 patients had presented with type B IMH and had initially received medical treatment, with 3 eventually requiring surgical intervention. In-hospital survival was 90% for type A IMH treated surgically, 93% for type A IMH treated medically, and 97% for type B IMH treated medically. At the last follow-up imaging study of the medically treated patients, 36% of those with type A IMH and 31% of those with type B IMH had experienced complete resolution of IMH at 3.7 and 31.5 months respectively, without surgical intervention. The development of an aortic aneurysm at the site of a previous IMH had occurred in 18% (2 of 11) and 12% (3 of 26) of the type A medical and type B medical cohorts. The overall rate of aortic aneurysm formation in the region of IMH or in another segment was 50%. No difference was found in long-term survival between the three cohorts at a mean follow-up of 22.8 months. CONCLUSIONS: A role appears to exist for medical treatment with anti-impulse therapy for appropriately selected patients with type A IMH. These patients must be followed up closely clinically and radiographically for signs of deterioration in the short- and long-term phases of their care. They can achieve long-term survival similar to that of surgically treated type A IMH and medically treated type B IMH patients using this algorithm. However, they might require late surgical intervention, especially for aneurysmal disease.

Effects of clonidine on progressive ratio schedule performance in Fmr1 knockout mice.

RATIONALE: Fragile X syndrome (FXS), the most prevalent genetic form of intellectual disability, is characterized by intellectual impairment, impaired sociability, aggression, self-injury, hyperactivity, and attention deficits. A consequence of the hyperactivity and attention deficits is that individuals with FXS are frequently diagnosed with attention deficit hyperactivity disorder (ADHD) and treated with medications approved for ADHD (e.g., the α2-agonist clonidine). The pharmacotherapy of FXS is often accompanied with behavioral therapies that rely on positive reinforcement and other operant principles. Despite the commonplace mixture of drug and behavioral therapy, little attention has been paid to the observation that clonidine or other psychotropic drugs may alter operant processes. OBJECTIVES: In the present progressive ratio study, we used a knockout mouse model to test the effects of the fragile X genotype, the α2-agonist clonidine, and the fragile X genotype and clonidine together on operant processes in a positive reinforcement task. RESULTS: We found that clonidine decreased the progressive ratio breakpoint, increased the length of post-reinforcement pauses, and slowed the run rate. None of these effects varied by genotype. The effect on breakpoint suggests that clonidine alters motivation, but analysis using mathematical principles of reinforcement (MPR) did not rule out motor parameters as a contributor. CONCLUSIONS: Our findings show that clonidine alters operant behavior and serve as a caution for combining clonidine with behavioral therapies that rely on positive reinforcement. Further research using different murine behaviors (e.g., touchscreen tasks) or different animal models (e.g., knockout rats) is needed to explore the interaction between pharmaco- and behavioral therapy.

Analysis of Instrument Motion and the Impact of Residency Level and Concurrent Distraction on Laparoscopic Skills.

OBJECTIVE: Using a laparoscopic box trainer fitted with motion analysis trackers and software, we aim to identify differences between junior and senior residents performing the peg transfer task, and the impact of a distracting secondary task on performance. DESIGN: General surgery residents were asked to perform the laparoscopic peg transfer task on a trainer equipped with a motion tracker. They were also asked to perform the laparoscopic task while completing a secondary task. Extreme velocity and acceleration events of instrument movement in the 3 rotational degrees of freedom were measured during task completion. The number of extreme events, defined as velocity or acceleration exceeding 1 SD above or below their own mean, were tabulated. The performance of junior residents was compared to senior residents. SETTING: Simulation learning institute, Beaumont Hospital, Royal Oak, Michigan. PARTICIPANTS: Thirty-seven general surgery residents from Beaumont Hospital, Royal Oak. RESULTS: When completing the primary task alone, senior residents executed significantly fewer extreme motion events specific to acceleration in pitch (16.63 vs. 20.69, p = 0.04), and executed more extreme motion events specific to velocity in roll (16.14 vs. 15.11, p = 0.038), when compared to junior residents. With addition of a secondary task, senior residents had fewer extreme acceleration events specific to pitch, (14.69 vs. 22.22, p < 0.001). CONCLUSIONS: While junior and senior residents completed the peg transfer task with similar times, motion analysis identified differences in extreme motion events between the groups, even when a secondary task was added. Motion analysis may prove useful for real-time feedback during laparoscopic skill acquisition.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database.

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

Blood Transfusion During Total Ankle Arthroplasty Is Associated With Increased In-Hospital Complications and Costs.

INTRODUCTION: Total ankle arthroplasty (TAA) is an increasingly used, effective treatment for end-stage ankle arthritis. Although numerous studies have associated blood transfusion with complications following hip and knee arthroplasty, its effects following TAA are largely unknown. This study uses data from a large, nationally representative database to estimate the association between blood transfusion and inpatient complications and hospital costs following TAA. METHODS: Using the Nationwide Inpatient Sample (NIS) database from 2004 to 2014, 25 412 patients who underwent TAA were identified, with 286 (1.1%) receiving a blood transfusion. Univariate analysis assessed patient and hospital factors associated with blood transfusion following TAA. RESULTS: Patients requiring blood transfusion were more likely to be female, African American, Medicare recipients, and treated in nonteaching hospitals. Average length of stay for patients following transfusion was 3.0 days longer, while average inpatient cost was increased by approximately 50%. Patients who received blood transfusion were significantly more likely to suffer from congestive heart failure, peripheral vascular disease, hypothyroidism, coagulation disorder, or anemia. Acute renal failure was significantly more common among patients receiving blood transfusion ( P < .001). CONCLUSION: Blood transfusions following TAA are infrequent and are associated with multiple medical comorbidities, increased complications, longer hospital stays, and increased overall cost. LEVELS OF EVIDENCE: Level III: Retrospective, comparative study.

Outcomes in patients with renal hyperparathyroidism requiring cinacalcet pre-operatively followed by parathyroidectomy.

BACKGROUND: Cinacalcet is an effective treatment for renal hyperthyroidism when traditional medical therapy has failed. We studied the impact of pre-operative cinacalcet administration on post-surgical outcomes. METHODS: A retrospective analysis was performed of patients from 2002 to 2017 diagnosed with renal hyperparathyroidism requiring parathyroidectomy to evaluate the need for post-operative supplementation and outcomes. RESULTS: 102 patients were identified; 34 patients were treated with cinacalcet prior to undergoing parathyroidectomy. The cinacalcet treatment cohort (CT) demonstrated a greater duration of renal replacement therapy (p = 0.03) relative to the untreated cohort (NC). NC had greater proportion receiving peritoneal dialysis (p=<0.0001) compared to other forms of renal replacement, greater pre-operative PTH levels (p = 0.001) and greater decrease in PTH after resection (p = 0.0086). Post-operative vitamin D supplementation was more frequent in the CT group (p = 0.02). After propensity matching for pre-operative PTH and duration of renal replacement therapy, there were no differences in post-operative supplementation or outcomes. CONCLUSIONS: Cinacalcet patients may have advanced disease. These patients have longer duration of renal failure and higher PTH levels. After propensity matching, no significant differences were noted in terms of need for supplementation or outcomes.

Blood Transfusion Incidence, Risk Factors, and Associated Complications in Surgical Treatment of Hip Dysplasia.

BACKGROUND: Perioperative bleeding requiring blood transfusion is a known complication of hip dysplasia (HD) surgery. Here we examine rates of, risk factors for, and postoperative complications associated with transfusion during HD surgery. METHODS: The National Surgical Quality Improvement Program (NSQIP) Pediatric database was queried for patients treated by an orthopaedist from 2012 to 2013. HD cases were categorized by Current Procedural Terminology codes into femoral osteotomies, acetabular osteotomies, combined femoral/acetabular osteotomies, and open reductions. Patients were grouped by comorbidities: neuromuscular (NM) disease (eg, cerebral palsy) group, non-NM with other comorbidity (Other) group, and no known comorbidity (NL) group. Patients were stratified by weight-normalized transfusion volume. Multivariate regression analysis of transfusion association with procedures, demographics, comorbidities, preoperative laboratory values, and 30-day complications was performed. RESULTS: A total of 1184 HD cases were included. Transfusion rates for the NL, Other, and NM groups, respectively, were 44/451 (9.8%), 61/216 (28.2%), and 161/517 (31.1%). Transfusion volumes (mean±SD) for the NL, Other, and NM groups, respectively, were 8.4±5.4, 13.9±8.8, and 15.5±10.0 mL/kg (P<0.001). Combined osteotomies had the highest transfusion rates in the NM and Other groups (35.7% and 45.8%, respectively), whereas acetabular osteotomies had the highest rate in the NL group (15.8%). Open reductions had the lowest transfusion rate (all groups). Longer operations were independently associated with transfusion (all groups, per hour increase, OR>1.5, P<0.001). Independent patient risk factors included preoperative hematocrit <31% (NM group, OR=18.42, P=0.013), female sex (NL group, OR=3.55, P=0.008), developmental delay (NM group, OR=2.37, P=0.004), pulmonary comorbidity (NM group, OR=1.73, P=0.032), and older age (NL group, per year increase: OR=1.29, P<0.001). In all groups, transfusion was associated with longer hospitalization (P<0.001). We observed a volume-dependent increase in overall complication rate within the Other group for transfusion volumes >15 mL/kg (25.0% vs. 5.4% for <15 mL/kg, P=0.048). CONCLUSIONS: We identified several risk factors for transfusion in HD surgery. The incidence of transfusion in HD surgery and its association with adverse outcomes warrants development of appropriate patient management guidelines. LEVEL OF EVIDENCE: Level III-prognostic.

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile?

PURPOSE: To provide a comparative 30-day postoperative analysis of complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for postoperative complications after open or arthroscopic RCR over an 8-year period, from 2007 through 2014. Patients were identified by use of Current Procedural Terminology codes. The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. The risk of complications was compared between the 2 groups, along with patient demographic characteristics, operative time, length of stay, and unplanned readmission within 30 days. We compared dichotomous variables using the Fisher exact test and continuous variables with 1-way analysis of variance. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated when appropriate. RESULTS: The open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05). Patients undergoing open RCR had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P = .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P = .0004). Open RCR was associated with a longer average hospital stay (0.48 ± 2.7 days vs 0.23 ± 4.2 days, P = .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001). CONCLUSIONS: Although both open and arthroscopic approaches to RCR had low morbidity, arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Predictors of readmission in nonagenarians: analysis of the American College of Surgeons National Surgical Quality Improvement Project dataset.

BACKGROUND: Increased longevity has led to more nonagenarians undergoing elective surgery. Development of predictive models for hospital readmission may identify patients who benefit from preoperative optimization and postoperative transition of care intervention. Our goal was to identify significant predictors of 30-d readmission in nonagenarians undergoing elective surgery. METHODS: Nonagenarians undergoing elective surgery from January 2011 to December 2012 were identified using the American College of Surgeons National Surgical Quality Improvement Project participant use data files. This population was randomly divided into a 70% derivation cohort for model development and 30% validation cohort. Using multivariate step-down regression, predictive models were developed for 30-d readmission. RESULTS: Of 7092 nonagenarians undergoing elective surgery, 798 (11.3%) were readmitted within 30 d. Factors significant in univariate analysis were used to develop predictive models for 30-d readmissions. Diabetes (odds ratio [OR]: 1.51, 95% confidence interval [CI]: 1.24-1.84), dialysis dependence (OR: 2.97, CI: 1.77-4.99), functional status (OR: 1.52, CI: 1.29-1.79), American Society of Anesthesiologists class II or higher (American Society of Anesthesiologist physical status classification system; OR: 1.80, CI: 1.42-2.28), operative time (OR: 1.05, CI: 1.02-1.08), myocardial infarction (OR: 5.17, CI: 3.38-7.90), organ space surgical site infection (OR: 8.63, CI: 4.04-18.4), wound disruption (OR: 14.3, CI: 4.80-42.9), pneumonia (OR: 8.59, CI: 6.17-12.0), urinary tract infection (OR: 3.88, CI: 3.02-4.99), stroke (OR: 6.37, CI: 3.47-11.7), deep venous thrombosis (OR: 5.96, CI: 3.70-9.60), pulmonary embolism (OR: 20.3, CI: 9.7-42.5), and sepsis (OR: 13.1, CI: 8.57-20.1), septic shock (OR: 43.8, CI: 18.2-105.0), were included in the final model. This model had a c-statistic of 0.73, indicating a fair association of predicted probabilities with observed outcomes. However, when applied to the validation cohort, the c-statistic dropped to 0.69, and six variables lost significance. CONCLUSIONS: A reliable predictive model for readmission in nonagenarians undergoing elective surgery remains elusive. Investigation into other determinants of surgical outcomes, including social factors and access to skilled home care, might improve model predictability, identify areas for intervention to prevent readmission, and improve quality of care.

Psychomotor Testing for Orthopedic Residency Applicants: A Pilot Study.

OBJECTIVE: The purpose of this study was to develop an objective motor skills testing system to aid in the evaluation of potential orthopedic residents. DESIGN: Participants attempted a battery of 5 motor skills tests (4 novel tests and the Grooved Pegboard [GPT] Test) in one 10-minute session. A percentile-based scoring system was created for each test based on raw scores. One-way analysis of variance was used to compare testing scores among 3 cohorts. Each novel test and overall scores were compared with GPT scores as a relative measure of validity. SETTING: The 2015 orthopedic surgery residency interview season at an academic institution. PARTICIPANTS: Thirty orthopedic residents and 72 nonresidents (15 community volunteers and 57 orthopedic surgery residency applicants). RESULTS: Overall, residents performed better than nonresidents (p < 0.0001) and applicants performed worse than residents or volunteers (p < 0.0001). There were positive correlations between the GPT score and overall battery score (r = 0.63), screw and nut test (r = 0.40), and mimic a structure test (r = 0.26). The fracture reduction test and drilling test scores did not correlate to performance on the GPT. CONCLUSIONS: Psychomotor testing for surgical applicants is an area in need of study. This investigation successfully piloted a novel battery of tests, which is easily reproducible and thus may be feasible for use in the orthopedic surgery residency interview setting. Longitudinal evaluation is required to explore correlation with future operative skill.

Risk factors for same-admission mortality after pathologic fracture secondary to metastatic cancer.

PURPOSE: The skeleton is the third most common site of cancer metastases. Approximately 10 % of patients with bone metastases will develop a pathologic fracture, with significant associated morbidity and mortality. The purpose of this study was to identify risk factors for same-admission mortality after pathologic fractures secondary to metastatic cancer. METHODS: The Nationwide Inpatient Sample database was queried from 2002 to 2013 for hospitalized patients with diagnoses of pathologic fracture and a primary cancer at high risk for skeletal metastasis. Univariate and multivariate analyses were performed to determine risk factors associated with same-admission mortality after fracture. RESULTS: A total of 371,163 patients were identified. The spine was the most common site of pathologic fracture (68.0 %) followed by lower extremity (25.0 %) and upper extremity (8.7 %). The following factors were independently associated with increased mortality (p < 0.001): cancer of lung or unspecified location; fracture of upper or lower extremity; male gender; age ≥65; non-Medicare insurance; coexisting congestive heart failure, chronic pulmonary disease, renal failure, or liver disease; and postoperative surgical site infection, acute myocardial infarction, pulmonary embolism, or pneumonia. Closed reductions were associated (p < 0.001) with increased mortality while open or percutaneous surgical treatments were protective (p < 0.001) against mortality. CONCLUSIONS: Pathologic fractures are a devastating consequence of metastatic bone disease, contributing significantly to morbidity and mortality. Numerous demographic and medical factors are associated with increased same-admission mortality. This data is useful for counseling patients with skeletal metastatic disease and should be taken into consideration when conducting routine skeletal surveillance in patients with metastatic cancer.

Risk Factors for Early Readmission After Anatomical or Reverse Total Shoulder Arthroplasty.

Hospital readmissions are costly for patients and institutions. We conducted a study to evaluate rates of readmission within 30 days after anatomical total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) and to determine independent risk factors for readmission. We queried the National Surgical Quality Improvement Program database for ATSAs and RTSAs performed between 2011 and 2013 and found a combined total of 3501 cases and an overall readmission rate of 2.7%. Of the readmissions, 67% were for medical complications, and 33% were for surgical complications. Of the medical complications, pneumonia was the most common (11.8%), followed by urinary tract infection (7.8%). Regarding surgical complications, surgical-site infection was the most common (13.7%), followed by prosthetic joint dislocation (9.8%). Hospital-acquired conditions, including surgical-site infection, urinary tract infection, deep vein thrombosis, and pulmonary embolism, accounted for 33% of all 30-day readmissions. Three independent risk factors for readmission were identified: revision surgery (odds ratio, 2.59), 3 or more comorbidities (odds ratio, 2.02), and extended length of stay (>4.3 days) during the index admission (odds ratio, 2.48). Other factors significantly (P < .05) associated with readmission were age over 75 years, dependent functional status, American Society of Anesthesiologists score of 4 or higher, cardiac comorbidity, 2 or more comorbidities, and urinary tract infection before discharge.

Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population.

INTRODUCTION: The risk of morbidity associated with venous thromboembolism (VTE) after pediatric orthopaedic surgery remains unclear despite increased use of thromboprophylaxis measures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program, Pediatric database was queried for patients undergoing an orthopaedic surgical procedure between 2012 and 2013. Upper extremity and skin/subcutaneous surgeries were excluded. Associations between VTE and procedure, demographics, comorbidities, preoperative laboratory values, and 30-day postoperative outcomes were evaluated. RESULTS: Of 14,776 cases, 15 patients (0.10%) experienced postoperative VTE. Deep vein thrombosis (DVT) occurred in 13 patients (0.09%), and pulmonary embolism developed in 2 patients (0.01%). The procedure with the highest VTE rate was surgery for infection (1.2%). Patient factors associated with the development of VTE included hyponatremia (P = 0.003), abnormal partial thromboplastin time (P = 0.046), elevated aspartate transaminase level (P = 0.004), and gastrointestinal (P = 0.011), renal (P = 0.016), and hematologic (P = 0.019) disorders. Nearly half (46.2%) of DVTs occurred postdischarge. Complications associated with VTE included prolonged hospitalization (P < 0.001), pneumonia (P < 0.001), unplanned intubation (P = 0.003), urinary tract infection (P = 0.003), and central line-associated bloodstream infection (P < 0.001). Most of the postoperative complications (66.7%) occurred before VTE diagnosis, and no patients with VTE died. CONCLUSION: In the absence of specified risk factors, thromboprophylaxis may be unnecessary for this population.

Abrasiveness of high-strength sutures used in rotator cuff surgery: are they all the same?

BACKGROUND: The suture-tendon interface remains the most common point of failure in rotator cuff repairs via suture pullout. Several high-strength braided sutures are available for rotator cuff surgery and are more abrasive than monofilaments. However, a comparison of these sutures has not been performed in a tissue model. METHODS: Ninety infraspinatus sheep tendons were randomized among 9 groups of sutures (n = 10), including FiberWire (Arthrex, Naples, FL, USA), Collagen Coated FiberWire (Arthrex), Orthocord (DePuy Mitek, Raynham, MA, USA), MaxBraid (Biomet, Warsaw, IN, USA), Force Fiber (Teleflex, Research Triangle Park, NC, USA), ULTRABRAID (Smith & Nephew, Memphis, TN, USA), Phantom Fiber BioFiber (Tornier, Bloomington, MN, USA), and Ti-Cron (Syneture, Mansfield, MA), with Surgipro (Syneture) monofilament as a control. Each suture was cycled 50 times through the tendon, which was fixed to a mechanical testing system under a constant load in saline solution. The distance cut through the tendon was measured and divided by the distance of suture sliding to determine displacement (mm/cm). Twist angle and picks per inch of each suture were measured using digital photography. One-way analysis of variance was used to compare the displacement and twist angle between sutures. RESULTS: Collagen Coated FiberWire was the most abrasive of the high-strength sutures. Four of the sutures (Collagen Coated FiberWire, Phantom Fiber BioFiber, FiberWire, Ti-Cron) had a mean displacement rate greater than 0.150 mm/cm. The remainder of the sutures had a mean displacement rate less than 0.050 mm/cm (Orthocord, Force Fiber, MaxBraid, ULTRABRAID). The difference in the displacement rates between these 2 groups was significant (P < .0001) and was related to both the twist angle and the picks per inch. CONCLUSION: Significant differences in suture abrasiveness were identified among high-strength braided sutures and correlated with lower twist angle and lower picks per inch.

Telemedicine with mobile devices and augmented reality for early postoperative care.

Advanced features are being added to telemedicine paradigms to enhance usability and usefulness. Virtual Interactive Presence (VIP) is a technology that allows a surgeon and patient to interact in a "merged reality" space, to facilitate both verbal, visual, and manual interaction. In this clinical study, a mobile VIP iOS application was introduced into routine post-operative orthopedic and neurosurgical care. Survey responses endorse the usefulness of this tool, as it relates to The virtual interaction provides needed virtual follow-up in instances where in-person follow-up may be limited, and enhances the subjective patient experience.

Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic.

BACKGROUND: Shoulder disorders are a common cause of disability and pain. The Shoulder Pain and Disability Index (SPADI) is a frequently employed and previously validated measure of shoulder pain and disability. Although the SPADI has high reliability and construct validity, greater differences between individual patients are often observed than would be expected on the basis of diagnosis and pathophysiology alone. This study aims to determine how psychological factors (namely depression, catastrophic thinking, and self-efficacy) affect pain and perceived disability in the shoulder. METHODS: A cohort of 139 patients completed a sociodemographic survey and elements from the SPADI, Pain Self-Efficacy Questionnaire (PSEQ), Pain Catastrophizing Scale (PCS), and Patient Health Questionnaire Depression Scale (PHQ-2). Bivariate and multivariate analyses were performed to determine the association of psychosocial factors, demographic characteristics, and specific diagnosis with shoulder pain and disability. RESULTS: The SPADI score showed medium correlation with the PCS (r = 0.43; p < 0.001), PHQ-2 (r = 0.39; p < 0.001), and PSEQ (r = -0.45; p < 0.001). Current work status (F = 4.35; p = 0.006) and body mass index (r = 0.27; p = 0.002) were also associated with the SPADI score. In the multivariate analysis, greater catastrophic thinking (estimate, 0.003; p = 0.029), lower self-efficacy (estimate, -0.005; p = 0.001), higher body mass index (estimate, 0.006; p = 0.048), and being disabled (estimate, 0.15; p = 0.017) or retired (estimate, 0.16; p < 0.001) compared with being employed were associated with worse SPADI scores. The primary diagnosis did not have a significant relationship (p > 0.05) with the SPADI. CONCLUSIONS: Catastrophic thinking and decreased self-efficacy are associated with greater shoulder pain and disability. Our data support the notion that patient-to-patient variation in symptom intensity and magnitude of disability is more strongly related to psychological distress than to the specific shoulder diagnosis.

Risk factors for complications and readmission after operative fixation of pediatric femur fractures.

PURPOSE: Operative fixation of pediatric femur fractures with intramedullary implants has grown in popularity in recent decades. However, risk factors for short-term adverse events and readmission have not been well studied. METHODS: Pediatric patients who underwent intramedullary nailing of a femur fracture between 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Risk factors for any adverse event (AAE) and readmission after intramedullary nailing were evaluated using univariate and multivariate analysis. RESULTS: A total of 522 pediatric patients who underwent intramedullary nailing of the femur during the study period were identified. The mean age of this patient cohort was 10.2 ± 3.8 years. Review of the cases revealed that 18 (3.4 %) patients had AAE and that 20 (3.8 %) patients were readmitted, of whom 13 (2.5 %) underwent a reoperation. Independent risk factors for AAE were a cardiac comorbidity [odds ratio (OR) 12.7, 95 % confidence interval (CI) 1.5, 103.7], open fracture (OR 10.2, 95 % CI 1.4, 74.4), and prolonged operative time (OR 17.5, 95 % CI 6.1, 50.5). Independent risk factors for readmission were a central nervous system disorder (OR 4.5, 95 % CI 1.3, 16.2) and a seizure disorder (OR 4.9, 95 % CI 1.0, 23.5). CONCLUSIONS: The results of the multivariate analysis suggest that cardiac comorbidities, open fractures, and prolonged operative time increase the risk for AAE and that central nervous system disorders and seizure disorders may increase the risk for readmission. Surgeons should be aware of these risk factors and counsel the families of pediatric patients who undergo intramedullary nailing of femur fractures.

Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty.

BACKGROUND: Despite that pulmonary embolism (PE) is a feared complication after shoulder arthroplasty, little is known about its perioperative associated factors. MATERIALS AND METHODS: We used the Nationwide Inpatient Sample to gather a sample of 422,372 patients who underwent shoulder arthroplasty between 2002 and 2011. This population was divided into 2 cohorts on the basis of those who experienced perioperative PE (0.25%) and those who did not. Demographics were compiled for both cohorts. Multivariable logistic regression analysis was used to account for confounding variables and to determine significant predictors of perioperative PE. RESULTS: After adjusting for patient demographic and clinical variables in multivariable regression modeling, the top 4 independent predictors for PE were primary diagnosis of proximal humerus fracture, deficiency anemia, congestive heart failure, and chronic lung disease. Other pertinent risk factors included increasing age, obesity, fluid and electrolyte abnormalities, undergoing total shoulder arthroplasty rather than hemiarthroplasty, and subsequent days of postoperative care. CONCLUSIONS: Knowledge of these factors might help in preoperative counseling and prove useful for implementation of quality improvement strategies to reduce the occurrence of PE. Surgeons may consider initiating thromboprophylaxis in patients with any of the aforementioned comorbidities.