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Article: Important Lessons Learned From Nearly a Half-Century of Orthopedic Practice.

Fleischman, Andrew N / Rothman, Richard H

2017 Volume 5, Issue 4, Page(s) 206–207

Language	English
Publishing date	2017-09-05
Publishing country	Iran
Document type	Editorial
ZDB-ID	2782053-1
ISSN	2345-461X ; 2345-4644
ISSN (online)	2345-461X
ISSN	2345-4644
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Article ; Online: Intravenous versus oral acetaminophen for pain and quality of recovery after ambulatory spine surgery: a randomized controlled trial.

Schwenk, Eric S / Ferd, Polina / Torjman, Marc C / Li, Chris J / Charlton, Alex R / Yan, Vivian Z / McCurdy, Michael A / Kepler, Christopher K / Schroeder, Gregory D / Fleischman, Andrew N / Issa, Tariq

Regional anesthesia and pain medicine

2024

Abstract: Introduction: As ambulatory spine surgery increases, efficient recovery and discharge become essential. Multimodal analgesia is superior to opioids alone. Acetaminophen is a central component of multimodal protocols and both intravenous and oral forms ... ...

Abstract	Introduction: As ambulatory spine surgery increases, efficient recovery and discharge become essential. Multimodal analgesia is superior to opioids alone. Acetaminophen is a central component of multimodal protocols and both intravenous and oral forms are used. While some advantages for intravenous acetaminophen have been touted, prospective studies with patient-centered outcomes are lacking in ambulatory spine surgery. A substantial cost difference exists. We hypothesized that intravenous acetaminophen would be associated with fewer opioids and better recovery. Methods: Patients undergoing ambulatory spine surgery were randomized to preoperative oral placebo and intraoperative intravenous acetaminophen or preoperative oral acetaminophen. All patients received general anesthesia and multimodal analgesia. The primary outcome was 24-hour opioid use in intravenous morphine milligram equivalents (MMEs), beginning with arrival to the postanesthesia care unit (PACU). Secondary outcomes included pain, Quality of Recovery (QoR)-15 scores, postoperative nausea and vomiting, recovery time, and correlations between pain catastrophizing, QoR-15, and pain. Results: A total of 82 patients were included in final analyses. Demographics were similar between groups. For the primary outcome, the median 24-hour MMEs did not differ between groups (12.6 (4.0, 27.1) vs 12.0 (4.0, 29.5) mg, p=0.893). Postoperative pain ratings, PACU MMEs, QoR-15 scores, and recovery time showed no differences. Spearman's correlation showed a moderate negative correlation between postoperative opioid use and QoR-15. Conclusion: Intravenous acetaminophen was not superior to the oral form in ambulatory spine surgery patients. This does not support routine use of the more expensive intravenous form to improve recovery and accelerate discharge. Trial registration number: NCT04574778.
Language	English
Publishing date	2024-03-18
Publishing country	England
Document type	Journal Article
ZDB-ID	1425299-5
ISSN	1532-8651 ; 1098-7339 ; 0146-521X
ISSN (online)	1532-8651
ISSN	1098-7339 ; 0146-521X
DOI	10.1136/rapm-2024-105386
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Article: Local Intra-wound Administration of Powdered Antibiotics in Orthopaedic Surgery.

Fleischman, Andrew N / Austin, Matthew S

Journal of bone and joint infection

2017 Volume 2, Issue 1, Page(s) 23–28

Abstract: Surgical site infection (SSI) is one of the most common complications after orthopaedic surgery, leading to significant morbidity and its associated costs. Surgical guidelines strongly recommend the use of systemic antibiotic prophylaxis to reduce the ... ...

Abstract	Surgical site infection (SSI) is one of the most common complications after orthopaedic surgery, leading to significant morbidity and its associated costs. Surgical guidelines strongly recommend the use of systemic antibiotic prophylaxis to reduce the risk for developing SSI. Locally administered powdered antibiotics have the potential to provide remarkably high intra-wound concentrations without risk for systemic toxicity. However, a paucity of high quality evidence in the orthopaedic literature has prevented widespread adoption of this technique. The majority of clinical studies on local intra-wound antibiotics have evaluated the use of topical powdered vancomycin in spinal surgery, though only a single prospective study currently exists. This review will discuss all the available evidence describing the effectiveness, pharmacokinetics, and potential adverse effects with the use of topical powdered antibiotics in orthopedic surgery.
Language	English
Publishing date	2017-01-01
Publishing country	Germany
Document type	Journal Article ; Review
ISSN	2206-3552
ISSN	2206-3552
DOI	10.7150/jbji.16649
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Article ; Online: The Penn State Protein Ladder system for inexpensive protein molecular weight markers.

Santilli, Ryan T / Williamson, John E / Shibata, Yoshitaka / Sowers, Rosalie P / Fleischman, Andrew N / Tan, Song

Scientific reports

2021 Volume 11, Issue 1, Page(s) 16703

Abstract: We have created the Penn State Protein Ladder system to produce protein molecular weight markers easily and inexpensively (less than a penny a lane). The system includes plasmids which express 10, 15, 20, 30, 40, 50, 60, 80 and 100 kD proteins in E. coli. ...

Abstract	We have created the Penn State Protein Ladder system to produce protein molecular weight markers easily and inexpensively (less than a penny a lane). The system includes plasmids which express 10, 15, 20, 30, 40, 50, 60, 80 and 100 kD proteins in E. coli. Each protein migrates appropriately on SDS-PAGE gels, is expressed at very high levels (10-50 mg per liter of culture), is easy to purify via histidine tags and can be detected directly on Western blots via engineered immunoglobulin binding domains. We have also constructed plasmids to express 150 and 250 kD proteins. For more efficient production, we have created two polycistronic expression vectors which coexpress the 10, 30, 50, 100 kD proteins or the 20, 40, 60, 80 kD proteins. 50 ml of culture is sufficient to produce 20,000 lanes of individual ladder protein or 3750 lanes of each set of coexpressed ladder proteins. These Penn State Protein Ladder expression plasmids also constitute useful reagents for teaching laboratories to demonstrate recombinant expression in E. coli and affinity protein purification, and to research laboratories desiring positive controls for recombinant protein expression and purification.
MeSH term(s)	Cloning, Molecular ; Electrophoresis, Polyacrylamide Gel/standards ; Escherichia coli/chemistry ; Escherichia coli/genetics ; Molecular Weight ; Plasmids ; Recombinant Proteins/chemistry ; Recombinant Proteins/genetics ; Reference Standards
Chemical Substances	Recombinant Proteins
Language	English
Publishing date	2021-08-18
Publishing country	England
Document type	Journal Article ; Research Support, N.I.H., Extramural
ZDB-ID	2615211-3
ISSN	2045-2322 ; 2045-2322
ISSN (online)	2045-2322
ISSN	2045-2322
DOI	10.1038/s41598-021-96051-x
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Article: Periprosthetic fractures around the femoral stem: overcoming challenges and avoiding pitfalls.

Fleischman, Andrew N / Chen, Antonia F

Annals of translational medicine

2015 Volume 3, Issue 16, Page(s) 234

Abstract: Management of periprosthetic fractures around the femoral stem after total hip arthroplasty (THA) represents a significant challenge and optimal treatment remains controversial. The most common treatment paradigm involves treating fractures around a well- ...

Abstract	Management of periprosthetic fractures around the femoral stem after total hip arthroplasty (THA) represents a significant challenge and optimal treatment remains controversial. The most common treatment paradigm involves treating fractures around a well-fixed stem with osteosynthesis, whereas fractures around a loose stem require revision arthroplasty and those with poor bone require augmentation with bone graft. Paradoxically, the literature reports a higher rate of failure for osteosynthesis around prostheses considered to be well-fixed. Such a high rate of poor outcomes may result not only from difficult fracture fixation and compromised biologic healing, but also from unrecognized peri-implant pathology. Therefore, proper preoperative and intraoperative evaluation is key, and a subset of patients may benefit from alternative management. We review the appropriate methods for evaluation and treatment of Vancouver type B fractures with particular emphasis on avoiding missteps that can lead to failure.
Language	English
Publishing date	2015-10-20
Publishing country	China
Document type	Journal Article ; Review
ZDB-ID	2893931-1
ISSN	2305-5847 ; 2305-5839
ISSN (online)	2305-5847
ISSN	2305-5839
DOI	10.3978/j.issn.2305-5839.2015.09.32
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Article ; Online: Higher Prevalence of Concomitant Shoulder Labral Tears in Patients With Femoroacetabular Impingement.

Vahedi, Hamed / Fleischman, Andrew N / Salvo, John P / Parvizi, Javad

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association

2019 Volume 35, Issue 4, Page(s) 1074–1079.e1

Abstract: ... in the FAO group (58.0%, n = 257) compared with those in the ACL group (48.9%, n = 150). The prevalence ...

Abstract	Purpose: To examine the prevalence of concomitant symptomatic glenoid labral tears in patients with femoroacetabular impingement (FAI) in comparison to a control group of patients undergoing anterior cruciate ligament (ACL) reconstruction. Methods: We retrospectively identified 1,644 patients who underwent femoroacetabular osteoplasty (FAO) and labrum repair from January 2007 to September 2016 and 1,055 patients who underwent arthroscopic ACL reconstruction from January 2012 to December 2014, which acted as our control group. An electronic questionnaire, including 8 questions regarding history of shoulder pathology, was sent to all patients in both groups. Symptomatic shoulder labral tears were identified on the basis of a positive magnetic resonance imaging scan or history of labral repair by reviewing patients' medical records and the filled questionnaire. Continuous variables were compared by use of a Mann-Whitney U test, and categorical variables were compared using Fisher's exact test. The Holm-Bonferroni sequential correction method was used to adjust P values for multiple comparisons of the presence of shoulder pathology. Results: A total of 443 patients (405 cam lesion) in the FAO group and 307 patients in the ACL reconstruction group completed the prepared questionnaire and were included in the study. Patients in the FAO group were slightly older (36.3 years [range, 15.4-61.7] vs 32.3 years [range, 16.3-75.7]) and more commonly female in the FAO group (58.0%, n = 257) compared with those in the ACL group (48.9%, n = 150). The prevalence of shoulder labral tear was 12.0% (95% confidence interval [CI], 9.3%-15.3%) for the FAO group compared with only 3.3% (95% CI, 1.8%-5.9%) for the ACL group. This represents a 3.7-fold (95% CI, 1.9-7.1) increase in the risk of shoulder labral tear for patients in the FAO group. Furthermore, shoulder labral tears were reported to be traumatic in only 43.4% of patients in the FAO group compared with 80.0% of patients in the ACL group. A similar proportion of patients in both groups (66.0% for FAO vs 60.0% for ACL) underwent a shoulder labral repair procedure. Conclusion: There appears to be an association between acetabular labral tear caused by FAI and shoulder labral lesions. Patients in the FAI group had a 3.7-fold increase in the risk of shoulder labral tear compared with the ACL group. Future studies are needed to examine a possible cause behind the current findings. Level of evidence: Level III, comparative trial study.
MeSH term(s)	Adolescent ; Adult ; Arthroscopy ; Case-Control Studies ; Female ; Femoracetabular Impingement/complications ; Femoracetabular Impingement/surgery ; Humans ; Male ; Prevalence ; Retrospective Studies ; Rotator Cuff Injuries/complications ; Rotator Cuff Injuries/surgery ; Young Adult
Language	English
Publishing date	2019-03-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	632528-2
ISSN	1526-3231 ; 0749-8063
ISSN (online)	1526-3231
ISSN	0749-8063
DOI	10.1016/j.arthro.2018.10.128
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Article ; Online: Femoral Nerve Palsy Following Total Hip Arthroplasty: Incidence and Course of Recovery.

Fleischman, Andrew N / Rothman, Richard H / Parvizi, Javad

The Journal of arthroplasty

2017 Volume 33, Issue 4, Page(s) 1194–1199

Abstract: Background: Femoral nerve palsy (FNP) is a relatively uncommon complication following total hip arthroplasty (THA). There is little recent literature regarding the incidence of FNP and the natural course of recovery.: Methods: Using our institutional ...

Abstract	Background: Femoral nerve palsy (FNP) is a relatively uncommon complication following total hip arthroplasty (THA). There is little recent literature regarding the incidence of FNP and the natural course of recovery. Methods: Using our institutional database, we identified postoperative FNPs from 17,350 consecutive primary THAs performed from 2011 to 2016. Hip exposures were performed using a direct lateral (modified Hardinge), direct anterior (Smith-Peterson), anterolateral (Watson-Jones), or posterolateral (Southern or Moore) approach. Patients with FNP were contacted to provide a subjective assessment of convalescence and underwent objective muscle testing to determine the extent of motor recovery. Results: The overall incidence of FNP was 0.21% after THA, with the incidence 14.8-fold higher in patients undergoing anterior hip surgery using either a direct anterior (0.40%) or anterolateral (0.64%) approach. Significant recovery from FNP did not commence for a majority of patients until greater than 6 months postoperatively. Motor weakness had resolved in 75% of patients at 33.3 months, with remaining patients suffering from mild residual weakness that typically did not necessitate an assistive walking device or a knee brace. Nearly all patients had improved sensory manifestations, but such symptoms had completely resolved in less than 20% of patients. Conclusion: FNP after hip surgery remains relatively uncommon, but may increase with a growing interest in anterior THA exposures. A near complete recovery with only mild motor deficits can be expected for a majority of patients in less than 2 years, although sensory symptoms may persist.
MeSH term(s)	Adult ; Aged ; Aged, 80 and over ; Arthroplasty, Replacement, Hip/adverse effects ; Arthroplasty, Replacement, Hip/statistics & numerical data ; Convalescence ; Female ; Femoral Nerve/injuries ; Humans ; Incidence ; Male ; Middle Aged ; Muscle Strength ; Muscle Strength Dynamometer ; Patient Reported Outcome Measures ; Peripheral Nerve Injuries/diagnosis ; Peripheral Nerve Injuries/epidemiology ; Peripheral Nerve Injuries/etiology ; Peripheral Nerve Injuries/rehabilitation ; Recovery of Function ; Retrospective Studies ; Self Report
Language	English
Publishing date	2017-11-04
Publishing country	United States
Document type	Journal Article
ZDB-ID	632770-9
ISSN	1532-8406 ; 0883-5403
ISSN (online)	1532-8406
ISSN	0883-5403
DOI	10.1016/j.arth.2017.10.050
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Article ; Online: The "Bundle Busters": Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty.

Luzzi, Andrew J / Fleischman, Andrew N / Matthews, Christopher N / Crizer, Meredith P / Wilsman, John / Parvizi, Javad

The Journal of arthroplasty

2018 Volume 33, Issue 9, Page(s) 2734–2739

Abstract: Background: Recently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle ... ...

Abstract	Background: Recently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). Methods: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. Results: Among 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. Conclusion: Joint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.
MeSH term(s)	Aged ; Arthroplasty, Replacement, Hip/adverse effects ; Arthroplasty, Replacement, Hip/economics ; Arthroplasty, Replacement, Knee/adverse effects ; Arthroplasty, Replacement, Knee/economics ; Costs and Cost Analysis ; Databases, Factual ; Female ; Health Expenditures ; Hospitals ; Humans ; Incidence ; Male ; Middle Aged ; Patient Care Bundles/economics ; Patient Readmission/economics ; Periprosthetic Fractures/etiology ; Postoperative Period ; Retrospective Studies ; Risk Factors ; United States
Language	English
Publishing date	2018-06-11
Publishing country	United States
Document type	Journal Article
ZDB-ID	632770-9
ISSN	1532-8406 ; 0883-5403
ISSN (online)	1532-8406
ISSN	0883-5403
DOI	10.1016/j.arth.2018.05.015
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Article ; Online: Mechanical Complications Following Total Hip Arthroplasty Based on Surgical Approach: A Large, Single-Institution Cohort Study.

Fleischman, Andrew N / Tarabichi, Majd / Magner, Zachary / Parvizi, Javad / Rothman, Richard H

The Journal of arthroplasty

2019 Volume 34, Issue 6, Page(s) 1255–1260

Abstract: ... DA; n = 5465), direct lateral (DL; n = 8561), or posterolateral approach with soft tissue repair (PL ... n = 2160). All mechanical complications within the first 2 years were identified. The primary ...

Abstract	Background: The influence of surgical approach on risk of early postoperative mechanical complications after total hip arthroplasty (THA) continues to be a focus of debate. We performed the first single-institution study on risk of early operative and nonoperative mechanical complications after THA based on approach, with the hypothesis that there would be no clinically significant difference with modern surgical methods. Methods: A retrospective study was conducted on 16,186 consecutive THA performed from 2010 to 2016. Revision or conversion THA and cases performed for hip fracture, with recalled prostheses, or during a surgeon's learning period were excluded. THAs were performed using direct anterior (DA; n = 5465), direct lateral (DL; n = 8561), or posterolateral approach with soft tissue repair (PL; n = 2160). All mechanical complications within the first 2 years were identified. The primary analysis was a time to event Cox regression, accounting for both patient and surgeon characteristics. Results: Compared with the DL approach, risk of mechanical complications was higher for both DA and PL. Adjusted risk of instability within 2 years was 0.17%, 0.74%, and 1.74% for DL, DA, and PL, respectively. While occurring at similar rates with the PL and DL approaches, the risk of periprosthetic fracture and loosening increased with DA. Consequently, femoral failure, including fracture or loosening, occurred more frequently for DA, with an adjusted incidence of 1.20% vs 0.58% and 0.47%, with DL and PL. Conclusion: Even with soft tissue repair, instability continues to occur with increased frequency with the PL approach. While reducing dislocation, a higher risk of femoral failure with DA must also be considered. Nevertheless, the DL approach appears to confer the lowest overall risk of mechanical complications.
MeSH term(s)	Adult ; Aged ; Arthroplasty, Replacement, Hip/adverse effects ; Female ; Femur/surgery ; Hip Prosthesis/adverse effects ; Humans ; Incidence ; Male ; Middle Aged ; Periprosthetic Fractures/surgery ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Proportional Hazards Models ; Prosthesis Failure ; Reoperation/adverse effects ; Retrospective Studies
Language	English
Publishing date	2019-02-21
Publishing country	United States
Document type	Journal Article ; Observational Study
ZDB-ID	632770-9
ISSN	1532-8406 ; 0883-5403
ISSN (online)	1532-8406
ISSN	0883-5403
DOI	10.1016/j.arth.2019.02.029
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Article ; Online: The Role of Perioperative Surveillance in 90-Day Total Joint Arthroplasty Care.

Luzzi, Andrew J / Crizer, Meredith P / Fleischman, Andrew N / Foltz, Carol / Parvizi, Javad

The Journal of arthroplasty

2018 Volume 33, Issue 10, Page(s) 3125–3129

Abstract: Background: With the recent implementation of a bundled payment model for total joint arthroplasty, healthcare providers are financially responsible for management of complications throughout the 90-day perioperative period. Our aim was to assess the ... ...

Abstract	Background: With the recent implementation of a bundled payment model for total joint arthroplasty, healthcare providers are financially responsible for management of complications throughout the 90-day perioperative period. Our aim was to assess the effectiveness of a surveillance system that was implemented to enhance communication during this period. Methods: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total joint arthroplasty from January 2015 to April 2016. Surveillance was performed using electronic messages and telephone calls. The use of this system in response to several clinical scenarios was measured by the total number of messages and calls exchanged. Results: Communication was greater among patients who experienced a complication (median 8), went to the emergency department (ED; median 9), and were readmitted to the hospital (median 8), relative to patients who had an uncomplicated course (median 5). Additionally, communication was greater among patients who presented to outside facilities for ED visits (median 11) and readmissions (median 9) relative to those who returned to the index hospital for ED visits (median 7) and readmissions (median 6). More distant patients had decreased follow-up attendance but did not have a compensatory increase in use of the surveillance system. Conclusion: Patients used the surveillance system to relay information about clinically significant events when such events arose. Additionally, patients who returned to outside facilities used the surveillance system to remain engaged with their original provider. However, more distant patients did not appear to use the surveillance system to compensate for decreased follow-up attendance.
MeSH term(s)	Aged ; Arthroplasty, Replacement/adverse effects ; Arthroplasty, Replacement/economics ; Communication ; Databases, Factual ; Emergency Service, Hospital/economics ; Emergency Service, Hospital/statistics & numerical data ; Female ; Humans ; Male ; Patient Care Bundles/economics ; Patient Care Bundles/statistics & numerical data ; Patient Readmission/statistics & numerical data ; Perioperative Care/economics ; Perioperative Care/statistics & numerical data ; Physician-Patient Relations ; Population Surveillance ; Retrospective Studies
Language	English
Publishing date	2018-06-20
Publishing country	United States
Document type	Journal Article
ZDB-ID	632770-9
ISSN	1532-8406 ; 0883-5403
ISSN (online)	1532-8406
ISSN	0883-5403
DOI	10.1016/j.arth.2018.06.017
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