Defining Distinct Stress Curve Morphologies for Coronal Plane Alignment of the Knee (CPAK) Phenotypes using an Imageless Navigation Robotic Platform in Total Knee Arthroplasty.

INTRODUCTION: The coronal plane alignment of the knee (CPAK) classification system divides coronal knee anatomy into nine phenotypes, suggesting different soft tissue balancing is needed for optimal outcomes. We investigated the interplay between CPAK phenotypes and gap stress curves throughout the knee's range of motion, aiming to understand their impact on total knee arthroplasty (TKA) balancing. METHODS: There were 1,112 TKA cases from two imageless robotic assisted navigation systems using posterior stabilized implants that were classified into CPAK phenotypes. Medial and lateral initial gap values were measured throughout the knee flexion-extension arc, gap curve morphologies were generated, and medio-lateral (ML) gap balance was calculated for each phenotype. The most common phenotypes were included in this study, CPAK I to VI. RESULTS: Each phenotype exhibited a distinct gap curve morphology. Type I maintained the largest ML gap difference (-3.6 to -2.1), with the medial compartment tightest in extension. Type II showed relative laxity in the lateral compartment compared to the medial gap (-1.0 to -1.9), with the medial compartment tightening through flexion. Type III had a looser medial and tighter lateral compartment in extension that inverts to a tighter medial compartment in deep flexion (2.1 to -0.8), while Type IV showed a decreasing compartment difference with increased flexion (-3.7 to 0.6). Type V had fluctuating tightness (-0.6 to 1.8), and Type VI had the medial compartment tightening more with flexion (0.6 to 1.8). CONCLUSION: The distinct stress curves and ML gap behavior provide a "fingerprint" for each corresponding CPAK phenotype. Investigating these morphologies can help determine the best phenotype-specific treatments, including alignment strategy, implant selection, and gap balance, for optimal functional and patient outcomes.

The relationship between pseudotumours and infected complications in patients who have undergone metal-on-metal total hip arthroplasty.

Aims: This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods: A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results: The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion: Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.

Virtual Scribes and Physician Time Spent on Electronic Health Records.

Importance: Time on the electronic health record (EHR) is associated with burnout among physicians. Newer virtual scribe models, which enable support from either a real-time or asynchronous scribe, have the potential to reduce the burden of the EHR and EHR-related documentation. Objective: To characterize the association of use of virtual scribes with changes in physicians' EHR time and note and order composition and to identify the physician, scribe, and scribe response factors associated with changes in EHR time upon virtual scribe use. Design, Setting, and Participants: Retrospective, pre-post quality improvement study of 144 physicians across specialties who had used a scribe for at least 3 months from January 2020 to September 2022, were affiliated with Brigham and Women's Hospital and Massachusetts General Hospital, and cared for patients in the outpatient setting. Data were analyzed from November 2022 to January 2024. Exposure: Use of either a real-time or asynchronous virtual scribe. Main Outcomes: Total EHR time, time on notes, and pajama time (5:30 pm to 7:00 am on weekdays and nonscheduled weekends and holidays), all per appointment; proportion of the note written by the physician and team contribution to orders. Results: The main study sample included 144 unique physicians who had used a virtual scribe for at least 3 months in 152 unique scribe participation episodes (134 [88.2%] had used an asynchronous scribe service). Nearly two-thirds of the physicians (91 physicians [63.2%]) were female and more than half (86 physicians [59.7%]) were in primary care specialties. Use of a virtual scribe was associated with significant decreases in total EHR time per appointment (mean [SD] of 5.6 [16.4] minutes; P < .001) in the 3 months after vs the 3 months prior to scribe use. Scribe use was also associated with significant decreases in note time per appointment and pajama time per appointment (mean [SD] of 1.3 [3.3] minutes; P < .001 and 1.1 [4.0] minutes; P = .004). In a multivariable linear regression model, the following factors were associated with significant decreases in total EHR time per appointment with a scribe use at 3 months: practicing in a medical specialty (-7.8; 95% CI, -13.4 to -2.2 minutes), greater baseline EHR time per appointment (-0.3; 95% CI, -0.4 to -0.2 minutes per additional minute of baseline EHR time), and decrease in the percentage of the note contributed by the physician (-9.1; 95% CI, -17.3 to -0.8 minutes for every percentage point decrease). Conclusions and Relevance: In 2 academic medical centers, use of virtual scribes was associated with significant decreases in total EHR time, time spent on notes, and pajama time, all per appointment. Virtual scribes may be particularly effective among medical specialists and those physicians with greater baseline EHR time.

Comparison of transforaminal and posterior lumbar interbody fusion outcomes in patients receiving a novel allograft versus rhBMP-2: a radiographic and patient-reported outcomes analysis.

OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been demonstrated to achieve the highest rates of arthrodesis in multilevel lumbar fusion but is also associated with possible perioperative morbidity. A novel allograft (OSTEOAMP) is a differentiated allograft that retains growth factors supporting bone healing. The authors sought to compare the clinical and radiographic outcomes of rhBMP-2 and the novel allograft in lumbar interbody arthrodesis to determine if the latter may be a safer and equally effective alternative to rhBMP-2 for single- and multilevel posterior or transforaminal lumbar interbody fusion (PLIF or TLIF). METHODS: Patients who underwent single- or multilevel TLIF or PLIF using either OSTEOAMP or rhBMP-2 at the authors' institution over a 2-year period were prospectively followed for 12 months. Healthcare utilization, safety measures, patient satisfaction, physical disability (measured on the Oswestry Disability Index [ODI]), back and leg pain (on the numeric rating scale [NRS]), quality of life (on the EQ-5D scale), and return to work (RTW) were prospectively recorded. For purposes of this study, this consecutive series was retrospectively analyzed and pseudarthrosis rates were assessed at 2 years of follow-up. All patients (100%) had both 12-month patient-reported outcome follow-up and 24-month clinical and radiographic follow-up. RESULTS: One thousand one hundred fifty-four patients (654 treated with OSTEOAMP, 500 with rhBMP-2) were prospectively enrolled in the institutional registry. After propensity score matching, there were no significant baseline differences between 330 novel allograft and 330 rhBMP-2 cases. Perioperative morbidity and 90-day hospital readmission (3.3% vs 2.4%, p = 0.485) did not significantly differ between the novel allograft and the rhBMP-2 cases. At the 2-year follow-up, symptomatic pseudarthrosis requiring revision surgery occurred in 8 patients (2.4%) with OSTEOAMP and 6 patients (1.8%) with rhBMP-2 (p = 0.589). The overall fusion rate at 2 years was similar between groups (p = 0.213). Both groups showed significant and equivalent improvement in patient-reported outcome measures (PROMs) from baseline to 12-month follow-up, with no significant difference in 1-year mean NRS leg pain score (2.5 vs 2.7), ODI (25 vs 26), quality-adjusted life years (0.73 vs 0.73), satisfaction (83% vs 80%), or RTW (6.6 vs 7 weeks). CONCLUSIONS: In the authors' institutional experience, OSTEOAMP is a clinically viable substitute for rhBMP-2 for single- and multilevel lumbar fusion. This novel allograft provides clinically effective arthrodesis and improvements in PROMs comparable to rhBMP-2 with a similar safety profile. Additional indications and outcome assessment in longitudinal studies are needed to further characterize this allogeneic graft.

Natural History of Opioid Use in Naive and Tolerant Patients in Revision Total Hip Arthroplasty.

BACKGROUND: Opioid use after revision total hip arthroplasty (rTHA) has not been well characterized. The purpose of this study was to characterize preoperative, perioperative, and postoperative opioid use during rTHA. METHODS: Patients undergoing revision THA from 2010 to 2018 were screened for opioid use 3 months before revision surgery and tracked 24 months postoperatively. Patients were categorized as naïve or tolerant. Opioid prescriptions and average morphine milligram equivalents (MME) were compared between the two groups. RESULTS: One hundred twenty-four of 247 patients (50%) in the tolerant group averaged a preoperative MME of 23.7 mg/day. Postoperatively, tolerant patients received significantly higher daily MME at all time points, including at 3 months 31.4 versus 18.1 mg/day (P < 0.001), 6 months 19.9 versus 2.95 mg/day (P < 0.001), 12 months 14.3 versus 3.5 mg/day (P < 0.001), and 24 months 10.7 versus 2.17 mg/day (P < 0.001). Tolerant patients were more likely to have a prescription at 6 months (44% versus 22%), 12 months (41.4% versus 24%), and 24 months (38% versus 19.3%) (P < 0.001, P = 0.002, P < 0.001, respectively). DISCUSSION: Opioid-tolerant patients had higher postoperative MME requirements for longer recovery duration. Both groups reduced opioid use at 3 months and plateaued at 6 months. These findings can help the revision surgeon counsel patients and expectations.

Trust with increasing and decreasing reliability.

OBJECTIVE: The primary purpose was to determine how trust changes over time when automation reliability increases or decreases. A secondary purpose was to determine how task-specific self-confidence is associated with trust and reliability level. BACKGROUND: Both overtrust and undertrust can be detrimental to system performance; therefore, the temporal dynamics of trust with changing reliability level need to be explored. METHOD: Two experiments used a dominant-color identification task, where automation provided a recommendation to users, with the reliability of the recommendation changing over 300 trials. In Experiment 1, two groups of participants interacted with the system: one group started with a 50% reliable system which increased to 100%, while the other used a system that decreased from 100% to 50%. Experiment 2 included a group where automation reliability increased from 70% to 100%. RESULTS: Trust was initially high in the decreasing group and then declined as reliability level decreased; however, trust also declined in the 50% increasing reliability group. Furthermore, when user self-confidence increased, automation reliability had a greater influence on trust. In Experiment 2, the 70% increasing reliability group showed increased trust in the system. CONCLUSION: Trust does not always track the reliability of automated systems; in particular, it is difficult for trust to recover once the user has interacted with a low reliability system. APPLICATIONS: This study provides initial evidence into the dynamics of trust for automation that gets better over time suggesting that users should only start interacting with automation when it is sufficiently reliable.

The Posterior Approach is Associated With Lower Total Encounter and 90-Day Costs When Compared to the Direct Anterior Approach.

BACKGROUND: The clinical impact of the surgical approach in total hip arthroplasty (THA) has been widely reviewed. This study evaluated the total encounter and 90-day costs of THA for 2 surgical approaches (posterior [P] and direct anterior [DA]) in 1 tertiary health system. METHODS: This is a retrospective review of 2,101 THAs (1,092 P and 1,009 DA) by 4 surgeons (2 with the highest volume of DA and P, respectively) from 2017 to 2022 at 1 academic center. Demographics, comorbidities, operative time, length of hospital stay, 90-day hospital returns, and complications were compared. The total encounter cost and 90-day postoperative cost were itemized. Multivariable regression analyses evaluated associations with increased cost at each time point. RESULTS: The DA cohort had a higher median encounter cost ($8,348.66 versus 7,332.42, P < .01), resulting from higher intraoperative (P < .01) and radiology (P < .01) expenses. Regression analyses demonstrated the DA was independently associated with increased encounter costs (odds ratio 1.1; 95% confidence interval 1.1 to 1.1; P < .01). There was a higher incidence of 90-day emergency department visits in the DA cohort (16 versus 12%, P = .02), with a trend toward increased readmissions. There was no difference in 90-day reoperations. Median 90-day cost was higher in the DA cohort ($126.99 versus 0.00, P < .01), and regression analyses demonstrated the DA had an association with increased 90-day cost (odds ratio 2.2; 95% confidence interval 1.5 to 3.0; P < .01). CONCLUSIONS: Despite a younger patient population, the DA was independently associated with increased encounter and 90-day costs in a single academic hospital system. This study may underestimate the cost difference, as capital costs such as specialized tables were not analyzed.

Ultracongruent Polyethylene Liners Do Not Affect Survival of Total Knee Arthroplasty for Valgus Deformity.

BACKGROUND: Valgus knee deformity is observed in nearly 10% of patients undergoing total knee arthroplasty (TKA). The degree of polyethylene constraint required to balance a valgus knee remains controversial, and historically, posterior-stabilized (PS) designs have been favored. This study evaluated the survivorship of TKA done in valgus knees based on implant design and specifically compared posterior-stabilized (PS) and ultracongruent (UC) liners. METHODS: A total of 549 primary TKAs performed on valgus knees by fellowship-trained arthroplasty surgeons from 2013 to 2019 were reviewed. Demographics, comorbidities, degrees of preoperative deformity, implants used, and all-cause revisions until final follow-up were recorded. Cox regression analyses evaluated survival to all-cause revision in each cohort. The mean follow-up was 4.9 years (range, 2 to 9). RESULTS: There were 403 UC liners compared to 146 PS liners. There was no difference in patient age (68 versus 67 years; P = .30), body mass index (30.9 versus 30.4; P = .36), or degree of deformity (8.6 versus 8.8 degrees; P = .75) between the cohorts. At final follow-up, there were 5 revisions in the PS cohort (3.4%) versus 11 revisions in the UC cohort (2.7%) (P = .90). The most common reason for revision in both cohorts was periprosthetic joint infection (4 PS; 8 UC). Multivariable regression analyses controlling for age, body mass index, Elixhauser comorbidity score, sex, and degree of deformity demonstrated UC polyethylene liners were not associated with revision (hazard ratio 0.76; 95% confidence interval [CI] 0.26 to 2.21; P = .62). There was no difference in eight-year survivorship to all-cause revision, including aseptic and septic failure. CONCLUSIONS: Alternative polyethylene liners from the historically utilized PS liners for TKA for valgus deformity did not reduce survivorship. With modern polyethylene designs, UC inserts can be utilized for this deformity without increasing the risk of failure.

Mental health comorbidities in workers' compensation patients and the effect on pain, disability, quality of life, and return to work after lumbar spine surgery.

OBJECTIVE: The impact of mental health comorbidities on outcomes after lumbar spine surgery in workers' compensation (WC) patients has not been robustly explored. The goal of this study was to examine the impact of mental health comorbidities on pain, disability, quality of life, and return to work after lumbar spine surgery in WC patients. METHODS: A nationwide, prospective surgical outcomes registry (National Neurosurgery Quality Outcomes Database [N2QOD]) was queried for all patients who underwent 1- to 4-level lumbar decompression and/or fusion from 2012 to 2021. Patients were stratified on the basis of compensation status into non-WC (25,507) and WC (1018) cohorts. Baseline demographic data, perioperative safety data, and patient-reported outcome measures were compared between groups. The WC cohort was further subdivided on the basis of mental health status into patients with anxiety and depression (n = 107) and those without anxiety and depression (n = 911). Propensity matching was used to generate parity between these subgroups, generating 214 patients (107 pairs) for analysis. Perioperative safety, facility utilization, 1-year patient-reported outcomes (back and leg pain, disability, and quality of life), and return to work were measured as a function of WC and mental health comorbidity status. RESULTS: A total of 26,525 patients (25,507 non-WC and 1018 WC) who underwent 1- to 4-level lumbar spine surgery were reviewed. WC patients were younger, healthier (lower American Society of Anesthesiologists class), more likely to be minorities, less educated, and more likely to smoke and had greater baseline back pain, disability, and quality of life compared to non-WC patients. The prevalence of anxiety and depression was similar between groups (11%). WC patients had worse outcomes for all measures and lower rates of return to work compared to non-WC patients. WC patients with anxiety and depression demonstrated even greater disparities in all outcomes. After propensity matching, WC patients with anxiety and depression continued to demonstrate significantly worse outcomes in comparison to WC patients without anxiety and depression. CONCLUSIONS: Disparities in outcomes after lumbar spine surgery in WC patients are exacerbated in patients with anxiety and depression. WC patients with mental health comorbidities receive the least benefit from lumbar spine surgery and may represent the most vulnerable subset of patients with spine pathology. Addressing mental health comorbidities preoperatively may represent an opportunity for valuable resource allocation and surgical optimization in the WC population.

Dual Mobility Articulation in Total Hip Arthroplasty: Mixed Femoral and Acetabular Components are a Feasible Option.

BACKGROUND: The utilization of a different manufacturer for the prosthetic femoral head and the polyethylene insert in dual mobility (DM) for total hip arthroplasty (THA) may be necessary, especially in the revision setting. However, there is no data in the literature about this application. This study evaluated the outcomes of mixed manufacturer components, with the hypothesis that there would be no difference in measured outcomes compared to matched components. METHODS: The DM articulations implanted during THA revision were retrospectively reviewed from 2011 to 2017. The study group was then stratified into 2 cohorts: matching components or mixed components. Of 130 hips included in the study with DM articulations with average follow-up of 7 years, 103 had mixed and 27 had matching manufacturer components. Rates of all cause reoperation and revision, intraprosthetic dislocation, dislocation, and aseptic loosening were compared using Chi-squared and Fisher's exact test; survival analysis was also performed. RESULTS: Matched and mixed manufacturer implants had no significant difference between all cause reoperation (33 versus 25.2%), dislocation (14.8 versus 7.7%), and aseptic loosening (3.7 versus 3.9%), respectively. Higher rates of intraprosthetic dislocation (11 versus 0.97%) were observed in the matching component cohort. Survival analysis showed similar outcomes at 2, 5, and 10 years. CONCLUSIONS: Mixed-component DM articulations show similar results compared to matching components. The off-label use of mixed manufacture DM articulation in THA is a feasible and safe option in the correct patient. Furthermore, when encountering a well-fixed femoral stem or acetabular shell, the use of a mixed component DM articulations may reduce the morbidity for the patient and prevent revision of all components.

Patent bibliometrics in spinal deformity: the first bibliometric analysis of spinal deformity's technological literature.

PURPOSE: Bibliometric analyses have gained popularity for studying scientific literature, but their application to evaluate technological literature (patents) remains unexplored. We conducted a bibliometric analysis on the top 100 most-cited patents in scoliosis surgery. METHODS: Multiple databases were queried using The Lens to identify the top 100 scoliosis surgery patents, which were selected based on forward patent citations. These patents were then categorized into 8 groups based on technological descriptors and assessed based on various factors including earliest priority date, year issued, and expiration status. RESULTS: The top 100 most-cited patents included technology underlying anterolateral tethering and distraction systems (n = 11), posterior tethering and distraction systems (n = 23), posterior segmental bone anchor and rod engagement systems (n = 29), interbody devices (n = 10), biological and electrophysiological agents for scoliosis treatment and/or improved arthrodesis (n = 8), intraoperative arthroplasty devices (n = 5), orthotic devices (n = 12), and implantable devices for non-invasive, postoperative alterations of skeletal alignment (n = 2). Seventy-five patents were expired, 21 are still active, and 4 were listed as inactive. The late 1970s and early 2000s saw increased numbers of patent filings. Demonstrated trends showed no meaningful correlation between patent rank and earliest priority date (linear trendline y = 0.2648x - 477.27; R2 = 0.0114), while a very strong correlation was found between patent rank and citations per year (power trendline y = 118.82x--0.83; R2 = 0.8983). CONCLUSION: Patent bibliometric analyses in the field of spinal deformity surgery provide a means to assess past advancements, better understand what it takes to make a difference in the field, and to potentially facilitate the development of innovative technologies in the future. The method described is a reliable and reproducible technique for evaluating technological literature in our field.

Remote cognitive behavioral therapy utilizing an in-home virtual reality toolkit (Vx Therapy) reduces pain, anxiety, and depression in patients with chronic cervical and lumbar spondylytic pain: A potential alternative to opioids in multimodal pain management.

Background Context: Virtual reality (VR) reduces pain through visual and auditory distraction without narcotic-related side effects or dependency. Cognitive behavioral therapy (CBT) improves pain-related disability and quality of life, but patient access remains a challenge. We hypothesized that in-home weekly CBT coordinated with daily use of a proprietary VR toolkit will reduce pain, anxiety, and depression for patients with non-operative chronic cervical and lumbar spondylitic pain with and without radiculopathy. Methods: A total of 145 patients with chronic spondylitic pain (63 cervical, 46 noradicular lumbar, 36 radicular lumbar) were enrolled into a guided 14-week VR+CBT program (Vx Therapy) consisting of weekly encounters with a trained therapist and 50 modules. Pain/anxiety severity scores and time to pain recurrence were recorded prospectively by patients. PROMIS measures of overall daily pain intensity, behavior, interference, anxiety, and depression were recorded at baseline and conclusion of the program. Results: A total of 52% of the 145 patients were male. The average (SD) age of the cohort was 51 (10.7) years (range: 24-76 years). Mean score for all PROMIS domains were significantly improved after 14 weeks of Vx Therapy (pain intensity 36±24 vs. 28±21, interference 39±25 vs. 24±21, behavior 35±21 vs. 25±16, anxiety 51±28 vs. 41±26, depression 58±32 vs. 48±32) for the entire cohort and each diagnosis group. Virtual reality acutely reduced pain on average by 33% (4.5±2.5 vs. 6.7±2.2, p<.05) across all 14 weeks, lasting a mean 2.8 hours after use. Duration of pain relief increased by the final vs. first month (4.5 hours vs. 2.5 hours, p<.05). Virtual reality acutely reduced anxiety on average by 46% (3.5±3 vs. 6.4±2, p<.05) across all 14 weeks lasting a mean 2.7 hours after use. The effect was similar for all 3 groups. Conclusions: Fourteen weeks of a remote CBT guided in-home VR toolkit provided effective and sustained pain, anxiety, and depression relief in patients with chronic degenerative neck/back pain with and without radiculopathy. The non-invasive, non-pharmacological nature of Vx Therapy makes it an ideal option for pain management in the post-opioid epidemic era.

Schiff-Sherrington phenomenon in a cat with complete spinal cord transection from traumatic dorsocranial luxation of the second lumbar vertebra.

A young stray entire female domestic shorthair cat was presented with symmetrical forelimb extensor rigidity, neck hyperextension and hindlimb paraplegia, characteristic of Schiff-Sherrington phenomenon (SSP), within 30 min of a motor vehicle accident. Radiographic and post-mortem studies disclosed complete transection of the spinal cord from traumatic dorsocranial luxation of the second lumbar vertebra, displacement of the sacrum from the ilium, seventh lumbar and first caudal vertebrae and multiple pelvic fractures. Other causes of forelimb extensor rigidity and neck hyperextension such as decerebrate and decerebellate rigidity were excluded by a lack of neurological signs consistent with these entities and unremarkable findings on post-mortem examination of the cranial cavity and brain and histological examination of the cerebrum, brainstem and cerebellum. To the best of the author's knowledge, this is the first report of SSP in the cat outside the experimental arena of decerebrate or non-decerebrate preparations following post-brachial spinal cord transection/cold block.

Treating Sleep Disorders After Total Hip and Total Knee Arthroplasty.

Disorders of sleep are common after total hip and knee arthroplasty and may contribute to patient dissatisfaction and poorer outcomes in the early postoperative period. Multiple factors contribute to sleep disorders, including poorly controlled pain, opioid medication, perioperative stress, and anxiety. Both pharmacologic and nonpharmacologic methods have been used for perioperative sleep disorders, but there is no consensus on the optimal treatment.

Intravenous Dexmedetomidine Use in Total Hip Arthroplasty May Lead to Elevated Rates of Hypotension.

Purpose Enhanced recovery protocols for total hip arthroplasty (THA), using opioid-sparing techniques have become widely used. Reports of novel additions to multimodal pain control regimens have been published, however, a paucity of literature exists on the use of intravenous dexmedetomidine. In this study, we analyzed our experience with intravenous dexmedetomidine and hypothesized that it would reduce postoperative opioid use. Secondary outcomes were also examined, including post-operative hypotension, hemoglobin, length of stay, and discharge disposition. Methods All patients who underwent primary THA at a single tertiary-level center between January 1, 2016, and September 1, 2019, underwent investigation. Diagnosis, surgical approach, anesthetic type, body mass index (BMI), and American Society of Anesthesiologists (ASA) score were recorded. Postoperative clinical measures were analyzed, adjusting for patient and surgical characteristics. Results Of the 599 patients included in the study, 218 patients received intravenous (IV) dexmedetomidine, at a mean dose of 44.9 mg during their operative event. Using a multivariate model, patients in the IV dexmedetomidine group were estimated to have received 24% elevated morphine milligram equivalent at postoperative day zero compared to those in the control group (p = 0.05). In addition, patients in the IV dexmedetomidine group who underwent spinal anesthesia had increased odds of hypotension 3.47 times that of the control [odds ratio (OR) 1.43-8.43, p=0.006]. Conclusions Surprisingly, we found no opioid-sparing effects with the use of IV dexmedetomidine. IV dexmedetomidine may be used cautiously as an anesthesia adjunct with spinal anesthesia in the setting of primary THA, as the experience at our institution illustrated increased odds of postoperative hypotension. Level of evidence This retrospective case-control study has a level of evidence III.

Effect of workers' compensation status on pain, disability, quality of life, and return to work after anterior cervical discectomy and fusion: a 1-year propensity score-matched analysis.

OBJECTIVE: Patients with workers' compensation (WC) claims are reported to demonstrate poorer surgical outcomes after lumbar spine surgery. However, outcomes after anterior cervical discectomy and fusion (ACDF) in WC patients remain debatable. The authors aimed to compare outcomes between a propensity score-matched population of WC and non-WC patients who underwent ACDF. METHODS: Patients who underwent 1- to 4-level ACDF were retrospectively reviewed from the prospectively maintained Quality Outcomes Database (QOD). After propensity score matching, 1-year patient satisfaction, physical disability (Neck Disability Index [NDI]), pain (visual analog scale [VAS]), EQ-5D, and return to work were compared between WC and non-WC cohorts. RESULTS: A total of 9957 patients were included (9610 non-WC and 347 WC patients). Patients in the WC cohort were significantly younger (50 ± 9.1 vs 56 ± 11.4 years, p < 0.001), less educated, and were more frequently male, non-Caucasian, and active smokers (29.1% vs 18.1%, p < 0.001), with greater baseline VAS and NDI scores and poorer quality of life (p < 0.001). One-year postoperative improvements in VAS, NDI, EQ-5D, and return-to-work rates and satisfaction were all significantly worse for WC compared with non-WC patients. After adjusting for baseline differences via propensity score matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS neck pain and NDI (p = 0.010), satisfaction (χ2 = 4.03, p = 0.045), and delayed return to work (9.3 vs 5.7 weeks, p < 0.001). CONCLUSIONS: WC status was associated with greater 1-year residual disability and axial pain along with delayed return to work, without any difference in quality of life despite having fewer comorbidities and being a younger population. Further studies are needed to determine the societal impact that WC claims have on healthcare delivery in the setting of ACDF.

Failure of a Femoral Revision Knee Component with Chemical Corrosion and Elevated Metal Ions: A Case Report and Literature Review.

CASE: Failure of the modular junction in revision total knee arthroplasty is a rare complication. We report a patient with late, atraumatic failure of a modern, modular revision femoral component, with preoperative elevation of serum cobalt and chromium levels. Retrieval analysis showed extensive chemical corrosion. CONCLUSION: Failure of a modern, modular femoral component may cause metal synovitis and elevated serum metal levels. Subtle radiographic changes and preoperative serum metal levels may identify this complication.