Patient genetic heterogeneities acting as indicators of post-operative pain and opioid requirement in orthopedic surgery: A systematic review.

INTRODUCTION: Orthopedic surgical procedures are expected to increase annually, making it imperative to understand the correlations between patient genetic makeup and post-operative pain levels. METHODS: We performed a systematic literature review using PubMed and Cochrane databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 299 articles were initially selected, 20 articles remained after title and abstract review, and nine articles were selected for inclusion upon full text review. RESULTS: Genetic risk factors identified included the A allele of the 5HT2A gene single nucleotide polymorphism, the AA genotype of the ADRB2 gene, the CG genotype of the IL6 gene, the genotypes CT and TT of the NTRK1 gene, genotypes AA and GA of the OPRM gene, and the AA and GA genotypes of the COMT gene. Additional studies in the review discuss statistical significance of other variants of the COMT gene. CONCLUSION: There have been genetic association studies performed on the patient heterogeneity and its relationship on patient pain levels, but more data need to be collected to understand the clinical utility of stratifying patients based on genomic sequence.

Pearls and Pitfalls of an Orthopaedic Mission Trip.

Many physicians chose to pursue years of rigorous medical training because of an innate desire to care for others, which often translates into volunteering in their local communities. Some physicians take this a step further by contributing their time and skills to global health delivery through medical mission trips. The need is apparent: a 40-year discrepancy in average life span, 36 deaths versus 4 deaths per 1,000 births in low-income versus high-income countries, and over 70% of preventable pediatric deaths occurring in solely 15 countries. In addition, a remarkable gap exists in the access of care and resources, with the world's poorest countries receiving only 4% of surgical services. Orthopaedic missions are seldom because the cost and complexity of these trips supersede many other specialties. However, the care that orthopaedic surgery can provide restores an individual's function, allowing them to increase productivity in their personal lives and in their community. Addressing this disparity in health care is a great first step, but studies have shown that mission trips may have some serious downfalls. We aim to discuss these downfalls and provide recommendations to mitigate them.

Bone marrow aspirate concentrate chondroplasty to delaying need for total knee arthroplasty: a retrospective review of a veteran cohort.

Aim: Osteoarthritis (OA) is a highly prevalent and costly condition, rooted in cartilaginous defects. Despite various causes, the inability for chondrocytes to regenerate prohibits these lesions from self-healing. Debridement commonly provides symptomatic relief but does not target the underlying disease process, necessitating investigation into possible treatments. Intraosseous and intraarticular bone marrow aspirate concentrate (BMAC) injection is a new promising therapy aimed at repairing these cartilage defects. Methods/materials: We retrospectively reviewed patients who underwent BMAC chondroplasty and examined the efficacy in delaying need for further intervention. Results: Only 5 of 23 procedures (21.7%) required postoperative intervention within the 2-year follow-up period. Only one request for total knee arthroplasty was made, but the procedure has not been done. Conclusion: This study demonstrates that BMAC chondroplasty may be an efficacious method to delay need for total knee arthroplasty.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis.

Background: The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022. Results: Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant. Conclusions: A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Frailty and Pre-Frailty in the Setting of Total Joint Arthroplasty: A Narrative Review.

Background: Total joint arthroplasties are among the most common surgical procedures performed in the United States. Although numerous safeguards are in place to optimize patient health and safety pre-, intra-, and postoperatively, patient frailty is often incompletely assessed or not assessed at all. Frailty has been shown to increase rates of adverse events and length of stay. We discuss the impact of frailty on patient outcomes and healthcare economics as well as provide widely accepted models to assess frailty and their optimal usage. Methods: Several databases were searched using the keywords "frailty," "TJA," "THA," "frailty index," "frailty assessment," and "frailty risk." A total of 45 articles were used in this literature review. Results: It is estimated that nearly half of patients over the age of 85 meet criteria for frailty. Frailty in surgical patients has been shown to increase total costs as well as length of stay. Additionally, increased rates of numerous adverse events are associated with increased frailty. Conclusions: The literature demonstrates that frailty poses increased risk of adverse events, increased length of stay, and increased cost. There are several models that accurately assess frailty and can feasibly be implemented into preoperative screening.

Osteoid osteoma of the wrist: Recent advances.

Osteoid osteoma is a benign bone tumor usually arising in the diaphysis and metaphysis of the long bones, with male predominance (sex ratio, 2:1). Despite being the most common bone tumor in the wrist, it is still an atypical location for this lesion. The usual presentation is pain that is exacerbated at night and relieved by aspirin or non-steroidal anti-inflammatory drugs. This presentation is not always the case in the wrist, which leads to numerous differential diagnoses and often a delay in definitive diagnosis and treatment. Various imaging modalities can confirm the presence of the tumor and guide the surgical approach. Resection is the gold-standard, with radiofrequency gaining popularity in recent years.

Identifying and Addressing Burnout in the Orthopaedic Surgeon.

Throughout the career of a physician, they are subjected to long working hours, high stress, life and death situations, risk of malpractice, significant financial debt, and an increasing bureaucratic load. This, in turn, has led to significant rates of burnout and potential suicidal ideation. Suicide prevalence has increased roughly 30% over the past 2 decades, with surgeon suicide rates reaching as high as 3x that of the general cohort. Orthopedic surgeons are most severely affected, composing 28.2% of physician suicides and seeing one third of their suicides from 2003 to 2017 occurring in the last 2 years alone. We provide the latest data and the current trends in orthopedic burnout and suicide rates, delve into the possible inciting factors driving their increase, and provide recommendations to identify their early signs and mitigate progression.

Neuraxial Anesthesia Significantly Reduces 30-Day Venous Thromboembolism Rate and Length of Hospital Stay in Primary Total Hip Arthroplasty: A Stratified Propensity Score-Matched Cohort Analysis.

BACKGROUND: General anesthesia (GA) has been the commonly used protocol for total hip arthroplasty (THA); however, neuraxial anesthesia (NA) has been increasingly performed. Our purpose was to compare NA and GA for 30-day postoperative outcomes in United States veterans undergoing primary THA. METHODS: A large veteran's database was utilized to identify patients undergoing primary THA between 1999 and 2019. A total of 6,244 patients had undergone THA and were included in our study. Of these, 44,780 (79.6%) had received GA, and 10,788 (19.2%) had received NA. Patients receiving NA or GA were compared for 30-day mortalities, cardiovascular, respiratory, and renal complications, and wound infections and hospital lengths of stay (LOS). Propensity score matching, multivariate regression analyses, and subgroup analyses by American Society of Anesthesiology classification were performed to control for selection bias and patient baseline characteristics. RESULTS: Upon propensity-adjusted multivariate analyses, NA was associated with decreased risks for deep venous thrombosis (odds ratio [OR] = 0.63; 95% CI = 0.4-0.9; P = .02), any respiratory complication (OR = 0.63; 95% CI = 0.5-0.9; P = .003), unplanned reintubation (OR = 0.51; 95% CI = 0.3-0.9; P = .009), and prolonged LOS (OR = 0.78; 95% CI = 0.72-0.84; P < .001). Subgroup analyses by American Society of Anesthesiology classes showed NA decreased 30-day venous thromboembolism rate in low-risk (class I/II) patients and decreased respiratory complications in high-risk (class III/IV) patients. CONCLUSION: Using a patient cohort obtained from a large national database, NA was associated with reduced risk of 30-day adverse events compared to GA in patients undergoing THA. Postoperative adverse events were decreased with NA administration with similar decreases observed across all patient preoperative risk levels. NA was also associated with a significant decrease in hospital LOS.

Genetic Polymorphisms Associated with Perioperative Joint Infection following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

The number of orthopedic procedures, especially prosthesis implantation, continues to increase annually, making it imperative to understand the risks of perioperative complications. These risks include a variety of patient-specific factors, including genetic profiles. This review assessed the current literature for associations between patient-specific genetic risk factors and perioperative infection. The PRISMA guidelines were used to conduct a literature review using the PubMed and Cochrane databases. Following title and abstract review and full-text screening, eight articles remained to be reviewed­all of which compared single nucleotide polymorphisms (SNPs) to periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). The following cytokine-related genes were found to have polymorphisms associated with PJI: TNFα (p < 0.006), IL-6 (p < 0.035), GCSF3R (p < 0.02), IL-1 RN-VNTR (p = 0.002), and IL-1B (p = 0.037). Protein- and enzyme-related genes that were found to be associated with PJI included: MBL (p < 0.01, p < 0.05) and MBL2 (p < 0.01, p < 0.016). The only receptor-related gene found to be associated with PJI was VDR (p < 0.007, p < 0.028). This review compiled a variety of genetic polymorphisms that were associated with periprosthetic joint infections. However, the power of these studies is low. More research must be conducted to further understand the genetic risk factors for this serious outcome.

Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries.

¼: In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC. ¼: Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively. ¼: The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team. ¼: Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.

Parathyroid adenoma autoinfarction: a report of a case.

BACKGROUND: Parathyroid adenoma autoinfarction, although uncommon, is an entity that has been previously reported in the literature; however, the influence of intraoperative parathyroid hormone (PTH) monitoring on therapeutic management has not been reported. METHODS: We present a case of parathyroid autoinfarction that is unique in that it applies a new technology to parathyroid surgery: intraoperative PTH monitoring. RESULTS: Intraoperative PTH monitoring aided in the successful surgical management of this patient. CONCLUSIONS: Intraoperative PTH monitoring can serve as a therapeutic adjunct in the surgical management of parathyroid adenoma autoinfarction.

A preliminary report on micronized AlloDerm injection laryngoplasty.

OBJECTIVES: To report the preliminary data of voice and quality-of-life improvement after micronized AlloDerm injection laryngoplasty in patients with unilateral vocal cord paralysis. STUDY DESIGN: A prospective study was conducted in patients with unilateral vocal cord paralysis who underwent injection laryngoplasty with micronized AlloDerm. METHODS: Preoperative and postoperative patient evaluation consisted of videostrobolaryngoscopy, computer voice analysis, airflow, and voice handicap index (VHI) assessment. All injections were conducted with the patient under general anesthesia using the Storz injector system and a 22-gauge spinal needle. RESULTS: Fourteen patients received injection with an average amount of 0.641 mL. Twelve patients were available for evaluation. Initial results at 4 weeks (n = 12) showed significant increase in habitual phonation time from 3.84 to 6.72 seconds (P <.01) and a decrease in airflow from 0.616 to 0.295 I's (P <.01). The VHI rating improved from 62.8 to 37.5 (P <.01). Jitter and shimmer also improved significantly (P <.05). Stroboscopic findings showed complete closure of glottic gap in 10 patients with excellent return of mucosal wave on the injected side. The mucosal wave return after injection was rapid with little evidence of tissue reaction. Postoperative follow-up at 3 months (n = 8) demonstrated slight resorption of the material, but sustained excellent voice was noted in 87.5%. Minimal morbidity and tissue reaction were noted. CONCLUSIONS: Micronized AlloDerm appears to be a safe new material that is suitable for injection laryngoplasty. Long-term results are pending.