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31.
Sariah Khormaee Andre M. Samuel William W. Schairer Peter B. Derman Alexander S. McLawhorn Michael C. Fu Todd J. Albert 《The spine journal》2019,19(3):430-436
BACKGROUND CONTEXT
Postdischarge care is a significant source of cost variability after posterior lumbar fusion surgery. However, there remains limited evidence associating postdischarge inpatient services and improved postoperative outcomes, despite the high cost of these services.PURPOSE
To determine the association between posthospital discharge to inpatient care facilities and postoperative complications.STUDY DESIGN
A retrospective review of all 1- to 3-level primary posterior lumbar fusion cases in the 2010-2014 National Surgical Quality Improvement Program registry was conducted. Propensity scores for discharge destination were determined based on observable baseline patient characteristics. Multivariable propensity-adjusted logistic regressions were performed to determine associations between discharge destination and postdischarge complications, with adjusted odds ratios (OR) and 95% confidence intervals (CI).RESULTS
A total of 18,652 posterior lumbar fusion cases were identified, 15,234 (82%) were discharged home, and 3,418 (18%) were discharged to continued inpatient care. Multivariable propensity-adjusted analysis demonstrated that being discharged to inpatient facilities was independently associated with higher risk of thromboembolic complications (OR [95% CI]: 1.79 [1.13–2.85]), urinary complications, (1.79 [1.27–2.51]), and unplanned readmissions (1.43 [1.22–1.68]).CONCLUSIONS
Discharge to continued inpatient care versus home after primary posterior lumbar fusion is independently associated with higher odds of certain major complications. To optimize clinical outcomes as well as cost savings in an era of value-based reimbursements, clinicians and hospitals should consider further investigation into carefully investigating which patients might be better served by home discharge after surgery. 相似文献32.
McLawhorn AS Sherman SL Blyakher A Widmann RF 《Journal of pediatric orthopedics. Part B》2011,20(2):111-116
Limb lengthening for humeral length discrepancy is typically accomplished using a traditional monolateral external fixator frame or an Ilizarov-type device, which have distinct shortcomings for the correction of concomitant deformity and application to the upper extremity, respectively. A new monolateral frame, the multiaxial correction (MAC) system, provides advantage over other monolateral frames and Ilizarov-type devices for humeral lengthening and may achieve similar outcomes. The purpose of this study was to report on the use of the MAC system for limb lengthening in pediatric patients, each with humeral length discrepancy and deformity. Surgical technique for applying the frame to the humerus is described briefly. A retrospective review of all pediatric patients with humeral length discrepancy treated with the MAC system by one orthopedic surgeon at a major teaching hospital was performed. Clinical data, operative records, and radiographs were reviewed for each patient. A total of three humeri in three children were lengthened over a 3-year period. There were two girls and a boy, with a mean age of 10.3 ± 1.9 years. Etiologies for their discrepancies were osteomyelitis and posttraumatic physeal arrest. Mean initial humeral length discrepancy was 9.4 ± 2.3 cm. All patients had proximal varus deformities, which were partially corrected during treatment. Mean lengthening was 6.5 ± 0.8 cm, and mean healing index was 27.1 ± 4.1 days/cm. Mean follow-up was 23.0 ± 9.9 months. There were no major complications. In conclusion, the MAC system is well suited to the correction of humeral length discrepancies and associated humeral deformities in children. Level of evidence: level IV case series. 相似文献
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34.
D. B. Earle J. R. Romanelli T. McLawhorn P. Omotosho P. Wu C. Rossini H. Swayze D. J. Desilets 《Hernia》2012,16(6):689-695
Purpose
Natural Orifice Translumenal Endoscopic Surgery (NOTES?) is a developing field in minimally invasive surgery that has been applied across a wide range of procedures; however, infectious concerns remain. Most of the applications have been for extraction, rather than reconstructive procedures. Prosthetic hernia repair, is a constructive procedure, has the unique challenge of avoiding contamination and infection of a permanent implant. Utilizing a novel device, we hypothesize that we can significantly reduce or eliminate prosthetic contamination during a transgastric approach for delivery of a clinically relevant, permanent, synthetic prosthetic.Methods
20 swine explants of stomach with attached esophagus were prepared by placing an ultraviolet (UV) light sensitive gel within the lumen of the stomach. Each stomach then underwent endoscopic gastrotomy utilizing a needle, wire guide, and 18-mm balloon dilator. A 10?×?15?cm polypropylene prosthetic was rolled and tied with a 2-0 silk suture, and delivered with one of two methods. Group A (control) utilized a snare to grasp the prosthetic adjacent to the endoscope, which was used to drag it through the gastrotomy. Group B (device) utilized a modified esophageal stent delivery system to deliver the prosthetic through the gastrotomy. Each prosthetic was then digitally photographed with UV illumination, with the contaminated areas illuminating brightly. Software analysis was performed on the photographs to quantify areas of contamination for each group. Statistical analysis was performed using a two-tailed t test with unequal variance.Results
Group A demonstrated a mean of 57?% of the surface area of the prosthetic contaminated with UV light sensitive gel. Group B (experimental group) showed a mean of 0.01?% of the surface area contaminated (p?<?0.0001). 95?% confidence intervals indicated that the unprotected delivery technique exposes approximately 6,000 times more of the surface area to contamination than the delivery device.Conclusion
Use of this modified stent delivery system can nearly eliminate prosthetic contamination when placed via a transgastric approach in a swine explants model. Theoretically, the reduced inoculum size would reduce or eliminate clinical infection. Since the inoculum size required for clinical prosthetic infection for intraperitoneal mesh is unknown, further study is warranted to test the ability to eliminate clinical infection related to prosthetic delivery with this technique. 相似文献35.
Alex Gu Adam J. Michalak Jordan S. Cohen Neil D. Almeida Alexander S. McLawhorn Peter K. Sculco 《The Journal of arthroplasty》2018,33(5):1598-1605
Background
Knee stiffness following primary total knee arthroplasty can lead to unsatisfactory patient outcomes secondary to persistent pain and loss of function. Manipulation under anesthesia (MUA) remains a viable option for treatment of post-operative stiffness. However, the optimal timing and clinical efficacy of manipulation of anesthesia remains unknown.Methods
A systematic review of the literature was performed to identify studies that reported clinical outcomes for patients who underwent MUA for post-operative stiffness treatment. Repeat MUA procedures were included in the study but were analyzed separately.Results
Twenty-two studies (1488 patients) reported on range of motion (ROM) after MUA, and 4 studies (81 patients) reported ROM after repeat MUA. All studies reported pre-MUA motion of less than 90°, while mean ROM at last follow-up exceeded 90° in all studies except 2. For studies reporting ROM improvement following repeat MUA, the mean pre-manipulation ROM was 80° and the mean post-manipulation ROM was 100.6°.Conclusion
MUA remains an efficacious, minimally invasive treatment option for post-operative stiffness following TKA. MUA provides clinically significant improvement in ROM for most patients, with the best outcomes occurring in patients treated within 12 weeks post-operatively.Prospero Registration Number
CRD42016052215. 相似文献36.
Joseph F. Konopka Robert L. Buly Bryan T. Kelly Edwin P. Su Alexander S. McLawhorn 《The Journal of arthroplasty》2018,33(6):1806-1812
Background
A significant number of patients who undergo hip arthroscopy will subsequently undergo total hip arthroplasty (THA) or hip resurfacing arthroplasty (HRA), although limited evidence exists regarding effects of prior hip arthroscopy on the outcomes of these procedures.Methods
Of 5091 patients who underwent hip arthroscopy, we identified 69 patients who underwent subsequent THA (46) or HRA (23). Patients were matched to patients with no history of hip arthroscopy. Preoperative and 2-year postoperative Hip disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Lower Extremity Activity Scale score, and satisfaction surveys were compared.Results
Patients who underwent THA with history of arthroscopy had lower postoperative Hip disability and Osteoarthritis Outcome Score Pain (82 ± 16 vs 93 ± 9, P = .003), Stiffness (85 ± 16 vs 93 ± 15, P = .01), Sports and Recreation (71 ± 22 vs 88 ± 18, P = .003), Quality-of-Life (65 ± 22 vs 86 ± 11, P < .0001), WOMAC Pain (86 ± 16 vs 93 ± 15, P = .03), WOMAC Stiffness (80 ± 21 vs 88 ± 17, P = .05), and Short Form-12 Physical Component Scores (48 ± 11 vs 54 ± 6, P = .008). They were less likely to be “very satisfied” after arthroplasty (71% vs 89%, P = .0008).Conclusion
Hip arthroscopy before hip arthroplasty is associated with slightly lower results in several patient-reported outcomes. These results are relevant when assessing patients for hip arthroscopy and when counseling prospective arthroplasty patients with history of arthroscopy. 相似文献37.
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Leonard T. Buller Alexander S. McLawhorn Joseph D. Maratt Kaitlin M. Carroll David J. Mayman 《The Journal of arthroplasty》2021,36(3):1143-1148
BackgroundTemplating is a critical part of preoperative planning for total hip arthroplasty (THA). The accuracy of templating on images acquired with EOS is unknown. This study sought to compare the accuracy and reproducibility of templating for THA using EOS imaging to conventional digital radiographs.MethodsForty-three consecutive primary unilateral THAs were retrospectively templated, six months postoperatively, using preoperative 2D EOS imaging and conventional radiographs. Two blinded observers templated each case for acetabular and femoral component size and femoral offset. The retrospectively templated sizes were compared to the sizes selected during surgery. Interobserver agreement was calculated, and the influence of demographic variables was explored.ResultsEOS templating predicted the exact acetabular and femoral size in 71% and 66% of cases, respectively, and to within one size in 98% of cases. The acetabular and femoral component size was more likely to be templated to the exact size using EOS compared to conventional imaging (P < .05). The femoral component offset choice was accurately predicted in 83% of EOS cases compared to 80% of conventional templates (P = .341). Component size and offset were not influenced by patient age, gender, laterality, or BMI. Interobserver agreement was excellent for acetabular (Cronbach’s alpha = 0.94) and femoral (Cronbach’s alpha = 0.96) component size.ConclusionsPreoperative templating for THA using EOS imaging is accurate, with an excellent interobserver agreement. EOS exposes patients to less radiation than traditional radiographs, and its three-dimensional applications should be explored as they may further enhance preoperative plans. 相似文献
39.
Alexander S. McLawhorn Leonard T. Buller 《Current reviews in musculoskeletal medicine》2017,10(3):370-377
Purpose of review
The purpose of this review was to evaluate the literature regarding bundle payment reimbursement models for total joint arthroplasty (TJA).Recent findings
From an economic standpoint, TJA are cost-effective, but they represent a substantial expense to the Centers for Medicare & Medicaid Services (CMS). Historically, fee-for-service payment models resulted in highly variable cost and quality. CMS introduced Bundled Payments for Care Improvement (BPCI) in 2012 and subsequently the Comprehensive Care for Joint Replacement (CJR) reimbursement model in 2016 to improve the value of TJA from the perspectives of both CMS and patients, by improving quality via cost control.Summary
Early results of bundled payments are promising, but preserving access to care for patients with high comorbidity burdens and those requiring more complex care is a lingering concern. Hospitals, regardless of current participation in bundled payments, should develop care pathways for TJA to maximize efficiency and patient safety.40.
Alexander S. McLawhorn Michael E. Steinhaus Daniel L. Southren Yuo-Yu Lee Emily R. Dodwell Mark P. Figgie 《The Journal of arthroplasty》2017,32(1):143-149