New England Baptist Hospital (NEBH) is a 141-bed adult medical-surgical hospital in Boston, Massachusetts specializing in orthopedic care and complex orthopedic procedures. NEBH is an international leader in the treatment of all forms of musculoskeletal disorders and disease."The Baptist" (as the hospital is called for short) is located atop Parker Hill in the Mission Hill neighborhood within walking distance of the Longwood Medical and Academic Area.The hospital is a teaching affiliate of both the University of Massachusetts Medical School and Tufts University School of Medicine. It also conducts teaching programs in collaboration with the Harvard T.H. Chan School of Public Health and the Harvard School of Medicine.CareGroup, Inc. is the parent non-profit holding company for New England Baptist, Beth Israel Deaconess Medical Center, Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, and Mount Auburn Hospital.
STUDY DESIGN: Retrospective Cohort Study. PURPOSE: To compare 30-day postoperative outcomes of cervical disc replacement (CDR) versus anterior cervical discectomy and fusion (ACDF) in single-level cervical degenerative disc disease (CDDD) using a frailty-based propensity score matched model. Frailty, quantified using the Risk Analysis Index (RAI), was treated as both a confounding variable for matching and as an independent predictor of postoperative outcomes, allowing assessment of its predictive value and potential role as an effect modifier in evaluating surgical outcomes following CDR. METHODS: The ACS-NSQIP database (2012-2022) was queried for adults undergoing single-level ACDF or CDR for CDDD. Patients with fractures, tumors, emergent cases, or incomplete data were excluded. Outcomes included 30-day mortality, major and minor complications, Clavien-Dindo IV complications, non-home discharge (NHD), readmission, reoperation, and extended length of stay. Propensity score matching was performed controlling for frailty as quantified by the RAI. Multivariate logistic regression and receiver operating characteristic curves assessed associations and predictive accuracy. RESULTS: Among 97,408 patients (8.7% CDR), CDR patients were younger and less frail. After matching 16,974 patients, CDR was associated with significantly lower odds of major complications (OR 0.57), NHD (OR 0.60), readmission (OR 0.60), and reoperation (OR 0.61) compared to ACDF, with no mortality difference. Each 1-point increase in RAI corresponded to higher odds of mortality (+24%), major complications (+11%), and NHD (+17%). RAI demonstrated strong discrimination for mortality (C=0.85) and NHD (C=0.76). CONCLUSIONS: CDR is associated with fewer short-term adverse outcomes than ACDF, even in frail patients. Frailty strongly predicts postoperative risk but does not diminish the relative safety of CDR. The RAI is a valuable preoperative risk stratification tool for cervical spine surgery.
Study Design:Systematic review and meta-analysis. Objective:To determine whether venous thromboembolism (VTE) prophylaxis is necessary after spine trauma and to assess the efficacy and safety profiles of anticoagulation agents. Summary of Background Data:Venous stasis, endothelial disruption, hypercoagulability, and orthopedic injury in spine trauma predispose 12%-64% of patients to deep vein thrombosis (DVT). Recent guidelines provide insufficient evidence to support or oppose routine VTE prophylaxis in this population. Methods:A systematic search was conducted in Medline, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials from inception to March 2023. Controlled vocabulary, key terms, and synonyms related to spinal trauma and anticoagulation were used. Studies comparing different classes of anticoagulants or anticoagulation versus no anticoagulation were included. Four reviewers independently performed abstract screening, full-text review, and data extraction, resolving conflicts by consensus. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality. Results:Our search yielded 2948 articles, with 103 advancing to full-text review and 16 meeting inclusion criteria. Bias assessment using MINORS for 10 retrospective studies resulted in an average score of 16.8 +/- 1.6, whereas 6 prospective studies had NOS scores >6, indicating high-quality evidence. Anticoagulation was significantly associated with lower odds of DVT (OR: 0.40; P=0.0013), with low heterogeneity (I-2 = 2%). Low-molecular-weight heparin (LMWH) was associated with significantly lower odds of DVT (OR: 0.78; P=0.0050) and PE (OR: 0.66; P=0.0013) compared with unfractionated heparin (UH). No significant difference in major bleeding was found (OR: 0.52; P=0.1397). LMWH was linked to reduced mortality (OR: 0.43; P<0.0001). Conclusion:Chemical anticoagulants reduce DVT risk in spine trauma patients. LMWH provides superior protection against DVT, pulmonary embolism, and mortality compared with UH, with no significant increase in major bleeding.
PURPOSE:To compare patient-reported outcome measures (PROMs) and return-to-sport rates following proximal hamstring repair between patients older than versus younger than 60. METHODS:A retrospective study was conducted with patients who have undergone proximal hamstring repair between October 2021 and February 2023. Patients with acute or chronic, partial, or complete proximal hamstring tears who underwent open surgical repair, completed preoperative and postoperative PROMS, and had a minimum follow-up of 24 months were included. PROMs included: Perth Hamstring Assessment Tool (PHAT); Lower Extremity Functional Scale (LEFS); Hip Outcome Score (HOS), including the Activities of Daily Living (ADL) and Sports subscales; and 12-Item Short Forms Survey Questionnaire (SF-12). Patients were stratified into 2 cohorts depending on age at time of surgery: those under versus those 60 years and older (U-60 and O-60, respectively). Univariate analysis was performed to compare cohort demographics and clinical outcomes. RESULTS:Fifty-five of the 59 eligible patients met the inclusion requirements of the study. The U-60 cohort included 36 patients with a mean age of 49.3 (21.8-58.6) years and the O-60 cohort included 19 patients with a mean age of 66 (60.0-75.0) years. The mean follow-up time was 23.3 ± 0.44 months for the O-60 group and 23.4 ± 0.50 months for the U-60 group (P = .664). There were no significant differences between the O-60 and U-60 postoperative PROM scores (LEFS P = .346, HOS-ADL P = .389, HOS-Sports P = .648, PHAT P = .123, SF-12 mental component score P = .943, SF-12 physical component score P = .680). There were no significant differences between groups after disaggregating by sex (females: LEFS P = .273, HOS-ADL P = .278, HOS-Sports P = .963, PHAT P = .146; Males: LEFS P = .536, HOS-ADL P = .099, HOS-Sports P = .693, PHAT P = .446). There were no significant differences in achievement of cohort-specific minimal clinically important difference between the O-60 and U-60 groups for LEFS (P = .345), HOS-ADL (P = .067), HOS-Sports (P = .219), or PHAT (P = .426). These differences remained nonsignificant after disaggregating the data by sex. Forty-seven patients (85%) completed 2-year follow-up return-to-sport surveys. In the O-60 group, 100% (12/12) patients returned to sports, compared with 82.9% of patients (29/35) in the U-60 group (P = .315). CONCLUSIONS:Proximal hamstring repair is a viable treatment option for the aging population and provides similar postoperative functional outcomes compared with younger patients. LEVEL OF EVIDENCE:Level III, retrospective comparative case series.
BACKGROUND:Reverse shoulder arthroplasty (rTSA) and anatomic total shoulder arthroplasty (aTSA) treat glenohumeral osteoarthritis (GHOA) with comparable early outcomes. Given increasing utilization of rTSA for GHOA, we sought to evaluate outcomes of rTSA and aTSA for GHOA at early and midterm follow-up. METHODS:A retrospective propensity-matched cohort study of patients undergoing aTSA and rTSA for GHOA with early and midterm follow-up was performed. Matching included age, sex, body mass index, preoperative American Shoulder and Elbow Surgeons (ASES) score, preoperative forward elevation, and Walch glenoid morphology. Baseline patient characteristics, range of motion, ASES, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain scores, complications and revision rTSAs/aTSAs were assessed at early and midterm follow-up. RESULTS:One hundred twenty-two patients (61 per group) were included with early and midterm follow-up. Baseline characteristics, comorbidities, preoperative ASES, SANE, VAS pain scores, and range of motion were similar (P > .05). Both groups showed significant improvements in ASES, SANE, and VAS scores at both time points (P < .001); >96% achieved minimal clinically important difference for ASES. While more aTSA patients met substantial clinical benefit early (95.1% vs. 80.3%, P = .027); there was no statistically significant difference at midterm follow-up (P = .074). aTSA patients had better early internal (5.0 vs. 3.3, P < .001) and external rotation (63.0° vs. 57.0°, P = .036), with no difference at midterm follow-up. Complication rates were similar; however, aTSA had more revisions and radiolucencies. CONCLUSION:aTSA and rTSA yield similar clinical outcomes for GHOA at early and midterm follow-up. Early differences in substantial clinical benefit, internal, and external rotation with aTSA diminished by midterm follow-up. Complication rates were similar between the cohorts. One patient in the aTSA group was revised to rTSA and no patients with primary rTSA required revision. While rTSA and aTSA result in excellent clinical outcomes, longer follow-up is needed to determine durability.
The removal of osteophytes during total knee arthroplasty (TKA) results in reduced soft tissue tension, which may result in joint laxity. Thus, for gap balancing, a surgeon may try to predict the effect of osteophyte removal on the resulting flexion and extension gap before any bone cuts are made and before those osteophytes are removed. Posterior osteophytes, however, are relatively inaccessible, since their removal can be done only after posterior bone cuts are made on the femur. Any laxity created by posterior osteophyte removal cannot be corrected by adjusting bone cuts because they have already been made. The authors have developed a predictive algorithm for use in robotic TKA, which anticipates the effect of osteophyte removal, allowing adjustment in bony resection before any bone cuts are made. The cross-sectional area of the posterior femoral osteophytes is measured on the sagittal plane of the preoperative computed axial tomography (CAT) scan. The authors' method of osteophyte correction is to make changes to the tibial cut based on the size and shape of the posterior osteophytes, as they believe the laxity created by osteophyte removal effects both extension and flexion. The amount and specific location of bony resection are then determined based on the size and location (posteromedial vs. posterolateral) of the osteophytes. Through the described technique, the authors have found that the amount of laxity created by osteophyte removal correlates directly to the dimension of the osteophyte over which the soft tissue extends. The size and shape of initially inaccessible posterior osteophytes, determined using CAT scan-based imaging, were used to create a predictive bony balancing algorithm, designed to be incorporated with the surgeon's preferred bony balancing technique. Our predictive algorithm anticipates the laxity created by osteophyte removal prior to their removal and can be used to alter bone resection parameters and/or implant parameters (e.g., thickness of a tibial liner) to accommodate the increased laxity, allowing for the conservation of bone and correction of deformity.
