Chad Cook

The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty

BACKGROUND As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital peri-operative complications following lower extremity total joint arthroplasty. METHODS From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-I and Type-II diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities. RESULTS Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001). CONCLUSIONS Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.

Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests

Objective: To compile and critique research on the diagnostic accuracy of individual orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice. Methods: A computer-assisted literature search of MEDLINE, CINAHL, and SPORTDiscus databases (1966 to October 2006) using keywords related to diagnostic accuracy of physical examination tests of the shoulder. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to critique the quality of each paper. Meta-analysis through meta-regression of the diagnostic odds ratio (DOR) was performed on the Neer test for impingement, the Hawkins−Kennedy test for impingement, and the Speed test for superior labral pathology. Results: Forty-five studies were critiqued with only half demonstrating acceptable high quality and only two having adequate sample size. For impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 79% and 53%, respectively, and for the Hawkins−Kennedy test was 79% and 59%, respectively. For superior labral (SLAP) tears, the summary sensitivity and specificity of the Speed test was 32% and 61%, respectively. Regarding orthopaedic special tests (OSTs) where meta-analysis was not possible either due to lack of sufficient studies or heterogeneity between studies, the list that demonstrates both high sensitivity and high specificity is short: hornblowers’s sign and the external rotation lag sign for tears of the rotator cuff, biceps load II for superior labral anterior to posterior (SLAP) lesions, and apprehension, relocation and anterior release for anterior instability. Even these tests have been under-studied or are from lower quality studies or both. No tests for impingement or acromioclavicular (AC) joint pathology demonstrated significant diagnostic accuracy. Conclusion: Based on pooled data, the diagnostic accuracy of the Neer test for impingement, the Hawkins−Kennedy test for impingement and the Speed test for labral pathology is limited. There is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the numerous physical examination tests of the shoulder. Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.

Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests

Objective To update our previously published systematic review and meta-analysis by subjecting the literature on shoulder physical examination (ShPE) to careful analysis in order to determine each tests clinical utility. Methods This review is an update of previous work, therefore the terms in the Medline and CINAHL search strategies remained the same with the exception that the search was confined to the dates November, 2006 through to February, 2012. The previous study dates were 1966 – October, 2006. Further, the original search was expanded, without date restrictions, to include two new databases: EMBASE and the Cochrane Library. The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper. Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models. Results Since the publication of the 2008 review, 32 additional studies were identified and critiqued. For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 72% and 60%, respectively, for the Hawkins-Kennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively. Also from the meta-analysis, regarding superior labral anterior to posterior (SLAP) tears, the test with the best sensitivity (52%) was the relocation test; the test with the best specificity (95%) was Yergasons test; and the test with the best positive likelihood ratio (2.81) was the compression-rotation test. Regarding new (to this series of reviews) ShPE tests, where meta-analysis was not possible because of lack of sufficient studies or heterogeneity between studies, there are some individual tests that warrant further investigation. A highly specific test (specificity >80%, LR+ ≥ 5.0) from a low bias study is the passive distraction test for a SLAP lesion. This test may rule in a SLAP lesion when positive. A sensitive test (sensitivity >80%, LR− ≤ 0.20) of note is the shoulder shrug sign, for stiffness-related disorders (osteoarthritis and adhesive capsulitis) as well as rotator cuff tendinopathy. There are six additional tests with higher sensitivities, specificities, or both but caution is urged since all of these tests have been studied only once and more than one ShPE test (ie, active compression, biceps load II) has been introduced with great diagnostic statistics only to have further research fail to replicate the results of the original authors. The belly-off and modified belly press tests for subscapularis tendinopathy, bony apprehension test for bony instability, olecranon-manubrium percussion test for bony abnormality, passive compression for a SLAP lesion, and the lateral Jobe test for rotator cuff tear give reason for optimism since they demonstrated both high sensitivities and specificities reported in low bias studies. Finally, one additional test was studied in two separate papers. The dynamic labral shear may be sensitive for SLAP lesions but, when modified, be diagnostic of labral tears generally. Conclusion Based on data from the original 2008 review and this update, the use of any single ShPE test to make a pathognomonic diagnosis cannot be unequivocally recommended. There exist some promising tests but their properties must be confirmed in more than one study. Combinations of ShPE tests provide better accuracy, but marginally so. These findings seem to provide support for stressing a comprehensive clinical examination including history and physical examination. However, there is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the many aspects of the clinical examination and what combinations of these aspects are useful in differentially diagnosing pathologies of the shoulder.

The Impact of Diabetes on Perioperative Patient Outcomes After Total Hip and Total Knee Arthroplasty in the United States

The purpose of this study was to determine whether patients with diabetes mellitus (DM) have a higher likelihood of immediate, inpatient complications following primary and revision total hip (THA) and total knee arthroplasty (TKA) than patients without DM. From 1988 to 2003, the Nationwide Inpatient Sample identified 751340 primary or revision THA or TKA patients. 64262 (8.55%) had DM. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed using bivariate and multivariate analyses with logistic regression modeling. Diabetic patients had fewer routine discharges and higher inflation-adjusted hospital charges for all procedures. Although complications were not uniformly increased, diabetic patients had significantly increased odds of pneumonia, stroke, and transfusion (P < .001) after primary arthroplasty. This analysis of a large patient database indicates clinically relevant information for patients and surgeons, suggesting that patients undergoing THA and TKA demonstrate more complications and utilize more resources if they have the comorbidity of DM level II evidence.

Cross-Cultural Adaptation and Validation of the Brazilian Portuguese Version of the Neck Disability Index and Neck Pain and Disability Scale

Study Design. This studys design was a cross-cultural validation of the Neck Disability Index and Neck Pain and Disability Scale. Objectives. This studys objective was to translate, culturally adapt, and validate a Brazilian Portuguese version of the Neck Disability Index (NDI-BR) and the Neck Pain and Disability Scale (NPDS-BR). Summary of Background Data. Although several valid measures exist for measurement of neck pain and functional impairment, these measures have yet been validated in Brazilian Portuguese. Successful linguistic and cultural translation may allow appropriate cross-cultural comparison for clinical and laboratory research analysis. Methods. The NDI-BR and NPAD-BR were culturally and linguistically translated from English into Brazilian Portuguese. The translated version of the instrument was administered to 203 patients at a midsize hospital in southern Brazil. Psychometric evaluation included factor analysis, internal reliability measures, test-retest reliability at 1 and 7 days, and criterion validity comparison with the Brazilian version of the SF-36. Results. Factor analyses demonstrated a single-factor subscale for the NDI-BR and three subscales for the NPDS-BR. An item analysis showed a high degree of internal consistency for the NDI-BR (r = 0.74) and the three subscales of the NPDS-BR (subscale 1, r = 0.89; subscale 2, r = 0.81; subscale 3, r = 0.72). Test-retest reliability was also acceptable at for the NDI-BR (0.98 at baseline and 0.48 at 7 days) and subset one (0.96 at baseline and 0.91 at 7 days), subset 2 (0.96 at baseline and 0.62 at 7 days), and subset 3 (0.52 at baseline and 0.45 at 7 days) of the NPDS-BR. Construct validity was established during comparison of the Brazilian version of the SF-36. Only items associated with physical role, bodily pain, and emotional role failed significant correlation. Conclusions. A reliable and valid Portuguese version of the Neck Disability Index and Neck Pain and DisabilityScale was developed, which will facilitate the examination of functional performance within a large patient population, as well as cross-cultural comparisons.

Clinimetrics Corner: The Minimal Clinically Important Change Score (MCID): A Necessary Pretense

Abstract Minimal clinically important differences (MCID) are patient derived scores that reflect changes in a clinical intervention that are meaningful for the patient. At present, there are a number of different methods to obtain an MCID, as there a number of different factors that can influence the MCID value. This clinimetric corner outlines the hidden challenges associated with identifying a viable MCID and possible suggestions to improve the future development of these single scores.

Diabetes and early postoperative outcomes following lumbar fusion.

Study Design. Retrospective cohort study using data from the Nationwide Inpatient Sample administrative data from 1988 through 2003. Objective. To examine perioperative morbidity and mortality for patients with and without diabetes mellitus following lumbar spinal fusion. Summary of Background Data. Diabetes has been associated with worse outcomes in a variety of orthopedic procedures including spinal surgery. There is limited evidence that diabetic patients have more complications following lumbar fusion with little published data to support this conclusion. Methods. Data from 197,461 patients who underwent lumbar fusion were included. Over 11,000 patients (5.6%) with a postoperative diagnosis of diabetes mellitus were identified. Selected variables were used for comparison of patients with and without diabetes. Bivariate statistical analyses compared postoperative complication rates while multivariate statistics were used to determine likelihood of complications with diabetes. Results. Bivariate analysis demonstrated that diabetes was significantly associated with postoperative infection, need for transfusion, pneumonia, in-hospital mortality, and nonroutine discharge (P ≤ 0.001). Adjusted multivariate regression analyses, however, suggested no difference in mortality although infection, transfusion, and nonroutine discharge continued to be highly significant (P ≤ 0.002). Significantly higher inflation adjusted total charges were also present with patients with diabetes as well as increased lengths of stay (P < 0.001). Conclusion. This nationally representative study of inpatients in the United States provides evidence that diabetes is associated with increased risk for postoperative complications, nonroutine discharge, increased total hospital charges, and length of stay following lumbar fusion. Prospective studies to determine causality as well as the potential impact of diabetes control on these variables have not yet been done.

A Comparison of 3 Methodological Approaches to Defining Major Clinically Important Improvement of 4 Performance Measures in Patients With Hip Osteoarthritis

STUDY DESIGN Prospective cohort study. OBJECTIVES To establish the major clinically important improvement (MCII) of the timed up-and-go test (TUG), 40-meter self-paced walk test (40-m SPWT), 30-second chair stand (30 CST), and a 20-cm step test in patients with hip osteoarthritis (OA) undergoing physiotherapy treatment. As a secondary aim, a comparison of methods was employed to evaluate the effect of method on the reported MCII. BACKGROUND Minimal clinically important difference scores are commonly used by rehabilitation professionals to determine patient response following treatment. A gold standard for calculating MCII has yet to be determined, which has resulted in problems of interpretation due to varied results. METHODS As part of a randomized controlled trial, 65 patients were randomized into a physiotherapy treatment group for hip OA, in which they completed 4 physical performance measures at baseline and 9 weeks. Upon completion of physiotherapy, patients assessed their response to treatment on a 15-point global rating of change scale (GRCS). MCII was estimated using 3 variations of an anchor-based method, based on the patients opinion. RESULTS A comparison of 3 methods resulted in the following change scores being best associated with our definition of MCII: a reduction equal to or greater than 0.8, 1.4, and 1.2 seconds for the TUG; an increase equal to or greater than 0.2, 0.3, and 0.2 m/s for the 40-m SPWT; an increase equal to or greater than 2.0, 2.6, and 2.1 repetitions for the 30 CST; an increase equal to or greater than 5.0, 12.8, and 16.4 steps for the 20-cm step test. CONCLUSION The variation in methods provided very different results. This illustrates the importance of comparing methodologies and reporting a range of values associated with the MCII, as such values vary, depending upon the methodology chosen.

Impact of surgical approach on complications and resource utilization of cervical spine fusion: a nationwide perspective to the surgical treatment of diffuse cervical spondylosis

BACKGROUND CONTEXT Cervical spine fusion is performed for various indications in patient populations ranging from young and healthy to aged and frail. The choice of surgical approach is affected not only by disease pathoanatomy, but also by age, medical comorbidities, and the number of involved levels. Anterior fusion is more common for single-level pathology in relatively young, healthy patients; and posterior fusion is typically performed on older, more comorbid patients with multilevel disease. Consequently, retrospective comparisons of surgical approaches for cervical fusion will be impacted by this bias, and the optimal management of multilevel cervical spine pathology remains ambiguous with surgeon preference and experience playing a significant role in choice of procedures. PURPOSE To define the complications and resource utilization related to multilevel cervical spine fusion surgery, and to evaluate the impact of surgical approach on these outcomes. STUDY DESIGN/SETTING A retrospective nationwide database study of inpatient perioperative complications. PATIENT SAMPLE All patients undergoing multilevel (four to eight levels) cervical spine fusion for degenerative disease between 2003 and 2005 at institutions represented in the Nationwide Inpatient Sample database. OUTCOME MEASURES Measures of patient periprocedural mortality, selected specific morbidities, and resource utilization were evaluated. Resource utilization included length of hospitalization, inflation-adjusted cost, and likelihood of nonroutine discharge to assisted living. METHODS Data for 8,548 patients who underwent cervical fusion of four to eight levels were collected from the Nationwide Inpatient Sample database (2003-2005), and subjects were grouped by surgical approach (anterior vs. posterior). Descriptive statistics compared baseline characteristics, and bivariate analysis and logistic regression modeling evaluated the effect of surgical approach on mortality, selected postoperative complications, length of stay, hospitalization cost, and discharge disposition. All tests were performed at the 0.05 level of significance. RESULTS This observational study indicates that a posterior approach to multilevel cervical fusion is associated with more respiratory complications, postoperative infections, symptomatic hematomas, and transfusions when compared with an anterior approach. Resource utilization was nearly double for those undergoing a posterior approach, including hospital length of stay, inflation-adjusted cost, and likelihood of discharge to an assisted-living facility. Not surprisingly, this study confirms that patients fused posteriorly had a lower incidence of symptomatic postoperative dysphagia. CONCLUSIONS This nationwide study defines the incidence of mortality and the frequency of inpatient complications encountered during multilevel cervical fusion. The results suggest that immediate morbidity from anterior approaches is less than those undergoing posterior fusion. Prospective analysis is required to evaluate if these findings remain significant in a randomized study population. Further, these results represent only perioperative complications. However, based on the data presented herein, when confronted with the patient requiring a four-level cervical fusion, the anterior approach may offer a less risky and less costly option.

Variables Associated With the Progression of Hip Osteoarthritis: A Systematic Review

OBJECTIVE As populations age and the prevalence of hip osteoarthritis (OA) increases, health care providers must manage increasing demands for services. Evidence regarding the progression of hip OA can assist health care practitioners in determining expected patient prognosis and planning care. This systematic review of prospective cohort studies examines prognostic variables in patients with hip OA. METHODS Articles were selected following a comprehensive search of Medline, EMBase, CINAHL, and Allied and Complementary Medicine from database inception to October 2008 and hand searches of the reference lists of retrieved articles. Inclusion criteria involved 1) estimates of the association between prognostic variables and progression of OA, 2) prospective cohort design, 3) patients diagnosed with hip OA based on established criteria, 4) at least 1 year of followup, and 5) access to the full published text. Two independent reviewers assessed the methodologic quality of each study and the association between prognostic variables and OA progression. RESULTS Eighteen articles met the inclusion criteria; 17 were considered to be of high quality. Strong evidence of progression was associated with age, joint space width at entry, femoral head migration, femoral osteophytes, bony sclerosis, Kellgren/Lawrence hip grade 3, baseline hip pain, and Lequesne index score > or =10. Strong evidence of no association with progression was associated with acetabular osteophytes. Evidence was weak or inconclusive regarding associations between various other radiographic or clinical variables, molecular biomarkers, or use of nonsteroidal inflammatory drugs. CONCLUSION Overall, few variables were found to be strongly associated with the progression of hip OA, and a variety of other variables were weakly predictive of outcome.