Utility of Synovial White Blood Cell Count and Differential Before Reimplantation Surgery.

BACKGROUND: Determining optimal timing of reimplantation during 2-stage exchange for periprosthetic joint infection (PJI) remains elusive. Joint aspiration for synovial white blood cell (WBC) count and neutrophil percentage (PMN%) before reimplantation is widely performed; yet, the implications are rarely understood. Therefore, this study investigates (1) the diagnostic yield of synovial WBC count and differential analysis and (2) the calculated thresholds for persistent infection. METHODS: Institutional PJI databases identified 129 patients undergoing 2-stage exchange arthroplasty who had joint aspiration before reimplantation between February 2005 and May 2014. Persistent infection was defined as a positive aspirate culture, positive intraoperative cultures, or persistent symptoms of PJI-including subsequent PJI-related surgery. Receiver-operating characteristic curve was used to calculate thresholds maximizing sensitivity and specificity. RESULTS: Thirty-three cases (33 of 129; 25.6%) were classified with persistent PJI. Compared with infection-free patients, these patients had significantly elevated PMN% (62.2% vs 48.9%; P = .03) and WBC count (1804 vs 954 cells/µL; P = .04). The receiver-operating characteristic curve provided thresholds of 62% and 640 cells/µL for synovial PMN% and WBC count, respectively. These thresholds provided sensitivity of 63% and 54.5% and specificity of 62% and 60.0%, respectively. The risk of persistent PJI for patients with PMN% >90% was 46.7% (7 of 15). CONCLUSION: Synovial fluid analysis before reimplantation has unclear utility. Although statistically significant elevations in synovial WBC count and PMN% are observed for patients with persistent PJI, this did not translate into useful thresholds with clinical importance. However, with little other guidance regarding the timing of reimplantation, severely elevated WBC count and differential analysis may be of use.

Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle.

For AO 44-B2 ankle fractures of uncertain stability, the current diagnostic standard is to obtain a gravity stress radiograph, but some have advocated for the use of weight-bearing radiographs. The primary aim was to compare measures of medial clear space (MCS) on weight-bearing cone beam computed tomography (CBCT) scans versus gravity stress radiographs for determining the state of stability of ankle fractures classified as AO SER 44-B2 or Weber B. The secondary aim was to evaluate the details offered by CBCT scans with respect to other findings that may be relevant to patient care. Nine patients were enrolled in this cross-sectional study between April 2016 and February 2017 if they had an AO SER 44-B2 fracture of uncertain stability, had a gravity stress radiograph, and were able to undergo CT scan within seven days. The width of the MCS was measured at the level of the talar dome on all radiographs and at the mid coronal slice on CT. Wilcoxon signed-ranks tests were used to compare MCS between initial radiographs, gravity stress radiographs and weight-bearing CBCT scans. MCS on weight-bearing CBCT scan (1.41±0.41 mm) was significantly less than standard radiographs (3.28±1.63 mm, P=0.004) and gravity stress radiographs (5.82±1.93 mm, P=0.02). There was no statistically significant difference in MCS measured on standard radiographs versus gravity stress radiographs (P=0.11). Detailed review of the multiplanar CT images revealed less than perfect anatomical reduction of the fractures, with residual fibular shortening, posterior displacement, and fracture fragments in the incisura as typical findings. Similar to weight-bearing radiographs, weight-bearing CBCT scan can predict stability of AO 44-B2 ankle fractures by showing restoration of the MCS, and might be used to indicate patients for non-operative treatment. None of the fractures imaged in this study were perfectly reduced however, and further clinical research is necessary to determine if any of the detailed weight-bearing CBCT findings are related to patient outcomes.

Length of stay after shoulder arthroplasty-the effect of an orthopedic specialty hospital.

BACKGROUND: One potential avenue for the realization of health care savings is reduction in hospital length of stay (LOS). Initiatives to reduce LOS may also reduce infection and improve patient satisfaction. We compare LOS after shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). METHODS: A single institutional database was used to retrospectively identify all primary shoulder arthroplasties performed between January 1, 2013, and July 1, 2015, at the OSH and TRC. Manually matched cohorts from the OSH and TRC were compared for LOS and readmission rate. RESULTS: There were 136 primary shoulder arthroplasties performed at the OSH matched with 136 at the TRC during the same study period. OSH and TRC patients were similar in age (P = .949), body mass index (P = .967), Charlson Comorbidity Index (P = 1.000), gender (both 52.21% male), procedure (69.12% total shoulder arthroplasty, 7.35% hemiarthroplasty, and 23.53% reverse shoulder arthroplasty), insurance status (P = .714), and discharge destination (P = .287). Despite equivalent patient characteristics, average LOS at the OSH was 1.31 ± 0.48 days compared with 1.85 ± 0.57 days at the TRC (t = 8.41, P < .0001). Of the 136 OSH patients, 3 (2.2%) required transfer to a TRC. Readmission rates for the OSH patients (2/136, 1.5%) and TRC patients (1/136, 0.7%) were similar (z = 0.585, P = .559). CONCLUSION: LOS at the OSH was significantly shorter than at the TRC for a strictly matched cohort of patients. This may be a result of fast-track rehabilitation and strict disposition protocols at the OSH. With rising shoulder arthroplasty demand, utilization of an OSH may be a safe avenue to delivery of more efficient and effective orthopedic care.

Workers' Compensation patients after total joint arthroplasty: do they return to work?

Clinicians identify patients receiving Workers' Compensation (WC) as unlikely to fully benefit from total joint arthroplasty (TJA), with possibly decreased ability to return to work. We completed follow-up for 164 patients undergoing 177 arthroplasties while receiving WC between 2000 and 2009. Inquiry was made regarding work status, nature of work, and return to work time frame. Patients undergoing primary versus revision TJA returned to work 70.2% versus 43.9%, respectively (p=0.002). The mean time frame for return to work following primary TJA was 16.4 weeks. Manual laborers versus sedentary workers returned to work 67.1% versus 84.8%, respectively (p=0.05). As this group is limited by the strenuous nature of their employment, clinicians should be aware that receiving WC may modestly impact return to work following arthroplasty.

What is the incidence of dysphagia after posterior cervical surgery?

STUDY DESIGN: Prospective comparative study. OBJECTIVE: To determine whether dysphagia is a unique complication of anterior neck dissection or whether it occurs after any cervical surgery. SUMMARY OF BACKGROUND DATA: Dysphagia is a common complication after anterior cervical discectomy and fusion. However, current literature is scarce whether dysphagia occurs as a direct result of the anterior approach (dissection or instrumentation) or because of cervical spine surgery itself. METHODS: Patients undergoing posterior cervical surgery were prospectively evaluated for dysphagia up to 6 months after surgery. Patients were evaluated for dysphagia preoperatively, at 2 weeks and 6 weeks postoperatively using the dysphagia numeric rating scale. The data was compared with a previously published cohort of anterior cervical and lumbar surgical procedures from the same institution. Statistical significance was evaluated using the Fisher exact test. RESULTS: Eighty-five patients were included who underwent posterior cervical surgery. Baseline dysphagia was present in 11% (10/85) of patients. The incidence of new dysphagia was 10 of 85 (11%) at 2 weeks, 8 of 85 (8%) at 6 weeks, 13 of 85 (13%) at 12 weeks, and 5 of 85 (6%) at 24 weeks. The incidence of new dysphagia was significantly less than that of anterior cervical surgery at 2 weeks (posterior [P] 11% vs. anterior [A] 61.5%, P = 0.0001), 6 weeks (P 8% vs. A 44%, P = 0.0001), but not 12 weeks (P 13% vs. A 11%, P = 1). The incidence of dysphagia after posterior cervical surgery was significantly increased compared with that of lumbar surgery at 2 weeks (P 11% vs. lumbar surgery [L] 9%, P = 0.78), 6 weeks (P 8% vs. L 0%, P = 0.02), and 12 weeks (P 13% vs. L 0%, P = 0.007). At 12 weeks postoperatively, there was a statistically significant increase in postoperative neck pain (P = 0.008), tightness (P = 0.032), and peripheral pain/numbness (P = 0.032) in patients with dysphagia. CONCLUSION: Both anterior and posterior cervical surgery may result in long-term dysphagia in a small number of patients, perhaps due to loss of motion or postoperative pain. Surgeons should counsel their patients about possibility for dysphagia prior to all cervical spine surgery.