The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023.

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.

Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities.

BACKGROUND: Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. METHODS: A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, "disparities", "arthroplasty", "income", "insurance", "outcomes", and "hospital volume" in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. RESULTS: A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. CONCLUSION: This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients' access to, utilization of, and outcomes after TJA. LEVEL OF EVIDENCE: IV.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities.

BACKGROUND: Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS: A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS: A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS: This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pubic root fractures are commonly misread as anterior column fractures by radiologists: Single-institution study from a level 1 trauma center.

BACKGROUND: We sought to determine how frequently pubic root fracture is incorrectly identified as anterior column fracture by radiologists and describe differences in characteristics and outcomes between injury patterns. METHODS: We identified 155 patients who sustained pelvic or acetabular fractures at a single, level 1 trauma academic institution. Pelvis computed tomography (CT) scans were evaluated to determine whether patients sustained an anterior column fracture or pubic root fracture. Demographic and clinical factors such as mortality, ambulatory status, type of treatment (nonoperative/surgery), and mechanism of energy were assessed. RESULTS: There were a total of 83 patients in the anterior column group and 72 patients in the pubic root cohort. Eighty-five percent of pubic root fractures were read as anterior column fractures by radiologists. A total of 77.8% of pubic root fractures had posterior ring involvement. Patients with true anterior column acetabular fracture were more likely to need surgery (63.86% vs 41.70%, P = 0.01) and be discharged to skilled nursing or inpatient rehabilitation (59.04% vs 40.27%, P = 0.02) compared to patients with pubic root fracture. CONCLUSION: Pubic root fractures are frequently misread as anterior column fractures in radiology reports. Correctly diagnosing pubic root fractures and differentiating them from anterior column acetabular fractures can have significant impact on patients. LEVEL OF EVIDENCE: III, Therapeutic.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review.

BACKGROUND: The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery. METHODS: A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected. RESULTS: A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy. CONCLUSIONS: Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of total joint arthroplasty in patients with depression: A systematic review.

BACKGROUND: Depression has been implicated as a poor predictor of outcomes after total joint arthroplasty (TJA) of the lower extremity in some studies. We aimed to determine whether depression as a comorbidity affects the TJA outcomes and whether pain reduction associated with successful TJA alters depressive symptoms. METHODS: A search of PUBMED was performed using keywords "depression", "arthroplasty", "depressive disorder", and "outcomes." All English studies published over the last ten years were considered for inclusion. Quantitative and qualitative analysis was then performed on the data. RESULTS: Thirty articles met inclusion criteria (16 retrospective, 14 prospective). Three showed that depressed patients were at higher risk for readmission. Two reported that depressed patients had higher likelihood of non-home discharge after TJA compared to non-depressed patients. Four noted that depressed patients incur higher hospitalization costs than non-depressed patients. Ten suggest depression is a predictor of poor patient-reported outcome measures, pain, and satisfaction after TJA. Five suggested the gains depressed patients experience in functional outcome scores after TJA are similar to gains experienced by patients without depression. Another eight suggested that TJA improves not only function and pain but also depressive symptoms in patients with depression. CONCLUSION: The results of this review show that depression increases the risk of persistent pain, dissatisfaction, and complications after TJA. Additionally, depressed patients may incur higher costs than non-depressed patients undergoing TJA and may have worse preoperative and postoperative patient reported outcome measures (PROMs). However, the gains in function that depressed patients experience after TJA are equivalent to gains experienced by non-depressed patients and depressed patients may experience improvement in their depressive symptoms after TJA. Patient selection for TJA is critical and counseling regarding increased risk for complications is crucial in depressed patients undergoing TJA.

Referral to Cardiac Rehabilitation and Outcomes for Patients With Takotsubo Cardiomyopathy.

PURPOSE: The aim of this study was to determine participation rates and outcomes for patients with Takotsubo cardiomyopathy (TC) in a cardiac rehabilitation (CR) program. METHODS: Patients at 2 academic medical centers with a discharge diagnosis of TC from January 2008 to March 2015 were retrospectively identified. Patients meeting the Mayo Clinic criteria for TC were cross-matched to the CR center affiliated with the hospitals to determine the referral rate and outcomes after completion of the program. RESULTS: In total, 380 unique patients were identified who survived the index hospitalization. Eighteen patients (5%) were referred to CR, 15 enrolled, and of those enrolled, 10 patients (67%) completed the program. Patients undergoing percutaneous coronary intervention of a nonculprit vessel at the time of diagnosis was the only predictor for referral to CR (11% vs 1%, P = .01). The 10 patients who completed CR attended 33 ± 6 (range, 20-36) sessions. Weight and body mass index reduction were 2.8 ± 3.5 lb and 0.6 ± 0.7 kg/m (P = .04, both), respectively. Post-CR exercise duration was 37 ± 4 min/session, which improved by 13 ± 6 min/session from baseline (P < .01). Two patients entered the phase III maintenance program. One-year cardiac readmission rates were comparable among patients who completed CR and those who were referred but did not attend or complete CR (0% vs 13%, P = .47). CONCLUSIONS: Referral for the TC population was low; however, enrollment and completion rates were adequate, with percutaneous coronary intervention in nonculprit vessel as the only predictor of CR referral. Limited data showed CR may help with weight reduction and improve exercise duration.

Reliability analysis for radiographic measurement of limb length discrepancy: full-length standing anteroposterior radiograph versus scanogram.

Patients with limb length discrepancy (LLD) often have associated angular deformities requiring a standing full-length radiograph of the lower limb in addition to a scanogram. The purpose of our study was to determine the intraobserver and interobserver reliability of measuring LLD with both techniques, using computed radiography. The LLD was measured on 70 supine scanograms and standing anteroposterior radiographs of the lower extremity by 5 blinded observers on 2 separate occasions. Intraclass correlation coefficient (ICC) and mean absolute difference (in millimeters) was calculated to assess intraobserver and interobserver reliability and found to be excellent for both radiographic techniques. Intraobserver ICC and mean absolute difference was 0.975 to 0.995 and 1.5 to 2.6 mm for scanogram and 0.939 to 0.996 and 1.5 to 4.6 mm for the standing radiograph, respectively. Repeated measurements for both radiographic studies were within 5 mm of the first measurement greater than 90% and within 10 mm greater than 95% of times. Interobserver ICC and mean absolute difference was 0.979 and 2.6 mm for scanogram and 0.968 and 3.0 mm for the standing radiograph. The reliability was excellent irrespective of age, sex, and underlying diagnosis other than Blount disease, which had good reliability. A standing anteroposterior radiograph of the lower extremity should be the imaging modality of choice when evaluating patients with limb length inequality who may have angular deformities because it allows a comprehensive evaluation of the extremity and is as reliable as a scanogram for measuring LLD. This approach may decrease the radiation exposure and financial burden involved in assessing patients with unequal limb lengths.

Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram.

BACKGROUND: Although a scanogram is commonly used to measure limb-length discrepancy, there are several potential pitfalls associated with this imaging technique. The purpose of the present study was to evaluate the results obtained with use of a full-length standing anteroposterior radiograph of the lower extremities and to compare them with those obtained with use of a scanogram. Both imaging studies were performed using computed radiography. METHODS: One hundred and eleven patients with limb-length discrepancy had a full-length standing anteroposterior radiograph and a scanogram made on the same day. The patients included seventy-nine children and thirty-two adults in whom the discrepancy was secondary to trauma (55%), congenital shortening (18%), Blount disease (14%), or another cause (13%). Limb length and limb-length discrepancy were measured utilizing both imaging studies. The agreement between the standing anteroposterior radiograph and the scanogram was assessed with use of the correlation coefficient r, and the limits of agreement between the two imaging studies were assessed. RESULTS: An average magnification of 4.6% (3.3 cm) was observed in association with the measurement of lower extremity length with use of the full-length standing anteroposterior radiograph. The mean difference in limb-length-discrepancy measurements between the two techniques was 0.5 cm, and the limits of agreement (that is, the mean plus or minus two standard deviations) were 0.5 to 1.5 cm. When the limb-length discrepancy on the standing anteroposterior radiograph was compared with that on the scanogram, the correlation coefficient r was 0.96. A difference of >0.5 cm between the limb-length discrepancy measured on the standing radiograph and that measured on the scanogram was associated with a mechanical axis deviation of >2 cm. Remaining variables, including age, gender, etiology, and scanogram ruler inclination, did not correlate with a difference in the measurement of limb-length discrepancy with use of these two imaging studies. CONCLUSIONS: The measurement of limb-length discrepancy on a standing anteroposterior radiograph was very similar to that on a scanogram, especially in the absence of substantial mechanical axis deviation. These findings support the use of a standing anteroposterior radiograph of the lower extremities as the initial imaging study for patients presenting with unequal limb lengths. This approach allows for a more comprehensive radiographic evaluation of the lower extremity, including deformity analysis, while reducing the expense and radiation exposure as compared with the use of additional imaging studies for the assessment of limb-length discrepancy.

Langerhans cell histiocytosis involving epiphysis of a long bone.

Eosinophilic granulomas of long tubular bones, a form of Langerhans cell histiocytosis, occurs in metaphyses and diaphyses with equal frequency. Epiphyseal location is unusual, with only 13 cases previously reported in the literature. The present case involves the epiphysis of the upper end of the left femur in a 12-year-old boy with pain and limp in the affected area. Radiographic findings were an oval, radiolucent rarefaction with nonsclerotic border, measuring approximately 3.5 x 3.0 cm. Microscopic examination identified aggregates of histiocytes, multinucleated giant cells, scattered eosinophils, and few plasma cells and lymphocytes. Ultrastructural studies demonstrated Birbeck granules within cytoplasm of histiocytes diagnostic of Langerhans cell histiocytosis. Whether Langerhans cell histiocytosis is a neoplastic disorder or a reactive process remains controversial. The true nature of the Langerhans cell, the proliferating cells and hallmark of this disease, is likewise under scrutiny.