Publications by authors named "Armin Arshi"

62 Publications

Comparison of complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures.

Arch Orthop Trauma Surg 2021 Jun 10. Epub 2021 Jun 10.

Department of Orthopaedic Surgery, David Geffen School of Medicine At UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA, 90095-6902, USA.

Introduction: Most geriatric hip fractures occur in the femoral neck (FN) and intertrochanteric (IT) regions of the femur, while a minority occur in the subtrochanteric (ST) region. Relative outcomes based on the anatomical subtype of fracture are not well studied. This study characterizes postoperative complications and outcomes of hip fractures distinguished by anatomic region.

Materials And Methods: The targeted hip fracture series of the American College of Surgeons National Surgical Quality Improvement Program database was queried to identify geriatric (≥ 65 years) patients who sustained operative FN, IT, and ST hip fractures. Primary patient demographic and perioperative data were collected and correlated with 30-day postoperative complications and outcomes. Multivariate regression was used to calculate relative risks of adverse events (AEs) between groups.

Results: In total, 8220 geriatric hip fracture patients were identified. Risk-adjusted 30-day mortality was not significantly different between patients with ST (5.8%, p = 0.735) and IT (7.3%, p = 0.169) femur fractures relative to those with FN fractures (6.6%). The overall risk-adjusted rate of minor and major medical AEs within 30 days and risk-adjusted rate of wound complications was not significantly different between FN, IT, and ST fractures. Patients with IT [34.4%, OR 2.35 (2.35-3.08), p < 0.001] and ST fractures [49.8%, OR 5.94 (4.58-7.70), p < 0.00] had higher risk-adjusted incidence of postoperative blood transfusion relative to FN fractures (18.5%). Furthermore, patients with IT fractures had a slightly lower risk-adjusted incidence of unplanned reoperation [2.1 vs. 2.7%, OR 0.69 (0.47-0.99), p = 0.046] and hospital readmission (7.8 vs. 9.2%, OR 0.76 [0.63-0.91], p = 0.003) than patients with FN fractures.

Conclusions: With respect to anatomic region, geriatric hip fractures have similar short-term mortality and medical AE profiles with differences in transfusion, reoperation, and readmission rates. Knowledge of these short-term outcomes may guide surgeons in counseling hip fracture patients peri-operatively.
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http://dx.doi.org/10.1007/s00402-021-03978-xDOI Listing
June 2021

Analysis of perioperative outcomes in hip resection arthroplasty.

Arch Orthop Trauma Surg 2021 Feb 24. Epub 2021 Feb 24.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 100 UCLA Medical Plaza, Suite 755, Los Angeles, CA, 90095, USA.

Background: Hip resection arthroplasty (HRA) is a salvage surgical technique for the management of complex hip conditions wherein arthroplasty may be contraindicated. The purpose of this study was to review modern-day indications for HRA and compare outcomes between patients undergoing HRA and revision total hip arthroplasty (RTHA).

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used to identify patients undergoing HRA or RTHA between 2012 and 2017. Patient demographics, risk factors, and perioperative complications were analyzed. Multivariate regression was used to determine predictors of early postoperative complications. Propensity score matching (PSM) was performed to compare relative risks (RR) of complications in HRA compared to RTHA.

Results: 290 patients underwent HRA between 2012 and 2017. Infection was the most common indication for HRA (39.8%), followed by femoral neck fracture or malunion/nonunion (26%) and prosthetic instability (12.2%). Increased body mass index (BMI) (p = 0.012) and chronic obstructive pulmonary disease (COPD) (p = 0.007) were associated with increased risk of complication in HRA. There were no significant differences in short-term complication risks between RTHA and HRA.

Conclusions: HRA was associated with short-term complication rates comparable to RTHA. These findings may help in surgical decision-making and appropriate indications in the present day.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00402-021-03833-zDOI Listing
February 2021

Patellar Rebar Augmentation in Revision Total Knee Arthroplasty.

J Arthroplasty 2021 02 1;36(2):670-675. Epub 2020 Sep 1.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

Background: In revision total knee arthroplasty, osteolysis, mechanical abrasion, and infection may leave patellar bone stock severely attenuated with cavitary and/or segmental rim deficiencies that compromise fixation of patellar implant pegs. The purpose of this study was to retrospectively review the use of cortical "rebar" screws to augment cement fixation in revision patelloplasty.

Methods: From 2006 to 2018, dorsal patellar rebar technique was used for patellar reconstruction in 128 of 1037 revision total knee arthroplasty cases (12.3%). Follow-up was achieved with serial radiographs and prospective comparison of Knee Society Scores (KSSs) for clinical outcome. Complications and implant failures requiring reoperation or modified rehabilitation were also assessed.

Results: Of the 128 patellar revisions performed using the rebar technique, 69 patients were women and 59 patients were men. The average age of the group was 69.5 years (range, 32-83 years). The mean follow-up of the cohort was 37 months (range, 13-109 months). The most common causes for revision were kinematic conflict, periprosthetic joint infection, and aseptic loosening. The median number of rebar screws used was 5 (range, 1-13). Preoperative KSSs for the study cohort averaged 50 (range, 0-90) At latest follow-up, mean KSS was 85 (range, 54-100). There were 4 patellar-related complications (3.1%) with no implant failures at study conclusion. Retrieval analysis revealed rigid fixation of the reconstructed patellar component in all cases.

Conclusions: Patellar rebar screw augmentation is a useful technique when there are significant cavitary deficiencies and limited segmental rim deficiencies. This technique allows the surgeon to extend indications for patellar revision arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2020.08.057DOI Listing
February 2021

Extensive Atraumatic Heterotopic Ossification of the Achilles Tendon in an Adolescent with Metabolic Syndrome: A Case Report.

JBJS Case Connect 2020 Jan-Mar;10(1):e0394

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

Case: A 15-year-old boy with type 1 diabetes mellitus, hypertension, and obesity presented with atraumatic posterior ankle pain and stiffness due to extensive heterotopic ossification (HO) of the Achilles tendon. The ossification was successfully surgically resected and tendon primarily repaired. Wound dehiscence was noted at the first preoperative visit, managed conservatively by local wound care, and healed uneventfully by secondary intention. One-year follow-up showed no recurrence of HO, return to baseline activities, yet low Oxford scores.

Conclusion: HO of the Achilles tendon is a rare clinical entity. We report an atraumatic case in an adolescent patient with metabolic syndrome, which may demonstrate systemic inflammation because of metabolic syndrome as a risk factor for HO.
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http://dx.doi.org/10.2106/JBJS.CC.19.00394DOI Listing
January 2021

Preoperative Vitamin D Repletion in Total Knee Arthroplasty: A Cost-Effectiveness Model.

J Arthroplasty 2020 05 27;35(5):1379-1383. Epub 2019 Dec 27.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Background: Recent studies have identified vitamin D deficiency (serum 25-hydroxyvitamin D [25(OH)D] < 20 ng/L) as a potentially modifiable risk factor for prosthetic joint infection (PJI) in arthroplasty. The purpose of this study is to determine whether implementation of preoperative 25(OH)D repletion is cost-effective for reducing PJI following total knee arthroplasty (TKA).

Methods: A cost estimation predictive model was generated to determine the utility of both selective and nonselective 25(OH)D repletion in primary TKA to prevent PJI. Input data on the incidence of 25(OH)D deficiency, relative complication rates, and costs of serum 25(OH)D repletion and 2-stage revision for PJI were derived from previously published literature identified using systematic review and publicly available data from Medicare reimbursement schedules. Mean, lower, and upper bounds of 1-year cost savings were computed for nonselective and selective repletion relative to no repletion.

Results: Selective preoperative 25(OH)D screening and repletion were projected to result in $1,504,857 (range, $215,084-$4,256,388) in cost savings per 10,000 cases. Nonselective 25(OH)D repletion was projected to result in $1,906,077 (range, $616,304-$4,657,608) in cost savings per 10,000 cases. With univariate adjustment, nonselective repletion is projected to be cost-effective in scenarios where revision for PJI costs ≥$10,636, incidence of deficiency is ≥1.1%, and when repletion has a relative risk reduction ≥4.2%.

Conclusion: This predictive model supports the potential role of 25(OH)D repletion as a cost-effective mechanism of reducing PJI risk in TKA. Given the low cost of 25(OH)D repletion relative to serum laboratory testing, nonselective repletion appears to be more cost-effective than selective repletion. Further prospective investigation to assess this modifiable risk factor is warranted.
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http://dx.doi.org/10.1016/j.arth.2019.12.037DOI Listing
May 2020

Recurrent Patellofemoral Instability in the Pediatric Patient: Management and Pitfalls.

Curr Rev Musculoskelet Med 2020 Feb;13(1):58-68

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.

Purpose Of Review: The purpose of the review is to discuss the relevant pathoanatomy, management, complications, and technical considerations for recurrent patellofemoral instability (PFI) in the pediatric population. Special consideration is given to recent literature and management of the patient with repeat instability following surgery.

Recent Findings: Patellar stabilization surgery is in principle dependent upon restoration of normal patellofemoral anatomy and dynamic alignment. Historically, treatment options have been numerous and include extensor mechanism realignment, trochleoplasty, and more recently repair and/or reconstruction of the medial patellofemoral ligament (MPFL) as a dynamic check rein during initial knee flexion. In skeletally immature patients, preference is given to physeal-sparing soft tissue procedures. While medial patellofemoral ligament reconstruction has become a popular option, postoperative failure is a persistent issue with rates ranging from 5 to 30% for PFI surgery in general without any single procedure (e.g., distal realignment, MPFL reconstruction) demonstrating clear superiority. Failure of surgical patellar stabilization is broadly believed to occur for three main reasons: (1) technical failure of the primary stabilization method, (2) unaddressed static and dynamic pathoanatomy during the primary stabilization, and (3) intrinsic risk factors (e.g., collagen disorders, ligamentous laxity). PFI is a common orthopedic condition affecting the pediatric and adolescent population. Treatment of repeat instability following surgery in the PFI patient requires understanding and addressing underlying pathoanatomic risk factors as well as risks and reasons for failure.
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http://dx.doi.org/10.1007/s12178-020-09607-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083998PMC
February 2020

Stem Cell Treatment for Knee Articular Cartilage Defects and Osteoarthritis.

Curr Rev Musculoskelet Med 2020 Feb;13(1):20-27

Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, 76-143 CHS, Los Angeles, CA, 90095-6902, USA.

Purpose Of Review: To review the current basic science and clinical literature on mesenchymal stem cell (MSC) therapy for articular cartilage defects and osteoarthritis of the knee.

Recent Findings: MSCs derived from bone marrow, adipose, and umbilical tissue have the capacity for self-renewal and differentiation into the chondrocyte lineage. In theory, MSC therapy may help restore cartilage focally or diffusely where nascent regenerative potential in the intra-articular environment is limited. Over the last several years, in vitro and animal studies have elucidated the use of MSCs in isolation as injectables, in combination with biological delivery media and scaffolding, and as surgical adjuvants for cartilage regeneration and treatment of knee degenerative conditions. More recently, clinical and translational literature has grown more convincing from early descriptive case series to randomized controlled trials showing promise in efficacy and safety. Studies describing MSC for knee cartilage regeneration applications are numerous and varied in quality. Future research directions should include work on elucidating optimal cell concentration and dosing, as well as standardization in methodology and reporting in prospective trials. Backed by promise from in vitro and animal studies, preliminary clinical evidence on MSC therapy shows promise as a nonoperative therapeutic option or an adjuvant to existing surgical cartilage restoration techniques. While higher quality evidence to support MSC therapy has emerged over the last several years, further refinement of methodology will be necessary to support its routine clinical use.
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http://dx.doi.org/10.1007/s12178-020-09598-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7083980PMC
February 2020

Blood transfusion rates and predictors following geriatric hip fracture surgery.

Hip Int 2021 Mar 8;31(2):272-279. Epub 2020 Jan 8.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Background: Postoperative blood product transfusions in elderly hip fracture patients cause concern for morbidity and mortality. The purpose of this study was to identify predictors and short-term sequelae of postoperative transfusion following geriatric hip fracture surgery.

Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to identify geriatric (⩾65 years) patients who sustained operative femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to determine risk-adjusted odds ratios (OR) of associated perioperative risk factors and sequelae of postoperative transfusion.

Results: In total, 8416 geriatric hip fracture patients were identified of whom 28.3% had documented postoperative transfusion. In multivariate analysis, age (OR 1.03 [1.02-1.04],  < 0.001), preoperative anaemia (OR 4.69 [3.99-5.52],  = 0.001), female sex (OR 1.61 [1.39-1.87],  < 0.001), lower BMI (OR 0.97 [0.96-0.98],  < 0.001), American Society of Anesthesiologists (ASA) classification (OR 1.14 [1.01-1.27],  = 0.031), COPD (OR 1.30 [1.06-1.59],  = 0.011), hypertension (OR 1.17 [1.01-1.35],  = 0.038), increased OR time (OR 1.02 [1.01-1.03],  < 0.001), and intertrochanteric (OR 2.99 [2.57-3.49],  < 0.001) and subtrochanteric femur fractures (OR 5.07 [3.84-6.69],  < 0.001) were independent risk factors for receiving postoperative blood transfusion. Patients with postoperative transfusion had a significantly higher risk-adjusted 30-day mortality (8.4% vs. 6.4%, OR 1.29 [1.02-1.64],  = 0.035), hospital readmission rate (9.4% vs. 7.7%, OR 1.27 [1.04-1.55],  = 0.018), and total hospital LOS (7.3 vs. 6.3 days,  < 0.001).

Conclusions: Postoperative transfusion is a common occurrence in geriatric fragility hip fractures with multiple risk factors. Careful preoperative planning and multidisciplinary management efforts are warranted to reduce use of postoperative transfusions.
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http://dx.doi.org/10.1177/1120700019897878DOI Listing
March 2021

Roux-Goldthwait and Medial Patellofemoral Ligament Reconstruction for Patella Realignment in the Skeletally Immature Patient.

Arthrosc Tech 2019 Dec 9;8(12):e1479-e1483. Epub 2019 Nov 9.

Department of Orthopaedic Surgery, Division of Sports Medicine and Shoulder Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, U.S.A.

Surgical management of patellofemoral instability is technically challenging in skeletally immature patients. Special considerations in this population include activity and sports limitations, recurrence rate, risk of long-term injury to patellofemoral cartilage, and potential for physeal disruption with operative intervention. Numerous procedures have been described to address causative pathoanatomy in the patellofemoral joint, as well as its static and dynamic stabilizers. We describe our technique of combined medial patellofemoral ligament and modified Roux-Goldthwait reconstruction to address both proximal and distal malalignment in a skeletally immature patient with open physes.
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http://dx.doi.org/10.1016/j.eats.2019.07.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928364PMC
December 2019

Postacute Care Utilization in Postsurgical Orthogeriatric Hip Fracture Care.

J Am Acad Orthop Surg 2020 Sep;28(18):743-749

From the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Introduction: Among surgical patients, utilization of institutional-based postacute care (PAC) presents a notable financial burden and is associated with increased risk of complications and mortality rates when compared with discharge home. The purpose of this study was to identify predictors of postdischarge disposition to PAC in geriatric patients after surgical fixation of native hip fractures.

Methods: We have done a query of the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained surgical femoral neck, intertrochanteric, and subtrochanteric hip fractures in 2016. Multivariate regression was used to compute risk factors for discharge to and prolonged stay (>30 days) in PAC.

Results: Eight thousand one hundred thirty-three geriatric hip fracture patients with sufficient follow-up data were identified. Of these, 6,670 patients (82.0%) were initially discharged to PAC after their hip fracture episode of care, and 2,986 patients (36.7%) remained in PAC for >30 days. Age (odds ratio [OR] 1.06 [1.05 to 1.08], P < 0.001), partial (OR 2.41 [1.57 to 3.71], P < 0.001) or total dependence (OR 3.03 [1.92 to 4.46], P < 0.001) for activities of daily living, dementia (OR 1.62 [1.33 to 1.96], P < 0.001), diabetes (OR 1.46 [1.14 to 1.85], P = 0.002), hypertension (OR 1.32 [1.10 to 1.58], P = 0.002), and total hospital length of stay (OR 1.04 [1.01 to 1.08], P = 0.006) were independent risk factors for discharge to PAC. Age (OR 1.05 [1.04 to 1.06], P < 0.001), partial (OR 2.86 [1.93 to 3.79], P < 0.001) or total dependence (OR 3.12 [1.45 to 4.79], P < 0.001) for activities of daily living, American Society of Anesthesiologist's classification (OR 1.27 [1.13 to 1.43], P < 0.001), dementia (OR 1.49 [1.28 to 1.74], P < 0.001), and total hospital length of stay (OR 1.10 [1.08 to 1.13], P < 0.001) were independent risk factors for prolonged PAC stay >30 days.

Discussion: Discharge to PAC is the norm among patients undergoing hip fracture surgery. Provider foreknowledge of risk factors may help improve hip fracture outcomes and decrease healthcare costs.
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http://dx.doi.org/10.5435/JAAOS-D-19-00073DOI Listing
September 2020

The Role of Gender, Academic Affiliation, and Subspecialty in Relation to Industry Payments to Orthopaedic Surgeons.

J Natl Med Assoc 2020 Feb 2;112(1):82-90. Epub 2019 Nov 2.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Background: The Physician-Payments-Sunshine-Act (PPSA) was introduced in 2010 to provide transparency regarding physician-industry payments by making these payments publicly available. Given potential ethical implications, it is important to understand how these payments are being distributed, particularly as the women orthopaedic workforce increases. The purpose of this study was thus to determine the role of gender and academic affiliation in relation to industry payments within the orthopaedic subspecialties.

Methods: The PPSA website was used to abstract industry payments to Orthopaedic surgeons. The internet was then queried to identify each surgeon's professional listing and gender. Mann-Whitney U, Chi-square tests, and multivariable regression were used to explore the relationships. Significance was set at a value of P < 0.05.

Results: In total, 22,352 orthopaedic surgeons were included in the study. Payments were compared between 21,053 men and 1299 women, 2756 academic and 19,596 community surgeons, and across orthopaedic subspecialties. Women surgeons received smaller research and non-research payments than men (both, P < 0.001). There was a larger percentage of women in academics than men (15.9% vs 12.1%, P < 0.001). Subspecialties with a higher percentage of women (Foot & Ankle, Hand, and Pediatrics) were also the subspecialties with the lowest mean industry payments (all P < 0.001). Academic surgeons on average, received larger research and non-research industry payments, than community surgeons (both, P < 0.001). Multivariable linear regression demonstrated that male gender (P = 0.006, P = 0.029), adult reconstruction (both, P < 0.001) and spine (P = 0.008, P < 0.001) subspecialties, and academic rank (both, P < 0.001) were independent predictors of larger industry research and non-research payments.

Conclusions: A large proportion of the US orthopaedic surgeon workforce received industry payments in 2014. Academic surgeons received larger payments than community surgeons. Despite having a larger percentage of surgeons in academia, women surgeons received lower payments than their male counterparts. Women also had a larger representation in the subspecialties with the lowest payments.
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http://dx.doi.org/10.1016/j.jnma.2019.09.004DOI Listing
February 2020

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complications in Arthroscopic Rotator Cuff Repair.

J Am Acad Orthop Surg Glob Res Rev 2019 Jul 3;3(7):e075. Epub 2019 Jul 3.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA (Mr. Harada, Dr. Arshi, Dr. Fretes, Dr. McAllister, and Dr. Petrigliano) and the Department of Orthopaedic Surgery, Keck School of Medicine of USC (Mr. Formanek, Dr. Gamradt), Los Angeles, CA.

Introduction: Rotator cuff tears are one of the most common injuries worldwide, yet it is difficult to predict which patients will have poor outcomes after arthroscopic rotator cuff repair (RCR). The purpose of this study was to identify an association between preoperative vitamin D (25D) levels and postoperative complications in arthroscopic RCR.

Methods: From a national claims database, patients undergoing arthroscopic RCR with preoperative 25D levels were reviewed. Patients were stratified into 25D-sufficient (≥20 ng/dL) or 25D-deficient (<20 ng/dL) categories and examined for development of postoperative complications. Multivariate logistic regression was performed using age, sex, and Charlson Comorbidity Index (CCI) as covariates. From this, risk-adjusted odds ratios (ORs) were calculated comparing complications between the two groups.

Results: One thousand eight hundred eighty-one patients with measured preoperative 25D levels were identified; 229 patients were 25D deficient (12.2%). After adjusting for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had increased odds of revision RCR (OR 1.54, 95% confidence interval 1.21 to 1.97, < 0.001) and stiffness requiring manipulation under anesthesia (OR 1.16, 95% confidence interval 1.03 to 2.03, = 0.035).

Conclusions: Vitamin D deficiency is associated with a greater risk of postoperative surgical complications after arthroscopic RCR and may be a modifiable risk factor. Further investigation on preoperative vitamin D repletion is warranted.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-19-00075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743985PMC
July 2019

Multiple Concussions Increase Odds and Rate of Lower Extremity Injury in National Collegiate Athletic Association Athletes After Return to Play.

Am J Sports Med 2019 11 12;47(13):3256-3262. Epub 2019 Sep 12.

Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.

Background: Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury.

Purpose: To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls.

Study Design: Cohort study; Level of evidence, 3.

Methods: From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis.

Results: The incidence of lower extremity injury after RTP was significantly greater ( = .049) in the MC cohort (36/48, 75%) than in SC athletes (25/48 = 52%) and NC athletes (27/48 = 56%). Similarly, odds of lower extremity injury were significantly greater in the MC cohort than in SC athletes (OR, 3.00; 95% CI, 1.26-7.12; = .01) and NC athletes (OR, 1.66; 95% CI, 1.07-2.56; = .02). Time to lower extremity injury was significantly shorter in the MC group compared with matched controls ( = .01). No difference was found in odds of lower extremity injury or time to lower extremity injury between SC and NC athletes.

Conclusion: Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC.
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http://dx.doi.org/10.1177/0363546519872502DOI Listing
November 2019

Comparative Effectiveness of Cartilage Repair With Respect to the Minimal Clinically Important Difference.

Am J Sports Med 2019 11 13;47(13):3284-3293. Epub 2019 May 13.

Hospital for Special Surgery, New York, New York, USA.

Background: Recent studies demonstrated a 5% increase in cartilage repair procedures annually in the United States. There is currently no consensus regarding a superior technique, nor has there been a comprehensive evaluation of postoperative clinical outcomes with respect to a minimal clinically important difference (MCID).

Purpose: To determine the proportion of available cartilage repair studies that meet or exceed MCID values for clinical outcomes improvement over short-, mid-, and long-term follow-up.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review was performed via the Medline, Scopus, and Cochrane Library databases. Available studies were included that investigated clinical outcomes for microfracture (MFX), osteoarticular transfer system (OATS), osteochondral allograft transplantation, and autologous chondrocyte implantation/matrix-induced autologous chondrocyte implantation (ACI/MACI) for the treatment of symptomatic knee chondral defects. Cohorts were combined on the basis of surgical intervention by performing a meta-analysis that utilized inverse-variance weighting in a DerSimonian-Laird random effects model. Weighted mean improvements in International Knee Documentation Committee (IKDC), Lysholm, and visual analog scale for pain (VAS pain) scores were calculated from preoperative to short- (1-4 years), mid- (5-9 years), and long-term (≥10 years) postoperative follow-up. Mean values were compared with established MCID values per 2-tailed 1-sample Student tests.

Results: A total of 89 studies with 3894 unique patients were analyzed after full-text review. MFX met MCID values for all outcome scores at short- and midterm follow-up with the exception of VAS pain in the midterm. OATS met MCID values for all outcome scores at all available time points; however, long-term data were not available for VAS pain. Osteochondral allograft transplantation met MCID values for IKDC at short- and midterm follow-up and for Lysholm at short-term follow-up, although data were not available for other time points or for VAS pain. ACI/MACI met MCID values for all outcome scores (IKDC, Lysholm, and VAS pain) at all time points.

Conclusion: In the age of informed consent, it is important to critically evaluate the clinical outcomes and durability of cartilage surgery with respect to well-established standards of clinical improvement. MFX failed to maintain VAS pain improvements above MCID thresholds with follow-up from 5 to 9 years. All cartilage repair procedures met MCID values at short- and midterm follow-up for IKDC and Lysholm scores; ACI/MACI and OATS additionally met MCID values in the long term, demonstrating extended maintenance of clinical benefits for patients undergoing these surgical interventions as compared with MFX.
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http://dx.doi.org/10.1177/0363546518824552DOI Listing
November 2019

Fresh Osteochondral Allograft Transplantation for Uncontained, Elongated Osteochondritis Dissecans Lesions of the Medial Femoral Condyle.

Arthrosc Tech 2019 Mar 11;8(3):e267-e273. Epub 2019 Feb 11.

Department of Orthopaedic Surgery, Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, U.S.A.

Osteochondritis dissecans (OCD) lesions of the knee are a significant source of pain and disability. Although the pathologic process for this condition remains poorly understood, histologic studies suggest vascular insufficiency of the subchondral bone may be the underlying cause for focal necrosis and subsequent compromise of the overlying articular cartilage. These lesions most commonly affect the medial femoral condyle and can be found along the margins of the intercondylar notch. Because of significant bone involvement, osteochondral allograft (OCA) transplantation has emerged as a dominant treatment option for OCD lesions because it can accurately restore the entire osteochondral unit. Given the characteristic location and large, irregular shapes of these lesions, surgical management can be challenging. These lesions are often uncontained along the periphery of the condyle, which can compromise OCA graft fixation and healing. We describe our preferred technique for the treatment of large, uncontained OCD lesions of the medial femoral condyle using a unicompartmental OCA augmented with screw fixation.
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http://dx.doi.org/10.1016/j.eats.2018.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470404PMC
March 2019

Accurate Reporting of Concomitant Procedures Is Highly Variable in Studies Investigating Knee Cartilage Restoration.

Cartilage 2019 Apr 11:1947603519841673. Epub 2019 Apr 11.

1 Department of Orthopaedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA.

Objective: Successful clinical outcomes following cartilage restoration procedures are highly dependent on addressing concomitant pathology. The purpose of this study was to document methods for evaluating concomitant procedures of the knee when performed with articular cartilage restoration techniques, and to review their reported findings in high-impact clinical orthopedic studies. We hypothesized that there are substantial inconsistencies in reporting clinical outcomes associated with concomitant procedures relative to outcomes related to isolated cartilage repair.

Design: A total of 133 clinical studies on articular cartilage repair of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2017. Studies were included if they were primary research articles reporting clinical outcomes data following surgical treatment of articular cartilage lesions with a minimum sample size of 5 patients. Studies were excluded if they were review articles, meta-analyses, and articles reporting only nonclinical outcomes (e.g., imaging, histology). A full-text review was then used to evaluate details regarding study methodology and reporting on the following variables: primary cartilage repair procedure, and the utilization of concomitant procedures to address additional patient comorbidities, including malalignment, meniscus pathology, and ligamentous instability. Each study was additionally reviewed to document variation in clinical outcomes reporting in patients that had these comorbidities addressed at the time of surgery.

Results: All studies reported on the type of primary cartilage repair procedure, with autologous chondrocyte implantation (ACI) noted in 43% of studies, microfracture (MF) reported in 16.5%, osteochondral allograft (OCA) in 15%, and osteochondral autograft transplant (OAT) in 8.2%. Regarding concomitant pathology, anterior cruciate ligament (ACL) reconstruction (24.8%) and meniscus repair (23.3%) were the most commonly addressed patient comorbidities. A total of 56 studies (42.1%) excluded patients with malalignment, meniscus injury, and ligamentous instability. For studies that addressed concomitant pathology, 72.7% reported clinical outcomes separately from the cohort treated with only cartilage repair. A total of 16.5% of studies neither excluded nor addressed concomitant pathologies. There was a significant amount of variation in the patient reported outcome scores used among the studies, with the majority of studies reporting International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcomes Score (KOOS) in 47.2% and 43.6% of articles, respectively.

Conclusions: In this study on knee cartilage restoration, recognition and management of concomitant pathology is inadequately reported in approximately 28% of studies. Only 30% of articles reported adequate treatment of concomitant ailments while scoring their outcomes using one of a potential 18 different scoring systems. These findings highlight the need for more standardized methods to be applied in future research with regard to inclusion, exclusion, and scoring concomitant pathologies with regard to treatment of cartilage defects in the knee.
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http://dx.doi.org/10.1177/1947603519841673DOI Listing
April 2019

Standardized Hospital-Based Care Programs Improve Geriatric Hip Fracture Outcomes: An Analysis of the ACS NSQIP Targeted Hip Fracture Series.

J Orthop Trauma 2019 Jun;33(6):e223-e228

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Objective: To determine relative complication rates and outcome measures in patients treated under a standardized hip fracture program (SHFP).

Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients who underwent operative fixation of femoral neck, intertrochanteric hip, and subtrochanteric hip fractures in 2016. Cohorts of patients who were and were not treated under a documented SHFP were identified. Relevant perioperative clinical and outcomes data were collected. Multivariate regression was used to assess risk-adjusted complication rates and outcomes for patients treated in SHFPs.

Results: A total of 9360 hip fracture patients were identified of whom 5070 (54.2%) were treated under a documented SHFP. Median age was 84 years, and 69.9% of patients were women. Patients in an SHFP had a lower risk-adjusted incidence of postoperative deep vein thrombosis [odds ratio (OR) 0.48 (0.32-0.72), P < 0.001]. Rates of other medical and surgical complications and 30-day mortality were statistically comparable. Risk-adjusted evaluation showed that SHFP patients were less likely to be discharged to an inpatient facility versus home [OR 0.72 (0.63-0.81), P < 0.001] and had a lower 30-day readmission rate [OR 0.83 (0.71-0.97), P = 0.023]. Furthermore, the SHFP patients had higher rates of immediate postoperative weight-bearing as tolerated [OR 1.23 (1.10-1.37), P < 0.001], adherence to deep vein thrombosis prophylaxis at 28 days [OR 1.27 (1.16-1.38), P < 0.001], and initiation of bone protective medications [OR 1.79 (1.64-1.96), P < 0.001].

Conclusions: Care in a modern hospital-based SHFP is associated with improved short-term outcome measures. Further development and widespread implementation of organized, multidisciplinary orthogeriatric hip fracture protocols is recommended.

Level Of Evidence: Therapeutic Level III.
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http://dx.doi.org/10.1097/BOT.0000000000001443DOI Listing
June 2019

Predictors and Sequelae of Postoperative Delirium in Geriatric Hip Fracture Patients.

Geriatr Orthop Surg Rehabil 2018 5;9:2151459318814823. Epub 2018 Dec 5.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Introduction: Perioperative delirium in elderly hip fracture patients has been correlated with significant morbidity. The purpose of this study was to determine the preoperative risk factors for and short-term sequelae of postoperative delirium in geriatric hip fracture patients.

Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program to identify geriatric (≥65 years) patients who sustained operative hip fractures in 2016. Cohorts of patients with and without documented postoperative delirium were identified. Primary data on patient demographics and comorbidities were collected and correlated with postoperative complications and hip fracture outcome measures. Multivariate regression was used to compute risk-adjusted odds ratios (OR) of risk factors and sequelae of delirium.

Results: In total, 8,439 geriatric hip fracture patients were identified of whom 2,569 patients (30.4%) had postoperative delirium. Age (OR 1.03 [1.02-1.04, < 0.001), white race (OR 1.54 [1.19-2.00], = 0.001), American Society of Anesthesiologists classification (OR 1.20 [1.07-1.36], = 0.003), baseline dementia (OR 2.46 [2.11-2.86], < 0.001), and preoperative delirium (OR 10.06 [8.12-12.45], < 0.001) were independent risk factors for postoperative delirium in multivariate analysis. Patients with postoperative delirium had a significantly higher risk-adjusted 30-day mortality (12.0% vs. 4.8%, OR 2.22 [1.74-2.84], < 0.001) and morbidity profile. Postoperative delirium was also independently associated with higher rates of discharge to (OR 1.65 [1.32-2.06], < 0.001) and prolonged stay in (OR 1.79 [1.53-2.09], < 0.001) an inpatient facility, hospital readmission (OR 1.94 [1.58-2.38], < 0.001) and hospital length of stay (7.6 ± 5.0 vs. 6.1 ± 4.1 days, < 0.001), as well as lower rates of immediate postoperative weight bearing (OR 0.73 [0.63-0.86], < 0.001).

Discussion: Postoperative delirium is a common occurrence in geriatric hip fractures with multiple risk factors. Delirium portends higher mortality and worse perioperative hospital-based outcomes.

Conclusions: Multidisciplinary foreknowledge and management efforts are warranted to mitigate the risk of developing delirium, which strongly predicts perioperative morbidity, mortality, and hip fracture outcomes.
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http://dx.doi.org/10.1177/2151459318814823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299329PMC
December 2018

Incidence and predictors of early complications following primary and revision total ankle arthroplasty.

Foot Ankle Surg 2019 Dec 8;25(6):785-789. Epub 2018 Nov 8.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA 76-143 CHS, 10833 Le Conte Ave, Los Angeles, CA, 90095, United States. Electronic address:

Background: Total ankle arthroplasty (TAA) offers an effective option for end-stage osteoarthritis. The incidence and preoperative risk factors for early adverse events (AEs) following primary and revision TAA may be useful information for providers.

Methods: A large database was queried from 2010 to 2016 to identify 905 patients of whom 818 underwent primary TAA (90.4%) and 87 underwent revision TAA (9.6%). Data on patient demographics, comorbidities, and hospital length of stay were analyzed as risk factors for reported 30-day AEs.

Results: The overall AE rate was 5.5% (50/905) for the entire cohort. AEs occurred more frequently for revision TAA (9/87) than primary TAA (41/818) cases (OR 2.43, p=0.022). Age (OR 1.03, p=0.045), BMI (OR 1.04, p=0.046), and revision TAA (OR 2.56, p=0.002) were independent risk factors for 30-day AEs in multivariate analysis.

Conclusions: Older age, higher BMI, and revision cases are associated with a higher risk of AEs.
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http://dx.doi.org/10.1016/j.fas.2018.10.009DOI Listing
December 2019

Outpatient Total Hip Arthroplasty in the United States: A Population-based Comparative Analysis of Complication Rates.

J Am Acad Orthop Surg 2019 Jan;27(2):61-67

From the Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA (Dr. Arshi, Dr. SooHoo), the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Leong), the Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA (Dr. C. Wang, Dr. Buser, Dr. J. C. Wang).

Introduction: With healthcare expenditure in the national forefront, outpatient arthroplasty is an appealing option in select patient populations. The purpose of this study was to determine the complication rates associated with outpatient total hip arthroplasty (THA) in comparison to standard inpatient THA.

Methods: We performed a retrospective review of the Humana subset of the PearlDiver insurance records database to identify patients undergoing THA (Current Procedural Terminology-27130 and Current Procedural Terminology-27132) as either outpatients or inpatients from 2007 to 2016. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index were used to calculate odds ratios of complications among outpatients undergoing THA relative to inpatients undergoing THA.

Results: The query identified 2,184 patients who underwent outpatient THA and 73,596 patients who underwent inpatient THA. The median age was in the 65 to 69 age group and in the 70 to 74 age group for the outpatient and inpatient cohorts, respectively (P < 0.001). Outpatients undergoing THA had a significantly lower incidence of comorbid hypertension (P < 0.001), cerebrovascular disease (P = 0.001), obesity (P = 0.017), chronic obstructive pulmonary disorder (P = 0.045), and chronic kidney disease (P = 0.049). The incidence of both outpatient THA (P = 0.001) and inpatient THA (P < 0.001) increased over the study period. After adjusting for age, gender, and Charlson Comorbidity Index, patients undergoing outpatient THA had comparable rates of all queried surgical complications, including component revision, irrigation and debridement, and hip dislocation at 1 year. Rates of postoperative medical complications were also comparable between the two cohorts.

Conclusion: Outpatient THA is increasing in frequency nationwide and has comparable postoperative complication rates. With its potential to minimize arthroplasty care costs, outpatient THA is a safe and effective option among appropriately selected patients.
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http://dx.doi.org/10.5435/JAAOS-D-17-00210DOI Listing
January 2019

Efficacy of intraarticular corticosteroid hip injections for osteoarthritis and subsequent surgery.

Skeletal Radiol 2018 Dec 28;47(12):1635-1640. Epub 2018 Aug 28.

Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.

Objective: Our study aimed to determine the duration of pain relief from intraarticular hip corticosteroid injections and identify patient predictive factors on injection response. We also sought to determine the subsequent rate of hip surgery and whether severity of hip osteoarthritis or injection response correlated with the decision to undergo surgery.

Materials And Methods: All intraarticular hip steroid injections performed for osteoarthritis under fluoroscopic guidance at a single institution between January 2010 to December 2012 were retrospectively reviewed. Response was divided into three groups: no relief, immediate (≤ 2 weeks of pain relief), and continued (> 2 weeks of pain relief). Presence of hip surgery for osteoarthritis performed within 2 years following injection was obtained. Correlation between patient characteristics with injection outcome and hip surgery was analyzed.

Results: Of 78 patients, a total of 82 injections were analyzed. For injections, 19.5% (16/82) showed no response, 47.6% (39/82) showed immediate response, and 32.9% (27/82) showed continued response. There was no significant correlation between injection outcome with age, Tönnis grade, BMI, or duration of symptoms. In total, 48.7% had hip surgery within 2 years after initial injection. There was a significant association between Tönnis grade and surgery, with higher Tönnis grades correlating with decision to undergo surgery (p = 0.002).

Conclusions: Gender, age, BMI, duration of symptoms, and radiographic severity of disease do not predict injection response. Due to high surgical rates and poor response, intraarticular hip steroid injections may be less effective in the long term, and surgical management may be considered earlier.
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http://dx.doi.org/10.1007/s00256-018-3052-zDOI Listing
December 2018

Articular Cartilage Repair of the Pediatric and Adolescent Knee with Regard to Minimal Clinically Important Difference: A Systematic Review.

Cartilage 2020 01 2;11(1):9-18. Epub 2018 Jul 2.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Objective: To perform a systematic review of clinical outcomes following microfracture (MFX), autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA), and osteochondral autograft transplantation system (OATS) to treat articular cartilage lesions in pediatric and adolescent patients. We sought to compare postoperative improvements for each cartilage repair method to minimal clinically important difference (MCID) thresholds.

Design: MEDLINE, Web of Science, Scopus, and Cochrane Library databases were searched for studies reporting MCID-validated outcome scores in a minimum of 5 patients ≤19 years treated for symptomatic knee chondral lesions with minimum 1-year follow-up. One-sample tests were used to compare mean outcome score improvements to established MCID thresholds.

Results: Twelve studies reporting clinical outcomes on a total of 330 patients following cartilage repair were identified. The mean age of patients ranged from 13.7 to 16.7 years and the mean follow-up was 2.2 to 9.6 years. Six studies reported on ACI, 4 studies reported on MFX, 2 studies reported on OATS, and 1 study reported on OCA. ACI ( < 0.001, = 0.008) and OCA ( < 0.001) showed significant improvement for International Knee Documentation Committee (IKDC) scores with regard to MCID while MFX ( = 0.66) and OATS ( = 0.11) did not. ACI ( < 0.001) and OATS ( = 0.010) both showed significant improvement above MCID thresholds for Lysholm scores. MFX ( = 0.002) showed visual analog scale (VAS) pain score improvement above MCID threshold while ACI ( = 0.037, = 0.070) was equivocal.

Conclusions: Outcomes data on cartilage repair in the pediatric and adolescent knee are limited. This review demonstrates that all available procedures provide postoperative improvement above published MCID thresholds for at least one reported clinical pain or functional outcome score.
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http://dx.doi.org/10.1177/1947603518783503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6921952PMC
January 2020

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complication Rates in Total Knee Arthroplasty.

Orthopedics 2018 Jul 30;41(4):e489-e495. Epub 2018 Apr 30.

The purpose of this study was to determine the relative incidence of postoperative complications in 25-hydroxyvitamin D (25D)-deficient and -sufficient patients undergoing total knee arthroplasty (TKA). Patients who were either serum 25D deficient (25D <20 ng/mL) or 25D sufficient (25D ≥20 ng/mL) 90 days prior to primary TKA from 2007 to 2016 were identified using the Humana administrative claims registry. The incidence of postoperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes. Risk-adjusted odds ratios (ORs) were calculated using multivariate logistic regression with age, sex, and Charlson Comorbidity Index as covariates. In total, 868 of 6593 patients who underwent TKA from 2007 to 2016 were 25D deficient, corresponding to a 13.2% prevalence rate. On adjustment for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had a higher incidence of postoperative stiffness requiring manipulation under anesthesia (OR, 1.69; 95% confidence interval [CI], 1.39-2.04; P<.001), surgical site infection requiring irrigation and debridement (OR, 1.76; 95% CI, 1.25-2.48; P=.001), and prosthesis explantation (OR, 2.97; 95% CI, 2.04-4.31; P<.001) at 1 year. Patients who were 25D deficient also had higher rates of postoperative deep venous thrombosis (OR, 1.80; 95% CI, 1.36-2.38; P<.001), myocardial infarction (OR, 2.11; 95% CI, 1.41-3.15; P<.001), and cerebrovascular accident (OR, 1.73; 95% CI, 1.17-2.57; P=.006). Thus, serum 25D levels below 20 ng/mL are associated with a higher incidence of postoperative complications and may be a perioperative modifiable risk factor in TKA. [Orthopedics. 2018; 41(4):e489-e495.].
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http://dx.doi.org/10.3928/01477447-20180424-04DOI Listing
July 2018

Relative Complications and Trends of Outpatient Total Shoulder Arthroplasty.

Orthopedics 2018 May 16;41(3):e400-e409. Epub 2018 Apr 16.

Outpatient arthroplasty is an appealing option among select patient populations as a mechanism for reducing health care expenditure. The purpose of this study was to determine the nationwide trends and complication profile of outpatient total shoulder arthroplasty (TSA). The authors reviewed a national administrative claims database to identify patients undergoing TSA as outpatients and inpatients from 2007 to 2016. The incidence of perioperative surgical and medical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Multivariate logistic regression adjusted for age, sex, and Charlson Comorbidity Index was used to calculate odds ratios of complications among outpatients relative to inpatients undergoing TSA. The query identified 1555 patients who underwent outpatient TSA and 15,987 patients who underwent inpatient TSA. The median age was in the 70 to 74 years age group in both the outpatient and the inpatient cohorts, and the age distribution was comparable between the 2 cohorts (P=.287). The incidence of both outpatient (P<.001) and inpatient (P<.001) TSA increased during the study period. On adjustment for age, sex, and comorbidities, patients undergoing outpatient TSA had significantly lower rates of stiffness requiring manipulation under anesthesia (outpatient, 1.09%; inpatient, 2.35%; odds ratio, 0.52; 95% confidence interval, 0.38-0.71; P<.001) and higher rates of postoperative surgical site infections requiring reoperation (outpatient, 0.90%; inpatient, 0.65%; odds ratio, 1.65; 95% confidence interval, 1.15-2.35; P<.001) at 1 year. Rates of all other postoperative complications were comparable. Ambulatory TSA is increasing in incidence nationwide and is associated with an overall favorable postoperative complication profile. [Orthopedics. 2018; 41(3):e400-e409.].
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http://dx.doi.org/10.3928/01477447-20180409-01DOI Listing
May 2018

Outpatient Posterior Lumbar Fusion: A Population-Based Analysis of Trends and Complication Rates.

Spine (Phila Pa 1976) 2018 Nov;43(22):1559-1565

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Study Design: A retrospective case-control study.

Objective: The aim of this study was to determine the nationwide trends and complication rates associated with outpatient posterior lumbar fusion (PLF).

Summary Of Background Data: Outpatient lumbar spine fusion is now possible secondary to minimally invasive techniques that allow for reduced hospital stays and analgesic requirements. Limited data are currently available regarding the clinical outcome of outpatient lumbar fusion.

Methods: The Humana administrative claims database was queried for patients who underwent one to two-level PLF (CPT-22612 or CPT-22633 AND ICD-9-816.2) as either outpatients or inpatients from Q1 2007 to Q2 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases and Current Procedural Terminology codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients undergoing PLF.

Results: Cohorts of 770 patients who underwent outpatient PLF and 26,826 patients who underwent inpatient PLF were identified. The median age was in the 65 to 69 years age group for both cohorts. The annual relative incidence of outpatient PLF remained stable across the study period (R = 0.03, P = 0.646). Adjusting for age, gender, and comorbidities, patients undergoing outpatient PLF had higher likelihood of revision/extension of posterior fusion [(OR 2.33, confidence interval (CI) 2.06-2.63, P < 0.001], anterior fusion (OR 1.64, CI 1.31-2.04, P < 0.001), and decompressive laminectomy (OR 2.01, CI 1.74-2.33, P < 0.001) within 1 year. Risk-adjusted rates of all other postoperative surgical and medical complications were statistically comparable.

Conclusion: Outpatient lumbar fusion is uncommonly performed in the United States. Data collected from a national private insurance database demonstrate a greater risk of postoperative surgical complications including revision anterior and posterior fusion and decompressive laminectomy. Surgeons should be cautious in performing PLF in the outpatient setting, as the risk of revision surgery may increase in these cases.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179957PMC
November 2018

Articular Cartilage Lesion Characteristic Reporting Is Highly Variable in Clinical Outcomes Studies of the Knee.

Cartilage 2019 07 6;10(3):299-304. Epub 2018 Feb 6.

3 Department of Orthopedic Surgery, University of Missouri Health, Columbia, MO, USA.

Objective: The purpose of this study was to investigate the degree of standardized evaluation and reporting of cartilage lesion characteristics in high-impact clinical studies for symptomatic lesions of the knee. We hypothesized that there are significant inconsistencies in reporting these metrics across orthopedic literature.

Design: A total of 113 clinical studies on articular cartilage restoration of the knee were identified from 6 high-impact orthopedic journals between 2011 and 2016. Full-text review was used to evaluate sources for details on study methodology and reporting on the following variables: primary procedure, location, size, grade, and morphology of cartilage lesions.

Results: All studies reported on the type of primary cartilage procedure and precise lesion location(s). Approximately 99.1% reported lesion morphology (chondral, osteochondral, mixed). For lesion size, 32.7% of articles did not report how size was measured and 11.5% did not report units. The lesion sizing method was variable, as 27.4% used preoperative magnetic resonance imaging to measure/report lesion size, 31.0% used arthroscopy, and 8.8% used both. The majority of studies (83.2%) used area to report size, and 5.3% used diameter. Formal grading was not reported in 17.7% of studies. Only 54.8% of studies reported depth when sizing osteochondral defects.

Conclusions: Recent literature on cartilage restoration provides adequate information on surgical technique, lesion location, and morphology. However, there is wide variation and incomplete reporting on lesion size, depth, and grading. Future clinical studies should include these important data in a consistent manner to facilitate comparison among surgical techniques.
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http://dx.doi.org/10.1177/1947603518756464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585291PMC
July 2019

Can Biologic Augmentation Improve Clinical Outcomes Following Microfracture for Symptomatic Cartilage Defects of the Knee? A Systematic Review.

Cartilage 2018 04 15;9(2):146-155. Epub 2017 Dec 15.

1 Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.

Objective To perform a systematic review of clinical outcomes following microfracture augmented with biological adjuvants (MFX+) compared with microfracture (MFX) alone. Design The MEDLINE, Scopus, and Cochrane databases were searched for clinical studies on MFX+ for chondral defects of the knee. Study characteristics and clinical outcome score data were collected. Subjective synthesis was performed using data from randomized controlled studies to determine effect size of MFX+ procedures performed with either injectable or scaffold-based augmentation compared with MFX alone. Results A total of 18 articles reporting on 625 patients (491 MFX+, 134 MFX) were identified. Six studies were level II evidence and 1 study was level I evidence. Mean patient age range was 26 to 51 years, and mean follow-up ranged from 2 to 5 years. All studies demonstrated significant improvement in reported clinical outcome scores at follow-up after MFX+ therapy, and 87% of patients reported satisfaction with treatment. The most commonly reported treatment complication was postoperative stiffness (3.9% of patients). Subjective synthesis on randomized controlled trials demonstrated that 2/2 injectable MFX+ interventions had significantly greater improvements in International Knee Documentation Committee Subjective Knee Form (IKDC; P = 0.004) and Knee injury and Osteoarthritis Outcome Score (KOOS; P = 0.012) scores compared with MFX alone, while 2/2 trials on scaffolding MFX+ adjuvants showed comparable postoperative improvements. Conclusions MFX+ biological adjuvants are safe supplements to marrow stimulation for treating cartilage defects in the adult knee. Early literature is heterogenous and extremely limited in quality. Individual trials report both equivalent and superior clinical outcomes compared with MFX alone, making definitive conclusions on the efficacy of MFX+ difficult without higher quality evidence.
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http://dx.doi.org/10.1177/1947603517746722DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871129PMC
April 2018

Outpatient Total Knee Arthroplasty Is Associated with Higher Risk of Perioperative Complications.

J Bone Joint Surg Am 2017 Dec;99(23):1978-1986

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

Background: As concerns regarding health-care expenditure in the U.S. remain at the national forefront, outpatient arthroplasty is an appealing option for carefully selected patient populations. The purpose of this study was to determine the nationwide trends and complication rates associated with outpatient total knee arthroplasty (TKA) in comparison with standard inpatient TKA.

Methods: We performed a retrospective review of the Humana subset of the PearlDiver Patient Record Database to identify patients who had undergone TKA (Current Procedural Terminology [CPT] code 27447) as either outpatients or inpatients from 2007 to 2015. The incidence of perioperative medical and surgical complications was determined by querying for relevant International Classification of Diseases, Ninth Revision (ICD-9) and CPT codes. Multivariate logistic regression analysis adjusted for age, sex, and Charlson Comorbidity Index (CCI) was used to calculate odds ratios (ORs) of complications among outpatients relative to inpatients treated with TKA.

Results: Cohorts of 4,391 patients who underwent outpatient TKA and 128,951 patients who underwent inpatient TKA were identified. The median age was in the 70 to 74-year age group in both cohorts. The incidence of outpatient TKA increased across the study period (R = 0.60, p = 0.015). After adjustment for age, sex, and CCI, outpatient TKAs were found to more likely be followed by tibial and/or femoral component revision due to a noninfectious cause (OR = 1.22, 95% confidence interval [CI] = 1.01 to 1.47; p = 0.039), explantation of the prosthesis (OR = 1.35, CI = 1.07 to 1.72; p = 0.013), irrigation and debridement (OR = 1.50, CI = 1.28 to 1.77; p < 0.001), and stiffness requiring manipulation under anesthesia (OR = 1.28, CI = 1.17 to 1.40; p < 0.001) within 1 year. Outpatient TKA was also more frequently associated with postoperative deep vein thrombosis (OR = 1.42, CI = 1.25 to 1.63; p < 0.001) and acute renal failure (OR = 1.13, CI = 1.01 to 1.25; p = 0.026).

Conclusions: With the potential to minimize arthroplasty costs among healthy patients, outpatient TKA is an increasingly popular option. Nationwide data from a private insurance database demonstrated a higher risk of perioperative surgical and medical complications including component failure, surgical site infection, knee stiffness, and deep vein thrombosis.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.16.01332DOI Listing
December 2017

Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database.

Spine J 2018 07 16;18(7):1180-1187. Epub 2017 Nov 16.

Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404. Electronic address:

Background Context: With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population.

Purpose: The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF.

Study Design/setting: This is a large-scale retrospective case control study.

Patient Sample: The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery.

Materials And Methods: A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF.

Results: Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable.

Conclusions: Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.
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http://dx.doi.org/10.1016/j.spinee.2017.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6291305PMC
July 2018

MRI-Arthroscopy Correlation of the Rotator Cuff: A Case-based Review.

Sports Med Arthrosc Rev 2017 Dec;25(4):164-171

Departments of *Orthopaedic Surgery †Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.

With significant advancements over recent decades, magnetic resonance imaging (MRI) and shoulder arthroscopy are important complementary tools in guiding orthopedic surgeons to diagnosis, decision making, and treatment of rotator cuff pathology. The objective of this article is to review the basic principles and pearls of MRI-arthroscopy correlation of the rotator cuff through an overview of our approach to reading shoulder MRI followed by a case-based review of selected conditions. By understanding and comparing the subtleties of these modalities, radiologists and clinicians can better appreciate both the utility and limitations of MRI in predicting operative findings.
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http://dx.doi.org/10.1097/JSA.0000000000000162DOI Listing
December 2017