Juvenile Idiopathic Arthritis is Associated With Early Medical and Surgical Complications Following Primary Total Hip Arthroplasty: A National Database Study.

Background: Juvenile idiopathic arthritis (JIA) is an inflammatory arthropathy that classically affects children but can cause long-term deformity to the femoral head and hip joint, which may require an arthroplasty procedure. There is a paucity of data surrounding the medical and surgical outcomes of total hip arthroplasty (THA) in patients with JIA compared to a control cohort. Methods: Patients with JIA who underwent THA from 2010 to 2019 were identified in a large national insurance database. A propensity score matching algorithm was used to obtain a control cohort who did not have JIA based upon age, sex, and Elixhauser Comorbidity Index in a 1:10 ratio. Seven hundred sixty-three patients with JIA and 7434 patients without JIA were identified who underwent THA. Ninety-day medical outcomes, 1-year surgical outcomes, and 90-day return to the emergency department and readmission were calculated. Results: Patients with JIA were at increased risk of 90-day transfusion (odds ratio [OR] 1.79; P < .001), pneumonia (OR 2.68; P < .001), urinary tract infection (OR 2.64; P < .001), and wound disruption (OR 2.72; P < .001), as well as 1-year risk of revision THA (OR 2.27; P < .001), periprosthetic joint infection (OR 2.98; P < .001), periprosthetic fracture (OR 2.93; P < .001), aseptic loosening (OR 3.92; P < .001), dislocation (OR 2.61; P = .001), and debridement, antibiotics, and implant retention procedure (OR 2.71; P < .001). Patients with JIA were also at increased risk of 90-day emergency department visit (OR 2.54; P < .001) and readmission (OR 2.59; P < .001). Conclusions: Patients with JIA were at increased risk of early medical and surgical complications following THA. These findings are imperative for surgeons to consider and may warrant tailored perioperative decision-making to avoid the aforementioned medical and surgical complications.

Previous Extensor Mechanism Repair Is Associated With Increased Rates of Surgical Complications Following Total Knee Arthroplasty: A Propensity-matched Analysis.

Background: Although extensor mechanism failure following total knee arthroplasty (TKA) is a devastating complication and has been heavily studied in the literature, the impact of extensor mechanism rupture and concomitant repair prior to TKA has not previously been evaluated. The purpose of this investigation was to evaluate how quadriceps and/or patellar tendon repairs prior to TKA would impact medical and surgery-related complications following TKA. Methods: The PearlDiver database was retrospectively reviewed to identify all primary TKA patients from 2010 to 2019. Patients who underwent quadriceps or patellar tendon repair prior to TKA were matched using a propensity score algorithm to a control cohort. We compared medical and surgical complication rates, emergency room visits, readmissions, and 90-day cost of care between the groups. Results: A total of 1197 patients underwent extensor mechanism repair prior to TKA and were matched to 11,970 patients who did not undergo repair prior to TKA. Patients who underwent extensor mechanism repair had higher rates of 90-day medical complications, as well as 1-year surgery-related complications including revision TKA (odds ratio [OR] 6.06; P < .001), lysis of adhesions (OR 2.18; P = .026), aseptic loosening (OR 2.21; P = .018), infection (OR 7.58; P < .001), and fracture (OR 8.53; P < .001). Patients with prior extensor mechanism repair were more likely to return to the emergency department (OR 1.66; P < .001) and become readmitted (OR 4.15; P < .001) within 90 days. Conclusions: Patients with previous extensor mechanism repair exhibited higher medical and surgery-related complications, including lysis of adhesions, following TKA than a control cohort. These findings may suggest that patients may require additional surveillance in the early postoperative period to avoid these disastrous complications following primary TKA.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older.

BACKGROUND: Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older. METHODS: We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance. RESULTS: The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries. CONCLUSIONS: This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

100 Complex posterior spinal fusion cases performed with robotic instrumentation.

Robotic navigation has been shown to increase precision, accuracy, and safety during spinal reconstructive procedures. There is a paucity of literature describing the best techniques for robotic-assisted spine surgery for complex, multilevel cases or in cases of significant deformity correction. We present a case series of 100 consecutive multilevel posterior spinal fusion procedures performed for multilevel spinal disease and/or deformity correction. 100 consecutive posterior spinal fusions were performed for multilevel disease and/or deformity correction utilizing robotic-assisted placement of pedicle screws. The primary outcome was surgery-related failure, which was defined as hardware breakage or reoperation with removal of hardware. A total of 100 consecutive patients met inclusion criteria. Among cases included, 31 were revision surgeries with existing hardware in place. The mean number of levels fused was 5.6, the mean operative time was 303 min, and the mean estimated blood loss was 469 mL. 28 cases included robotic-assisted placement of S2 alar-iliac (S2AI) screws. In total, 1043 pedicle screws and 53 S2AI screws were placed with robotic-assistance. The failure rate using survivorship analysis was 18/1043 (1.7%) and the failure rate of S2AI screws using survivorship analysis was 3/53 (5.7%). Four patients developed postoperative wound infections requiring irrigation and debridement procedures. None of the 1043 pedicle screws nor the 53 S2AI screws required reoperation due to malpositioning or suboptimal placement. This case series of 100 multilevel posterior spinal fusion procedures demonstrates promising results with low failure rates. With 1043 pedicle screws and 53 S2AI screws, we report low failure rates of 1.7% and 5.7%, respectively with zero cases of screw malpositioning. Robotic screw placement allows for accurate screw placement with no increased rate of postoperative infection compared to historical controls. Level of evidence: IV, Retrospective review.

Robotic-assisted technology does not influence functional outcomes among obese and morbidly obese total knee arthroplasty patients.

PURPOSE: Despite benefits of total knee arthroplasty (TKA) on function and quality of life, obese patients have less improved functional outcomes following TKA compared to their normal weight counterparts. Furthermore, obesity is a risk factor for aseptic loosening and revision surgery following TKA. With known benefits of robotic-assisted TKA (RaTKA) in precision and patient satisfaction, we aimed to evaluate the differences in patient reported outcome and early complication rates for patients undergoing RaTKA versus conventional TKA among patients of varying BMI groups. METHODS: This study was a retrospective cohort study of patients who underwent conventional versus RaTKA. Patients were grouped by BMI range (< 30 kg/m2, 30-40 kg/m2, and > 40 kg/m2). Patient-reported outcomes were measured by Oxford Knee Scores and 12-Item Short Form Survey scores preoperatively, 6-month, 1-year, and 2-year postoperatively. Mixed-effects linear models were built for each patient-reported outcome to assess the interaction between type of surgery and BMI while adjusting for known confounders such as demographic variables. RESULTS: A total of 350 patients (n = 186 RaTKA, n = 164 conventional TKA) met inclusion criteria. SF-12 physical scores were significantly higher at 2-year follow-up among non-obese patients compared to obese and morbidly obese patients (p = 0.047). There was no statistically significant interaction between the type of surgery performed (RaTKA versus conventional TKA) and obesity regarding their effects on patient reported outcomes. CONCLUSIONS: This study demonstrates no differences in functional outcomes among patients undergoing RaTKA compared to conventional TKA. Furthermore, obesity had no significant effect on this association. LEVEL OF EVIDENCE: III.

Hormone replacement therapy does not increase thrombosis risk following THA: a national database study.

PURPOSE: Hormone replacement therapy (HRT) causes a significant increase in the risk of venous thrombosis. The risk of medical and surgery-related complications among women taking HRT following total hip arthroplasty (THA) is poorly understood, and there are currently no guidelines in place regarding venous thromboembolism prophylaxis in this patient population. The purpose of this study was to evaluate the frequency of early medical and surgery-related complications following THA among women taking HRT. METHODS: Women aged > 40 years of age who underwent primary THA were identified from a retrospective database review. A control group of non-HRT users was matched using propensity scoring to HRT users. Rates of 90-day medical complications and 1-year surgery-related complications were compared between cohorts using odds ratios. Postoperative anticoagulation regimens were also compared. RESULTS: There were 3,936 patients in the HRT cohort who were matched to 39,360 patients not taking HRT. There were no significant differences in rates of DVT (OR 0.94, p = 0.6601) or PE (OR 0.80, p = 0.4102) between cohorts. Patients on HRT were more likely to sustain a dislocation (OR 1.35, p = 0.0269) or undergo revision surgery (OR 1.23, p = 0.0105). HRT patients were more likely to be prescribed warfarin (OR 1.21, p = 0.0001) or enoxaparin (OR 1.18, p = 0.0022) and less likely to be prescribed rivaroxaban (OR 0.62, p < 0.0001) compared to controls. CONCLUSIONS: HRT was not found to be an independent risk factor for thromboembolism following THA. Further research is warranted to better delineate the ideal perioperative medical management of HRT users undergoing THA.

Cushing's Syndrome Is Associated With Early Medical- and Surgical-Related Complications Following Total Joint Arthroplasty: A National Database Study.

BACKGROUND: Cushing's syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA). METHODS: Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios (ORs). RESULTS: The THA patients with CS had higher incidences of pulmonary embolism (OR 2.21, P = .0026), urinary tract infection (UTI) (OR 1.29, P = .0417), pneumonia (OR 1.58, P = .0071), sepsis (OR 1.89, P = .0134), periprosthetic joint infection (OR 1.45, P = .0109), and all-cause revision surgery (OR 1.54, P = .0036). The TKA patients with CS had significantly higher incidences of UTI (OR 1.34, P = .0044), pneumonia (OR 1.62, P = .0042), and dislocation (OR 2.43, P = .0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P = .0027). CONCLUSION: CS is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA.

Study Quality and Patient Inclusion in Geriatric Orthopaedic Trauma Research: A Scoping Review.

OBJECTIVES: To evaluate the quality of evidence published in geriatric traumatology, to investigate how many studies include patients with cognitive impairment, and to investigate which methods are used to determine cognitive impairment. DATA SOURCES: A search was conducted in PubMed for all publications in English in 154 selected journals between 01/01/2017 and 01/01/2020. STUDY SELECTION: Clinical studies investigating patients 65 years of age and older with fractures in the appendicular skeleton or pelvis were included. DATA EXTRACTION: Two independent reviewers performed full-text screening and data extraction for all articles. DATA SYNTHESIS: A comparative analysis was performed for prospective cohort studies and RCTs. The results are discussed in a narrative review. CONCLUSIONS: A total of 2711 publications were screened for eligibility, and after exclusion, a total of 723 articles were included. There is a focus on retrospective studies investigating mortality and complications. Studies are often small in sample size, and there are relatively few prospective studies, RCT studies, patient-reported outcomes, and quality of life. Patients with cognitive impairment are selectively excluded from clinical studies, and no consensus exists on how cognitive impairment is diagnosed. This review identified pitfalls and provides recommendations to navigate these issues for future studies. Many studies exclude cognitively impaired patients, which may result in selection bias and inability to extrapolate results. The lack of use of objective measures to define cognitive impairment and lack appropriate outcome measures for the cognitively impaired is an important issue that needs to be addressed in future research.

Home Health Care Is Associated With an Increased Risk of Emergency Department Visit, Readmission, and Cost of Care Without Reducing Risk of Complication Following Total Hip Arthroplasty: A Propensity-Score Analysis.

BACKGROUND: Home health services have long been implemented for patients to receive additional professional care and supervision following discharge from the hospital to theoretically reduce the risk of complications and health care utilizations. The aim of this investigation was to determine if patients assigned home health services exhibited lower rates of medical and surgical complications, health care utilizations, and costs of care following total hip arthroplasty. METHODS: A large national database was retrospectively reviewed to identify all primary total hip arthroplasty patients from 2010 to 2019. Patients who received home health services were matched using a propensity score algorithm to a set of similar patients who were discharged home under self-care. We compared medical and surgical complication rates, emergency room visits, readmissions, and 90-day costs of care between the groups. Multivariate regression analyses were performed to determine the independent effect of home health services on all outcomes. There were 7,243 patients who received home health services and were matched to 72,430 patients who were discharged home under self-care. RESULTS: Patients who received home health services had higher rates of emergency department visits at 30 days (Odds Ratio [OR] R statistical programming software v 3.6.1 [Lucent Technologies, New Providence, RJ] 1.1544; P = .002) as well as increased readmissions at 30 days (OR 1.137; P = .039); complication rates were similar between groups. Episode-of-care costs for home health patients were higher than those discharged under self-care ($14,236.97 versus $12,817.12; P < .001). CONCLUSION: Patients assigned home health care services exhibited higher costs of care without decreased risk of complications and had increased risk of early returns to the emergency department and readmissions.

The Use of Continuous Positive Airway Pressure for Patients With Obstructive Sleep Apnea is Associated With Early Medical and Surgery-Related Complications Following Total Knee Arthroplasty: A National Database Study.

Background: Obstructive sleep apnea (OSA) has been shown to increase the risk of complications following total knee arthroplasty (TKA) although prior studies were limited by their ability to stratify OSA patients by disease severity. The objective of this study was to determine the effect size of the use of continuous positive airway pressure (CPAP) on early medical and surgery-related complications following TKA among patients with OSA. Methods: Patients with OSA who underwent primary TKA were identified using the PearlDiver Mariner database. Ninety-day incidences of medical complications and 1-year incidences of surgery-related complications as well as hospital utilization were evaluated for OSA patients who had used CPAP prior to TKA compared to those who did not. Results: CPAP patients were at increased 90-day risk of emergency department presentation (odds ratio [OR] 1.61; P < .0001), hospital admission (OR 1.33; P < .001), ICU admission (OR 1.45, P < .0001), pulmonary embolism (OR 1.68, P < .0001), deep vein thrombosis (OR 1.31, P < .0001), transfusion (OR 1.89, P < .0001), pneumonia (OR 1.63, P < .0001), cerebrovascular accident (OR 1.92, P < .0001), myocardial infarction (OR 1.57, P = .0015), sepsis (OR 1.35, P = .0025), blood loss anemia (OR 1.67, P < .0001), acute kidney injury (OR 1.65, P < .0001), and urinary tract infection (OR 1.99, P < .0001), as well as increased 1-year risk of undergoing revision surgery (OR 1.14, P = .0028), compared to OSA patients not using CPAP. Conclusions: OSA patients on CPAP undergoing TKA have significantly increased complication rates compared to OSA patients not using CPAP. Level of Evidence: III, Retrospective review.

Dual Semitendinosus Allograft Reconstruction of Chronic Achilles Tendon Ruptures: Operative Technique and Outcomes.

BACKGROUND: Dual semitendinosus allograft reconstruction of chronic Achilles tendon ruptures has several potential benefits including superior tensile strength compared with a turndown construct and avoidance of the morbidity and operative time associated with autograft augmentation. We present a series of chronic Achilles tendon ruptures reconstructed with dual semitendinosus allograft. METHODS: We retrospectively reviewed the charts of patients aged 18 years and older who underwent reconstruction of chronic Achilles tendon ruptures using dual semitendinosus allograft. The primary outcome of this study was to evaluate the need for revision surgery. Secondary outcomes included patient-reported outcomes, for which Achilles Tendon Rupture Scores (ATRS) were collected at final follow-up. Nine patients with a mean age of 58.9 (range, 43-75) years met inclusion criteria. RESULTS: Median follow-up was 66 months (range, 27-121 months). One patient (11.1%) required revision reconstruction after sustaining graft failure 9.5 years after her index procedure, and 1 patient reported a poor ATRS score at the 27-month final follow-up despite an intact surgical repair. At final follow-up, no patient required the use of an assistive device for ambulation or a walking boot. The median ATRS at final follow-up was 93 (range, 30-100). DISCUSSION: Good clinical outcomes without rerupture were observed in 7 of 9 patients (77.8%) at short- to midterm follow-up, suggesting that dual semitendinosus allograft reconstruction is a viable option for the reconstruction of chronic Achilles tendon tears. LEVEL OF EVIDENCE: Level IV, case series.

The Use of Continuous Positive Airway Ventilation for Patients With Obstructive Sleep Apnea is Associated With Early Medical and Surgery-related Complications Following Total Hip Arthroplasty: A National Database Study.

Background: The objective of this study was to determine the effect size of the use of continuous positive airway pressure (CPAP), as a surrogate in cases of active and more severe diseases, on early medical and surgery-related complications following total hip arthroplasty (THA) within an obstructive sleep apnea (OSA) patient population. Methods: Patients with OSA who underwent primary THA between 2010 and 2019 were identified using a large national insurance database. Ninety-day incidence of various medical and surgery-related complications and hospital utilization were evaluated for OSA patients who had used CPAP prior to THA and those who did not. Propensity score matching was used to control for patient demographic factors and comorbidities as covariates. Results: Propensity score matching resulted in 7351 OSA patients who had used CPAP within 6 months of primary THA and 7351 OSA patients who had not. Patients who had used CPAP were at increased 90-day risk of medical complications, as well as 1-year risk of periprosthetic fracture (OR 1.5429; P = .0356), osteolysis (OR 2.4488; P = .0237), aseptic loosening (OR 2.4057; P < .001), and dislocation (OR 1.283; P = .016). Conclusions: Our findings suggest that OSA patients on CPAP are at increased risk of several 90-day medical complications, 1-year surgical complications, and health-care utilization compared to OSA patients not recently using CPAP. Level of Evidence: III, Retrospective review.

Short-Term Outcomes Following Cemented Versus Cementless Robotic-Assisted Total Knee Arthroplasty.

BACKGROUND: Cemented fixation during total knee arthroplasty (TKA) has long been the gold standard due to excellent survivorship and clinical outcomes. With recent biomaterial advancements, cementless fixation has gained renewed interest. Most studies demonstrate similar clinical outcomes and survivorship between these two fixation methods, without consensus regarding the optimal method of fixation during TKA. Outcomes following TKA also depend upon the proper alignment and positioning of components. Robotic-assisted TKA has been shown to improve outcomes related to component positioning, overall lower limb alignment, and soft tissue balancing. No study to date has investigated the role of robotic-assisted surgery on postoperative outcomes following cementless versus cemented TKA. METHODS: This is a retrospective cohort study of patients 18 years of age and older who underwent primary robotic-assisted TKA performed by a single fellowship-trained arthroplasty surgeon. Oxford Knee Scores and Short Form Health Survey scores were obtained preoperatively and at a two-year follow-up. Complications such as DVT, infection, arthrofibrosis requiring manipulation, and revision surgery were collected. RESULTS: Three hundred eighty knees in the cementless cohort and 72 cemented knees were included for analysis. There were no statistically significant differences between the two cohorts in terms of SF-12, Oxford Knee Scores, complications, or revision surgery rates. CONCLUSION: Cementless fixation during TKA offers an alternative to cemented fixation with similar short-term results in terms of patient-reported outcomes, complication rates, and revision surgery rates. Further research is warranted to better understand long-term outcomes and survivorship following cementless versus cemented fixation during robotic-assisted TKA.

Treatment modalities and outcomes following acetabular fractures in the elderly: a systematic review.

PURPOSE: The treatment of geriatric acetabular fractures remains controversial. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), total hip arthroplasty (THA) with or without internal fixation, and closed reduction with percutaneous pinning (CRPP). There is currently no consensus on the optimal treatment strategy for geriatric patients with acetabular fractures. The purpose of this study is to compare adverse event rates, functional and radiographic outcomes, and intraoperative results between the various treatment modalities in order to help guide surgical decision making. METHODS: We performed a systematic review (registration number CRD42019124624) of observational and comparative studies including patients aged ≥ 55 with acetabular fractures. RESULTS: Thirty-eight studies including 3,928 patients with a mean age of 72.6 years (range 55-99 years) and a mean follow-up duration of 29.4 months met our eligibility criteria. The pooled mortality rate of all patients was 21.6% (95% confidence interval [CI] 20.9-22.4%) with a mean time to mortality of 12.6 months, and the pooled non-fatal complication rate was 24.7% (95% CI 23.9-25.5%). Patients treated with ORIF had a significantly higher non-fatal complication rate than those treated with ORIF + THA, THA alone, CRPP, or nonoperative management (odds ratios [ORs] 1.87, 2.24, 2.15, and 4.48, respectively; p < 0.01). Patients that underwent ORIF were significantly less likely to undergo subsequent THA than these treated with CRPP (OR 0.49, 95% CI 0.32-0.77) but were more likely to require THA than patients treated nonoperatively (OR 6.81, 95% CI 4.63-10.02). CONCLUSION: Elderly patients with acetabular fractures tend to have favorable functional outcomes but suffer from high rates of mortality and complications. In patients treated with internal or percutaneous fixation, there was a high rate of conversion to THA. When determining surgical treatment in this population, THA alone or concurrent with ORIF should be considered given the significantly lower rate of non-fatal complications and similar mortality rate. Nonoperative management remains a viable option and was associated with the lowest non-fatal complication rate. LEVEL OF EVIDENCE: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part I: System Planning and Care Teams.

BACKGROUND: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. METHODS: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. RESULTS: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. CONCLUSIONS: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic.

A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management.

(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.

Standardized Platelet Rich Plasma Injections for Osteoarthritis of the Knee.

Objective Platelet-rich plasma (PRP) and adipose-derived stem cells (ADSC) injections are non-surgical treatments for knee osteoarthritis (OA). The purpose of this study is to assess the effectiveness of serial PRP with or without ADSC injections in the treatment of refractory OA of the knee.  Design Patients who failed to achieve pain relief with conventional non-surgical treatments, with Kellgren-Lawrence grade 3 or 4 knee OA, were recruited from a private outpatient clinic. Over 67 patients were elected to receive serial PRP injections and 22 patients were elected to receive an ADSC+PRP injection. These patients completed Western Ontario and McMaster Universities Arthritis Index (WOMAC) surveys prior to each treatment and at follow-up appointments. These surveys were retrospectively reviewed to assess changes in functional status and pain over time. Results Twenty-nine patients from the PRP group and eight patients in the ADSC+PRP group had adequate follow-up for inclusion in the analysis. The PRP group had an improvement in WOMAC scores by 34.30%, 60.2%, and 58.5% for patients reporting at 1-3, 4-6, and >6 months of follow-up. The ADSC+PRP group experienced an improvement of 51% at an average of 4.66 months of follow-up. Conclusions Serial PRP injections and a single ADSC+PRP injection yield improved and sustained functional outcome scores for patients with severe, refractory OA of the knee. Future studies should consider consistent orthobiologic preparation protocols to ensure reproducibility.

Utility of Ottawa Ankle Rules in an Aging Population: Evidence for Addition of an Age Criterion.

The Ottawa ankle rules (OAR) indicate that any patient with the inability to ambulate up to four steps or with tenderness at either malleoli should receive diagnostic imaging for an acute ankle injury. Current trends indicate that health care providers tend to order more images in practice than necessary according to OAR. The purpose of this study is to analyze OAR in geriatric versus nongeriatric patients. Secondarily, we hope to refine these guidelines for ankle imaging in the hopes that health care providers will be comfortable in adhering to these guidelines more strictly. A retrospective chart review was conducted of 491 adult patients with an average (± standard deviation) age of 54.4 ± 21.6 years (range 18 to 96). Applying the current OAR resulted in a sensitivity of 98.2% and a specificity of 58.6% in this entire cohort. The calculated sensitivities were comparable between the nongeriatric and geriatric cohorts, at 98.60% and 97.99%, respectively. The specificities varied between the nongeriatric and geriatric cohorts, at 60.13% and 33.33%. We propose new guidelines that would mandate imaging studies for any patient ≥65 years of age presenting to the emergency department with ankle pain. When applying these proposed guidelines, the sensitivity of the entire study population was found to be improved to 99.0%, whereas the specificity dropped to 56.7%. The slight decrease in specificity was deemed acceptable because these guidelines are meant to be used as a screening tool and because the risk of OAR not correctly identifying ankle fracture (2% of geriatric fractures) was completely mitigated in the geriatric population.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods.

BACKGROUND: Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods. PURPOSE/HYPOTHESIS: The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation. STUDY DESIGN: Meta-analysis. METHODS: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months' mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05. RESULTS: Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 (P = .004) and satisfaction with cosmesis by 20.50% (P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair. CONCLUSION: Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Operative and Nonoperative Treatment.

BACKGROUND: The incidence of pectoralis major tendon tears is increasing, and repair is generally considered; however, a paucity of comparative data are available to demonstrate the superiority of operative treatment. PURPOSE/HYPOTHESIS: The purpose of this study is to compare the outcomes of operative and nonoperative treatment of pectoralis major tendon tears. We hypothesized that repair would result in superior outcomes compared with nonoperative treatment. METHODS: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed by use of MEDLINE, SPORTDiscus, CINAHL, Cochrane, EMBASE, and Web of Science databases. We included English-language studies that had a minimum of 6 months of average follow-up and 5 cases per study. The MINORS (Methodological Index for Non-Randomized Studies) was used to assess the quality of the existing literature. Meta-analysis of pooled mechanisms of injury and outcomes was completed. Pooled effect sizes were calculated from random-effects models. Continuous variables were assessed by use of mixed-model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed via the Freeman-Tukey log-linear transformation for variance stabilization and then assessed through use of a mixed model with a study level random effect and subsequently back-transformed. Significance was set at P < .05. RESULTS: A total of 23 articles with 664 injuries met the inclusion criteria for comparison. All patients were male, with an average age of 31.48 years; 63.2% of injuries occurred during weight training, and the average follow-up was 37.02 months. Included studies had moderately high methodological quality. Operative treatment was significantly superior to nonoperative treatment, with relative improvements of functional outcome by 23.33% (0.70 improvement by Bak criteria which is scored 1-4; P = .027), full isometric strength 77.07% (P < .001), isokinetic strength 28.86% (P < .001) compared with the uninjured arm, cosmesis satisfaction 13.79% (P = .037), and resting deformity 98.85% (P < .001). The overall complication rate for operative treatment was 14.21%, including a 3.08% rate of rerupture. CONCLUSION: Pectoralis major tendon repair resulted in significantly superior outcomes compared with nonoperative treatment, with an associated 14.21% complication rate. Statistically significant improvements were noted in functional outcome, isokinetic strength, isometric strength, cosmesis, and resting deformity.