Surgical treatment of Lenke 5 adolescent idiopathic scoliosis: Comparison of anterior vs posterior approach

AIM To compare the posterior vs anterior approaches for fusion of Lenke 5 adolescent idiopathic scoliosis curves,matched for curve magnitude and for the distal level of fixation(dLOF) standardized to the third lumbar vertebrae(L3).METHODS A prospectively collected multicenter database was used for this retrospective comparative study. Our dependent variables included sagittal and coronal radiographic measurements, number of fused vertebrae, estimated blood loss, length of hospitalization and SRS total and individual domain scores at the two-year follow-up. Subject demographics were similar for all group comparisons.Independent t-test was used to compare groups for all analyses at P < 0.01.RESULTS For all matched cases of Lenke 5 curves, a selective approach was used only 50% of the time in cases undergoing a posterior fusion. When comparing a posterior selective approach to an anterior selective approach,surgeons utilizing a posterior approach fused significantly more levels than surgeons using an anterior approach with no other significant differences in radiographic or SRS outcomes(Ant = 4.8 ± 1.0 levels vs post = 6.1 ± 1.0 levels, P < 0.0001). When the dLOF was standardized to L3, the anterior approached provided significantly greater lumbar Cobb percent correction than the posterior approach(Ant = 69.1% ± 12.6% vs post =54.6% ± 16.4%, P = 0.004), with no other significant radiographic or SRS score differences between approaches.CONCLUSION Surgeons treating Lenke 5c curves with a posterior instrumentation and fusion vs an anterior approach include more motion segments, even with a selective fusion. When controlled for the distal level of fixation,the anterior approach provides greater correction of the thoracolumbar curve.

Reducing costly falls after total knee arthroplasty

AIM To investigate whether adductor canal nerve block(ACB) reduces patient falls when compared to femoral nerve block(FNB) after total knee arthroplasty(TKA). METHODS We conducted an institutional review of all-cause falls after TKA from January 2013 to August 2016 using a quality improvement database. Our inclusion criteria were patients with diagnosis of primary knee osteoarthritis who underwent primary unilateral TKA with either a FNB or an ACB and sustained a fall during their hospitalization. We excluded patients who had revision TKA and extensor mechanism reconstruction. We also excluded patients with a history of post-traumatic arthritis, prior history of lower extremity fracture, history of neurological disease, or cerebrovascular disease. RESULTS A total of 834 patients had TKA with femoral nerve block and knee immobilizer(FNB + KI). Of those patients, 11(1.3%) experienced a fall during their hospital stay. In contrast, 791 patients had TKA with ACB. Of those patients, only one(0.13%) patient fall was recorded within this group. We used the Fisher's exact test to compare the differences between the two groups. The difference between the two groups achieves statistical significance(P = 0.006). We also found that 11 out of the 12 patients that fell had a right TKA procedure while one patient had a left TKA procedure. Nine out of twelve patients that fell were female, while only three patients were male.CONCLUSION Given the reduction in the number of falls with ACB, it is recommended that ACB be considered the preferred analgesia for patients undergoing a TKA procedure.

Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation

BACKGROUND In 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care.Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients.AIM To determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility(SNF)with the diagnosis of a hip fracture requiring operative intervention.METHODS A retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015.Inclusion criteria included a total or partial hip replacement for a hip fracture.Exclusion criteria included pathologic,periprosthetic,and fracture non-union.Data was collected to compare total observed costs for patients from the emergency department,patients from skilled nursing facilities,and patients from an outside hospital.RESULTS A total of 223 patients met the inclusion criteria.135(60.54%)of these patients presented primarily to the emergency department,58 patients(26.01%)were transferred from an outside hospital,and 30 patients(13.43%)were transferred from a SNF.Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization($43302)compared to emergency department patients($28875,P=0.000)and SNF patients($28282,P=0.000).CONCLUSION Patients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF.This is a strong argument for riskadjustment models when bundling payments for the care of hip fracture patients.

Systematic review of the etiology behind patellar clunk syndrome

BACKGROUND Total knee arthroplasty is one of the most successful operations performed worldwide today.Patellar clunk syndrome(PCS)is a postoperative complication that arises due to the development of a fibrous nodule along the undersurface of the quadriceps tendon.The current literature on PCS has not yet come to a consensus regarding its etiology.To date,this is the first study that analyzes the existing literature on PCS in order to generate a conclusion regarding its etiology.It is hypothesized that prosthesis design is the main component behind the development of PCS.AIM To determine the etiology of PCS and its association with pre and post-operative characteristics of the prosthesis and native knee.METHODS We conducted a systematic review according to the PRISMA guidelines by searching through PubMed,Cochrane,and Google Scholar from May-July 2018 for cases of PCS using search MeSH terms“patella OR patellar”AND“clunk”OR“catch”OR“crepitus”.The search included case series and clinical trials and excluded review articles,yielding 30 articles from the original search and 3 additional articles from reference lists.We extracted data upon the outcomes in patients afflicted with PCS to determine the etiology of PCS.We performed additional bias assessments to validate our search algorithm and results.RESULTS Prosthesis design was the metric most frequently implicated in the incidence of PCS,though several other metrics were contributory toward its pathogenesis.Later prosthetic designs incorporate a reduced intercondylar box ratio and box width to reduce contact between the proximal patellar pole and the intercondylar box,thereby reducing incidence of PCS.CONCLUSION The etiology of PCS is multifactorial,owing to the growing metrics that have associations with its incidence.This conclusion is validated by the significance of prosthesis design as the most likely parameter involved in developing PCS since different prosthesis designs are often the result of different parameters.Future studies should be directed at isolating individual prosthetic parameters of prosthesis designs in order to determine what permutation of parameters is most closely associated with the development of PCS.