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Blackburn AZ, Ottesen TD, Katakam A, Bedair HS, Melnic CM. Mental Robustness May Be Associated With Improved Physical Function in Bilateral Total Knee Arthroplasty Patients. J Arthroplasty 2024; 39:1207-1213. [PMID: 37981110 DOI: 10.1016/j.arth.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND In accordance with the high incidence of bilateral knee osteoarthritis, many patients have undergone bilateral total knee arthroplasty (BTKA). Whether patients undergo bilateral procedures in a staged or simultaneous fashion, the physical and mental burden of undergoing 2 major orthopedic procedures is considerable. The aims of this study were to (1) investigate differences between minimal clinically important difference (MCID) achievement between staged versus simultaneous BTKA, and (2) identify the patient variables, specifically mental scores, that were associated with MCID achievement in patients undergoing BTKA. METHODS Simultaneous and staged BTKA patients within a single health care network from 2016 to 2021 were retrospectively reviewed. Patient demographics, surgery details, and Patient-Reported Outcome Measurement Information System Physical Function Short Forms 10a (PROMIS PF10a), PROMIS Mental scores, and Knee Disability Osteoarthritis Outcome Scores (KOOS) were reviewed. Preoperative and postoperative patient-reported outcome measures were collected before the first total knee arthroplasty (TKA) and after the second TKA, respectively, in staged BTKA patients. The final cohort consisted of 249 patients, with an average age of 66 years (range, 21 to 87), 63% women, and an average body mass index of 32 (range, 20 to 52), at a mean follow-up of 1.1 years (range, 0.5 to 2.4). Multivariate regressions were performed on MCID PF10a and KOOS achievement, as well as whether the BTKA was performed simultaneously versus staged. RESULTS A preoperative PROMIS Mental score in the upper 2 quartiles was associated with MCID PF10a achievement in BTKA. Men and surgeries performed at an Academic Medical Center were negatively associated with the achievement of MCID KOOS. Interestingly, those who underwent simultaneous BTKA were less likely to achieve MCID KOOS than those who underwent a staged BTKA. CONCLUSIONS Preoperative mental robustness may be positively associated with improved physical function outcome in BTKA patients.
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Affiliation(s)
- Amy Z Blackburn
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Taylor D Ottesen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Akhil Katakam
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Hany S Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Christopher M Melnic
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts
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Bellaire CP, Ottesen TD, Gu A, Mulcahey MK, Levine WN. What's Important: #OrthoTwitter as an Online Community for Orthopaedic Surgeons. J Bone Joint Surg Am 2024:00004623-990000000-01034. [PMID: 38442196 DOI: 10.2106/jbjs.23.00851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Christopher P Bellaire
- Department of Orthopaedic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Taylor D Ottesen
- Department of Orthopaedic Surgery, Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - William N Levine
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
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Brameier DT, Tischler EH, Ottesen TD, McTague MF, Appleton PT, Harris MB, Weaver MJ, Suneja N. Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention. J Orthop Trauma 2024; 38:148-154. [PMID: 38385974 DOI: 10.1097/bot.0000000000002753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 02/23/2024]
Abstract
OBJECTIVES To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. METHODS DESIGN Retrospective cohort study. SETTING Three academic Level 1 trauma centers. PATIENT SELECTION CRITERIA Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. OUTCOME MEASURES AND COMPARISONS Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Devon T Brameier
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eric H Tischler
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Taylor D Ottesen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael F McTague
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Paul T Appleton
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Ottesen TD, Amick M, Kirwin DS, Mercier MR, Brand J, Frumberg DB, Grauer JN, Rubin LE. Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202401000-00006. [PMID: 38252550 PMCID: PMC10805463 DOI: 10.5435/jaaosglobal-d-22-00239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/27/2023] [Accepted: 12/07/2023] [Indexed: 01/24/2024]
Abstract
INTRODUCTION The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. METHODS The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. RESULTS Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. DISCUSSION Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.
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Affiliation(s)
- Taylor D Ottesen
- From the Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT (Dr. Ottesen, Dr. Amick, Dr. Kirwin, Dr. Mercier, Dr. Brand, Dr. Frumberg, Dr. Grauer, and Dr. Rubin), and the Harvard Combined Orthopaedic Residency Program, Boston, MA (Dr. Ottesen)
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Ottesen TD, Pathak N, Mercier MR, Kirwin DS, Lukasiewicz AM, Grauer JN, Rubin LE. Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database. Orthopedics 2023; 46:e237-e243. [PMID: 36719412 DOI: 10.3928/01477447-20230125-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].
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Amick M, Ottesen TD, O'Marr J, Frenkel MY, Callahan B, Grauer JN. Effects of anode position on pedicle screw testing during lumbosacral spinal fusion surgery. Spine J 2022; 22:2000-2005. [PMID: 35843532 DOI: 10.1016/j.spinee.2022.07.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/11/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
OF BACKGROUND DATA Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements. PURPOSE To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws). STUDY DESIGN Prospective cohort study. Tertiary medical center. PATIENT SAMPLE Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement. METHODS Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. R2 coefficients of correlation were determined, and variances were compared with F-tests. RESULTS A total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an R2 of 0.96. Comparisons between the four anode locations demonstrated R2 values ranging from 0.76 to 0.87. F-tests comparing thresholds between each anode site demonstrated all groups not to be statistically different. CONCLUSION The current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.
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Affiliation(s)
- Michael Amick
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA; Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA, 02114, USA
| | - Jamieson O'Marr
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Mikhail Y Frenkel
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA; UConn Main Campus 2131 Hillside Road, Unit 3088 Storrs, CT 06269-3088
| | - Brooke Callahan
- Nuvasive Clinical Services 10275 Little Patuxent Pkwy Ste 300 Columbia, MD 21044, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
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Galivanche AR, Schneble CA, David WB, Mercier MR, Kammien AJ, Ottesen TD, Saifi C, Whang PG, Grauer JN, Varthi AG. A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease. N Am Spine Soc J 2022; 12:100164. [PMID: 36304443 PMCID: PMC9594612 DOI: 10.1016/j.xnsj.2022.100164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 01/22/2023]
Abstract
Background Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology. Methods The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD. Results After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality. Conclusions After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.
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Affiliation(s)
- Anoop R. Galivanche
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Christopher A. Schneble
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Wyatt B. David
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Michael R. Mercier
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Taylor D. Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Comron Saifi
- Penn Orthopaedics, University of Pennsylvania, 235 S 8th Street, Philadelphia, PA 19107, USA
| | - Peter G. Whang
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Arya G. Varthi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06511, USA
- Corresponding author: Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT 06510.
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Ottesen TD, Shultz BN, Munger AM, Amick M, Toombs CS, Friedaender GE, Grauer JN. Chondrosarcoma patient characteristics, management, and outcomes based on over 5,000 cases from the National Cancer Database (NCDB). PLoS One 2022; 17:e0268215. [PMID: 35901087 PMCID: PMC9333210 DOI: 10.1371/journal.pone.0268215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chondrosarcoma, although relatively uncommon, represents a significant percentage of primary osseous tumors. Nonetheless, there are few large-cohort, longitudinal studies of long-term survival and treatment outcomes of chondrosarcoma patients and none using the National Cancer Database (NCDB). METHODS Chondrosarcoma patients were identified from the 2004-2015 NCDB datasets and divided on three primary tumor sites: appendicular, axial, and other. Demographic, treatment, and long-term survival data were determined for each group. Multivariate Cox analysis and Kaplan-Meier survival curves were generated to assess long-term survival over time for each. RESULTS In total, 5,329 chondrosarcoma patients were identified, of which 2,686 were appendicular and 1,616 were axial. Survival was higher among the appendicular cohort than axial at 1-year, 5-year, and 10-year (89.52%, 75.76%, and 65.24%, respectively). Multivariate Cox analysis identified patients in the appendicular cohort to have significantly greater likelihood of death with increasing age category, distant metastases at presentation, and male sex (p<0.001 for each). Best outcomes for seen for those undergoing surgical treatment (p<0.001). Patients in the axial cohort were with increased likelihood of death with increasing age category and distant metastases (p<0.001), while surgical treatment with or without radiation were associated with a significant decrease (p<0.001). Kaplan-Meier survival analysis showed worst survival for the axial cohort (p<0.001) and patients with distant metastases at presentation (p<0.001). Survival was not significantly different between older (2004-2007) and more recent years (2012-2016) (p = 0.742). CONCLUSIONS For both appendicular and axial chondrosarcomas, surgical treatment remains the mainstay of treatment due to its continued superiority for the long-term survival of patients, although advancements in survival over the last decade have been insignificant. Presence of distant metastases and axial involvement are significant, poor prognostic factors perhaps because of difficulty in surgical excision or extent of disease.
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Affiliation(s)
- Taylor D. Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
- Harvard Combined Orthopaedics Residency Program, Boston, MA, United States of America
| | - Blake N. Shultz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Alana M. Munger
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Michael Amick
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Courtney S. Toombs
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Gary E. Friedaender
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
- * E-mail:
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Ottesen TD, Galivanche AR, Greene JD, Malpani R, Varthi AG, Grauer JN. Underweight patients are the highest risk body mass index group for perioperative adverse events following stand-alone anterior lumbar interbody fusion. Spine J 2022; 22:1139-1148. [PMID: 35231643 DOI: 10.1016/j.spinee.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/19/2022] [Accepted: 02/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts. PURPOSE The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI. STUDY DESIGN/SETTING A retrospective cohort study. PATIENT SAMPLE Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases. OUTCOME MEASURES Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality. METHODS Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/m3), were calculated. Multivariate analysis was then performed controlling for patient factors. RESULTS In total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI<18.5 kg/m3) and super morbidly obese (>50 kg/m3), however, multivariate risks for adverse events and postoperative infection were elevated for underweight patients beyond those found in any other BMI category. No effect was noted in these identical variables between normal, overweight, obese class 1, or even obese class 2 patients. Multivariate analysis also found overweight patients to show a slightly protective trend against mortality while the super morbidly obese had elevated odds. CONCLUSIONS Underweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.
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Affiliation(s)
- Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA; Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114, USA
| | - Anoop R Galivanche
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Janelle D Greene
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Rohil Malpani
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Arya G Varthi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT, 06510, USA.
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Ottesen TD, Amick M, Kapadia A, Ziatyk EQ, Joe JR, Sequist TD, Agarwal-Harding KJ. The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States. J Bone Joint Surg Am 2022; 104:e47. [PMID: 35104253 DOI: 10.2106/jbjs.21.00512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
ABSTRACT Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.
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Affiliation(s)
- Taylor D Ottesen
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Massachusetts General Hospital/Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Michael Amick
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Yale University School of Medicine, New Haven, Connecticut
| | - Ami Kapadia
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Q Ziatyk
- Department of Family Medicine, Chinle Comprehensive Healthcare Facility, Chinle, Arizona
| | - Jennie R Joe
- Department of Family and Community Medicine, University of Arizona Health Sciences, Tucson, Arizona
- Native American Research and Training Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Thomas D Sequist
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Healthcare Policy, Harvard Medical School, Boston, Massachusetts
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts
- Department of Orthopaedic Surgery, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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11
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Stratton CSM, Fagher K, Li X, Ottesen TD, Tuakli-Wosornu YA. Blind sports’ blind spot: The global epidemiology of visual impairment against participation trends in elite blind para sport. J Rehabil Assist Technol Eng 2022; 9:20556683221122276. [PMID: 36061585 PMCID: PMC9434663 DOI: 10.1177/20556683221122276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 12/03/2022] Open
Abstract
Background: It remains unknown whether access to elite blind sports
opportunities is globally balanced or matches the prevalence of blindness/visual
impairment (VI). The primary objective of this study was to determine the rate
of elite blind sports participation in each world region registered in the
International Blind Sports Federation’s (IBSA) and to assess its association
with the global and regional prevalence of blindness/VI. The secondary objective
was to determine the association between other covariates, such as age, vision
class, and sex, with the number of IBSA-registered athletes from each
region. Methods: A baseline estimate of blindness/VI data was established
and used when comparing participation rates to blindness/VI rates. Descriptive
statistics were used to describe sports participation and associated
co-variates. Results: Among 123 member countries registered in IBSA, 31 did not
have any completed registrations in blind sports, of which 22 had a prevalence
of blindness/VI higher than the global average. During the summer season 2019,
738 (29.52%) IBSA athletes were female and 1762 (70.48%) were male. Conclusions: These results suggest elite blind/VI sport
participation is limited independently from blindness/VI prevalence. Increasing
blind-friendly sport resources, especially in low-and-middle-income countries
(LMICs), would improve the rate of elite sport participation among athletes with
blindness/VI.
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Affiliation(s)
- Catherine S M Stratton
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Kristina Fagher
- Rehabilitation Medicine Research Group, Department of Health Sciences, Lund University, Lund, Sweden
| | - Xiang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Carey Law School, University of Pennsylvania, Philadelphia, PA, USA
| | - Taylor D Ottesen
- Yale School of Medicine, New Haven CT, USA
- Harvard Combined Orthopedic Residency Program, Boston, MA, USA
| | - Yetsa A Tuakli-Wosornu
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
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12
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Ottesen TD, Montoya RL, Ogunleye TD, Brown KE, Woolley PM, Dejean JMCB, Qudsi RA, Agarwal-Harding KJ, Dyer GSM. Implementation and Impact Evaluation of a Virtual Orthopaedic Continuing Medical Education Conference in a Low-Resource Country. J Surg Educ 2021; 78:1629-1636. [PMID: 33573909 DOI: 10.1016/j.jsurg.2021.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The Haitian Annual Assembly of Orthopaedic Trauma (HAAOT) is an annual continuing medical education (CME) conference for Haitian orthopedists and trainees converted to a pilot virtual format in 2020 due to the COVID-19 pandemic. We evaluated this virtual format's effectiveness at teaching, facilitating bilingual discussion, and encouraging cross-cultural exchange of experiences - all aimed at improving orthopedic knowledge in a low-resource country like Haiti. DESIGN Planned collaboratively between North American and Haitian colleagues, the conference involved 4 bilingual weekly Zoom meetings comprised of 4 to 6 prerecorded presentations and live-translated discussion. Pre- and postmeeting knowledge assessments in French (Haitian language of medical instruction) were administered weekly with results compared via 2-sample t-tests. An online postconference survey evaluated attendee satisfaction with the virtual format. SETTING Virtual. PARTICIPANTS Weekly attendance involved approximately 50 Haitian orthopedists and trainees, with 20 to 25 completing pre- and postmeeting assessments. RESULTS Statistically significant increases between pre/post scores were seen during 3 of 4 sessions. Session-wide significant score increases occurred for residents and attending surgeons with <10 years of experience. 85.7% of attendees reported the virtual platform exceeded expectations and 100% indicated likely or extremely likely participation in further virtual events. CONCLUSIONS The pilot virtual HAAOT was extremely well received with high desire for future sessions. Beyond short-term knowledge retention among attendees, nonmeasurable benefits included collaboration between orthopedists and trainees in the United States, Canada, United Kingdom, Haiti, and Burkina Faso. As COVID-19 spurs online learning in high-income nations, the successful low-resource context adjustments and local partnership underlying this model attest that travel restrictions need not impede delivery of virtual CME conferences in lower-income nations. Attendee learning and the decreased cost and travel requirements allude to this platform's sustainability and reproducibility in facilitating future international education and capacity building. Further studies will assess long-term retention of presented material.
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Affiliation(s)
- Taylor D Ottesen
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut; Harvard Global Orthopaedics Collaborative, Boston, Massachusetts.
| | - Rachel L Montoya
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Temi D Ogunleye
- Burrell College of Osteopathic Medicine, Las Cruces, New Mexico
| | - Kelsey E Brown
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Pierre Marie Woolley
- University Hospital of La Paix (HUP), Orthopedic and Traumatology Department, Port-Au-Prince, Haïti
| | | | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kiran J Agarwal-Harding
- Harvard Global Orthopaedics Collaborative, Boston, Massachusetts; Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - George S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Gardezi M, Ottesen TD, Tyagi V, Sherman JJZ, Grauer JN, Rubin LE. Arthroplasty implants and materials: Cost awareness and value perception. PLoS One 2021; 16:e0255061. [PMID: 34310629 PMCID: PMC8312923 DOI: 10.1371/journal.pone.0255061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022] Open
Abstract
Arthroplasty procedures are commonly performed and contribute to healthcare expenditures seen in the United States. Surgical team members may make selections among implants and materials without always knowing their relative cost. The current study reports on a survey aimed to investigate the perceptions of an academic group about the relative cost and value of commonly used operating room implants and materials related to joint arthroplasty cases using 10 matched pairs of items. Of the 124 persons eligible to take the survey, 102 responded (response rate of 82.3%) including attendings, fellows, residents, physician assistants (PAs), advanced practice registered nurses (APRNs) and registered nurses (RNs). On average for the ten pairs of items, the more expensive items were correctly selected by 90.2+/-13.9% (mean+/- standard deviation) of respondents with a range from 54.9% to 100%. Of note, the cost differences were significantly overestimated for 8/10 item pairs. The majority of respondents perceived the more expensive item as the item with the higher clinical value for 9/10 item pairs. Most arthroplasty attendings (91.3%) indicated willingness to use the less expensive item of two similar items. Nonetheless, 17.9% of fellows, residents, PAs, APRNs and RNs indicated that they would not feel comfortable suggesting using the less expensive item. Although attending arthroplasty surgeons stated a desire to consider costs, a knowledge deficit with regards to identifying the extent of cost differences was identified, and a significant portion of the surgical support team reported being hesitant to suggest less expensive options.
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Affiliation(s)
- Mursal Gardezi
- Yale School of Medicine, New Haven, CT, United States of America
| | | | - Vineet Tyagi
- Department of Orthopaedics and Rehabilitation, New Haven, CT, United States of America
| | | | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, New Haven, CT, United States of America
| | - Lee E. Rubin
- Department of Orthopaedics and Rehabilitation, New Haven, CT, United States of America
- * E-mail:
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14
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Kebaish KJ, Galivanche AR, Varthi AG, Ottesen TD, Rubin LE, Grauer JN. Long-term Corticosteroid Use Independently Correlates With Complications After Posterior Lumbar Spine Surgery. Orthopedics 2021; 44:172-179. [PMID: 34039214 DOI: 10.3928/01477447-20210416-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
With the increasing medical complexity of patients undergoing posterior lumbar surgery, more patients are pharmacologically immunosuppressed to manage chronic conditions. The effects of immunosuppression have become of greater interest across multiple surgical specialties. The goal of the current study was to investigate whether long-term corticosteroid use is independently associated with perioperative adverse outcomes among patients undergoing posterior lumbar surgery. Patients who underwent elective posterior lumbar spine surgery (decompression and/or fusion) were identified in the 2005-2016 National Surgical Quality Improvement Program (NSQIP) database. Patient factors, surgical factors, and 30-day perioperative outcomes for patients taking long-term corticosteroids were compared with those for patients who were not taking these drugs. Propensity matching and multivariate analysis were used to evaluate comparable patients while controlling for potentially confounding variables. In total, 140,519 patients undergoing posterior lumbar spine surgery were identified. Of these, 5243 (3.73%) were taking corticosteroids. After propensity matching and controlling for age, sex, body mass index, functional status, American Society of Anesthesiologists class, and surgical procedure, those taking corticosteroids were at greater risk for any adverse event (odds ratio, 1.45), a serious adverse event (odds ratio, 1.57), a minor adverse event (odds ratio, 1.47), infection (odds ratio, 1.48), reoperation (odds ratio, 1.48), and readmission (odds ratio, 1.47) (P≤.001 for each). The findings confirmed that long-term corticosteroid use is associated with significant increases in perioperative adverse outcomes for patients undergoing elective posterior lumbar surgery, even with matching and controlling for potentially confounding variables. These findings can guide patient counseling and preemptive interventions before surgery for this patient population. [Orthopedics. 2021;44(3):172-179.].
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Barau Dejean JMC, Pean JTMA, Ottesen TD, Woolley PM, Qudsi RA, Dyer GSM. Advantages of a New Low-Cost Negative Pressure Wound Therapy Using the "Turtle VAC": A Case Series. JBJS Case Connect 2021; 11:01709767-202106000-00031. [PMID: 33857023 DOI: 10.2106/jbjs.cc.20.00056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a clinical case and technique guide demonstrating the use and effectiveness of a novel, low-cost negative pressure wound therapy (NPWT) device to achieve soft-tissue coverage in a 34-year-old patient with failed rotational flap and Masquelet technique on infected tibial nonunion. Local debridement was executed, NPWT initiated, and treatment culminated with complete wound healing. CONCLUSION The "Turtle VAC" offers an effective low-cost alternative to commercially vacuum-assisted closure systems for post-traumatic wounds in low-resource setting of Haiti. Its use of available equipment makes NPWT accessible and can function as a bridge to definitive closure when primary wound closure is not possible and/or between debridement procedures.
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Affiliation(s)
| | - J T Marc-Alain Pean
- Orthopaedic and Traumatology Department, University Hospital of La Paix (HUP), Port-au-Prince, Haiti
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Pierre Marie Woolley
- Department of Orthopaedic and Traumatology, University of Notre Dame Haiti (UNDH), Port-au-Prince, Haiti
| | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Nemours A.I. du Pont Hospital for Children, Wilmington, Delaware
| | - George S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Ottesen TD, Bagi PS, Malpani R, Galivanche AR, Varthi AG, Grauer JN. Underweight patients are an often under looked “At risk” population after undergoing posterior cervical spine surgery. North American Spine Society Journal (NASSJ) 2021; 5:100041. [PMID: 35141608 PMCID: PMC8820029 DOI: 10.1016/j.xnsj.2020.100041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/07/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022]
Abstract
Background Body Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery. Methods Patients undergoing elective posterior cervical spine surgery were abstracted from the 2005–2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5–24.9 kg/m2). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health. Results A total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI < 18.5 kg/m2) were the highest among any category of patients along the BMI spectrum. These patients experienced increased odds of any adverse event (Odds Ratio (OR) = 1.67, p = 0.008, major adverse events (OR=2.08, p = 0.001), post-operative infection (OR = 1.95, p = 0.002), and reoperation (OR = 1.84, p = 0.020). Interestingly, none of the overweight or obese categories were found to be correlated with increased risk of adverse event categories other than super-morbidly obese patients (BMI>50.0 kg/m2) for post-operative infection (OR = 1.54, p = 0.041). Conclusions The current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.
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17
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Haynes MS, Ondeck NT, Ottesen TD, Malpani R, Rubin LE, Grauer JN. Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations. J Arthroplasty 2020; 35:3188-3194. [PMID: 32654940 DOI: 10.1016/j.arth.2020.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/28/2020] [Accepted: 06/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study. METHODS Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts. RESULTS In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation. CONCLUSION Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Monique S Haynes
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Nathaniel T Ondeck
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Rohil Malpani
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
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Ottesen TD, Shultz BS, Munger AM, Sibindi C, Yurter A, Varthi AD, Grauer JD. Despite Advances in Tumor Management Modalities, Surgery Prevails as Best Predictor of Survival for Osteosarcoma: An Analysis of Primary Osseous Tumor Characteristics, Management, and Outcomes from the National Cancer Database. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Scheffers MF, Ottesen TD, Kaye LH, Ona Ayala KE, Kadakia SM, Buckley JM, Tuakli-Wosornu YA. A novel portable and cost-efficient wheelchair training roller for persons with disabilities in economically disadvantaged settings: the EasyRoller. Disabil Rehabil Assist Technol 2020; 17:681-686. [PMID: 32880508 DOI: 10.1080/17483107.2020.1807622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE Stationary training rollers enable wheelchair users to maintain physical health and train as athletes, which serves to treat and prevent immobility-associated chronic disease and improve cardiorespiratory fitness required for sports performance. However, conventional exercise equipment is largely inaccessible for persons with disabilities in low-resource areas, primarily due to cost. The aim of this study was to prototype, develop, and test a portable, cost-efficient stationary training device for wheelchair users in low-resource settings - The EasyRoller. MATERIALS AND METHODS Stakeholder input from wheelchair athletes, trainers, and potential commercial manufacturers was solicited and utilized to conceptualize The EasyRoller design. The device was constructed from easily sourced, low cost components, following which it was user-tested with Para athletes. Feedback was analysed and incorporated into newer versions of the prototype.Results and conclusions: The EasyRoller creatively combines easily-sourced components to significantly cut down cost and ease both manufacture and repair for use in low-resource settings. The device is portable with a total weight of 34 pounds and total size of 42 linear inches while also affordable with a total cost of USD$199. Hereby, The EasyRoller has the potential to increase physical activity participation in populations with impairment who live in socioeconomically deprived world regions.Implications for rehabilitationExercise and physical activity are key aspects of health and quality of life for persons with disabilitiesStationary training rollers, devices that enable wheelchair users to train, are often bulky and expensive and therefore inaccessible for populations in socio-economically disadvantaged settingsThe EasyRoller is a portable and affordable training device that increases access to exercise and physical activity for these populations.
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Affiliation(s)
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Laurel H Kaye
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Kimberly E Ona Ayala
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Shevali M Kadakia
- Department of Computing and Mathematical Sciences, California Institute of Technology, Pasadena, CA, USA
| | - Jennifer M Buckley
- Department of Mechanical Engineering, University of Delaware, Newark, DE, USA
| | - Yetsa A Tuakli-Wosornu
- Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale University, New Haven, CT, USA
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Ottesen TD, Malpani R, Galivanche AR, Zogg CK, Varthi AG, Grauer JN. Underweight patients are at just as much risk as super morbidly obese patients when undergoing anterior cervical spine surgery. Spine J 2020; 20:1085-1095. [PMID: 32194246 PMCID: PMC7380546 DOI: 10.1016/j.spinee.2020.03.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Past studies have focused on the association of high body mass index (BMI) on spine surgery outcomes. These investigations have reported mixed conclusions, possible due to insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (e.g. underweight, overweight, and obese). Few studies have considered outcomes of patients with low BMI. PURPOSE To analyze how anterior cervical spine surgery outcomes track with World Health Organization categories of BMI to better assess where along the BMI spectrum patients are at risk for adverse perioperative outcomes. DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients undergoing elective anterior cervical spine surgery were abstracted from the 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program database. OUTCOME MEASURES Thirty-day adverse events, hospital readmissions, postoperative infections, and mortality. METHODS Patients undergoing anterior cervical spine procedures (anterior cervical discectomy and fusion, anterior cervical corpectomy, cervical arthroplasty) were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Patients were then aggregated into modified World Health Organization categories of BMI. Odds ratios of adverse outcomes, normalized to average risk of normal weight subjects (BMI 18.5-24.9 kg/m2), were calculated. Multivariate analyses were then performed on aggregated adverse outcome categories controlling for demographics (age, sex, functional status) and overall health as measured by the American Society of Anesthesiologists classification. RESULTS In total, 51,149 anterior cervical surgery patients met inclusion criteria. Multivariate analyses revealed the odds of any adverse event to be significantly elevated for underweight and super morbidly obese patients (Odds Ratios [OR] of 1.62 and 1.55, respectively). Additionally, underweight patients had elevated odds of serious adverse events (OR=1.74) and postoperative infections (OR=1.75) and super morbidly obese patients had elevated odds of minor adverse events (OR=1.72). Relative to normal BMI patients, there was no significant elevation for any adverse outcomes for any of the other overweight/obese categories, in fact some had reduced odds of various adverse outcomes. CONCLUSIONS Underweight and super morbidly obese patients have the greatest odds of adverse outcomes after anterior cervical spine surgery. The current study identifies underweight patients as an at-risk population that has previously not received significant focus. Physicians and healthcare systems should give additional consideration to this population, as they often already do for those at the other end of the BMI spectrum.
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Affiliation(s)
- Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Rohil Malpani
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Anoop R Galivanche
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Cheryl K Zogg
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Arya G Varthi
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, CT 06511, USA.
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Ottesen TD, Qudsi RA, Kahanu AK, Baptiste BJ, Woolley PM, Socci AR, Dyer GSM. The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings. Arch Bone Jt Surg 2020; 8:198-203. [PMID: 32490051 DOI: 10.22038/abjs.2019.34372.1906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin's solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin's solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin's solution for modern wound care.
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Affiliation(s)
- Taylor D Ottesen
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, USA
| | - Rameez A Qudsi
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexis K Kahanu
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | | | | | - Adrienne R Socci
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, Connecticut, USA
| | - George S M Dyer
- Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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22
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Gala RJ, Ottesen TD, Kahan JB, Varthi AG, Grauer JN. Perioperative adverse events after different fusion approaches for single-level lumbar spondylosis. ACTA ACUST UNITED AC 2020; 1:100005. [PMID: 35141578 PMCID: PMC8820031 DOI: 10.1016/j.xnsj.2020.100005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/10/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022]
Abstract
Background Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion). Methods Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts. Results In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events. Conclusion The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion. Summary Sentence Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.
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Navarro SM, Sibiya A, Nourian MM, Stewart KA, Ottesen TD, Price RR. Addressing Supply Chain Management Issues in Cost-effective Maternal and Pediatric Global Surgery: A Call to Action. Int J MCH AIDS 2020; 9:77-80. [PMID: 32123631 PMCID: PMC7031878 DOI: 10.21106/ijma.295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework.
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Affiliation(s)
- Sergio M Navarro
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Said Business School, University of Oxford, Oxford, UK.,Global Surgery Student Alliance (GSSA), Boston, MA, USA
| | - Andile Sibiya
- Said Business School, University of Oxford, Oxford, UK
| | - Maziar M Nourian
- Global Surgery Student Alliance (GSSA), Boston, MA, USA.,Department of Anesthesia, Vanderbilt School of Medicine, Nashville, TN, USA
| | - Kelsey A Stewart
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN, USA
| | - Taylor D Ottesen
- Global Surgery Student Alliance (GSSA), Boston, MA, USA.,Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, USA
| | - Raymond R Price
- Center for Global Surgery, University of Utah, Salt Lake City, UT, USA
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Scheffers MF, Ona Ayala KE, Ottesen TD, Tuakli-Wosornu YA. Design and development of mobility equipment for persons with disabilities in low-resource and tropical settings: bamboo wheelchairs. Disabil Rehabil Assist Technol 2019; 16:377-383. [PMID: 31795784 DOI: 10.1080/17483107.2019.1695962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE For persons with disabilities in low-resource and tropical settings, barriers to mobility and physical activity are steep. The aim of this study was to develop and test two low-cost, durable, sustainable, purpose-built wheelchair prototypes to support wheelchair users in low-resource and tropical settings. These bamboo wheelchairs, nicknamed African Chairs by Ghanaian daily manual wheelchair users who tested the devices, adopt two designs: an urban-targeted and a rural-targeted design. MATERIALS AND METHODS The rural-targeted design incorporated stability as its key design property for the purpose of navigating variable terrain. The urban-targeted design adopted a sleeker, more portable profile for environments that require wheelchair transport in vehicles and the navigation of elevators and ramps. Both designs integrated bamboo-rod skeletons, bonded by hot-glue gun, jointed and wrapped with epoxy-soaked fibers, then upholstered by a local tailor, with basic standard wheel components. An iterative design process incorporated expert consultation as well as user feedback. RESULTS AND CONCLUSIONS The final prototypes received positive testing reviews from daily manual wheelchair users in Ghana. These locally-built, safe, economical bamboo wheelchairs have the potential to improve accessibility, provide more independence and reduce immobility-related health risks for many.Implications for rehabilitationPersons with disabilities have a right to mobility, maximum independence, and the psychological, emotional, and physical health benefits of physical activity those rights confer.For persons with disabilities in low-resource settings, barriers to mobility and physical activity are steep, due to social stigmatization and the cost and adaptability of equipment.Bamboo wheelchairs have the potential to increase access to mobility and physical activity by allowing wheelchairs to be efficiently produced at cost, according to the user's needs.The aesthetics of bamboo wheelchairs can help reduce social stigma by avoiding the "medicalization" of wheelchairs and other traditional mobility devices.
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Affiliation(s)
| | | | | | - Yetsa A Tuakli-Wosornu
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
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Ottesen TD, Pathak N, Mercier MR, Lukasiewicz AM, Grauer JN, Rubin LE. Is There Value in Subspecialty Training? Comparison of Differences in Outcomes between Fellowship-Trained Orthopaedic Foot and Ankle Surgeons and All Other Orthopaedic Surgeons Using the American Board of Orthopaedic Surgery Database. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Scott EM, Fallah PN, Blitzer DN, NeMoyer RE, Sifri Z, Hanna JS, Peck GL, Acker R, Aharon S, Alty I, Anyanwu C, Beck N, Brandt A, Briggs L, Caminita C, Chaet A, Chan J, Chiu L, Cueto C, Daneshdoost S, Edalatpour R, Garba D, Giles AE, Gualy S, Haider A, Hamilton C, Hauser BM, He P, Im C, Jayaram A, Jhun R, Joshi A, Kahanu A, Kim NE, Kim R, Lauffer S, McHargue C, Meeks M, Mehta A, Mendoza A, Miller M, Nourian M, Ottesen TD, Patel P, Peck CJ, Pyarali M, Ramirez AG, Rehman S, Shankar B, Stetson A, Still ME, Tutunjian A, Yibrehu B, Yu KE. Next Generation of Global Surgeons: Aligning Interest With Early Access to Global Surgery Education. J Surg Res 2019; 240:219-226. [DOI: 10.1016/j.jss.2019.03.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/08/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
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Tuakli-Wosornu YA, Sun Q, Gentry M, Ona Ayala KE, Doolan FC, Ottesen TD, Caldwell B, Naushad N, Huang P, Kirby S. Non-accidental harms (‘abuse’) in athletes with impairment (‘para athletes’): a state-of-the-art review. Br J Sports Med 2019; 54:129-138. [DOI: 10.1136/bjsports-2018-099854] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2019] [Indexed: 11/03/2022]
Abstract
ObjectivePara athletes reap significant health benefits from sport but are vulnerable to non-accidental harms. Little is known about the types and impacts of non-accidental harms Para athletes face. In this literature review, we summarise current knowledge and suggest priorities for future research related to non-accidental harms in Para athletes.DesignSix electronic databases were searched between August and September 2017. 2245 articles were identified in the initial title/abstract review, and 202 records were selected for full-text review following preliminary screening. Two independent examiners evaluated each full text, and eight citations were selected based on inclusion/exclusion criteria.Data sourcesMEDLINE, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Scopus and Academic Search Premier.Eligibility criteria for selecting studiesInclusion criteria: (A) human participants; (B) written in English; (C) descriptive, cohort and case series, case–control, qualitative, mixed methods studies and all clinical trials; and (D) data pertain to harassment/abuse of youth, recreational, collegiate, national-level and/or elite-level athletes with a physical and/or intellectual impairment.ResultsMost studies focused on young, visually impaired athletes and approximately half of all studies described high rates of bullying and its social implications. One study confirmed remarkably high rates of psychological, physical and sexual harms in Para athletes, compared with able-bodied peers.ConclusionsBullying in young, visually impaired athletes is described most commonly in the available literature. Due to the limited amount of data, the prevalence of non-accidental harms in Para athletes remains unclear and information on trends over time is similarly unavailable.
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Shultz BN, Bovonratwet P, Ondeck NT, Ottesen TD, McLynn RP, Grauer JN. Evaluating the effect of growing patient numbers and changing data elements in the National Surgical Quality Improvement Program (NSQIP) database over the years: a study of posterior lumbar fusion outcomes. Spine J 2018; 18:1982-1988. [PMID: 29649610 DOI: 10.1016/j.spinee.2018.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/26/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The use of national databases in spinal surgery outcomes research is increasing. A number of variables collected by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) changed between 2010 and 2011, coinciding with a rapid increase in the number of patients included per year. However, there has been limited study evaluating the effect that these changes may have on the results of outcomes studies. PURPOSE The present study aimed to investigate the influence of changing data elements and growth of the NSQIP database on results of lumbar fusion outcomes studies. STUDY DESIGN/SETTING This is a retrospective cohort study of prospectively collected data. PATIENT SAMPLE The NSQIP database was retrospectively queried to identify 19,755 patients who underwent elective posterior lumbar fusion surgery with or without interbody fusion between 2005 and 2014. Patients were split into two groups based on year of surgery: 2,802 from 2005 to 2010 and 16,953 from 2011 to 2014. OUTCOME MEASURES The occurrence of adverse events after discharge from the hospital, within postoperative day 30, was determined. METHODS Preoperative characteristics and 30-day perioperative outcomes were compared between the era groups using bivariate analysis. To illustrate the effect of such changing data elements, the association between age and postoperative outcomes in the era groups was analyzed using multivariate Poisson regression. The present study had no funding sources, and there were no study-related conflicts of interest for any authors. RESULTS There were significant differences between the era groups for a variety of preoperative characteristics. Postoperative events such blood transfusion and deep vein thrombosis were also significantly different between the era groups. For the 2005-2010 cohort, age was significantly associated with septic shock by multivariate analysis. For the 2011-2014 cohort, age was significantly associated with septic shock, urinary tract infection, blood transfusion, myocardial infarction, and extended length of stay. CONCLUSIONS The NSQIP database has undergone substantial changes between 2005 and 2014. These changes may contribute to different results in analyses, such as the association between age and postoperative outcomes, when using older versus newer data. Conclusions from early studies using this database may warrant reconsideration.
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Affiliation(s)
- Blake N Shultz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA
| | - Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA
| | - Ryan P McLynn
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06510, USA.
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Zogg CK, Ottesen TD, Kebaish K, Galivanche A, Murthy S, Changoor NR, Zogg DL, Pawlik TM, Haider AH. The Cost of Complications Following Major Resection of Malignant Neoplasia. J Gastrointest Surg 2018; 22:1976-1986. [PMID: 29946953 PMCID: PMC6224301 DOI: 10.1007/s11605-018-3850-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rising healthcare costs have led to increased focus on the need to achieve a higher "value of care." As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally representative data. METHODS National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥ 18 years) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One fourth (26.1%; 95% CI, 25.7-26.4%) experienced ≥ 1 pre-discharge complication (range, 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT,Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | | | | | - Shilpa Murthy
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA,Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Navin R. Changoor
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Adil H. Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard T.H. Chan School of Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
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Ottesen TD, Hsiang WR, Malpani R, Varthi AG, Rubin LE, Grauer JN. Underweight Patients Are the Highest-Risk BMI Group for Perioperative Adverse Events after Total Shoulder Arthroplasty. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ottesen TD, McLynn RP, Galivanche AR, Bagi PS, Zogg CK, Grauer JN. Increased 30-Day Complications in Geriatric Hip-Fracture Patients with Postoperative Weight-Bearing Restrictions: An American College of Surgeons NSQIP Analysis of 4,918 Patients. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bovonratwet P, Ottesen TD, Gala RJ, Rubio DR, Ondeck NT, McLynn RP, Grauer JN. Outpatient elective posterior lumbar fusions appear to be safely considered for appropriately selected patients. Spine J 2018; 18:1188-1196. [PMID: 29155341 DOI: 10.1016/j.spinee.2017.11.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/08/2017] [Accepted: 11/09/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There has been growing interest in performing posterior lumbar fusions (PLFs) in the outpatient setting to optimize patient satisfaction and reduce cost. Although still done in only a small percentage of cases, this has been more possible because of advances in surgical techniques and anesthesia. However, data on the perioperative course of outpatient compared with inpatient PLF in a large sample size are scarce. PURPOSE This study aimed to compare perioperative complications between outpatient and inpatient PLF in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN/SETTING A retrospective cohort comparison study was carried out. PATIENT SAMPLE Patients undergoing PLF with or without interbody fusion from the 2005 to 2015 NSQIP database comprised the sample. OUTCOME MEASURES Outcome measures were postoperative complications within 30 days and readmission within 30 days. METHODS Patients who underwent PLF with or without interbody fusion were identified in the 2005-2015 NSQIP database. Outpatient procedures were defined as cases that had hospital length of stay (LOS)=0 days, whereas inpatient procedures were defined as LOS=1-30 days. Patient characteristics, comorbidities, and procedural variables (inclusion of interbody fusion, instrumentation, and number of levels fused) were compared between the two cohorts. Propensity score-matched comparisons were then performed for postoperative complications and 30-day readmissions between the two groups. RESULTS The current study included 360 outpatient and 36,610 inpatient PLF cases. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in postoperative adverse events other than significantly lower blood transfusions in the outpatient group (2.78% vs. 10.83%, p<.001). Notably, the rate of readmissions was not different between the groups. CONCLUSIONS Based on the lack of differences in rates of most perioperative complications and 30-day readmissions between the outpatient and inpatient cohorts, it seems that outpatient PLF may be appropriately considered for select patients. However, extremely careful patient selection should be exercised.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Raj J Gala
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Daniel R Rubio
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Ryan P McLynn
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT 06510, USA.
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McLynn RP, Diaz-Collado PJ, Ottesen TD, Ondeck NT, Cui JJ, Bovonratwet P, Shultz BN, Grauer JN. Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery. Spine J 2018; 18:970-978. [PMID: 29056565 DOI: 10.1016/j.spinee.2017.10.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 09/01/2017] [Accepted: 10/05/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Venous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery. PURPOSE The objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery. STUDY DESIGN/SETTING This is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center. PATIENT SAMPLE This study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery. OUTCOME MEASURES The incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort. MATERIALS AND METHODS Associations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression. RESULTS Among 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048). CONCLUSIONS Pharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.
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Affiliation(s)
- Ryan P McLynn
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Pablo J Diaz-Collado
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Jonathan J Cui
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Blake N Shultz
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College St, New Haven, CT 06510, USA.
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McLynn RP, Ottesen TD, Ondeck NT, Cui JJ, Rubin LE, Grauer JN. The Rothman Index Is Associated With Postdischarge Adverse Events After Hip Fracture Surgery in Geriatric Patients. Clin Orthop Relat Res 2018; 476:997-1006. [PMID: 29419631 PMCID: PMC5916609 DOI: 10.1007/s11999.0000000000000186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population. QUESTIONS/PURPOSES (1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes? METHODS One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes. RESULTS We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05). CONCLUSIONS The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- Ryan P McLynn
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Bovonratwet P, Tyagi V, Ottesen TD, Ondeck NT, Rubin LE, Grauer JN. Revision Total Knee Arthroplasty in Octogenarians: An Analysis of 957 Cases. J Arthroplasty 2018; 33:178-184. [PMID: 28844628 DOI: 10.1016/j.arth.2017.07.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 07/15/2017] [Accepted: 07/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (<70 and 70-79 year olds). METHODS Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups: <70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions. RESULTS This study included 6523 (<70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to <70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations. CONCLUSION These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age.
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Affiliation(s)
- Patawut Bovonratwet
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Vineet Tyagi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Taylor D Ottesen
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Nathaniel T Ondeck
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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