PROMIS Scores Should Not be Used in Isolation to Measure Outcomes in Lumbar Stenosis Patients.

STUDY DESIGN: Retrospective cross-sectional analysis. OBJECTIVE: The aim of this study was to establish the strength of relationship between the Patient-reported Outcomes Measurement Information System (PROMIS) Adult Depression (AD), Physical Function (PF), and Pain Interference (PI) with the Swiss Spinal Stenosis Questionnaire (SSSQ) in assessing lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: In 2009, there were >35,000 surgeries for LSS, which amounted to $1.65 billion in health care cost. By 2021, there will be >2.4 million people in the United States with symptomatic LSS. There is an increasing emphasis on patient-reported outcomes (PROs) to define value in medicine. Therefore, it would be beneficial to compare PROMIS, a universal PRO, against the SSSQ, the "criterion standard" for assessing LSS. METHODS: Eighty-two patients with LSS completing the PROMIS and SSSQ were enrolled. Per existing institutional protocol, PROMIS AD, PF, and PI were completed at every clinic visit. Linear regression analysis was then performed to evaluate how well the SSSQ and PROMIS scores correlated to each other. RESULTS: When linear regression was performed for pre-treatment values, the R2 value for the SSSQ PF versus PROMIS PF was 0.14 (P = 0.0008), whereas the R2 value for the SSSQ symptom severity versus PROMIS PI was 0.03 (P = 0.13). The R2 value for the combined SSSQ physical function and symptom severity versus PROMIS AD was 0.07 (P = 0.02). When post-treatment SSSQ satisfaction scores were correlated to postoperative PROMIS AD, PI, and PF scores, the R2 values for a good linear fit were 0.13, 0.25, and 0.18 respectively (P values: 0.01, 0.003, and 0.003). CONCLUSION: Pre-treatment PROMIS scores do not adequately capture the disease-specific impact of spinal stenosis, but postoperative PROMIS scores better reflect outcomes after surgery for LSS. PROMIS scores should not be used in isolation to assess outcomes in patients with LSS.Level of Evidence: 4.

Traumatic Bilateral L3-4 Facet Dislocation With Open Decompression and Short Segment Fusion.

Traumatic lumbar facet dislocations are exceedingly rare, with reported cases primarily involving the lumbosacral junction. This injury arises from very high flexion distraction forces imparted on the lumbar spine. Herein we describe a bilateral L3-4 facet dislocation, a particularly rare injury pattern, using a short-segment posterior decompression and fusion followed by an interbody fusion through a lateral approach. Our case involves a 24-year-old man who presented to the emergency department after a high-speed, head-on motor vehicle collision. He was a restrained passenger with no prior significant medical history. He was found to have multisystem injuries, the most notable a L3-4 bilateral lumbar facet dislocation. The patient was neurologically intact upon his presentation but developed radiculopathy several hours into his hospital admission. He was treated operatively through a posterior decompression and instrumented short-segment fusion as well as a subsequent interbody fusion through a lateral approach at the same level. Pure lumbar spine facet dislocations outside the lumbosacral junction, especially bilateral dislocations, are exceedingly rare and often result in neurological deficits. A literature review reveals only a few cases outside of Asia, all of which were treated with decompression and either short- or long-segment fusion. No accepted treatment algorithm for this injury has been established. Open treatment is almost always indicated. Decompression and short-segment fusion is a valid treatment option, but patient and injury characteristics must be considered on an individualized basis.Level of Evidence: 5.

What Is the Association Between Hospital Volume and Complications After Revision Total Joint Arthroplasty: A Large-database Study.

BACKGROUND: Studies of primary total joint arthroplasty (TJA) show a correlation between hospital volume and outcomes; however, the relationship of volume to outcomes in revision TJA is not well studied. QUESTIONS/PURPOSES: We therefore asked: (1) Are 90-day readmissions more likely at low-volume hospitals relative to high-volume hospitals after revision THA and TKA? (2) Are in-hospital and 90-day complications more likely at low-volume hospitals relative to high-volume hospitals after revision THA and TKA? (3) Are 30-day mortality rates higher at low-volume hospitals relative to high-volume hospitals after revision THA and TKA? METHODS: Using 29,948 inpatient stays undergoing revision TJA from 2008 to 2014 in the Statewide Planning and Research Cooperative System (SPARCS) database for New York State, we examined the relationship of hospital revision volume by quartile and outcomes. The top 5 percentile of hospitals was included as a separate cohort. Advantages of the SPARCS database include comprehensive catchment of all cases regardless of payer, and the ability to track each patient across hospital admissions at different institutions within the state. The outcomes of interest included 90-day all-cause readmission rates and 30- and 90-day reoperation rates, postoperative complication rates, and 30-day mortality rates. The initial cohort that met the MS-DRG and ICD-9 criteria consisted of 30,354 inpatient stays for revision hip or knee replacements. Exclusions included patients with a missing patient identifier (n = 221), missing admission or discharge dates (n = 5), and stays from hospitals that were closed during the study period (n = 180). Our final analytic cohort comprised 29,948 inpatient stays for revision hip and knee replacements from 25,977 patients who had nonmissing data points for the variables of interest. Outcomes were adjusted for underlying hospital, surgeon, and patient confounding variables. The analytic cohort included observations from 25,977 patients, 138 hospitals, 929 surgeons, 14,130 revision THAs, 11,847 revision TKAs, 15,341 female patients (59% of cohort). RESULTS: Patients had lower all-cause 90-day readmission rates in the highest 5th percentile by volume hospitals relative to all other lower hospital volume categories. Reoperation rates within the first 90 days, however, were not different among volume categories. All-cause 90-day readmissions were higher in the quartile 4 hospitals excluding the top 5th percentile (17%) versus the top 5th percentile by volume hospitals (12%) (odds ratio [OR]: 1.3; 95% confidence interval [CI], 1.0-1.5; p = 0.030). All-cause 90-day readmissions were higher in the quartile 3 hospitals (18%) relative to the top 5 percentile by volume hospitals (12%) (OR: 1.5; 95% CI, 1.2-1.9; p < 0.001). All-cause 90-day readmissions were higher in quartile 2 hospitals (18%) relative to the top 5 percentile by volume hospitals (12%) (OR: 1.4; 95% CI, 1.1-1.8; p = 0.010). All-cause 90-day readmissions were higher in quartile 1 hospitals (21%) versus the top 5 percentile by volume hospitals (12%) (OR: 1.6; 95% CI, 1.1-2.3; p = 0.010). Postoperative complication rates were higher among only the quartile 1 hospitals compared with institutions in each higher-volume category after revision TJA. The odds of 90-day complications compared with quartile 1 hospitals were 0.49 (95% CI, 0.33-0.72; p = 0.010) for quartile 2, 0.60 (95% CI, 0.40-0.88; p = 0.010) for quartile 3, 0.43 (95% CI, 0.28-0.64; p = 0.010) for quartile 4 excluding top 5 percentile, and 0.36 (95% CI, 0.22-0.59; p = 0.010) for the top 5 percentile of hospitals. There does not appear to be an association between 30-day mortality rates and hospital volume in revision TJA. The odds of 30-day mortality compared with quartile 1 hospitals were 0.54 (95% CI, 0.20-1.46; p = 0.220) for quartile 2, 0.75 (95% CI, 0.30-1.91; p = 0.550) for quartile 3, 0.57 (95% CI, 0.22-1.49; p = 0.250) for quartile 4 excluding top 5 percentile, and 0.61 (95% CI, 0.20-1.81; p = 0.370) for the top 5 percentile of hospitals. CONCLUSIONS: These findings suggest that regionalizing revision TJA services, or concentrating surgical procedures in higher-volume hospitals, may reduce early complications rates and 90-day readmission rates. Disadvantages of regionalization include reduced access to care, increased patient travel distances, and possible capacity issues at receiving centers. Further studies are needed to evaluate the benefits and negative consequences of regionalizing revision TJA services to higher-volume revision TJA institutions. LEVEL OF EVIDENCE: Level III, therapeutic study.

Indications and Guidelines for Debridement and Implant Retention for Periprosthetic Hip and Knee Infection.

PURPOSE OF REVIEW: Prosthetic joint infection is one the most common causes of revision surgery after hip or knee replacement. Debridement and implant retention (DAIR) is one method of treating these infections; however, significant controversy exists. The purpose of our review was to describe current knowledge about indications, intraoperative/postoperative patient management, and outcomes of DAIR. RECENT FINDINGS: Patient selection affects the success of DAIR. Medical comorbidities, duration of symptoms, and nature of infectious organism all influence outcomes. Intraoperative techniques such as open arthrotomy, extensive debridement, copious irrigation, and exchange of modular parts remain current standards for DAIR. Postoperative administration of antibiotics tailored to operative cultures remains critical. Antibiotic suppression may increase the success of DAIR. DAIR provides reasonable infection eradication between 50 and 80% with improved outcomes in appropriately selected patients. More research is needed on the use of adjuvant therapies intraoperatively and the role of postoperative antibiotic suppression.

Evaluation of Physical Examination Tests for Thumb Basal Joint Osteoarthritis.

BACKGROUND: We compare the ability of 3 diagnostic tests to reproduce the pain of basilar joint arthritis (BJA): the grind test, the lever test (grasping the first metacarpal just distal to the basal joint and shucking back and forth in radial and ulnar directions), and the metacarpophalangeal extension test. METHODS: Sixty-two patients with thumb BJA were enrolled. The 3 tests were performed in a random order on both hands of each patient. Prior to testing, patients reported their typical pain level and subsequently rated their pain after each test on a 0 to 10 scale, also specifying the extent to which the test reproduced their thumb pain (fully, partially, not at all). All patients had radiographs that displayed basal joint arthritis. A test was defined as positive for BJA if pain produced was greater than 0. Sensitivity and specificity for each test were calculated using the patients' history of pain localized to the basal joint and BJA diagnosis on radiographs as the gold standard. RESULTS: The lever test produced the greatest level of pain and best reproduced the presenting pain. The lever test also had the highest sensitivity, high specificity, and the lowest false-negative rate. The grind test had the lowest sensitivity, highest specificity, and highest false-negative rate. CONCLUSIONS: The lever test was the diagnostic test that best reproduced the pain caused by thumb basal joint osteoarthritis. We recommend using the lever physical examination test when evaluating the patient with suspected basal joint osteoarthritis. The often-quoted grind test is of limited diagnostic value.