Paul T. Ogink

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

Background: Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate. Purpose: To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans. Study Design: Case series; Level of evidence, 4. Methods: Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES. Results: Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° (P < .001); extension deficit slightly improved from 8° to 3° (P < .001). Pronation (P = .47) and supination did not improve (P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non–elbow-related reasons. No complications were recorded. Conclusion: Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.

Reoperation After Combined Injury of the Index Finger: Repair Versus Immediate Amputation

PURPOSE To identify factors associated with unplanned reoperation of severely injured index fingers and to address the number of amputations after initial repair. METHODS In this retrospective study, we included all patients older than 18 years of age who had repair or immediate amputation for combined index finger injury at 2 level I trauma centers and 1 community hospital tied to a level I trauma center between January 2004 and February 2014. Twelve patients were excluded because of inadequate follow-up. Bivariate and multivariable analyses sought factors associated with unplanned reoperation after repair and immediate amputation. RESULTS Among 114 patients with combined injury, 75 were treated with repair and 39 with immediate amputation. A total of 41 patients had an unplanned reoperation, 33 after repair (44%) and 8 after immediate amputation (21%). In multivariable analysis, patients who had a reoperation for fingers other than the index finger were at risk for unplanned reoperation after repair. Women were more likely to have an unplanned reoperation than men, and patients who had a ray amputation were at risk for unplanned reoperation after immediate amputation. Six patients (18%) had amputation after initial repair. CONCLUSIONS Surgeons may counsel patients that they are twice as likely to have an unplanned reoperation after a repair for combined injury of the index finger compared with an immediate amputation. Unplanned reoperations were more common among patients with injuries involving multiple fingers. Effective shared decision making is particularly important in this setting given that 1 in 5 repaired index fingers were eventually amputated. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Development of Machine Learning Algorithms for Prediction of 5-Year Spinal Chordoma Survival

BACKGROUND Chordomas are locally invasive slow-growing tumors that are difficult to study because of the rarity of the tumors and the lack of significant volumes of patients with longitudinal follow-up. As such, there are currently no machine learning studies in the chordoma literature. The purpose of this study was to develop machine learning models for survival prediction and deploy them as open access web applications as a proof of concept for machine learning in rare nervous system lesions. METHODS The National Cancer Institutes Surveillance, Epidemiology, and End Results program database was used to identify adult patients diagnosed with spinal chordoma between 1995 and 2010. Four machine learning models were used to predict 5-year survival for spinal chordoma and assessed by discrimination, calibration, and overall performance. RESULTS The 5-year overall survival for 265 patients with spinal chordoma was 67.5%. Variables used for prediction were age at diagnosis, tumor size, tumor location, extent of tumor invasion, and extent of surgery. For 5-year survival prediction, the Bayes Point Machine achieved the best performance with a c statistic of 0.80, calibration slope of 1.01, calibration intercept of 0.03, and Brier score of 0.16. This model for 5-year mortality prediction was incorporated into an open access application and can be found online (https://sorg-apps.shinyapps.io/chordoma/). CONCLUSIONS This analysis of patients with spinal chordoma demonstrated that machine learning models can be developed for survival prediction in rare pathologies and have the potential to serve as the basis for creation of decision support tools in the future.

Independent predictors of spinal epidural abscess recurrence

BACKGROUND CONTEXT Recurrence of spinal epidural abscess (SEA) after treatment is an important cause of continued morbidity for patients. PURPOSE The purpose of this study was to identify independent predictors of recurrence of SEA. STUDY DESIGN/SETTING This was a retrospective, case-control study. PATIENT SAMPLE Patients 18 years or older with a diagnosis of SEA admitted to our hospital system during the study period were included in the study sample. OUTCOME MEASURES The outcome measure was recurrence of SEA, defined as a reaccumulation of pus or infected granulation tissue in the epidural space after initial treatment. METHODS All patients older than 18 years admitted to our hospital system with a diagnosis of SEA from 1993 to 2016 were identified, and explanatory variables and outcomes were collected retrospectively. Patients 18 years or older diagnosed with SEA were included. We excluded patients whose treatment was initiated at an outside institution. Bivariate and multivariate analyses were performed to identify independent predictors of recurrence. RESULTS We identified 1,053 patients with SEA. We only considered patients to be recurrence-free if they had no documented recurrence with greater than 20 weeks of follow-up. Five hundred thirty-four patients were recurrence-free and 38 had documented recurrence, yielding 572 patients who were included in this analysis. Bivariate and multivariate analyses identified three independent predictors of recurrence: history of intravenous drug use, fecal incontinence or retention, and local spinal wound infection. CONCLUSIONS Patients with SEA who have a history of intravenous drug use, bowel dysfunction at presentation, or concurrent local spinal wound infection are at increased risk of disease recurrence. These patients ought to be closely followed up after discharge, with frequent serial imaging and aggressive antibiotic treatment.

Variation in costs among surgeons for lumbar spinal stenosis

BACKGROUND CONTEXT Lumbar spinal stenosis is a common condition in the elderly for which costs vary substantially by region. Comparing differences between surgeons from a single institution, thereby omitting regional variation, could aid in identifying factors associated with higher costs and individual drivers of costs. The use of decision aids (DAs) has been suggested as one of the possible tools for diminishing costs and cost variation. PURPOSE (1) To determine factors associated with higher costs for treatment of spinal stenosis in the first year after diagnosis in a single institution; (2) to find individual drivers of costs for providers with higher costs; and (3) to determine if the use of DAs can decrease costs and cost variability. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE A total of 10,858 patients in 18 different practices diagnosed with lumbar spinal stenosis between January 2003 and July 2015 in three associated hospitals of a single institution. OUTCOME MEASURES Mean cost for a patient per provider in US dollars within 1 year after diagnosis of lumbar spinal stenosis. METHODS We collected all diagnostic testing, office visits, injections, surgery, and occupational or physical therapy related to lumbar spinal stenosis within 1 year after initial diagnosis. We used multivariable linear regression to determine independent predictors for costs. Providers were grouped in tiers based on mean total costs per patient to find drivers of costs. To assess the DAs effect on costs and cost variability, we matched DA patients one-to-one with non-DA patients. RESULTS Male gender (β 0.10, 95% confidence interval [CI] 0.05-0.15, p<.001), seeing an additional provider (β 0.77, 95% CI 0.69-0.86, p<.001), and having an additional spine diagnosis (β 0.79, 95% CI 0.74-0.84, p<.001) were associated with higher costs. Providers in the high cost tier had more office visits (p<.001), more imaging procedures (p<.001), less occupational or physical therapy (p=.002), and less surgery (p=.001) compared with the middle tier. Eighty-two patients (0.76%) received a DA as part of their care; there was no statistically significant difference between the DA group and the matched group in costs (p=.975). CONCLUSIONS Male gender, seeing an additional provider, and having an additional spine diagnosis were independently associated with higher costs. The main targets for cost reduction we found are imaging procedures and number of office visits. Decision aids were not found to affect cost.