Publications by authors named "Hilal Maradit Kremers"

136 Publications

Primary and Revision Total Knee Arthroplasty in Patients With Pulmonary Hypertension: High Perioperative Mortality and Complications.

J Arthroplasty 2021 Jul 16. Epub 2021 Jul 16.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Although perioperative medical management during total knee arthroplasty (TKA) has improved, there is limited literature characterizing outcomes of patients with pulmonary hypertension (HTN). This study examined mortality, medical complications, implant survivorship, and clinical outcomes in this medically complex cohort.

Methods: We identified 887 patients with pulmonary HTN who underwent 881 primary TKAs and 228 revision TKAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analysis was used for reporting mortality, revision, and reoperation with death as a competing risk.

Results: The 90-day mortality was 0.7% and 4.8% for primary and revision TKAs, respectively. The risk of death was 2-fold higher compared to primary (hazard ratio 2.54, 95% confidence interval [CI] 2.12-3.05) and revision (hazard ratio 2.16, 95% CI 1.78-2.62) TKA patients without pulmonary HTN. Rate of medical complications within 90 days from surgery was 6.5% and 14% in primary and revision TKAs. The 10-year cumulative incidence of any revision was 5% and 16% in primaries and revisions, respectively.

Conclusion: Patients with pulmonary HTN undergoing primary and revision TKAs had excess risk of death and experience a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to tertiary centers should be considered.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.07.005DOI Listing
July 2021

Immortal Time Bias in the Analysis of Time-to-Event Data in Orthopedics.

J Arthroplasty 2021 Jun 21. Epub 2021 Jun 21.

Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Many outcomes in arthroplasty research are analyzed as time-to-event outcomes using survival analysis methods. When comparison groups are defined after a time-delayed exposure or intervention, a period of immortal time arises and can lead to biased results. In orthopedics research, immortal time bias often arises when a minimum amount of follow-up is required for study inclusion or when comparing outcomes in staged bilateral vs unilateral arthroplasty patients. We present an explanation of immortal time and the associated bias, describe how to correctly account for it using proper data preparation and statistical techniques, and provide an illustrative example using real-world arthroplasty data. We offer practical guidelines for identifying and properly handling immortal time to avoid bias.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.06.012DOI Listing
June 2021

Costs of open, arthroscopic and combined surgery for developmental dysplasia of the hip.

J Hip Preserv Surg 2020 Aug 23;7(3):570-574. Epub 2020 Nov 23.

Department of Orthopedic Surgery, Mayo Clinic, 5777 E. Mayo Blvd, Phoenix, AZ 85054, USA.

A variety of options exist for management of patients with developmental dysplasia of the hip (DDH). Most studies to date have focused on clinical outcomes; however, there are currently no data on comparative cost of these techniques. The purpose of this study was to evaluate in-hospital costs between patients managed with periacetabular osteotomy, hip arthroscopy or a combination for DDH. One hundred and nine patients were included: 35 PAO + HA, 32 PAO and 42 HA. There were no significant differences in the demographic parameters. Operative times were significantly different between groups with a mean of 52 min for PAO, 100 min for HA and 155 min for PAO + HA, ( < 0.001). Total direct medical costs were calculated and adjusted to nationally representative unit costs in 2017 inflation-adjusted dollars. Total in-hospital costs were significantly different between each of the three treatment groups. PAO + HA was the most expensive with a median of $21 852, followed by PAO with a median of $15 124, followed by HA with a median of $11 582 ( < 0.001). There was a significant difference between outpatient median costs of $11 385 compared with $24 320 for inpatients ( < 0.001). Procedures with greater complexity were more expensive. However, a change from outpatient to inpatient status with HA moved that group from the least expensive to similar to PAO and PAO + HA. These data provide an important complement to clinical outcomes reports as surgeons and policymakers aim to provide optimal value.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jhps/hnaa048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081411PMC
August 2020

Living With Survival Analysis in Orthopedics.

J Arthroplasty 2021 Apr 22. Epub 2021 Apr 22.

Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Time to event data occur commonly in orthopedics research and require special methods that are often called "survival analysis." These data are complex because both a follow-up time and an event indicator are needed to correctly describe the occurrence of the outcome of interest. Common pitfalls in analyzing time to event data include using methods designed for binary outcomes, failing to check proportional hazards, ignoring competing risks, and introducing immortal time bias by using future information. This article describes the concepts involved in time to event analyses as well as how to avoid common statistical pitfalls.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.04.014DOI Listing
April 2021

Competing Risk Analysis: What Does It Mean and When Do We Need It in Orthopedics Research?

J Arthroplasty 2021 Apr 21. Epub 2021 Apr 21.

Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN; Division of Rheumatology, Mayo Clinic, Rochester, MN.

Most orthopedic studies involve survival analysis examining the time to an event of interest, such as a specific complication or revision surgery. Competing risks commonly arise in such studies when patients are at risk of more than one mutually exclusive event, such as death, or when the rate of an event depends on the rates of other competing events. In this article, we briefly describe the survival analysis censoring methodology, common fatal and nonfatal competing events, and define circumstances where standard survival analysis can fail in the setting of competing risks with real-world examples from orthopedics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.04.015DOI Listing
April 2021

Machine learning in sports medicine: need for improvement.

J ISAKOS 2021 01;6(1):1-2

Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jisakos-2020-000572DOI Listing
January 2021

The Epidemiology of Psoriatic Arthritis Over Five Decades: A Population-Based Study.

Arthritis Rheumatol 2021 Mar 28. Epub 2021 Mar 28.

Mayo Clinic, Rochester, Minnesota.

Objective: To determine the incidence of psoriatic arthritis (PsA) in a US population and describe trends in incidence and mortality over 5 decades.

Methods: The previously identified population-based cohort that included Olmsted County, Minnesota residents ≥18 years of age who fulfilled PsA criteria during 1970-1999 was extended to include patients with incident PsA during 2000-2017. Age- and sex-specific incidence rates and point prevalence, adjusted to the 2010 US White population, were reported.

Results: There were 164 incident cases of PsA in 2000-2017 (mean ± SD age 46.4 ± 12.0 years; 47% female). The overall age- and sex-adjusted annual incidence of PsA per 100,000 population was 8.5 (95% confidence interval [95% CI] 7.2-9.8) and was higher in men (9.3 [95% CI 7.4-11.3]) than women (7.7 [95% CI 5.9-9.4]) in 2000-2017. Overall incidence was highest in the 40-59 years age group. The incidence rate was relatively stable during 2000-2017, with no evidence of an overall increase or an increase in men only (but a modest increase of 3% per year in women), compared to 1970-1999 when a 4%-per-year increase in incidence was observed. Point prevalence was 181.8 per 100,000 population (95% CI 156.5-207.1) in 2015. The percentage of women among those with PsA increased from 39% in 1970-1999 and 41% in 2000-2009 to 54% in 2010-2017 (P = 0.08). Overall survival in PsA did not differ from the general population (standardized mortality ratio 0.85 [95% CI 0.61-1.15]).

Conclusion: The incidence of PsA in this predominantly White US population was stable in 2000-2017, in contrast to previous years. However, an increasing proportion of women with PsA was found in this study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/art.41741DOI Listing
March 2021

A Deep Learning Tool for Automated Radiographic Measurement of Acetabular Component Inclination and Version After Total Hip Arthroplasty.

J Arthroplasty 2021 07 16;36(7):2510-2517.e6. Epub 2021 Feb 16.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Inappropriate acetabular component angular position is believed to increase the risk of hip dislocation after total hip arthroplasty. However, manual measurement of these angles is time consuming and prone to interobserver variability. The purpose of this study was to develop a deep learning tool to automate the measurement of acetabular component angles on postoperative radiographs.

Methods: Two cohorts of 600 anteroposterior (AP) pelvis and 600 cross-table lateral hip postoperative radiographs were used to develop deep learning models to segment the acetabular component and the ischial tuberosities. Cohorts were manually annotated, augmented, and randomly split to train-validation-test data sets on an 8:1:1 basis. Two U-Net convolutional neural network models (one for AP and one for cross-table lateral radiographs) were trained for 50 epochs. Image processing was then deployed to measure the acetabular component angles on the predicted masks for anatomical landmarks. Performance of the tool was tested on 80 AP and 80 cross-table lateral radiographs.

Results: The convolutional neural network models achieved a mean Dice similarity coefficient of 0.878 and 0.903 on AP and cross-table lateral test data sets, respectively. The mean difference between human-level and machine-level measurements was 1.35° (σ = 1.07°) and 1.39° (σ = 1.27°) for the inclination and anteversion angles, respectively. Differences of 5⁰ or more between human-level and machine-level measurements were observed in less than 2.5% of cases.

Conclusion: We developed a highly accurate deep learning tool to automate the measurement of angular position of acetabular components for use in both clinical and research settings.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.02.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8197739PMC
July 2021

Deep Learning Artificial Intelligence Model for Assessment of Hip Dislocation Risk Following Primary Total Hip Arthroplasty From Postoperative Radiographs.

J Arthroplasty 2021 06 16;36(6):2197-2203.e3. Epub 2021 Feb 16.

Department of Radiology, Radiology Informatics Laboratory, Mayo Clinic, Rochester, MN.

Background: Dislocation is a common complication following total hip arthroplasty (THA), and accounts for a high percentage of subsequent revisions. The purpose of this study is to illustrate the potential of a convolutional neural network model to assess the risk of hip dislocation based on postoperative anteroposterior pelvis radiographs.

Methods: We retrospectively evaluated radiographs for a cohort of 13,970 primary THAs with 374 dislocations over 5 years of follow-up. Overall, 1490 radiographs from dislocated and 91,094 from non-dislocated THAs were included in the analysis. A convolutional neural network object detection model (YOLO-V3) was trained to crop the images by centering on the femoral head. A ResNet18 classifier was trained to predict subsequent hip dislocation from the cropped imaging. The ResNet18 classifier was initialized with ImageNet weights and trained using FastAI (V1.0) running on PyTorch. The training was run for 15 epochs using 10-fold cross validation, data oversampling, and augmentation.

Results: The hip dislocation classifier achieved the following mean performance (standard deviation): accuracy = 49.5 (4.1%), sensitivity = 89.0 (2.2%), specificity = 48.8 (4.2%), positive predictive value = 3.3 (0.3%), negative predictive value = 99.5 (0.1%), and area under the receiver operating characteristic curve = 76.7 (3.6%). Saliency maps demonstrated that the model placed the greatest emphasis on the femoral head and acetabular component.

Conclusion: Existing prediction methods fail to identify patients at high risk of dislocation following THA. Our radiographic classifier model has high sensitivity and negative predictive value, and can be combined with clinical risk factor information for rapid assessment of risk for dislocation following THA. The model further suggests radiographic locations which may be important in understanding the etiology of prosthesis dislocation. Importantly, our model is an illustration of the potential of automated imaging artificial intelligence models in orthopedics.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.02.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154724PMC
June 2021

Analysis of patient characteristics and outcomes related to distance traveled to a tertiary center for primary reverse shoulder arthroplasty.

Arch Orthop Trauma Surg 2021 Jan 28. Epub 2021 Jan 28.

Department of Orthopedic Surgery, Mayo Clinic, Gonda 14, 200 First Street SW, Rochester, 55905, USA.

Introduction: The reasons for referral and travel patterns are lacking for patients undergoing reverse shoulder arthroplasty (RSA). The purpose of this study was to compare comorbidities, surgical time, cost and complications between local and distant primary RSA patients.

Methods: Between 2007 and 2015, 1,666 primary RSAs were performed at our institution. Patients were divided into two cohorts, local patients (from within Olmstead county and surrounding counties, 492 RSAs) and those from a distance (1,174 RSAs).

Results: Local patients were older (74 vs 71 years, p < .001), more likely to have RSA for fracture, had a higher Charlson comorbidity score (3.8 vs 3.2, p < .001) and longer hospital stays (2.0 vs 1.8 days, p < 0.001) compared to referred patients. Referral patients required longer operative times (95 vs 88 min, p = .002), had higher hospitalization costs ($19,101 vs $18,735, p < .001), and had a higher rate of prior surgery (32% vs 24%, p < .001). There were no differences between cohorts regarding complications or need for reoperation.

Conclusions: Patients traveling from a distance to undergo primary RSA had longer operative times and were more likely to have had prior surgery than local patients. This may demonstrate the referral bias seen at large academic centers and should be considered when reviewing RSA outcomes, hospital performance, and calculating insurance reimbursement.

Level Of Evidence: Level IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00402-021-03764-9DOI Listing
January 2021

Direct Inpatient Medical Costs of Operative Treatment of Periprosthetic Hip and Knee Infections Are Twofold Higher Than Those of Aseptic Revisions.

J Bone Joint Surg Am 2021 Feb;103(4):312-318

Departments of Orthopedic Surgery (M.H., D.G.L., D.J.B., and H.M.K.) and Health Sciences Research (S.L.V., J.E.R., and H.M.K.), Mayo Clinic, Rochester, Minnesota.

Background: Periprosthetic joint infections (PJIs) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with substantial morbidity. A better understanding of the costs of PJI treatment can inform prevention, treatment, and reimbursement strategies. The purpose of the present study was to describe direct inpatient medical costs associated with the treatment of hip and knee PJI.

Methods: At a single tertiary care institution, 176 hips and 266 knees that underwent 2-stage revisions for the treatment of PJI from 2009 to 2015 were compared with 1,611 hips and 1,276 knees that underwent revisions for aseptic indications. In addition, 84 hips and 137 knees that underwent irrigation and debridement (I&D) with partial component exchange were compared with 39 hips and 138 knees that underwent partial component exchange for aseptic indications. Line-item details of services billed during hospitalization were retrieved, and standardized direct medical costs were calculated in 2018 inflation-adjusted dollars.

Results: The mean direct medical cost of 2-stage revision THA performed for the treatment of PJI was significantly higher than that of aseptic revision THA ($58,369 compared with $22,846, p < 0.001). Similarly, the cost of 2-stage revision TKA performed for the treatment of PJI was significantly higher than that of aseptic revision TKA ($56,900 compared with $24,630, p < 0.001). Even when the total costs of aseptic revisions were doubled for a representative comparison with 2-stage procedures, the costs of PJI procedures were 15% to 28% higher than those of the doubled costs of aseptic revisions (p < 0.001). The mean direct medical cost of I&D procedures for PJI was about twofold higher than of partial component exchange for aseptic indications.

Conclusions: The direct medical costs of operative treatment of PJI following THA and TKA are twofold higher than the costs of similar aseptic revisions. The high economic burden of PJI warrants efforts to reduce the incidence of PJI. Reimbursement schemes should account for the high costs of treating PJI in order to ensure sustainable patient care.

Level Of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.20.00550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327701PMC
February 2021

Use of Natural Language Processing Algorithms to Identify Common Data Elements in Operative Notes for Knee Arthroplasty.

J Arthroplasty 2021 03 10;36(3):922-926. Epub 2020 Oct 10.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Natural language processing (NLP) methods have the capability to process clinical free text in electronic health records, decreasing the need for costly manual chart review, and improving data quality. We developed rule-based NLP algorithms to automatically extract surgery specific data elements from knee arthroplasty operative notes.

Methods: Within a cohort of 20,000 knee arthroplasty operative notes from 2000 to 2017 at a large tertiary institution, we randomly selected independent pairs of training and test sets to develop and evaluate NLP algorithms to detect five major data elements. The size of the training and test datasets were similar and ranged between 420 to 1592 surgeries. Expert rules using keywords in operative notes were used to implement NLP algorithms capturing: (1) category of surgery (total knee arthroplasty, unicompartmental knee arthroplasty, patellofemoral arthroplasty), (2) laterality of surgery, (3) constraint type, (4) presence of patellar resurfacing, and (5) implant model (catalog numbers). We used institutional registry data as our gold standard to evaluate the NLP algorithms.

Results: NLP algorithms to detect the category of surgery, laterality, constraint, and patellar resurfacing achieved 98.3%, 99.5%, 99.2%, and 99.4% accuracy on test datasets, respectively. The implant model algorithm achieved an F1-score (harmonic mean of precision and recall) of 99.9%.

Conclusions: NLP algorithms are a promising alternative to costly manual chart review to automate the extraction of embedded information within knee arthroplasty operative notes. Further validation in other hospital settings will enhance widespread implementation and efficiency in data capture for research and clinical purposes.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.09.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897213PMC
March 2021

Automated Detection of Periprosthetic Joint Infections and Data Elements Using Natural Language Processing.

J Arthroplasty 2021 02 5;36(2):688-692. Epub 2020 Aug 5.

Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Periprosthetic joint infection (PJI) data elements are contained in both structured and unstructured documents in electronic health records and require manual data collection. The goal of this study is to develop a natural language processing (NLP) algorithm to replicate manual chart review for PJI data elements.

Methods: PJI was identified among all total joint arthroplasty (TJA) procedures performed at a single academic institution between 2000 and 2017. Data elements that comprise the Musculoskeletal Infection Society (MSIS) criteria were manually extracted and used as the gold standard for validation. A training sample of 1208 TJA surgeries (170 PJI cases) was randomly selected to develop the prototype NLP algorithms and an additional 1179 surgeries (150 PJI cases) were randomly selected as the test sample. The algorithms were applied to all consultation notes, operative notes, pathology reports, and microbiology reports to predict the correct status of PJI based on MSIS criteria.

Results: The algorithm, which identified patients with PJI based on MSIS criteria, achieved an f1-score (harmonic mean of precision and recall) of 0.911. Algorithm performance in extracting the presence of sinus tract, purulence, pathologic documentation of inflammation, and growth of cultured organisms from the involved TJA achieved f1-scores that ranged from 0.771 to 0.982, sensitivity that ranged from 0.730 to 1.000, and specificity that ranged from 0.947 to 1.000.

Conclusion: NLP-enabled algorithms have the potential to automate data collection for PJI diagnostic elements, which could directly improve patient care and augment cohort surveillance and research efforts. Further validation is needed in other hospital settings.

Level Of Evidence: Level III, Diagnostic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.07.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855617PMC
February 2021

Predictors of cost for posterior spinal fusion in adolescent idiopathic scoliosis.

Spine Deform 2020 06 24;8(3):421-426. Epub 2020 Feb 24.

Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Study Design: Single-center retrospective review of pediatric patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis (AIS).

Objective: To determine what clinical and operative factors influence inflation-adjusted hospital costs of posterior spine fusion surgery for AIS. With rising healthcare costs and the advent of bundled payments, it is essential understand the predictors of costs for surgical procedures. We sought to determine the components of hospital costs for AIS posterior spine fusion surgery using standardized, inflation-adjusted, line-item costs for services and procedures.

Methods: The study population comprised 148 AIS patients who underwent spinal fusion surgery at a large tertiary care center between 2009 and 2016. Data on medical characteristics, curve type, curve magnitude, number of screws and the number of levels was collected through manual chart review of X-rays and medical records. Hospital costs from admission until discharge were retrieved from an institutional database that contained line-item details of all procedures and services billed during the hospital episode. Bottom-up microcosting valuation techniques were used to generate standardized inflation-adjusted estimates of costs and standard deviations in 2016 dollars.

Results: Mean cost of AIS surgery was $48,058 ± 9379. Physician fees averaged 15% of the total cost ($7045 ± 1732). Implant costs and surgical/anesthesia/surgeon's fees accounted for over 70% of the hospital costs. Mean number of screws was 16 ± 4.5, mean number of levels fused was 11.2 ± 2.2, and the mean implant density (screws per level fused) was 1.45 ± 0.35. On multivariate analysis, the number of screws per level fused, number of levels fused, curve magnitude and length of stay were all significantly associated with hospital costs (p < 0.01).

Conclusions: Bundled payments for AIS surgery should include adjustments for number of levels fused and curve size. Areas for cost savings include further reduction in implant costs, shortening length of stay, and reducing intraoperative costs.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s43390-020-00053-0DOI Listing
June 2020

Use of Natural Language Processing Algorithms to Identify Common Data Elements in Operative Notes for Total Hip Arthroplasty.

J Bone Joint Surg Am 2019 Nov;101(21):1931-1938

Departments of Orthopedic Surgery (C.C.W., M.E.T., D.J.B., D.G.L., and H.M.-K.) and Health Sciences Research (S.F., Y.W., S.S., W.K.K., and H.M.-K.), Mayo Clinic, Rochester, Minnesota.

Background: Manual chart review is labor-intensive and requires specialized knowledge possessed by highly trained medical professionals. Natural language processing (NLP) tools are distinctive in their ability to extract critical information from raw text in electronic health records (EHRs). As a proof of concept for the potential application of this technology, we examined the ability of NLP to correctly identify common elements described by surgeons in operative notes for total hip arthroplasty (THA).

Methods: We evaluated primary THAs that had been performed at a single academic institution from 2000 to 2015. A training sample of operative reports was randomly selected to develop prototype NLP algorithms, and additional operative reports were randomly selected as the test sample. Three separate algorithms were created with rules aimed at capturing (1) the operative approach, (2) the fixation method, and (3) the bearing surface category. The algorithms were applied to operative notes to evaluate the language used by 29 different surgeons at our center and were applied to EHR data from outside facilities to determine external validity. Accuracy statistics were calculated with use of manual chart review as the gold standard.

Results: The operative approach algorithm demonstrated an accuracy of 99.2% (95% confidence interval [CI], 97.1% to 99.9%). The fixation technique algorithm demonstrated an accuracy of 90.7% (95% CI, 86.8% to 93.8%). The bearing surface algorithm demonstrated an accuracy of 95.8% (95% CI, 92.7% to 97.8%). Additionally, the NLP algorithms applied to operative reports from other institutions yielded comparable performance, demonstrating external validity.

Conclusions: NLP-enabled algorithms are a promising alternative to the current gold standard of manual chart review for identifying common data elements from orthopaedic operative notes. The present study provides a proof of concept for use of NLP techniques in clinical research studies and registry-development endeavors to reliably extract data of interest in an expeditious and cost-effective manner.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.19.00071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406139PMC
November 2019

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture.

J Hand Surg Am 2019 Nov 17;44(11):919-927. Epub 2019 Sep 17.

Department of Orthopedic Surgery, Rochester, MN. Electronic address:

Purpose: The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy.

Methods: A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges.

Results: Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively.

Conclusions: Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate.

Type Of Study/level Of Evidence: Therapeutic IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2019.07.017DOI Listing
November 2019

Use of Natural Language Processing Tools to Identify and Classify Periprosthetic Femur Fractures.

J Arthroplasty 2019 10 24;34(10):2216-2219. Epub 2019 Jul 24.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background: Manual chart review is labor-intensive and requires specialized knowledge possessed by highly trained medical professionals. The cost and infrastructure challenges required to implement this is prohibitive for most hospitals. Natural language processing (NLP) tools are distinctive in their ability to extract critical information from unstructured text in the electronic health records. As a simple proof-of-concept for the potential application of NLP technology in total hip arthroplasty (THA), we examined its ability to identify periprosthetic femur fractures (PPFFx) followed by more complex Vancouver classification.

Methods: PPFFx were identified among all THAs performed at a single academic institution between 1998 and 2016. A randomly selected training cohort (1538 THAs with 89 PPFFx cases) was used to develop the prototype NLP algorithm and an additional randomly selected cohort (2982 THAs with 84 PPFFx cases) was used to further validate the algorithm. Keywords to identify, and subsequently classify, Vancouver type PPFFx about THA were defined. The gold standard was confirmed by experienced orthopedic surgeons using chart and radiographic review. The algorithm was applied to consult and operative notes to evaluate language used by surgeons as a means to predict the correct pathology in the absence of a listed, precise diagnosis. Given the variability inherent to fracture descriptions by different surgeons, an iterative process was used to improve the algorithm during the training phase following error identification. Validation statistics were calculated using manual chart review as the gold standard.

Results: In distinguishing PPFFx, the NLP algorithm demonstrated 100% sensitivity and 99.8% specificity. Among 84 PPFFx test cases, the algorithm demonstrated 78.6% sensitivity and 94.8% specificity in determining the correct Vancouver classification.

Conclusion: NLP-enabled algorithms are a promising alternative to manual chart review for identifying THA outcomes. NLP algorithms applied to surgeon notes demonstrated excellent accuracy in delineating PPFFx, but accuracy was low for Vancouver classification subtype. This proof-of-concept study supports the use of NLP technology to extract THA-specific data elements from the unstructured text in electronic health records in an expeditious and cost-effective manner.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2019.07.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6760992PMC
October 2019

Conversion of Failed Hemiarthroplasty to Total Hip Arthroplasty Remains High Risk for Subsequent Complications.

J Arthroplasty 2019 Sep 26;34(9):2030-2036. Epub 2019 Apr 26.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Few studies have described the outcomes following conversion of failed hemiarthroplasties to total hip arthroplasty (THA) and the impact of mortality when estimating implant survivorship. The aims of this study were to evaluate the following: (1) the risks and predictors of complications, dislocations, reoperations, and revisions and (2) the extent of competing risk of death when evaluating outcomes in patients converted from hemiarthroplasty to THA.

Methods: The study comprised 389 patients treated with conversion THA following hemiarthroplasty for femoral neck fractures between 1985 and 2014. Revision rates were calculated using both the Kaplan-Meier method and cumulative incidence accounting for death as a competing risk. Risk factors were evaluated using Cox regression models.

Results: During an average 9.3 years of follow-up, there were 122 complications, 34 dislocations, 69 reoperations, and 51 revisions. Conversion for periprosthetic fractures was associated with a higher risk of reoperations (hazard ratio 4.30, 95% confidence interval 1.94-9.52). Increasing age was a risk factor for reoperations (hazard ratio 1.32, 95% confidence interval 1.10-1.59). No decrease in the rate of complications, dislocations, reoperations, or revisions was observed over the entire 30 years of the study either when evaluating year of surgery as a continuous variable or when comparing specific calendar year intervals (1985-1989, 1990-1999, 2000-2009, 2010-2014) (P > .05). Compared to the cumulative incidence accounting for the competing risk of death, the Kaplan-Meier method overestimated the risk of revision by 7% at 15 years and 10% at 20 years.

Conclusion: Conversion from hemiarthroplasty to THA remains at high risk for subsequent complications. The cumulative incidence estimate provides a more accurate estimate of revision risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2019.04.042DOI Listing
September 2019

Conversion of Hemiarthroplasty to THA Carries an Increased Risk of Reoperation Compared With Primary and Revision THA.

Clin Orthop Relat Res 2019 06;477(6):1392-1399

N. M. Hernandez, R. J. Sierra, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA K. M. Fruth, D.R. Larson, H. M. Kremers, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.

Background: There is limited information on the complications and costs of conversion THA after hemiarthroplasty for femoral neck fractures. Previous studies have found that patients undergoing conversion THA experience higher risk complications, but it has been difficult to quantify the risk because of small sample sizes and a lack of comparison groups. Therefore, we compared the complications of patients undergoing conversion THA with strictly matched patients undergoing primary and revision THA.

Questions/purposes: (1) What are the risks of complications, dislocations, reoperations, revisions and periprosthetic fractures after conversion THA compared with primary and revision THA and how has this effect changed over time? (2) What are the length of hospital stay and hospital costs for conversion THA, primary THA, and revision THA?

Methods: Using a longitudinally maintained total joint registry, we identified 389 patients who were treated with conversion THA after hemiarthroplasty for femoral neck fractures between 1985 and 2014. The conversion THA cohort was 1:2 matched on age, sex, and year of surgery to 778 patients undergoing primary THA and 778 patients undergoing revision THA. The proportion of patients having at least 5-year followup was 73% in those who underwent conversion THA, 77% in those who underwent primary THA, and 76% in those who underwent revision THA. We observed a significant calendar year effect, and therefore, compared the three groups across two separate time periods: 1985 to 1999 and 2000 to 2014. We ascertained complications, dislocations, reoperations, revisions and periprosthetic fractures from the total joint registry. Cost analysis was performed using a bottom-up, microcosting methodology for procedures between 2003 and 2014.

Results: Patients who converted to THA between 1985 and 1999 had a higher risk of complications (hazard ratio [HR], 2.3; 95% confidence interval [CI], 1.7-3.1; p < 0.001), dislocations (HR, 2.3; 95% CI, 1.3-4.2; p = 0.007), reoperations (HR, 1.7; 95% CI, 1.2-2.5, p = 0.005), and periprosthetic fractures (HR, 3.8; 95% CI, 2.2-6.6; p < 0.001) compared with primary THA. However, conversion THAs during the 1985 to 1999 time period had a lower risk of reoperations (HR, 0.7; 95% CI, 0.5-1.0; p = 0.037), revisions (HR, 0.6; 95% CI, 0.5-0.9; p = 0.014), and periprosthetic fractures (HR, 0.6; 95% CI, 0.4-0.9; p = 0.007) compared with revision THA. The risk differences across the three groups were more pronounced after 2000, particularly when comparing conversion THA patients with revision THA. Conversion THA patients had a higher risk of reoperations (HR, 1.9; 95% CI, 1.0-3.4; p = 0.041) and periprosthetic fractures (HR, 1.7; 95% CI, 1.0-2.9; p = 0.036) compared with revision THA, but there were no differences in the complication risk (HR, 1.4; 95% CI, 0.9-2.1; p = 0.120), dislocations (HR, 1.5; 95% CI, 0.7-3.2; p = 0.274), and revisions (HR, 1.4; 95% CI, 0.7-3.0; p = 0.373). Length of stay for conversion THA was longer than primary THA (4.7 versus 4.0 days; p = 0.012), but there was no difference compared with revision THA (4.7 versus 4.5 days; p = 0.484). Similarly, total inpatient costs for conversion THA were higher than primary THA (USD 22,662 versus USD 18,694; p < 0.001), but there was no difference compared with revision THA (USD 22,662 versus USD 22,071; p = 0.564).

Conclusions: Over the 30 years of the study, conversion THA has remained a higher risk procedure in terms of reoperation compared with primary THA, and over time, it also has become higher risk compared with revision THA. Surgeons should approach conversion THA as a challenging procedure, and patients undergoing this procedure should be counseled about the elevated risks. Furthermore, hospitals should seek appropriate reimbursement for these cases.

Level Of Evidence: Level III, therapeutic study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CORR.0000000000000702DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554100PMC
June 2019

Revision Total Hip Arthroplasty for the Treatment of Fracture: More Expensive, More Complications, Same Diagnosis-Related Groups: A Local and National Cohort Study.

J Bone Joint Surg Am 2019 May;101(10):912-919

Department of Orthopedic Surgery (M.H., C.C.W., J.J.Y., H.M.-K., D.G.L., and D.J.B.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program (E.B.H., A.E.G., and K.A.B.), and the Department of Health Sciences Research (H.M.-K., J.E.R., and S.L.V.), Mayo Clinic, Rochester, Minnesota.

Background: Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally.

Methods: Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex.

Results: Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001).

Conclusions: Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2106/JBJS.18.00523DOI Listing
May 2019

Low Back Pain in Adults With Transfemoral Amputation: A Retrospective Population-Based Study.

PM R 2019 09 1;11(9):926-933. Epub 2019 Apr 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Low back pain (LBP) is common among individuals with transfemoral amputation (TFA) and has a negative impact on quality of life. Little is known about health care utilization for LBP in this population and whether utilization varies by amputation etiology.

Objective: To determine if individuals with TFA have an increased likelihood of seeking care or reporting symptoms of acute or chronic LBP during physician visits after amputation compared with matched individuals without amputation.

Design: Retrospective cohort.

Setting: Olmsted County, Minnesota (2010 population: 144 248).

Participants: All individuals with incident TFA (N = 96), knee disarticulation, and transfemoral amputation residing in Olmsted County between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency. Individuals were divided by etiology of amputation: dysvascular and trauma/cancer.

Interventions: Not applicable.

Main Outcome Measurements: Death and presentation for evaluation of LBP (LBP event) while residing in Olmsted County. LBP events were identified using validated International Classification of Diseases, Ninth Revision (ICD-9) codes and corresponding Berkson, Hospital International Classification of Diseases Adapted (HICDA), and ICD-10 diagnostic codes. Hurdle and competing-risk Cox proportional hazard models were used.

Results: Having a TFA of either etiology did appear to correlate with increased frequency of LBP events, although this association was only statistically significant within the dysvascular TFA cohort (dysvascular TFA cohort: relative risk [RR] 1.80, 95% confidence interval [CI] 1.07-3.03, median follow-up 0.78 years; trauma/cancer TFA cohort: RR 1.14, 95% CI 0.58-2.22, median follow-up 7.95 years). In time to event analysis, dysvascular TFA had an increased risk of death and event. Obesity did not significantly correlate with increased frequency of LBP events or time to event for either cohort. At any given point in time, individuals with TFA of either etiology who had phantom limb pain were 90% more likely to have an LBP event (hazard ratio [HR] 1.91, 95% CI 1.11-3.31). Conditional on not dying and no LBP event within the first 2.5 years, individuals with prosthesis had a decreased risk of LBP events in subsequent years.

Conclusions: Risk of LBP events appears to vary by TFA etiology. Obesity did not correlate significantly with increased frequency of LBP event or time to event. Phantom limb pain correlated with decreased time to LBP event after amputation. The association between prosthesis receipt and LBP events is ambiguous.

Level Of Evidence: III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/pmrj.12087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669114PMC
September 2019

Cost and Patient Outcomes Associated With Bilateral Total Knee Arthroplasty Performed by 2-Surgeon Teams vs a Single Surgeon.

J Arthroplasty 2019 04 27;34(4):671-675. Epub 2018 Dec 27.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.

Background: Bilateral total knee arthroplasty (TKA) can be performed under a single-anesthetic (SA) or staged under a two-anesthetic (TA) technique. Recently, our institution began piloting a 2-surgeon team SA method for bilateral TKA. The purpose of this study was to compare the inpatient costs and clinical outcomes in the first 90 days after surgery between the team SA, single-surgeon SA, and single-surgeon TA approaches for bilateral TKA.

Methods: All primary TKAs performed from 2007 to 2017 by the 2 participating surgeons for each of the 3 groups of interest were identified: team SA (N = 42 patients; 84 knees), single-surgeon SA (N = 146 patients; 292 knees), single-surgeon TA (N = 242 patients; 484 knees). No patients were lost to follow-up.

Results: Median hospital cost (per TKA) for the episode(s) of care was as follows: team SA $20,962, single-surgeon SA $22,057, single-surgeon TA $31,145 (P < .001 overall; P = .0905 team SA vs single-surgeon SA). Rate of 90-day complications was 2.4% for team SA, 11.0% for single-surgeon SA, and 8.3% for single-surgeon TA (P = .2090). Discharge to skilled nursing facilities or rehab was as follows: team SA 31%, single-surgeon SA 53%, and single-surgeon TA after the second operation 34% (P < .001).

Conclusion: This pilot project suggests that team SA bilateral TKA is a potentially cost-effective option with fewer complications compared to single-surgeon SA bilateral TKA. The less frequent disposition to skilled nursing facilities in the team SA group in conjunction with more efficient operating room utilization may further enhance the financial benefits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2018.12.029DOI Listing
April 2019

Long-Term Mortality Trends After Revision Total Knee Arthroplasty.

J Arthroplasty 2019 03 1;34(3):542-548. Epub 2018 Dec 1.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN.

Background: Long-term mortality following primary total knee arthroplasty (TKA) is lower than the general population. However, it is unknown whether this is true in the setting of revision TKA. We examined long-term mortality trends following revision TKA.

Methods: This retrospective study included 4907 patients who underwent 1 or more revision TKA between 1985 and 2015. Patients were grouped by surgical indications and followed until death or October 2017. The observed number of deaths was compared to the expected number of deaths using standardized mortality ratios (SMR) and Poisson regression models.

Results: Compared to the general population, patients who underwent revision TKA for infection (SMR, 1.45; 95% confidence interval [CI], 1.33-1.57; P < .0001) and fracture (SMR, 1.16; 95% CI, 1.00-1.34; P = .04) experienced a significantly higher mortality risk. Patients who underwent revision TKA for infection and fracture experienced excess mortality soon after surgery which became more pronounced over time. In contrast, the mortality risk among patients who underwent revision TKA for loosening and/or bearing wear was similar to the general population (SMR, 0.95; 95% CI, 0.89-1.02; P = .16). Aseptic loosening and/or wear and instability patients had improved mortality initially; however, there was a shift to excess mortality beyond 5 years among instability patients, and beyond 10 years among aseptic loosening and/or wear patients.

Conclusion: Mortality is elevated soon after revision TKA for infection and fracture. Mortality is lower than the general population after revision TKA for loosening and/or bearing wear but gets worse than the general population beyond the first postoperative decade.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2018.11.031DOI Listing
March 2019

Mortality After Periprosthetic Femur Fractures During and After Primary and Revision Total Hip Arthroplasty.

J Am Acad Orthop Surg 2019 May;27(10):375-380

From the Department of Orthopedic Surgery (Dr. Maradit Kremers, Dr. Abdel, Dr. Lewallen, and Dr. Berry), and the Department of Health Sciences Research (Dr. Maradit Kremers, Ms. Ransom, and Mr. Larson), Mayo Clinic, Rochester, MN.

Introduction: We determined mortality rates after intraoperative and postoperative periprosthetic femur fractures in primary and revision total hip arthroplasty (THA).

Methods: The study population comprised 522 intraoperative and 480 postoperative femur fractures in 26,250 primary THA patients and 590 intraoperative and 224 postoperative femur fractures in 4,532 revision THA patients. The risk of death was examined using Cox regression models.

Results: In primary THA, intraoperative periprosthetic femur fractures were not associated with excess risk of death (hazard ratio, 1.03; 95% confidence interval, 0.86 to 1.22). The risk of death was slightly elevated among primary THA patients with postoperative femur fractures (hazard ratio, 1.19; 95% confidence interval, 1.08 to 1.43), but the excess risk was only confined to patients with comorbid orthopaedic conditions. In revision THA, neither intraoperative nor postoperative periprosthetic femur fractures were associated with excess risk of death.

Conclusion: Periprosthetic femur fractures are not associated with excess mortality among primary osteoarthritis patients.

Level Of Evidence: Level III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-17-00902DOI Listing
May 2019

The risk of major cardiovascular events for adults with transfemoral amputation.

J Neuroeng Rehabil 2018 09 5;15(Suppl 1):58. Epub 2018 Sep 5.

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.

Background: It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we examined the association between transfemoral amputation (TFA) status and the risk of experiencing a major cardiac event for those undergoing either dysvascular or traumatic amputations. The association of receiving a prosthesis with the risk of experiencing a major cardiac event was also examined.

Methods: Study Population: All individuals with TFA (N 162), i.e. knee disarticulation and transfemoral amputation, residing in Olmsted County, MN, between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency.

Data Analysis: A competing risk Cox proportional hazard model was used to estimate the relative likelihood of an individual with a TFA experiencing a major cardiac event in a given time period as compared to the matched controls. The cohort was divided by amputation etiology: dysvascular vs trauma/cancer. Additional analysis was performed by combining all individuals with a TFA to look at the relationship between prosthesis receipt and major cardiac events.

Results: Individuals with a dysvascular TFA had an approximately four-fold increased risk of a cardiac event after undergoing an amputation (HR 3.78, 95%CI: 3.07-4.49). These individuals also had an increased risk for non-cardiac mortality (HR 6.27, 95%CI: 6.11-6.58). The risk of a cardiac event was no higher for those with a trauma/cancer TFA relative to the able-bodied controls (HR 1.30, 95%CI: 0.30-5.85). Finally, there was no difference in risk of experiencing a cardiac event for those with or without prosthesis (HR 1.20, 95%CI: 0.55-2.62).

Conclusion: The high risk of initial mortality stemming from an amputation event may preclude many amputees from cardiovascular disease progression. Amputation etiology is also an important factor: cardiac events appear to be more likely among patients with a dysvascular TFA. Providing a prosthesis does not appear to be associated with a reduced risk of a major cardiac event following amputation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12984-018-0400-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6156832PMC
September 2018

Association between obesity and pediatric psoriasis.

Pediatr Dermatol 2018 Sep 19;35(5):e304-e305. Epub 2018 Jul 19.

Department of Dermatology, Mayo Clinic, Rochester, MN, USA.

Obese children are at higher risk of developing psoriasis, and obesity severity is correlated with psoriasis severity. The relationship between obesity and pediatric psoriasis was explored in a well-defined population. Obesity and psoriasis coexist at diagnosis, but it is likely that obesity commonly precedes psoriasis in children.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/pde.13539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379070PMC
September 2018

Does School Screening Affect Scoliosis Curve Magnitude at Presentation to a Pediatric Orthopedic Clinic?

Spine Deform 2018 Jul - Aug;6(4):403-408

Department of Orthopedic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA. Electronic address:

Background: With new data supporting the efficacy of bracing, the role of school screening for early detection of moderate scoliosis curves has been revisited. Because of a high rate of false-positive screening and cost concerns, a comprehensive county-wide school screening program was discontinued in 2004. We aim to determine the impact of a comprehensive school screening program on curve magnitude at presentation and initial scoliosis treatment for all local county patients presenting to a pediatric orthopedic clinic from all referral sources.

Methods: Between 1994 and 2014, a total of 761 county patients presented to a pediatric orthopedic clinic for new scoliosis evaluation. Curve magnitude and recommended treatment were recorded. Treatment indications for bracing, surgery, and observation were consistent over the study period.

Results: From January 1994 to July 2004 (school screening period), 514 children were seen by a pediatric orthopedic specialist for scoliosis evaluation compared to 247 patients from August 2004 to December 2014 (no school screening). There was a 48% decrease in the number of county children who were evaluated for idiopathic scoliosis by pediatric orthopedics once school screening was discontinued. Mean maximal Cobb angle at presentation increased from 20° (range, 4°-65°) to 23° (range, 7°-57°). At presentation, 5 of 514 (0.97%) patients in the screened group required surgery and 68 of 514 (13.2%) required bracing, compared to 3 of 247 (1.2%) patients in the nonscreened group requiring surgery and 47 of 247 (19%) requiring bracing (p>.05, p=.04, respectively).

Conclusion: After school screening was discontinued, mean curve magnitude and rates of bracing at presentation statistically increased in county patients evaluated for new scoliosis, although the clinical significance is unclear. After school screening was discontinued, there were fewer patient referrals, braces prescribed, and unnecessary evaluations (patients discharged at first visit). This study provides data to evaluate the role of school screening for children with regular access to health care.

Level Of Evidence: Level 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jspd.2017.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998334PMC
January 2019

Perioperative Inpatient Use of Selective Serotonin Reuptake Inhibitors Is Associated With a Reduced Risk of THA and TKA Revision.

Clin Orthop Relat Res 2018 06;476(6):1191-1197

J. J. Yao, H. Maradit Kremers, D. G. Lewallen, D. J. Berry, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA W. K. Kremers, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.

Background: Depression is common in the general population, and so it is likewise common among patients undergoing THA and TKA. Depression is associated with lower perioperative patient-reported outcomes and an increased risk of postoperative complications. Antidepressants are effective in managing symptoms of depression and may potentially contribute to better functional status and better clinical outcomes after THA and TKA.

Questions/purposes: We examined (1) whether perioperative depression is associated with all-cause revisions, revisions for aseptic loosening, revisions without infection, and periprosthetic joint infections (PJIs) in patients undergoing THA and TKA; and (2) whether perioperative antidepressant use reduces the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs in patients undergoing THA and TKA.

Methods: This was a retrospective study of adult patients (≥ 18 years) who underwent 20,112 primary and revision THAs and TKAs from January 1, 2002, through December 31, 2009, at a large US tertiary care hospital. Data on patient and surgery characteristics and outcomes (dates and types of revisions, death) were ascertained through the institutional joint registry. Perioperative antidepressant use was assessed by searching the daily medication administration records beginning at admission and ending at discharge. A diagnosis of depression was present in 4466 (22%), and antidepressants were administered at the time of 5077 (25%) surgical procedures. Multivariable Cox proportional hazard models were used to estimate associations between antidepressant use and the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs.

Results: Depression was associated with an increased risk of all-cause revisions (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.42-2.02; p < 0.001) and PJIs (HR, 2.23; 95% CI, 1.53-3.17; p < 0.001). Overall, perioperative antidepressant use was not associated with the risk of revision or PJI, but selective serotonin reuptake inhibitor (SSRI) users had a lower risk of all-cause revisions (HR, 0.77; 95% CI, 0.61-0.96; p = 0.001) and aseptic revisions (HR, 0.72; 95% CI, 0.56-0.93; p = 0.013).

Conclusions: The presence of a depression diagnosis confers an increased risk of revision and PJI among patients undergoing THA and TKA, yet the risk is lower within the subset of patients who received SSRIs during the perioperative period. Future longitudinal studies with detailed antidepressant medication histories are warranted to better understand the potential biologic effects of SSRI on the risk of revision in patients undergoing THA and TKA.

Level Of Evidence: Level III, therapeutic study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11999.0000000000000098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263602PMC
June 2018

Long-term Mortality After Revision THA.

Clin Orthop Relat Res 2018 02;476(2):420-426

Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Long-term mortality after primary THA is lower than in the general population, but it is unknown whether this is also true after revision THA.

Questions/purposes: We examined (1) long-term mortality according to reasons for revision after revision THA, and (2) relative mortality trends by age at surgery, years since surgery, and calendar year of surgery.

Methods: This retrospective study included 5417 revision THAs performed in 4532 patients at a tertiary center between 1969 and 2011. Revision THAs were grouped by surgical indication in three categories: periprosthetic joint infections (938; 17%); fractures (646; 12%); and loosening, bearing wear, or dislocation (3833; 71%). Patients were followed up until death or December 31, 2016. The observed number of deaths in the revision THA cohort was compared with the expected number of deaths using standardized mortality ratios (SMRs) and Poisson regression models. The expected number of deaths was calculated assuming that the study cohort had the same calendar year, age, and sex-specific mortality rates as the United States general population.

Results: The overall age- and sex-adjusted mortality was slightly higher than the general population mortality (SMR, 1.09; 95% CI, 1.05-1.13; p < 0.001). There were significant differences across the three surgical indication subgroups. Compared with the general population mortality, patients who underwent revision THA for infection (SMR, 1.35; 95% CI, 1.24-1.48; p < 0.001) and fractures (SMR, 1.23; 95% CI, 1.11-1.37; p < 0.001) had significantly increased risk of death. Patients who underwent revision THA for aseptic loosening, wear, or dislocation had a mortality risk similar to that of the general population (SMR, 1.01; 95% CI, 0.96-1.06; p = 0.647). The relative mortality risk was highest in younger patients and declined with increasing age at surgery. Although the relative mortality risk among patients with aseptic indications was lower than that of the general population during the first year of surgery, the risk increased with time and got worse than that of the general population after approximately 8 to 10 years after surgery. Relative mortality risk improved with time after revision THA for aseptic loosening, wear, or dislocation.

Conclusions: Shifting mortality patterns several years after surgery and the excess mortality after revision THA for periprosthetic joint infections and fractures reinforce the need for long-term followup, not only for implant survival but overall health of patients having THA.

Level Of Evidence: Level III, therapeutic study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11999.0000000000000030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259686PMC
February 2018
-->