JAAOS

JAAOS, Volume 24, No. 3


Administrative Databases in Orthopaedic Research: Pearls and Pitfalls of Big Data

The drive for evidence-based decision-making has highlighted the shortcomings of traditional orthopaedic literature. Although highquality, prospective, randomized studies in surgery are the benchmark in orthopaedic literature, they are often limited by size, scope, cost, time, and ethical concerns and may not be generalizable to larger populations. Given these restrictions, there is a growing trend toward the use of large administrative databases to investigate orthopaedic outcomes. These datasets afford the opportunity to identify a large numbers of patients across a broad spectrum of comorbidities, providing information regarding disparities in care and outcomes, preoperative risk stratification parameters for perioperative morbidity and mortality, and national epidemiologic rates and trends. Although there is power in these databases in terms of their impact, potential problems include administrative data that are at risk of clerical inaccuracies, recording bias secondary to financial incentives, temporal changes in billing codes, a lack of numerous clinically relevant variables and orthopaedic-specific outcomes, and the absolute requirement of an experienced epidemiologist and/or statistician when evaluating results and controlling for confounders. Despite these drawbacks, administrative database studies are fundamental and powerful tools in assessing outcomes on a national scale and will likely be of substantial assistance in the future of orthopaedic research.

      • Subspecialty:
      • Spine

      • Basic Science

      • General Orthpaedics

    Comparison of Surgical Techniques for Ulnar Collateral Ligament Reconstruction in Overhead Athletes

    Several surgical techniques and modifications for ulnar collateral ligament (UCL) reconstruction have been proposed since this procedure was first performed in 1974. The goal of these techniques has been restoration of stability to the medial elbow with minimal alteration to the surrounding anatomy. Outcome studies and systematic reviews on modified techniques for UCL reconstruction have shown a trend toward increased return to play in patients, particularly overhead athletes. Abandonment of flexor pronator mass detachment in favor of a muscle-splitting or muscle-elevating approach, minimal handling of the ulnar nerve, and the docking technique may result in improved outcomes and decreased complications without diminished performance. Several biomechanical studies have compared the structural properties of these techniques with those of the native UCL. However, a clear, concise surgical algorithm for UCL reconstruction is lacking. Additional studies that use sport-specific outcome measures and performance metrics may better demonstrate the true return to preinjury performance after UCL reconstruction in overhead athletes.

        • Subspecialty:
        • Sports Medicine

        • Shoulder and Elbow

      Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population

      Introduction: The risk of morbidity associated with venous thromboembolism (VTE) after pediatric orthopaedic surgery remains unclear despite increased use of thromboprophylaxis measures.

      Methods: The American College of Surgeons National Surgical Quality Improvement Program, Pediatric database was queried for patients undergoing an orthopaedic surgical procedure between 2012 and 2013. Upper extremity and skin/subcutaneous surgeries were excluded. Associations between VTE and procedure, demographics, comorbidities, preoperative laboratory values, and 30-day postoperative outcomes were evaluated.

      Results: Of 14,776 cases, 15 patients (0.10%) experienced postoperative VTE. Deep vein thrombosis (DVT) occurred in 13 patients (0.09%), and pulmonary embolism developed in 2 patients (0.01%). The procedure with the highest VTE rate was surgery for infection (1.2%). Patient factors associated with the development of VTE included hyponatremia (P = 0.003), abnormal partial thromboplastin time (P = 0.046), elevated aspartate transaminase level (P = 0.004), and gastrointestinal (P = 0.011), renal (P = 0.016), and hematologic (P = 0.019) disorders. Nearly half (46.2%) of DVTs occurred postdischarge. Complications associated with VTE included prolonged hospitalization (P < 0.001), pneumonia (P < 0.001), unplanned intubation (P = 0.003), urinary tract infection (P = 0.003), and central line-associated bloodstream infection (P < 0.001). Most of the postoperative complications (66.7%) occurred before VTE diagnosis, and no patients with VTE died.

      Conclusion: In the absence of specified risk factors, thromboprophylaxis may be unnecessary for this population.

          • Subspecialty:
          • Pediatric Orthopaedics

        Enhancing Drug Release From Antibiotic-loaded Bone Cement Using Porogens

        Objective: To evaluate whether the addition of porogens to polymethyl methacrylate (PMMA) enhances the antibiotic elution rate from antibiotic-loaded bone cement.

        Methods: Two porogens, gelatin sponge (Spongostan, Ferrosan Medical Devices) and ceramic granules (Bicera, Wiltrom), were added to liquid gentamicin-loaded PMMA at increasing concentrations. Porosity was analyzed using Fourier transform infrared (FTIR) spectroscopy and scanning electron microscopy. Young’s modulus and drug elution were also measured. The gentamicin content of the eluents was evaluated by o-phthaldialdehyde (OPA) assay on days 1, 2, 5, 7, 10, and 14.

        Results: After day 5, the drug-releasing rate of Spongostan was significantly higher than that of Bicera in the order G3 > G2 > T3 > G1 > T2 > T1 > bone cement, where G represents the concentration of Spongostan and T represents the concentration of Bicera. The addition of Bicera and Spongostan increased the drug-releasing efficiency of PMMA by 3.75-fold and 5.65-fold, respectively. Spongostan also resulted in larger pores (ie, 70 to approximately 200 mm) compared with Bicera (5 to 10 mm) but reduced biomechanical strength.

        Conclusion: Both gelatin sponge and ceramic granules improved the local antibiotic elution rate, although the drug-releasing rate of Spongostan was significantly higher than that of Bicera.

            • Subspecialty:
            • Basic Science

          Mediating the Secondary Effects of Spinal Cord Injury Through Optimization of Key Physiologic Parameters

          Spinal cord injury remains a challenging clinical entity with considerable socioeconomic impact on patients, their families, and the healthcare system. Advances in medical care and rehabilitation continue to improve, but treatment outcomes following tissue regeneration for spinal cord injury remain dismal. Therefore, attempts at mediating the secondary effects of spinal cord injury remain the mainstay of current treatment. Recent studies evaluating the timing of decompression suggest improved neurologic recovery with early surgical decompression and the maintenance of mean arterial pressures >85 mm Hg. With systemic and local treatments, including riluzole, minocycline, GM1 ganglioside, BA-210, and granulocytecolony stimulating factor, remaining in their infancy, randomized controlled trials demonstrating efficacy are needed before adopting their widespread use.

              • Subspecialty:
              • Trauma

              • Spine

            Orthopaedic Perspective on Barefoot and Minimalist Running

            In recent years, there has been a movement toward barefoot and minimalist running. Advocates assert that a lack of cushion and support promotes a forefoot or midfoot strike rather than a rearfoot strike, decreasing the impact transient and stress on the hip and knee. Although the change in gait is theorized to decrease injury risk, this concept has not yet been fully elucidated. However, research has shown diminished symptoms of chronic exertional compartment syndrome and anterior knee pain after a transition to minimalist running. Skeptics are concerned that, because of the effects of the natural environment and the lack of a standardized transition program, barefoot running could lead to additional, unforeseen injuries. Studies have shown that, with the transition to minimalist running, there is increased stress on the foot and ankle and risk of repetitive stress injuries. Nonetheless, despite the large gap of evidence-based knowledge on minimalist running, the potential benefits warrant further research and consideration.

                • Subspecialty:
                • Sports Medicine

              Tibiotalocalcaneal Fusion for Severe Deformity and Bone Loss

              Tibiotalocalcaneal fusion is an effective salvage procedure for combined end-stage ankle and subtalar arthrosis and for the management of severe planar deformities of the ankle and hindfoot. Although the procedure results in a rigid ankle and hindfoot, it is often the only means of providing patients with a stable and painless foot and ankle for ambulation. Some patients who require the procedure have substantial bone loss that can be managed with a variety of autograft and allograft options. Options for tibiotalocalcaneal fixation include both internal and external devices, the selection of which depends on the underlying pathology, amount of bone loss, and type of bone graft selected. Relatively high complication rates associated with tibiotalocalcaneal fusion have been reported, with complications ranging from superficial infection to ultimate amputation; however, proper patient selection and careful graft and fixation planning can minimize the postoperative complications of the procedure

                  • Subspecialty:
                  • Foot and Ankle

                Unplanned Resection of Sarcoma

                Unplanned resection is a common problem in the management of sarcoma. Because sarcomas are so rare, they may be misdiagnosed initially as more common benign lesions. When the treating surgeon is unaware of or does not adhere to proper surgical principles of orthopaedic oncology, an intralesional procedure may be performed without the requisite preoperative imaging, staging, or wide resection margins for optimal management of sarcoma. Studies show that oncologic outcomes after unplanned resections are mixed; however, surgical outcomes drastically deteriorate. Failure to adhere to oncologic principles accounts for increased morbidity and amputation rates with re-resection. No diagnostic modality has been proven to accurately predict residual disease in the resection bed following unplanned resection. Thus, repeat surgery with or without adjuvant treatment is usually offered to these patients, thereby adding considerable cost and morbidity. Medical malpractice litigation associated with unplanned sarcoma resectioniscommon, with delayed diagnosis and unnecessary amputation most often cited in cases decided in favor of the plaintiff.

                    • Subspecialty:
                    • General Orthopaedics

                    • Musculoskeletal Oncology

                  Variability in Surgical Case Volume of Orthopaedic Surgery Residents: 2007 to 2013

                  Introduction: Variability in orthopaedic surgery training is an important issue facing trainees. We examined orthopaedic surgery case logs for subspecialty case volume during residency training and assessed trends and variability in case volume over time. We hypothesized that there is variability in training in all subspecialties encountered in orthopaedic surgery resident training and that the volume of cases in each subspecialty has increased over time.

                  Methods: Annual surgical case logs of the Accreditation Council for Graduate Medical Education from 2007 to 2013 for orthopaedic surgery residency were assessed for variability and case volume trends.

                  Results: The average total adult cases logged per graduating resident in 2007 was 1,952, which increased to 2,291 in 2013, representing a 17.4% increase (P = 0.00041). The gap in case volume between residents in the 10th and 90th percentiles for case exposure decreased from 2007 to 2013 (P = 0.0268), although the 10th percentile group still logged significantly fewer procedures compared with the 90th percentile group in 2013 (P = 0.0159).

                  Conclusions: Although case volume is not the sole determinant of surgical skill and further study is needed to investigate the effects of training experience, this variability in surgical volume may affect the knowledge, skill, and practice patterns of surgeons.

                      • Subspecialty:
                      • General Orthopaedics

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