Using Big Data To Study The Safety Of New Surgical Pathways And Technologies In Orthopaedic Surgery

With the recent push for safe reductions in hospital length of stay (LOS) following orthopaedic procedures, increasing aging population, and new surgical technologies, the purposes of this thesis are three-fold. (1) To compare the complication profiles of patients who underwent outpatient versus inpatient total knee arthroplasty. (2) To determine the safety of performing revision total hip arthroplasty in the octogenarian patient population. (3) To establish any clinically meaningful differences between navigated versus conventional single-level instrumented posterior lumbar fusion. The following methods were used. (1) Patients undergoing outpatient (defined as LOS = 0 days) or inpatient (defined as LOS = 1 – 30 days) total knee arthroplasty were identified from the National Surgical Quality Improvement Program (NSQIP) database and their perioperative outcomes were compared. (2) Patients who underwent aseptic revision total hip arthroplasty were identified from the NSQIP database and stratified into two age groups: \u3c80 and ≥80 years old. Multivariate regressions were used to compare risk for postoperative complications and readmission between the two age groups. (3) Patients who underwent navigated or conventional single-level posterior instrumented lumbar fusions were identified in the NSQIP database. The usage of navigation was characterized. Propensity score matching was done and comparisons were made for operative time, hospital length of stay, postoperative complications, and thirty-day readmissions between the two cohorts. Findings were as follows. (1) After propensity matching, multivariate analysis revealed a higher rate of post-discharge blood transfusions (p\u3c0.001) in the outpatient total knee arthroplasty cohort. There were no other significant differences in 30-day postoperative individual adverse events or readmissions. (2) Multivariate analysis revealed higher risk for perioperative mortality, pneumonia, urinary tract infection, blood transfusion, and extended length of stay in ≥80 compared to \u3c80 year olds. (3) After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in operative time and for most adverse events including wound infection, return to the operating room, and readmission. There were significantly lower blood transfusions in the navigated cohort (2.84% versus 7.15%, p\u3c0.001). Conclusions are as follows. (1) Based on the perioperative outcome measures studied here, outpatient total knee arthroplasty can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients post discharge may be warranted. (2) Even after controlling for patient and procedural characteristics, aseptic revision total hip arthroplasty in ≥80 year olds is associated with greater risks than their younger counterparts. This is important for counseling and highlights the need for medical optimization in this vulnerable patient population. (3) The lack of differences in most perioperative outcomes suggest that the use of navigation should be guided by what the surgeon feels is best in their hands to deliver the best care to their patients, as opposed to objective measures assessed here

Male sex is an independent risk factor for patellar osteochondral fractures following acute patellar dislocation in pediatric patients

Abstract Purpose Although most patellar dislocations are associated with medial patellofemoral ligament (MPFL) injury, many patients also sustain concomitant patellar osteochondral fractures following a patellar dislocation. Few prior studies have described or evaluated risk factors for patellar osteochondral fractures in pediatric patients. The purpose of the present study was to describe the incidenceand location of patellar osteochondral fractures following acute patellar dislocation in pediatric patients. In addition, we described risk factors for patellar osteochondral fractures in this population. We hypothesized that most fractures would occur at the inferomedial quadrant of the patella following a traumatic injury mechanism. Methods Following Institutional Review Board approval, the electronic medical record was queried to identify pediatric patients ≤ 18 years old who underwent MPFL reconstruction (MPFLR) or non‐operative treatment for patellar instability between July 2016 and February 2020. Osteochondral fractures were defined as full‐thickness chondral injuries with attached subchondral bone or purely osseous injuries measuring ≥ 3 mm (mm) in at least two magnetic resonance imaging (MRI) planes. Patients were included in the study if they had complete preoperative x‐ray and MRI studies with minimum 6‐month follow‐up. Patients were excluded if they had incomplete imaging, isolated chondral fractures, or less than 6 months follow‐up. Univariate analysis was used to identify patient factors associated with osteochondral fractures. Multivariate regression analysis was used to identify risk factors for osteochondral fractures. Results Sixty patients (63 knees) were included in the study, 15 (23.8%) of whom had a patellar osteochondral fracture. The majority of osteochondral fractures (87%) involved the inferomedial quadrant of the patella. Univariate analysis showed an association between male sex (p = 0.041), skeletal immaturity (p = 0.028), and decreased patellar tilt (p = 0.021) and patellar osteochondral fractures. Multivariate regression analysis identified male sex as an independent risk factor for osteochondral fractures (relative risk: 4.8, 95% confidence interval [CI]: 1.08–20.9, p = 0.039). No patients had recurrent dislocation at minimum 6‐month follow‐up. All patients with osteochondral fractures returned to sports at most recent follow up. Conclusion In this study, 23% of pediatric patients with acute patellar dislocations have a concomitant patellar osteochondral fracture. The majority of patellar osteochondral fractures involve the inferomedial quadrant of the patella. Male sex is an independent risk factor for patellar osteochondral fractures, and skeletal immaturity is associated with patellar osteochondral fractures in this population. Level of evidence Level III