Publications by authors named "Tony Shen"

32 Publications

Hip Resurfacing vs Total Hip Arthroplasty in Patients Younger than 35 Years: A Comparison of Revision Rates and Patient-Reported Outcomes.

Arthroplast Today 2021 Oct 8;11:229-233. Epub 2021 Oct 8.

Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA.

Background: Hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) are two treatment options for end-stage degenerative hip conditions. The objective of this single-center retrospective cohort study was to compare implant survival and patient-reported outcomes (PROs) in young patients (≤35 years) who underwent HRA or THA.

Methods: All patients aged 35 years or younger who underwent HRA or THA with a single high-volume arthroplasty surgeon between 2004 and 2015 were reviewed. The sample included 33 THAs (26 patients) and 76 HRAs (65 patients). Five-year implant survival and minimum 2-year PROs were compared between patient cohorts.

Results: Three patients in the THA group (9%) were revised within 5 years for instability (n = 1), squeaking (n = 1), or squeaking with a ceramic liner fracture (n = 1). No patients who underwent HRA were revised. The University of California, Los Angeles, activity score, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement increased by 74%, 64%, and 49%, respectively, among all patients. Compared to the HRA cohort, patients who underwent THA had lower preoperative and postoperative University of California, Los Angeles, activity, modified Harris Hip score, and Hip Dysfunction and Osteoarthritis Outcome Scores for Joint Replacement scores, yet there were no differences in the absolute improvements in any of the three measures between the two groups.

Conclusions: Excellent functional outcomes were seen in young patients undergoing either HRA or THA. Although young patients undergoing THA started at lower preoperative baseline and postoperative PROs than patients undergoing HRA, both groups improved by an equal amount after surgery, suggesting that both HRA and THA afford a similar degree of potential improvement in a young population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.artd.2021.09.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8516816PMC
October 2021

Changes in Orthopaedic diagnoses during the COVID-19 pandemic.

J Clin Orthop Trauma 2021 Nov 23;22:101603. Epub 2021 Sep 23.

Weill Cornell Medicine, New York, NY, USA.

Background: The coronavirus disease 2019 (COVID-19) pandemic has been accompanied by significant reductions in patient volumes for non-COVID-19-related conditions ranging from acute coronary syndrome to ischemic strokes to acute trauma. However, the impact of the COVID-19 pandemic on patient volumes for a broad range of orthopedic conditions remains unknown. The purpose of this study was to investigate the association of the COVID-19 pandemic with changes in patient volumes of 35 emergent (e.g. dislocations, open fractures), urgent (e.g. fractures), and nonurgent orthopedic conditions (e.g. osteoarthritis, sprains).

Methods: A retrospective interrupted time-series analysis of patient volumes was conducted for 35 orthopedic conditions based on ICD-10 diagnosis codes. Patient hospitalizations and new problem visits were aggregated across two institutions in New York state, including one urban tertiary care orthopedic hospital, one urban academic medical center, and all state outpatient facilities affiliated with the orthopedic institution. Patient volumes in the COVID-19 peak period (03/2020-05/2020) and COVID-19 recovery period (06/2020-10/2020) were compared against pre-COVID-19 vol (01/2018-02/2020).

Results: Overall, 169,047 cases were included in the analysis across 35 conditions with 3775 emergent cases, 6376 urgent cases, and 158,896 nonurgent cases During the COVID-19 peak period, patient caseloads for 1 out of 7 emergent conditions (p = 0.02) and 26 out of 28 urgent and nonurgent conditions (p < 0.05) were significantly reduced compared to the pre-COVID-19 period. During the COVID-19 recovery period, patient volumes in 3 out of 13 emergent and urgent conditions (p < 0.03) and 11 out of 22 nonurgent conditions (p < 0.04) were decreased compared to pre-COVID-19 vol.

Conclusions: This study found that the pandemic was associated with considerable changes in patient patterns for non-COVID-19 orthopedic conditions. The long-term effects of patient volume reductions on both patient outcomes and orthopedic health systems remain to be seen.

Level Of Evidence: Cohort study; level of evidence IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcot.2021.101603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8458105PMC
November 2021

Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study.

Clin Orthop Relat Res 2021 Sep 20. Epub 2021 Sep 20.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA.

Background: Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described.

Questions/purposes: (1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA?

Methods: Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups.

Results: Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04).

Conclusion: Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted.

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.0000000000001985DOI Listing
September 2021

Postoperative Patient-reported Pain and Opioid Consumption After Total Hip Arthroplasty: A Comparison of the Direct Anterior and Posterior Approaches.

J Am Acad Orthop Surg 2021 Aug 16. Epub 2021 Aug 16.

From the Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery (Bovonratwet, Chen, Shen, Ondeck, Kunze, and Su); Department of Orthopaedic Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (Bovonratwet, Shen, Ondeck, and Kunze).

Introduction: Although one of the touted benefits of the direct anterior approach (DAA) includes decreased postoperative pain, there is no consensus on the effect of surgical approach on postoperative pain and subsequent analgesic consumption.

Methods: Consecutive patients undergoing total hip arthroplasty by a single surgeon from May 2016 to March 2020 were identified. Procedures were categorized as DAA or posterior approach. Patient demographics and surgical details were assessed. Patient-reported maximum pain by postoperative day (POD), total opioid consumption during hospitalization, and whether the patient required a refill of opioid prescription within 3 months after discharge were compared between the two surgical approaches through multivariate analyses.

Results: A total of 611 patients were included in this study (447 DAA and 164 posterior approaches). On multivariate analyses that controlled for preoperative/intraoperative differences, patients in the DAA group had lower average maximum reported pain (0 to 10 scale) on POD #0 (6.5 versus 6.8, P = 0.034) and POD #1 (5.4 versus 6.1, P = 0.018). However, the DAA was not associated with a statistically significant reduction in total inpatient oral morphine equivalents consumed (79.8 versus 100.1, P = 0.486). Furthermore, there was no association between surgical approach and opioid prescription refill within 3 months after discharge (P = 0.864).

Discussion: The DAA was associated with slightly lower patient-reported pain. Furthermore, statistical analysis did not provide the necessary evidence to reject the null hypothesis, which was that there would be no difference in opioid utilization between the two approaches. Other perioperative factors may be more important to opioid use reduction than the surgical approach alone.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-21-00082DOI Listing
August 2021

Analysis of the Basic Science Questions on the Orthopaedic In-Training Examination From 2014 to 2019.

J Am Acad Orthop Surg 2021 Dec;29(23):e1225-e1231

From the Hospital for Special Surgery, New York, NY.

Introduction: The Orthopaedic In-Training Examination (OITE), produced by the American Academy of Orthopaedic Surgeons (AAOS), plays an important role in the educational mission of orthopaedic residency programs nationwide. An up-to-date understanding of this examination is critical for programs to develop an appropriate curriculum and for individuals to identify learning resources. This study presents an updated analysis of the basic science section of the OITE from 2014 to 2019.

Methods: All questions from the OITE from 2014 to 2019 were reviewed. Each question from the basic science section was categorized by topic and taxonomy. The use of radiographic images or other clinical media was recorded. The reference section was analyzed for bibliometric factors. Pearson chi-square tests were used as appropriate for statistical comparison.

Results: In total, 185 of 1,600 questions in the basic science section were used over the 6-year study period (11.6%). The proportion of basic science questions ranged from 10.7% to 12.0% from year to year. The most frequently tested topics were cellular and molecular biology (23.8%), physiology/pathophysiology (16.8%), and pharmacology (10.8%). There was an increase in the number of biostatistics questions from 2017 to 2019 compared with the number from 2014 to 2016 (P = 0.02). The most common taxonomic category was knowledge recall (89.7%). A total of 383 references were cited from 122 sources. The 3 most common sources accounting for 44.4% of all citations were produced by the AAOS.

Discussion: The basic science section of the OITE accounts for approximately 11% of all questions, with the most common taxonomy being knowledge recall (89.7%). Recent tests have emphasized biostatistics, highlighting the importance of incorporating biostatistics into residency education. Reference materials produced by the AAOS were highly cited in this section.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5435/JAAOS-D-20-00862DOI Listing
December 2021

Industry Payments and Their Association With Academic Influence in Total Joint Arthroplasty.

J Arthroplasty 2021 08 17;36(8):3004-3009. Epub 2021 Mar 17.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY.

Background: The relationship between industry payments and academic influence, as measured by the Hirsch index (h-index) and number of publications, among adult reconstruction surgeons is not well characterized. The aims of the present study are to determine the relationship between an adult reconstruction surgeons' academic influence and their relevant industry payments and National Institutes of Health (NIH) funding.

Methods: Adult reconstruction surgeons were identified through the websites for the orthopedic surgery residency programs in the United States during the 2019-2020 academic year. Academic influence was approximated by each physician's h-index and total number of publications. Industry payment data were obtained through the Open Payments Database, and NIH funding was determined through the NIH website. Mann-Whitney U testing and Spearman correlations were performed to examine relevant associations.

Results: Surgeons who received industry research payments had a higher mean h-index (16.1 vs 10.2, P < .001) and mean number of publications (79.1 vs 35.9, P < .001) than physicians who received no industry research payments. Surgeons receiving NIH funding had a higher mean h-index (48.1 vs 10.4, P < .001) and mean number of publications (294.5 vs 36.8, P < .001) than surgeons who did not receive NIH funding. There was no association between the average h-index (P = .668) and number of publications (P = .387) among adult reconstruction surgeons receiving industry nonresearch funding.

Conclusion: h-index and total publications do not seem to be associated with industry nonresearch payments in the field of total joint arthroplasty. Altogether, these data suggest that industry bias may not play a strong role in total joint arthroplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.03.025DOI Listing
August 2021

Is There an Association Between Negative Patient-Experience Comments and Perioperative Outcomes After Primary Total Hip Arthroplasty?

J Arthroplasty 2021 06 20;36(6):2016-2023. Epub 2021 Jan 20.

Department of Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY.

Background: Multiple stakeholders are interested in improving patient experience after primary total hip arthroplasty due to shifts toward patient-centered care. Patient free-text narratives are a potentially valuable but largely unexplored source of data.

Methods: The records of 383 patients who underwent primary total hip arthroplasty between August 2016 and August 2019 were combined with vendor-supplied patient satisfaction data, which included patient free-text comments and the Press Ganey satisfaction survey. A total of 1295 patient comments were analyzed for sentiment, and negative comments were categorized into nine themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not. Multivariable regression was used to determine perioperative variables associated with providing a negative comment.

Results: Of the 1295 patient comments: 54% were positive, 24% were negative, 10% were mixed, and 12% were neutral. Top two themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in studied outcomes (eg. peak pain intensity, length of stay, or improvements in hip injury and osteoarthritis outcome scores Jr. and pain visual analog scale scores at 6-week follow-up) between those who provided negative comments vs those who did not (P > .05). However, patients who made negative comments were less likely to recommend their hospital care to peers (P < .001). Finally, patients who had >2 allergies (P = .024) were more likely to provide negative comments.

Conclusion: The present study demonstrates that patient satisfaction appears not to be a reliable sole proxy for traditional objective outcome measures of pain relief and functional improvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2021.01.023DOI Listing
June 2021

Total Joint Arthroplasty During the COVID-19 Pandemic: A Scoping Review with Implications for Future Practice.

Arthroplast Today 2021 Apr 6;8:15-23. Epub 2021 Jan 6.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA.

Background: Recent studies have examined the impact of the COVID-19 pandemic on the practice of total joint arthroplasty. A scoping review of the literature with compiled recommendations is a useful tool for arthroplasty surgeons as they resume their orthopedic practices during the pandemic.

Methods: In June 2020, PubMed, Embase (Ovid), Cochrane Library (Wiley), Scopus, LitCovid, CINAHL, medRxiv, and bioRxiv were queried for articles using controlled vocabulary and keywords pertaining to COVID-19 and total joint arthroplasty. Studies were characterized by their region of origin, design, and Center of Evidence Based Medicine level of evidence. The identified relevant studies were grouped into 6 categories: changes to future clinical workflow, education, impact on patients, impact on surgeons, technology, and surgical volume.

Results: The COVID-19 pandemic has had a significant impact on arthroplasty practice, including the disruption of the clinical teaching environment, personal and financial consequences for patients and physicians, and the drastic reduction in surgical volume. New pathways for clinical workflow have emerged, along with novel technologies with applications for both patients and trainees.

Conclusions: The COVID-19 pandemic emphasizes the recent trend in arthroplasty toward risk stratification and outpatient surgery, which may result in improved clinical outcomes and significant cost-savings. Furthermore, virtual technologies are a promising area of future focus that may ultimately improve upon previous existing inefficiencies in the education and clinical environments.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.artd.2020.12.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836630PMC
April 2021

The Effect of Travel Distance on Outcomes for Hip Resurfacing Arthroplasty at a High-Volume Center.

Arthroplast Today 2020 Dec 24;6(4):1033-1037.e2. Epub 2020 Nov 24.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA.

Background: Patients are increasingly traveling greater distances to receive care at high-volume centers. The effect of travel distance on patient-reported outcomes after hip resurfacing arthroplasty has not been described.

Methods: Patients undergoing HRA by a single surgeon from January 2007 to April 2018 with minimum 2-year follow-up were reviewed retrospectively. Five hundred ninety-nine patients were identified and divided into 2 cohorts: home-to-hospital distance >100 miles and ≤100 miles from our institution. Preoperative and 2-year postoperative patient-reported outcome measures (PROMs) were assessed, including the modified Harris Hip Score and Hip disability and Osteoarthritis Outcome Score. The minimal clinically important difference (MCID) for each PROM was calculated using the distribution-based method. Chi-square tests were used for univariate comparison. Poisson regressions controlling for demographic variables were performed to determine the effect of travel distance on whether patients achieved the MCID. Multivariate linear regressions were used to determine association between distance and improvement in PROMs.

Results: A total of 599 patients met criteria for inclusion. There were 113 (18.9%) with a home-to-hospital distance >100 miles and 486 (81.1%) with distance ≤100 miles. Age was the only demographic factor different between these groups (mean: 1.1-year difference, < .001). There were no significant differences in reaching the MCID on any PROM between these groups. Multivariate linear regressions revealed no associations between travel distance and improvement in PROMs.

Conclusions: Travel distance to a high-volume center did not affect 2-year patient-reported outcomes or rate of achieving the MCID in patients undergoing hip resurfacing arthroplasty.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.artd.2020.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7772453PMC
December 2020

Etiology and Complications of Early Aseptic Revision Total Hip Arthroplasty Within 90 Days.

J Arthroplasty 2021 05 13;36(5):1734-1739. Epub 2020 Nov 13.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY, USA.

Background: The etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.

Methods: A national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.

Results: Four hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).

Conclusion: Early aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.

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.2020.11.011DOI Listing
May 2021

Modern Internet Search Analytics and Total Joint Arthroplasty: What Are Patients Asking and Reading Online?

J Arthroplasty 2021 04 20;36(4):1224-1231. Epub 2020 Oct 20.

Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY.

Background: Patients considering total joint arthroplasty often search for information online regarding surgery; however, little is known about the specific topics that patients search for and the nature of the information provided. Google compiles frequently asked questions associated with a search term using machine learning and natural language processing. Links to individual websites are provided to answer each question. Analysis of this data may help improve understanding of patient concerns and inform more effective counseling.

Methods: Search terms were entered into Google for total hip and total knee arthroplasty. Frequently asked questions and associated websites were extracted to a database using customized software. Questions were categorized by topic; websites were categorized by type. JAMA Benchmark Criteria were used to assess website quality. Pearson's chi-squared and Student's t-tests were performed as appropriate.

Results: A total of 620 questions (305 total knee arthroplasties, 315 total hip arthroplasties) were extracted with 602 associated websites. The most popular question topics were Specific Activities (23.5%), Indications/Management (15.6%), and Restrictions (13.4%). Questions related to Pain were more common in the TKA group (23.0% vs 2.5%, P < .001) compared to THA. The most common website types were Academic (31.1%), Commercial (29.2%), and Social Media (17.1%). JAMA scores (0-4) were highest for Government websites (mean 3.92, P = .005).

Conclusion: The most frequently asked questions on Google related to total joint arthroplasty are related to arthritis management, rehabilitation, and ability to perform specific tasks. A sizable proportion of health information provided originate from non-academic, non-government sources (64.4%), with 17.1% from social media websites.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.10.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573653PMC
April 2021

What Are the Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Hip Arthroplasty?

J Arthroplasty 2021 07 15;36(7S):S258-S263.e1. Epub 2020 Oct 15.

Department of Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY.

Background: A higher volume of primary total hip arthroplasty (THA) is starting to be performed as an outpatient procedure. However, data on appropriate patient selection for this surgical protocol is scarce.

Methods: Patients who underwent primary THA were identified in the 2012-2018 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Risk factors for and effect of overnight hospital stay on 30-day readmission after outpatient THA were identified through multivariable models. Reasons for and timing of readmission were also identified.

Results: A total of 5245 outpatient THA patients and 44,171 patients who stayed 1 night were identified. The incidence of 30-day readmission after outpatient THA was 1.60% (95% confidence interval [CI] 1.26-1.94). Risk factors for 30-day readmission after outpatient THA include the following: older age relative to 18-60 years old (most notably 71-75 years old, relative risk [RR] = 2.3, 95% CI = 1.15-4.62; 76-80 years old, RR = 6.6, 95% CI = 3.55-12.43; and >80 years old, RR = 5.6, 95% CI = 2.43-12.89, P < .001) and bleeding disorders (RR = 4.5, 95% CI = 1.45-14.31, P = .010). For patients who had some of these risk factors, their risk of medically related 30-day readmission was reduced if they had stayed 1 night at the hospital (P < .05). The majority of readmissions were surgically related (62%), including wound complications (27%) and periprosthetic fractures (25%).

Conclusion: The rate of 30-day readmission after outpatient THA was low. Patients who are at high risk for 30-day readmission after outpatient THA include those with older age and bleeding disorders. Some of these patients may benefit from an inpatient hospital stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.10.011DOI Listing
July 2021

COVID-19-Related Internet Search Patterns Among People in the United States: Exploratory Analysis.

J Med Internet Res 2020 11 23;22(11):e22407. Epub 2020 Nov 23.

Hospital for Special Surgery, New York, NY, United States.

Background: The internet is a well-known source of information that patients use to better inform their opinions and to guide their conversations with physicians during clinic visits. The novelty of the recent COVID-19 outbreak has led patients to turn more frequently to the internet to gather more information and to alleviate their concerns about the virus.

Objective: The aims of the study were to (1) determine the most commonly searched phrases related to COVID-19 in the United States and (2) identify the sources of information for these web searches.

Methods: Search terms related to COVID-19 were entered into Google. Questions and websites from Google web search were extracted to a database using customized software. Each question was categorized into one of 6 topics: clinical signs and symptoms, treatment, transmission, cleaning methods, activity modification, and policy. Additionally, the websites were categorized according to source: World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), non-CDC government, academic, news, and other media.

Results: In total, 200 questions and websites were extracted. The most common question topic was transmission (n=63, 31.5%), followed by clinical signs and symptoms (n=54, 27.0%) and activity modification (n=31, 15.5%). Notably, the clinical signs and symptoms category captured questions about myths associated with the disease, such as whether consuming alcohol stops the coronavirus. The most common websites provided were maintained by the CDC, the WHO, and academic medical organizations. Collectively, these three sources accounted for 84.0% (n=168) of the websites in our sample.

Conclusions: In the United States, the most commonly searched topics related to COVID-19 were transmission, clinical signs and symptoms, and activity modification. Reassuringly, a sizable majority of internet sources provided were from major health organizations or from academic medical institutions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/22407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685696PMC
November 2020

Natural Language Processing of Patient-Experience Comments After Primary Total Knee Arthroplasty.

J Arthroplasty 2021 03 8;36(3):927-934. Epub 2020 Oct 8.

Department of Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, NY.

Background: There is interest in improving patient experience after total knee arthroplasty (TKA) due to recent shifts toward value-based medicine. Patient narratives are a valuable but unexplored source of information.

Methods: Records of 319 patients who had undergone primary TKA between August 2016 and August 2019 were linked with vendor-supplied patient satisfaction data, which included patient comments and the Press Ganey satisfaction survey. Using machine-learning-based natural language processing, 1048 patient comments were analyzed for sentiment and classified into themes. Postoperative outcomes, patient-reported outcome measures, and traditional measures of satisfaction were compared between patients who provided a negative comment vs those who did not (positive, neutral, mixed grouped together). Multivariable regression was used to determine perioperative variables associated with providing a negative comment.

Results: Of the 1048 patient comments, 25% were negative, 58% were positive, 8% were mixed, and 9% were neutral. Top 2 themes of negative comments were room condition (25%) and inefficient communication (23%). There were no differences in most of the studied outcomes (eg, peak pain intensity, length of stay, or Knee Injury and Osteoarthritis Outcome Score Junior and pain scores at 6-week follow-up) between the 2 cohorts (P > .05). However, patients who made negative comments were less likely to highly recommend their hospital care to peers (P < .001). Finally, patients who had higher American Society of Anesthesiologists Score and those who received a scopolamine patch were more likely to provide negative comments (P < .05).

Conclusion: Although the current study showed that patient satisfaction might not be a proxy for traditional objective perioperative outcomes, efforts to improve the nontechnical aspects of medicine are still crucial in providing patient-centered care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.09.055DOI Listing
March 2021

Analysis of Hand Surgery Questions on Orthopedic In-training Examination From 2014 to 2019.

Hand (N Y) 2020 Oct 26:1558944720964960. Epub 2020 Oct 26.

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

Background: The orthopedic in-training examination (OITE) continues to evolve over time. It is important for orthopedic residents and residency programs to have an up-to-date understanding of the content and resources being used on the OITE to study and tailor curricula accordingly. This study presents an updated analysis of the OITE hand domain from 2014 to 2019.

Methods: All OITE questions related to hand surgery from 2014 to 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, and bibliometric factors related to cited references.

Results: Of the 1600 OITE questions, there were 113 hand surgery questions (7.1%) over a 6-year period. The most commonly tested topics were nerve (n = 22; 19%), fracture/dislocation (n = 21; 19%), and tendon/ligament (n = 19; 17%). Complex clinical management questions were the most common taxonomic category (n = 66; 58%). Two hundred fifty-two references were cited, the most common of which were from the (n = 76; 30%), (n = 27; 11%), and (n = 21; 8%). Publication lag decreased over the study period ( = .009). Twenty-five questions (22%) used imaging modalities, and 21 (19%) used clinical photos. Compared with a prior analysis from 2002 to 2006, there were more questions related to nerves (19.5% vs 9.8%, = .041).

Conclusions: Residents and residency programs can benefit from an updated understanding of OITE hand surgery content and resources. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1558944720964960DOI Listing
October 2020

Analysis of Hip and Knee Reconstruction Questions on the Orthopedic In-Training Examination.

J Arthroplasty 2021 03 18;36(3):1156-1159. Epub 2020 Sep 18.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.

Background: It is vital for orthopedic residents and residency programs to have a current understanding of the materials and resources utilized on the Orthopedic In-Training Examination (OITE) to tailor resident educational curricula accordingly. This study presents an updated analysis of the hip and knee section of the OITE.

Methods: All OITE questions related to hip and knee reconstruction over six examinations between 2014 and 2019 were analyzed for topic, subtopic, taxonomy, imaging modalities, resident performance, and references.

Results: There were 166 hip and knee reconstruction questions of 1600 OITE questions (10.4%) over a six-year period. The most commonly tested topics include mechanical properties of total knee and hip implants (10.8%), instability after THA (10.8%), periprosthetic fracture (10.2%), and prosthetic joint infection (10.2%). A total of 362 references were cited from 68 different sources. The most common sources were JOA, JBJS, JAAOS, and CORR, which were collectively responsible for 68% of all citations. There was an average publication lag of 7.1 years, with 75% of all citations falling within 10 years of the question date. Compared with a prior analysis from 2005 and 2009, there were significantly more complex multistep questions regarding treatment and fewer one-step knowledge recall questions (P = .003). Similarly, recent tests had significantly more questions involving interpretation of radiographs (55%, P < .001) and advanced imaging (9.6%, P < .001), compared with a decade ago.

Conclusions: The OITE continues to evolve over time, incorporating recent literature and topics. The current analysis identifies high-yield topics and resources that can guide resident preparation for the OITE hip and knee section.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.09.018DOI Listing
March 2021

An Updated Analysis of the Pediatric Section of the Orthopaedic In-Training Examination.

J Pediatr Orthop 2020 Nov/Dec;40(10):e1017-e1021

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.

Background: An updated analysis of the pediatrics section of the Orthopaedic In-Training Examination (OITE) is helpful for resident education and preparation for the OITE. The purpose of this study is to provide an updated evaluation of the pediatric category of the OITE, and to explore trends in question topics and taxonomy compared with the previously published analysis from 2011 to 2014.

Methods: Five years (2015-2019) of OITE questions, answers, and references were reviewed. The number of pediatric questions per year was recorded, and questions were subcategorized based on topic tested. The presence or absence of imaging or a clinical photograph was noted. Each question was also assigned a cognitive taxonomy level, based on a previously published classification system.

Results: The percentage of pediatric questions on the 2015-2019 OITEs averaged 11.4% compared with 12.6% from 2011 to 2014 (P=0.349). The 3 most commonly tested pediatric topics were general trauma (17.8%), elbow trauma (13.2%), and genetic disorders/syndromes (11.2%). There was a significant increase in questions that required diagnosis and interpretation (27.6% vs. 8%, P<0.001) and a slight but not significant decrease in the questions requiring simple knowledge recall (26.3% vs. 35.5%, P=0.120) and decisions about management (46.1% vs. 56.5%, P=0.077). Overall, 65% of questions utilized clinical photographs or imaging studies compared with 62% from 2011 to 2014 (P=0.621). The most common references were the Journal of Pediatric Orthopaedics, Journal of American Academy of Orthopaedic Surgeons, and Journal of Bone and Joint Surgery. Textbooks were cited less frequently than in the past.

Conclusions: While the percentage of pediatric questions on the OITE has remained consistent over time, the percentage of questions requiring diagnosis and interpretation has increased. In addition, questions testing genetic disorders/syndromes have become more prevalent in recent years. The most commonly cited resources were high-impact journal articles, with textbooks cited less frequently than in previous years.

Clinical Relevance: Knowledge of the most frequently tested topics and resources cited may assist orthopaedic residents in preparing for the OITE and orthopaedic faculty to focus didactic sessions on the most commonly tested topics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000001663DOI Listing
March 2021

Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Knee Arthroplasty: A Review of 3015 Cases.

J Arthroplasty 2020 09 28;35(9):2451-2457. Epub 2020 Apr 28.

Department of Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York.

Background: A higher volume of primary total knee arthroplasty (TKA) is starting to be performed in the outpatient setting. However, data on appropriate patient selection in the current literature are scarce.

Methods: Patients who underwent primary TKA were identified in the 2012-2017 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Reasons for and timing of readmission were identified. Risk factors for and effect of overnight hospital stay on 30-day readmission were evaluated.

Results: A total of 3015 outpatient TKA patients were identified. The incidence of 30-day readmission was 2.59% (95% confidence interval [CI] 2.02-3.15). The majority of readmissions were nonsurgical site related (64%), which included thromboembolic and gastrointestinal complications. Risk factors for 30-day readmission include dependent functional status prior to surgery (relative risk [RR] 6.4, 95% CI 1.91-21.67, P = .003), hypertension (RR 2.5, 95% CI 1.47-4.25, P = .001), chronic obstructive pulmonary disease (RR 2.4, 95% CI 1.01-5.62, P = .047), and operative time ≥91 minutes (≥70th percentile) (RR 1.9, 95% CI 1.17-2.98, P = .008). For patients who had some of these risk factors, their rate of 30-day readmission was significantly reduced if they had stayed at least 1 night at the hospital.

Conclusion: Overall, the rate of 30-day readmission after outpatient TKA was low. Patients who are at high risk for 30-day readmission after outpatient TKA include those with dependent functional status, hypertension, chronic obstructive pulmonary disease, and prolonged operative time. These patients had reduced readmissions after overnight admission and seem to benefit from an inpatient hospital stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2020.04.073DOI Listing
September 2020

In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review.

HSS J 2019 Jul 27;15(2):201-204. Epub 2019 Feb 27.

Hospital for Special Surgery New York, 535 E 70th St, New York, NY 10021 USA.

Early-onset scoliosis (EOS) is defined by the presence of spinal deformity in children 10 years of age or younger. Left untreated, patients with EOS are at high risk for thoracic insufficiency and early demise. This article provides a critical review of a recent prospective cohort study of children with EOS: "Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach," by Kocyigit and colleagues ( 2017;99(18):1554-1564). Treatment for EOS requires deformity correction while accommodating the growing spine. Dual growing rod implantation is a well-described technique that consists of the placement of two telescoping rods anchored to vertebrae proximal and distal to the apex of the curve. Multiple lengthening procedures are then performed as the child grows. Management of the endpoint of growing rod treatment remains controversial, with high complication rates associated with final fusion. As an alternative to final fusion or implant retention, Kocyigit and colleagues examined the removal of growing rods without spinal fusion and found that this procedure resulted in substantial worsening of the deformity in nine out of ten patients. This treatment group was terminated on ethical grounds. We believe this important result demonstrates that the removal of implants without fusion is an unacceptable treatment strategy that leads to poor outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11420-019-09671-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609653PMC
July 2019

Conversion of Hip Resurfacing With Retention of Monoblock Acetabular Shell Using Dual-Mobility Components.

J Arthroplasty 2019 Sep 14;34(9):2037-2044. Epub 2019 May 14.

Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.

Background: Retention of the acetabular component is an option during conversion from hip resurfacing arthroplasty (HRA) to total hip arthroplasty (THA). The purpose of this study was to compare clinical outcomes of conversion of the femoral resurfacing component with retained acetabular components (RAC) and use of dual-mobility femoral heads to outcomes of patients treated with both component (BC) revisions.

Methods: A retrospective review was performed of the clinical outcomes of HRA to THA conversions performed at a single institution between 2008 and 2017.

Results: Seventy-one conversions were included (27 RAC and 44 BC). Average age at time of conversion was 54.4 years (range, 30-68 years). Median time to conversion was 5.14 (2.77-7.41) years and median follow-up post-conversion was 1.7 (0.33-4.0) years. There were no significant differences in indications for conversion between the 2 groups with the majority performed for complications related to elevated metal ions and aseptic loosening. Harris Hip Scores improved from pre-conversion to post-conversion in both cohorts (P < .01). There were no significant differences in pre-conversion and post-conversion metal ion levels between the RAC and BC groups. Serum metal ion levels decreased significantly in both cohorts (P < .01). There were 6 additional revisions in the cohort (4 in BC, 2 in RAC) at a median 2.94 (1.99-3.85) years post-conversion. Two RAC patients had intraprosthetic dislocations with extensive polyethylene wear requiring acetabular revision at median 3.92 (3.85-3.98) years post-conversion. Overall, there were a higher number of complications in the BC group related to acetabular fracture, failure of osseointegration, and periprosthetic joint infection; however, this did not reach statistical significance (P = .27).

Conclusion: Salvage of an appropriately positioned, well-fixed HRA acetabular component is a reasonable option in the setting of conversion to THA using dual-mobility components. This technique avoids the morbidity of acetabular revision and was associated with a decrease in metal ion levels and improvements in short-term functional outcomes comparable to a BC revision.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arth.2019.04.065DOI Listing
September 2019

Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents.

J Pediatr Orthop 2019 May/Jun;39(5):241-246

Department of Orthopaedic Surgery, Washington University, St. Louis, MO.

Background: Posttraumatic elbow contractures in children and adolescents are challenging to manage, and studies investigating surgical treatment are limited by the rarity of this condition. Small case series have shown variable gains in immediate and long-term elbow arc of motion after open surgical release. We reviewed our experience with open surgical release of posttraumatic elbow contracture in patients <21 years old at 2 institutions.

Methods: A retrospective chart review identified patients who underwent posttraumatic open elbow contracture release by 2 surgeons at 2 institutions between 2006 and 2013. Nontraumatic contractures and arthroscopic releases were excluded. Twenty-six patients were included in this study. Mean age at the time of injury was 12 years (5 to 19 y) and at the time of surgery was 14 years (7 to 20 y). Capsulotomy, osteoplasty, removal of hardware, ulnar nerve release or transposition, and ligament reconstruction were performed through medial and lateral approaches as indicated by the pathology. Ten patients had ligament repair or stabilization, and 16 patients used a continuous passive motion (CPM) postoperatively. Outcomes included active range of motion and complications.

Results: Mean time from injury to surgical release was 29 months. Mean postoperative follow-up was 42 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 49 and 70 degrees, respectively, at final follow-up. A mean 85% of intraoperative flexion-extension arc was maintained at final follow-up. Ligament repair or reconstruction and the use of a postoperative CPM did not significantly change these outcomes. Outcomes were not significantly different if our contracture release was performed within a year from injury. Patients who had surgery before our contracture release had decreased restoration of forearm rotation after release. Complications included 2 recurrent contractures (1 used a CPM and 1 did not), and 2 postoperative ulnar neuropathies (1 used a CPM and 1 did not).

Conclusions: Open contracture release for posttraumatic elbow contracture in an adolescent population can significantly improve active range of motion.

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

Download full-text PDF

Source
http://dx.doi.org/10.1097/BPO.0000000000000923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292736PMC
June 2019

Arthroscopic treatment of triangular fibrocartilage complex injuries in paediatric and adolescent patients.

J Hand Surg Eur Vol 2019 Jul 31;44(6):582-586. Epub 2019 Jan 31.

Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO, USA.

We assessed outcomes of 43 paediatric and adolescent patients (44 wrists) undergoing arthroscopic triangular fibrocartilage complex surgery by a single surgeon between 2003 and 2016. Medical records were reviewed for clinical, imaging, and operative data. Preoperatively, 49% of patients had additional diagnoses and mean QuickDASH was 47. Patients were telephoned to assess current wrist pain, subsequent treatment(s), satisfaction, and to complete QuickDASH and Patient-Rated Wrist Evaluation questionnaires. Twenty-five patients responded with mean follow-up of 70 months (minimum 13 months). In those patients not reached by telephone, mean clinical follow-up was 21 months. Seven patients had subsequent surgery (most commonly ulnar shortening osteotomy); this was associated with lower satisfaction scores. At final follow-up, mean QuickDASH was 4, Patient-Rated Wrist Evaluation 8 and patient and parent satisfaction scores were 9 and 9 out of 10, respectively. In conclusion, arthroscopic triangular fibrocartilage complex treatment in paediatric patients yielded favourable outcomes and patient/parent satisfaction. IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1753193418825070DOI Listing
July 2019

Arthroscopic Diagnosis of the Triangular Fibrocartilage Complex Foveal Tear: A Cadaver Assessment.

J Hand Surg Am 2018 07 1;43(7):680.e1-680.e5. Epub 2018 Feb 1.

Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: To determine whether the arthroscopic hook and trampoline tests are accurate and reliable diagnostic tests for foveal triangular fibrocartilage complex (TFCC) detachment.

Methods: Wrist arthroscopy was performed on 10 cadaveric upper extremities. Arthroscopic hook and trampoline tests were performed and videos recorded (baseline). The deep foveal TFCC insertion was then sharply detached. Arthroscopic hook and trampoline tests were repeated. Subsequently, the foveal detachment was repaired via an ulnar tunnel technique and the hook test was repeated for a third time. Videos were independently reviewed at 2 time points by 2 fellowship-trained hand surgeons and 1 hand surgery fellow in a randomized and blinded fashion. Hook and trampoline tests were graded as positive or negative. Proportions of categorical variables were compared via 2-tailed Fisher exact test. Inter- and intraobserver reliabilities were assessed via Cohen kappa coefficient.

Results: The sensitivity and specificity of the hook test for foveal detachment diagnosis were 90% and 90%, respectively. There was 90% agreement among all 3 observers for the baseline and foveal detachment hook tests. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the hook test were 0.87 and 0.81, respectively. Seventeen percent of trampoline tests were positive at baseline versus 43% after foveal detachment. The trampoline test had 45% agreement between the 3 observers. Cohen kappa coefficients for the inter- and intraobserver reliabilities of the trampoline test were 0.16 and 0.63, respectively. Following ulnar tunnel repair, 20% of hook tests were positive.

Conclusions: The hook test is highly sensitive, specific, and reliable for the diagnosis of isolated TFCC foveal detachment. The trampoline test has insufficient reliability to assess foveal detachment. A TFCC foveal repair using an ulnar tunnel technique returns the hook test to baseline.

Clinical Relevance: The hook test is a sensitive, specific, and reliable test for the diagnosis of isolated TFCC foveal detachment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2017.12.017DOI Listing
July 2018

Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger.

J Hand Surg Am 2017 Apr;42(4):227-235

Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: To quantify the long-term success of repeat injections for trigger fingers and to identify predictors of treatment outcomes.

Methods: This retrospective case series analyzed 292 repeat corticosteroid injections for trigger fingers administered by hand surgeons at a single tertiary center between January 2010 and January 2013. One hundred eighty-seven patients (64%) were female, 139 patients (48%) had multiple trigger fingers, and 63 patients (22%) were diabetic. The primary outcome, treatment failure, was defined as receiving a subsequent injection or surgical treatment. Patients without either documented failure or a return office visit in 2015 or 2016 were surveyed by telephone to determine if they had required subsequent treatment. Kaplan-Meier analyses with log-rank testing assessed the median time to treatment failure and the effect of demographic and disease-specific characteristics on injection success rate and predictors of injection outcome (success vs failure) were assessed with multivariable logistic regression.

Results: Second injections provided long-term treatment success in 39% (111 of 285) of trigger fingers with 86 receiving an additional injection and 108 ultimately undergoing surgical release. Thirty-nine percent (24 of 62) of third injections resulted in long-term success, with 22 receiving an additional injection, and 23 ultimately undergoing surgery. Median times-to-failure for second and third injections were 371 and 407 days, respectively. Success curves did not differ significantly according to any patient or disease factor. Logistic regression identified that advancing patient age and injection for trigger thumb were associated with success of second injections.

Conclusions: Thirty-nine percent of second and third corticosteroid injections for trigger finger yield long-term relief. Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. Repeat injections of trigger fingers should be considered in patients who prefer nonsurgical treatment.

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.2017.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5382803PMC
April 2017

Parental Assessment of Status of Congenital Upper Limb Differences: Analysis of the Pediatric Outcomes Data Collection Instrument.

J Hand Surg Am 2016 Mar 16;41(3):381-6.e1. Epub 2016 Jan 16.

Shriner's Hospital for Children in St. Louis, St. Louis, MO; St. Louis Children's Hospital at Washington University School of Medicine, St. Louis, MO.

Purpose: To determine the range of the Pediatric Outcomes Collection Instrument (PODCI) scores for children with a wide variety of congenital upper limb differences and to examine the scoring effect of the patient's surgical history, family history, severity of involvement, and syndromic associations.

Methods: We reviewed the PODCI scores for 109 patients, aged 2-18 years, treated for nontraumatic upper extremity conditions. Charts were reviewed for sex, age, extent of limb involvement, laterality, family history, surgical history, and syndrome association. All patients were classified based on the Oberg, Manske, Tonkin classification with general categories of malformation, deformation, or dysplasia.

Results: Of 109 patients, 80 (73%) had a malformation, 12 (11%) had a deformation, and 17 (16%) had a dysplasia. The cohort as a whole had a happiness PODCI score that was similar to the normal population, yet a lower (worse) PODCI score for upper extremity and global function. Patients with a dysplasia had a higher upper extremity function scores than those with malformations or deformations, but they had similar happiness and global function scores. Complete upper limb involvement and lower extremity involvement statistically lowered the PODCI score within our study cohort, whereas a positive family history and syndromic association increased PODCI scores.

Conclusions: This study showed that there was a similar level of perceived happiness between children/adolescents with congenital upper extremity conditions compared with the normal pediatric population based on PODCI scores. In contrast, the perceived upper extremity and global function was significantly decreased in patients with congenital differences compared with normal individuals. This investigation also revealed that the extent of upper extremity involvement, lower extremity involvement, family history, and syndromic association may affect PODCI scores as independent variables and should be taken into consideration in studies of upper extremity congenital anomalies.

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

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2015.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769941PMC
March 2016

The long tail and rare disease research: the impact of next-generation sequencing for rare Mendelian disorders.

Genet Res (Camb) 2015 Sep 14;97:e15. Epub 2015 Sep 14.

Rare Genomics Institute,5225 Pooks Hills Road,Suite 1701N,Bethesda,MD 20814,USA.

There are an estimated 6000-8000 rare Mendelian diseases that collectively affect 30 million individuals in the United States. The low incidence and prevalence of these diseases present significant challenges to improving diagnostics and treatments. Next-generation sequencing (NGS) technologies have revolutionized research of rare diseases. This article will first comment on the effectiveness of NGS through the lens of long-tailed economics. We then provide an overview of recent developments and challenges of NGS-based research on rare diseases. As the quality of NGS studies improve and the cost of sequencing decreases, NGS will continue to make a significant impact on the study of rare diseases moving forward.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1017/S0016672315000166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6863629PMC
September 2015

Hedgehog signaling mediates woven bone formation and vascularization during stress fracture healing.

Bone 2015 Dec 6;81:524-532. Epub 2015 Sep 6.

Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO 63110, USA; Department of Biomedical Engineering, Washington University, St. Louis, MO, USA.

Hedgehog (Hh) signaling is critical in developmental osteogenesis, and recent studies suggest it may also play a role in regulating osteogenic gene expression in the post-natal setting. However, there is a void of studies directly assessing the effect of Hh inhibition on post-natal osteogenesis. This study utilized a cyclic loading-induced ulnar stress fracture model to evaluate the hypothesis that Hh signaling contributes to osteogenesis and angiogenesis during stress fracture healing. Immediately prior to loading, adult rats were given GDC-0449 (Vismodegib - a selective Hh pathway inhibitor; 50mg/kg orally twice daily), or vehicle. Hh signaling was upregulated in response to stress fracture at 3 days (Ptch1, Gli1 expression), and was markedly inhibited by GDC-0449 at 1 day and 3 days in the loaded and non-loaded ulnae. GDC-0449 did not affect Hh ligand expression (Shh, Ihh, Dhh) at 1 day, but decreased Shh expression by 37% at 3 days. GDC-0449 decreased woven bone volume (-37%) and mineral density (-17%) at 7 days. Dynamic histomorphometry revealed that the 7 day callus was composed predominantly of woven bone in both groups. The observed reduction in woven bone occurred concomitantly with decreased expression of Alpl and Ibsp, but was not associated with differences in early cellular proliferation (as determined by callus PCNA staining at 3 days), osteoblastic differentiation (Osx expression at 1 day and 3 days), chondrogenic gene expression (Acan, Sox9, and Col2α1 expression at 1 day and 3 days), or bone resorption metrics (callus TRAP staining at 3 days, Rankl and Opg expression at 1 day and 3 days). To evaluate angiogenesis, vWF immunohistochemistry showed that GDC-0449 reduced fracture callus blood vessel density by 55% at 3 days, which was associated with increased Hif1α gene expression (+30%). Dynamic histomorphometric analysis demonstrated that GDC-0449 also inhibited lamellar bone formation. Lamellar bone analysis of the loaded limb (directly adjacent to the woven bone callus) showed that GDC-0449 significantly decreased mineral apposition rate (MAR) and bone formation rate (BFR/BS) (-17% and -20%, respectively). Lamellar BFR/BS in the non-loaded ulna was also significantly decreased (-37%), indicating that Hh signaling was required for normal bone modeling. In conclusion, Hh signaling plays an important role in post-natal osteogenesis in the setting of stress fracture healing, mediating its effects directly through regulation of bone formation and angiogenesis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.bone.2015.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640972PMC
December 2015

Clinical applications of next generation sequencing in cancer: from panels, to exomes, to genomes.

Front Genet 2015 17;6:215. Epub 2015 Jun 17.

Rare Genomics Institute Bethesda, MD, USA.

This article will review recent impact of massively parallel next-generation sequencing (NGS) in our understanding and treatment of cancer. While whole exome sequencing (WES) remains popular and effective as a method of genetically profiling different cancers, advances in sequencing technology has enabled an increasing number of whole-genome based studies. Clinically, NGS has been used or is being developed for genetic screening, diagnostics, and clinical assessment. Though challenges remain, clinicians are in the early stages of using genetic data to make treatment decisions for cancer patients. As the integration of NGS in the study and treatment of cancer continues to mature, we believe that the field of cancer genomics will need to move toward more complete 100% genome sequencing. Current technologies and methods are largely limited to coding regions of the genome. A number of recent studies have demonstrated that mutations in non-coding regions may have direct tumorigenic effects or lead to genetic instability. Non-coding regions represent an important frontier in cancer genomics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fgene.2015.00215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469892PMC
July 2015

Prenatal Detection of Upper Limb Differences With Obstetric Ultrasound.

J Hand Surg Am 2015 Jul 28;40(7):1310-1317.e3. Epub 2015 May 28.

Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Purpose: To determine the sensitivity, specificity, and predictive values of prenatal ultrasound detection of fetal upper extremity anomalies at a single tertiary care center in a large patient cohort. Our secondary purpose was to assess factors affecting prenatal detection including the presence of associated anomalies.

Methods: We performed a retrospective review of prenatal ultrasound and postnatal clinical records from each pregnancy evaluated with a prenatal ultrasound at the Washington University Department of Obstetrics and Gynecology over a 20-year period. We searched for upper extremity anomaly diagnosis codes pre- and postnatally and correlated with clinical postnatal follow-up to determine prevalence, sensitivity, specificity, predictive values, and associated conditions.

Results: A total of 100,856 pregnancies were evaluated by prenatal ultrasound, which included 843 fetuses diagnosed with a musculoskeletal anomaly (prevalence, 1 of 120) and 642 with an upper extremity anomaly (prevalence, 1 of 157). The postnatally confirmed sensitivity for prenatal ultrasound detection of an upper extremity anomaly was 42%. Sensitivity was lower in cases isolated to the upper extremity (25% vs 55%). Sensitivity was highest for conditions affecting the entire upper extremity (70%-100%) and lowest for those affecting the digits alone (4%-19%). Fetuses with limb reduction defects, radial longitudinal deficiency, phocomelia, arthrogryposis, abnormal hand positioning, and cleft hand had a higher likelihood of having an associated anomaly.

Conclusions: At our tertiary referral center, there was a notable prevalence of upper extremity anomalies; however, the overall sensitivity for detecting them with prenatal ultrasound was low. This was disappointing given the value of prenatal identification of anomalies for parental counseling. Prenatal diagnosis of anomalies affecting the entire upper limb was more reliable than diagnosis of more distal anomalies.

Type Of Study/level Of Evidence: Diagnostic III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jhsa.2015.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568827PMC
July 2015
-->