United States

Abstract Title: The Use of Preoperative CRP and ESR as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty
Background
Total hip (THA) and total knee (TKA) arthroplasty are two of the most performed orthopedic surgeries each year in the United States. Prosthetic joint infection (PJI) remains one of the most common serious complications among all patients undergoing total joint arthroplasty (TJA). There has been a significant amount of literature on the use of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the field of TJA, specifically for the diagnosis of PJI. However, there is much less data focused on the use of preoperative CRP and ESR in the setting of primary TJA. The purpose of this study was to further investigate any correlation that exists between preoperative CRP/ESR and PJI in primary TJA.
Methods
All patients of one of two surgeons who underwent primary THA or TKA between 2016 and 2020 at the same institution were identified and studied via a retrospective chart review. After exclusion criteria, 806 patients were included in the final cohort for analysis. Positive CRP was set at &gt;0.3 mg/dL and ESR as &gt;30 mm/hr.
Results
In our current study, which is the second-largest cohort to date that looks at preoperative inflammatory markers before primary TJA, we found no statistically significant correlation between pre-operative CRP or ESR and PJI. We did find that a higher proportion of patients with PJI had elevated preoperative CRP (70.6%) vs those with normal CRP (29.4%). However, among patients with no PJI, the preoperative CRP was still found to be elevated in half of all patients (49.7%).
Conclusion
This study is unable to validate the use of preoperative CRP/ESR as a predictive measure of future risk of PJI in primary total joint arthroplasty. However, it does provide quantitative insight into the prevalence of elevated preoperative inflammatory markers in all patients prior to TJA with a considerable proportion of patients having modifiable risk factors. Since there is such a large proportion of patients with elevated inflammatory markers that do not go on to develop PJI, we do not recommend cancellation of TJA unless there is an obvious identified modifiable risk factor that puts them at increased risk of PJI.

AMA Research Challenge 2022

The Use of Preoperative Crp and Esr as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty

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Ricardo Correa, MD, EdD
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Jessica Li, MD/PhD Candidate
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Charles Lopresto, DO

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Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Abstract Title: The Use of Preoperative CRP and ESR as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty
Background
Total hip (THA) and total knee (TKA) arthroplasty are two of the most performed orthopedic surgeries each year in the United States. Prosthetic joint infection (PJI) remains one of the most common serious complications among all patients undergoing total joint arthroplasty (TJA). There has been a significant amount of literature on the use of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the field of TJA, specifically for the diagnosis of PJI. However, there is much less data focused on the use of preoperative CRP and ESR in the setting of primary TJA. The purpose of this study was to further investigate any correlation that exists between preoperative CRP/ESR and PJI in primary TJA.
Methods
All patients of one of two surgeons who underwent primary THA or TKA between 2016 and 2020 at the same institution were identified and studied via a retrospective chart review. After exclusion criteria, 806 patients were included in the final cohort for analysis. Positive CRP was set at >0.3 mg/dL and ESR as >30 mm/hr.
Results
In our current study, which is the second-largest cohort to date that looks at preoperative inflammatory markers before primary TJA, we found no statistically significant correlation between pre-operative CRP or ESR and PJI. We did find that a higher proportion of patients with PJI had elevated preoperative CRP (70.6%) vs those with normal CRP (29.4%). However, among patients with no PJI, the preoperative CRP was still found to be elevated in half of all patients (49.7%).
Conclusion
This study is unable to validate the use of preoperative CRP/ESR as a predictive measure of future risk of PJI in primary total joint arthroplasty. However, it does provide quantitative insight into the prevalence of elevated preoperative inflammatory markers in all patients prior to TJA with a considerable proportion of patients having modifiable risk factors. Since there is such a large proportion of patients with elevated inflammatory markers that do not go on to develop PJI, we do not recommend cancellation of TJA unless there is an obvious identified modifiable risk factor that puts them at increased risk of PJI.

poster

Background
Opioid overdose has been on the constant rise since the beginning of the opioid epidemic. Orthopedic surgery has the 3rd highest average number of opioid prescriptions per prescriber. Efforts have been made nationally to decrease opioid prescribing and opioid use and abuse. Studies have shown patients with mental health disorders are more likely to be prescribed medications, such as opioids, for chronic pain management. This study aims to investigate the trends in prescription rates of analgesic medications for primary total shoulder arthroplasty (TSA) patients with a history of mental illness, chronic pain, or substance use.
Methods
A retrospective trends analysis was performed using a national database. Patients who underwent primary TSA were identified using the International Classification of Disease. Patients with diagnoses of mental illness, pain syndromes, and substance use were compared to a control group without diagnoses. Patients with a history of an opioid prescription claim within 6 months before TSA were excluded. Medications prescribed—opioids, gabapentinoids (GBPs), and nonsteroidal anti-inflammatory (NSAIDs)—were identified using Uniform Systems of Classification and codes specific to the database. Annual medication claims rates within 30 days, 90 days, and 1-year after TSA were analyzed with linear regression and compound annual growth.
Results
A total of 82,692 patients with a history of mental illness, chronic pain, or substance use underwent primary TSA. Among this cohort of patients, opioid prescription claims had significantly increasing trends by 30-days after surgery, however, trends were significantly decreasing by 90-days and 1-year after surgery. Prescription claims for GBPs were significantly increasing by all timepoints after TSA surgery among this cohort. For NSAIDs, prescription claims significantly increased by 30 and 90-days post-surgically while decreasing by the 1-year mark.
Conclusion
Patients with a diagnostic history of mental health, chronic pain, or substance use have significantly fewer opioid medication prescription claims after total shoulder arthroplasty surgery than patients who do not have those diagnoses. No difference in average prescription claims was observed between groups with GBPs or NSAIDs in the 30-day or 90-day postoperative periods.





Trends in analgesic medication claims after primary total shoulder arthroplasty in patients with a mental health diagnosis.

Background: The purpose of this study is to evaluate postoperative outcomes at minimum 5 year follow up in patients following unicompartmental knee arthroplasty (UKA) compared to a matched cohort of total knee arthroplasty (TKA) patients.
Methods: Patients with primarily medial compartment osteoarthritis (OA) who met criteria for medial UKA underwent TKA or medial UKA between 2014 and 2015 at a single institution, matched for age, sex, and BMI. 
Results: 127 UKAs in 120 patients and 118 TKAs in 116 patients were included with minimum 5 years follow-up. Mean (± standard deviation) age was 69 ± 10 years and 71 ± 9 years in the UKA and TKA groups respectively (p=0.049). At five years postoperatively, patients who underwent UKA had significantly higher mean (± SD)
Forgotten Joint Scores (87 ± 20 vs. 59 ± 34,  p&lt;0.001); higher Knee Society Scores (88 ± 14 vs. 75 ± 21, p&lt;0.001); and lower Numeric Pain Rating Scores (0.8 ± 1.6 vs. 1.9 ± 2.2, p&lt;0.001). Survivorship free from all-cause revision was 96% (95% CI=93-99%) and 99% (95% CI=97-100%) at 5 years for TKA and UKA, respectively (p=0.52). There were eight both component revisions in the TKA group within five years from the date of surgery and two UKA conversions to TKA after five years follow up.
Conclusions: Patients with medial compartment OA who underwent UKA had significantly lower joint awareness, decreased pain, improved function and higher satisfaction compared to matched TKA patients at minimum 5 year follow up while maintaining excellent survivorship.

Unicompartmental knee arthroplasty patients had lower joint awareness and higher function at 5 years compared to total knee replacements

Use of Periarticular Locked Plating Systems for Ankle, Subtalar, Tibial, and Talonavicular Arthrodesis

Using Machine Learning to Predict Complications Following Total Elbow Arthroplasty


Abstract Title:
Comparing primary versus secondary trancheoesophageal puncture prosthesis for speech rehabilitation post total laryngectomy
Background
Total laryngectomy (TL) is a catastrophic operation with sequalae of loss of natural voice, dysphagia, and permanent tracheotomy, performed as standard of care for advanced laryngeal/hypopharyngeal cancer. Early rehabilitation efforts have traditionally been focused on esophageal speech, electronic larynx, and tracheoesophageal puncture prosthetic (TEP). TEP is the most used method due to a more natural speech and high success rates, although the choice between primary (immediate) TEP and secondary (delayed) is controversial. While primary TEP allows the avoidance of additional surgery for voice restoration, and enables earlier rehabilitation, there has been concern for higher risk of stoma stenosis, fistula formation, and local infection. Thus, support for delayed TEP proposes possible avoidance of such complications with stomal maturation. This study reports a literature review of studies comparing the efficacy of primary and secondary TEP in terms of complication rates, voice quality, and long term efficacy. 

Methods
A literature review was conducted via PubMed with search phrase “tracheoesophageal voice prosthesis primary vs secondary” with six search results. Based on the inclusion criteria of direct comparison between study groups of primary and secondary TEP, 5 studies were selected for review and one study was eliminated 

Results
Barauna et al. reported a 10% statistically significant reduction in risk of leakage around the prosthesis in the secondary TEP group, and no difference in voice quality between the two groups. Emerick et al. reported an increased risk of pharyngocutaneous fistula with primary TEF, a 2 month sooner achievement of fluent speech in primary TEF group, and no difference in speech fluency. Massaro et al. reported no difference in long term outcome between the two groups. Kao et al. reported a higher success rate of speech restoration for primary TEF group with no difference in complication rates. Sinclair et al. reported no difference in early post-operative complication rate between the two techniques. 
Conclusion
The choice between primary versus secondary TEF should be personalized to the patient of interest to better control associated risks as both are equally effective techniques for speech rehabilitation in the long term.


Comparing primary versus secondary tracheoesophageal puncture prosthesis for speech rehabilitation post total laryngectomy

Background
Cochlear implantation (CI) surgery is the standard of care treatment for pediatric patients diagnosed with severe to profound sensorineural hearing loss. While considered a relatively safe operation, any invasive procedure involving the skull has risks. There are few recent studies in the United States that have analyzed complication rates among children who have received CI. Furthermore, existing studies fail to discuss specific risk factors that led to post-operative complications, nor offer solutions to reduce their incidence. This study aims to 1) determine the incidence of complications in pediatric CI patients and 2) identify evidence-based risk factors so pediatric otolaryngologists can better identify high-risk patients.

Methods
This is a single institution retrospective study analyzing the pre-, intra-, and post-operative data from 72 pediatric patients who underwent CI surgery between 2016 and 202. SPSS statistical software was used for statistical analysis. Data analysis included the prevalence of preoperative comorbidities, the incidence of postoperative complications, and the assessment of comorbidities versus complications using Chi-Squared tests.

Results
Patients were aged 8.9 months old to 25.8 years old with a mean age of 7.1 years old. Of the 72 patients, there were a total of 101 ears operated on. There were 24 total complications among the 101 ears, yielding an overall complication rate of 23.8%. The most common complication was an infection which occurred in 12.9% of ears. The second most common complication was dysgeusia (3.96%). Of the 72 patients, 72.2% had >1 preoperative comorbidity and 56.9% had an inner ear abnormality on imaging. The most common comorbidities were obesity (26.4%) and eustachian tube dysfunction (22.2%).

Conclusion
Cochlear implantation is a relatively safe procedure that can greatly improve hearing and overall quality of life in patients. Based on our data, there was an overall complication rate of 23.8% with the most common complications being infection and dysgeusia. Further statistical analysis is required before conclusions can be made regarding any correlation between preoperative risk factors and complication rates.


Complications of Pediatric Cochlear Implant Surgery

Background: Cystic fibrosis (CF) is a progressive, genetic disease caused by a mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene that disables the body's ability to move chloride to the cell surface. This subsequently causes patients to have chronic sinusitis and a plethora of symptoms. With the advent of modulator therapies for many CF patients, pulmonary function and nutritional status have improved. Their effects on sinus disease as well as the changing role of the otolaryngologist (ENT) is not yet clearly defined. 

Methods: Adult cystic fibrosis patients from Augusta University Adult Cystic Fibrosis Center were included in this study, with stratification of patients based on their demographics, specific gene mutation, modulator therapy, ENT clinic visits, history of polyps, history of nasal surgery, headaches, olfactory dysfunction, and sleep problems. Data was abstracted from the Port CF database and the electronic medical record after obtaining local IRB approval. 

Results: Out of the 98 adult CF patients, 54 were seen by an ENT after 2012. Sixty-one of them had a history of nasal or sinus surgery (62.24%) and 45 had a history of polyps (45.92%). 52% of the total patients were seen between the age ranges 20-29 years, with an equal distribution of male and female patients (27 of each). The most common race was white (83.33%). 42.6% had the commonest mutation F508del/F508del. The most common modulator treatment was elexacaftor/tezacaftor/ivacaftor (72.22%). 24% of patients saw ENT after having started elexacaftor/tezacaftor/ivacaftor therapy. 

Discussion: Sinus disease can contribute to substantial morbidity in CF patients even on modulator therapy with the majority of patients requiring surgical intervention at some point in their lifetime. Almost half of the patients have polyp history, which are known to recur and are difficult to treat adequately. Additionally, many patients have sinonasal symptoms that are untreated. An otolaryngologist, therefore, remains an integral part of the CF team. 

Significance to the audience: This data will help us understand the role of ENT in the standard care of CF patients for the purpose of planning evaluations, referrals, and interventions in the near future.

Sinus Symptoms in Cystic Fibrosis Patients on Modulator Therapy

Late onset sepsis in the NICU: differentiating CoNS from other bacteria and negative work-ups

Biking is a popular childhood activity that has an intrinsic risk of injury. While multiple advocacy groups have pushed for protective equipment to help mitigate these risks, to date, trends in the national health burden of fractures associated with biking in the pediatric population have not been explored in depth. The National Electronic Injury Surveillance System database was queried between 2001 and 2020 to identify fractures presenting to U.S. Emergency Departments associated with riding bicycles in patients aged ≤ 18 years. Analysis of the annual incidence over time was performed with linear regression to determine the significance of trends observed in the number of bicycle-related fractures. A total of 34,722 fractures were identified in the database, representing an estimated 1,019,509 fractures from 2001-2020, or 50,975 fractures annually. The average age was 10.15 years, and most patients were male (70.7%). Linear regression noted that the overall trend was significant for decreasing fractures over the time period (R2=0.9011; P<0.001). Patients struck by a motor vehicle were more likely to be hospitalized (27.1% vs. 5.3%; P<0.001) and more likely to sustain injuries to the axial skeleton (19.0% vs. 5.0%; P<0.001). The majority of patients who sustained a skull fracture were not wearing helmets at the time of injury (85.7%). Fractures in males were more likely to be at the shoulder (M: 12.5%, F: 5.4%; P<0.001) or hand (M: 5.0%, F: 2.6%; P<0.001), and fractures in females were more likely to be at the elbow (M: 7.6%, F: 9.5%; P<0.001) or wrist (M: 20.5%, F: 22.9%; P<0.001). The national burden of fractures associated with riding bicycles in pediatric populations has shown a steady decrease for many years. However, our research demonstrates alarming results regarding motor vehicle involvement and helmet use in pediatric bicycle fractures, as well as several differences across sex in injury patterns.

Pediatric Fractures Associated with Riding Bicycles: A National Twenty-Year Analysis

Background: Childhood obesity affects 1 in 3 children in the U.S. and is associated with a myriad of comorbidities. Executive functions (EF), including goal-directed behavior and self-management, are hypothesized to be impaired in obesity. Additionally, parental mental health issues such as depression, anxiety, and ADHD have seen a significant increase during the COVID-19 pandemic. The EF of children living with parents suffering from mental illnesses such as depression is likely to be impaired. To what degree parental mental health issues are associated with executive dysfunction (ED) in treatment seeking children with obesity is yet to be explored. The primary objective of this study was to compare the presence of ED in children with parents who have mental health diagnoses to those with parents who do not.

Methods: This was a double-blinded, cross-sectional study of 11-17 year old patients who were recruited from a multidisciplinary pediatric weight management (PWM) clinic. At initial appointments, all parents were asked about a family history of mental health diagnoses. Parents also completed the Behavior Rating Inventory of Executive Function-2 (BRIEF-2) parent form, to assess for ED in their presenting children. The scores that were analyzed from the BRIEF-2 assessments included the patients’ global executive composite (GEC), inhibit, and shift scores, which provide a global summary of all BRIEF-2 clinical scales, insight into impulsive behavior, and shifting attention between tasks, respectively. These scores were compared utilizing t-tests between the children of parents with and without mental health diagnoses.

Results: Of the 39 participants analyzed, 21 (53.8%) had one parent with a mental health diagnosis and 7 (17.9%) had both parents with a mental health diagnosis. Furthermore, 17 (43.5%) of the children had ED, 14 (35.9%) had problematic inhibit scores, and 19 (48.7%) had problematic shift scores. There were no significant differences in GEC, inhibit, and shift scores between children whose parents did and did not have mental health diagnoses, p = 0.07, 0.09, 0.08, respectively.

Conclusion: This study was underpowered to associate child ED with parental mental health diagnoses. Given that this is an interim analysis of an ongoing study, this association may be proven with a larger cohort. Of interest is that over half of our treatment seeking population had at least one parent with a mental health diagnosis, much higher than a global estimate of 15-23%. This suggests that parental mental health illnesses may be concentrated among children seeking PWM, over 70% of whom have severe obesity. Thus, further investigation is needed on how parental mental health illnesses impact patient PWM outcomes.


Next from AMA Research Challenge 2022

Trends in analgesic medication claims after primary total shoulder arthroplasty in patients with a mental health diagnosis.

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