Background: This study investigates the effects of preoperative carbohydrate-rich drinks on postoperative outcomes after primary total knee arthroplasty. Methods: We prospectively randomized 153 consecutive patients undergoing primary total knee arthroplasty at one institution. Patients were assigned to one of three groups: group A (50 patients) received a carbohydrate-rich drink; group B (51 patients) received a placebo drink; and group C (52 patients) did not receive a drink (control). All healthcare personnel and patients were blinded to group allocation. Controlling for demographics, we analyzed the rate of postoperative nausea and vomiting, length of stay, opiate consumption, pain scores, serum glucose, adverse events, and intraoperative and postoperative fluid intake. Results: Demographics and comorbidities were similar among the groups. There were no significant differences in surgical interventions or experience. Surgical fluid intake and total blood loss were similar among the three groups (P = 0.47, P = 0.23). Furthermore, acute postoperative outcomes (ie, pain, episodes of nausea, and length of stay) were similar across all three groups. There were no significant differences in adverse events between the three groups (P = 0.13). There was a significant difference in one-time postoperative bolus between the three groups (P = 0.02), but after multivariate analysis, it did not demonstrate significance. None of the intervention group were readmitted, whereas 5.9% and 11.5% were readmitted in the placebo and control groups, respectively (P = 0.047). The chance of 90-day readmission was reduced in group A compared with group C (odds ratio, 0.08; 95% confidence interval, 0.01 to 0.72; P = 0.02). There were no differences in other postoperative outcome measurements. Conclusion: This randomized controlled trial demonstrated that preoperative carbohydrate loading does not improve immediate postoperative outcomes, such as nausea and vomiting; however, it demonstrated that consuming fluid preoperatively proved no increased risk of adverse outcomes and there was a trend toward decrease of one-time boluses postoperatively. Clinical Trials Registry: NCT03380754

Frailty is a known predictor of poor outcomes following spine surgery. While both mFI-11 and mFI-5 are used to assess frailty, no pooled analysis has independently evaluated their prognostic performance across multiple outcomes. This study examines how mFI-11 and mFI-5 stratify frailty and how consistently each index predicts postoperative outcomes in elective spine surgery. A systematic literature search was conducted using PubMed, Scopus, and Web of Science databases to identify cohort studies reporting associations of mFI-11 or mFI-5 with postoperative outcomes in elective spine surgery. Meta-analyses using random-effects models calculated pooled odds ratios (ORs) and p-values for key outcomes including any adverse event, medical complication, surgical complication, mortality, reoperation, and non-routine discharge. A total of 22 studies were included in the meta-analysis. mFI-11 was associated with increased odds of medical complications (OR 2.09, p=0.0014) and surgical complications (OR 2.03, p=0.0390), but not reoperation (OR 0.95, p=0.8822). These findings were inconsistently significant across sub-analyses comparing higher mFI-11 scores to mFI-11=0. mFI-5 predicted a broader range of outcomes, including any complication (OR 1.7, p<0.0001), non-routine discharge (OR 3.29, p<0.0001), and mortality (OR 2.29, p=0.0133). These significant results persisted across sub-analyses comparing higher mFI-5 scores to mFI-5=0. mFI-5 showed more consistent associations with postoperative outcomes than mFI-11. MFI-5 demonstrates greater consistency in predicting adverse outcomes in elective spine surgery than mFI-11. mFI-5 may serve as a practical tool for frailty stratification in surgical patients. Further studies are needed to validate these results and optimize frailty assessment in spine surgery.

Case: Pain control after total knee arthroplasty (TKA) remains a significant challenge, especially in the context of certain patient-specific factors. We present a case of a 59-year-old woman with opioid-induced hyperalgesia who was referred for left knee pain and end-stage tricompartmental degenerative joint disease after failure of conservative management. We outline an approach to control postoperative pain in patients undergoing TKA who have severe opioid contraindications. Conclusions: TKA and rehabilitation with a 6-year follow-up period was accomplished using a multimodal nonopioid approach, consisting of a combination of gabapentin, acetaminophen, ketorolac, meloxicam, methocarbamol, a tunneled femoral nerve catheter, and periarticular injection.

Anterior, Oblique, and Lateral Lumbar Interbody Fusions (ALIF/OLIF/LLIF) are powerful modalities for achieving indirect decompression of lumbar foraminal stenosis while providing a large fusion surface and preserving the posterior vertebral structures. This study aimed to project future trends in the implementation rates and associated costs of ALIF/OLIF/LLIF in Medicare patients aged >65 in the US. Data was acquired from the Centers for Medicare and Medicaid Services (CMS) from January 1, 2000 to December 31, 2022, using CPT codes to identify ALIF/OLIF/LLIF procedures. The Prophet machine learning algorithm, using Bayesian Inference, was applied to data from 2000 to 2019 to generate point forecasts for 2020 to 2050 with 95% forecast intervals (FIs). Predictive performance was evaluated by splitting the data into training (75%) and validation (25%) sets, and calculating normalized root mean square error (NRMSE). Sensitivity analyses were conducted by comparing Prophet's projections with those from Linear and Log-linear Ordinary Linear Squares, Poisson, Negative-Binomial, and ARIMA models. Compound annual growth rates (CAGRs) were calculated to assess prior and future trends in procedural volume and costs from 2000 to 2050. CMS procedure counts were adjusted for Medicare Advantage patients using Kaiser Family Foundation data and costs were adjusted for inflation using the U.S. Consumer Price Index. Alternative volume projections were provided to account for the (I) impact of COVID-19 and (II) future expenditure limits using the 2022 to 2031 CMS National Health Expenditure report. Between 2000 and 2019, the adjusted annual ALIF/OLIF/LLIF volume increased from 5,093 to 45,758 cases, with a CAGR of 12.32%. The total adjusted cost for these procedures increased from $7,750,692 to $43,531,555, with a CAGR of 9.62%. During the same period, the mean inflation-adjusted reimbursement for ALIF/OLIF/LLIFs 37.8% from $1,194.86 to $743.21 per procedure. Based on Prophet model analysis, projections estimate that procedural volume and total cost will increase by 17.8% and 14.8%, respectively, for each 5-year period from 2020 to 2050. The COVID-19 pandemic caused a 2.9% decrease in ALIF/OLIF/LLIF procedural volume in 2020 compared to 2019, but volume recovered by 2022, increasing by 1.4% from prepandemic levels. By 2050, procedural volume accounting for COVID-19 reflects a 23.5% reduction compared to estimates that did not factor in COVID-19. The Prophet model demonstrated the best predictive performance, with NRMSE values of 0.0619 for volume and 0.0507 for costs. Large increases in the utilization and costs of ALIF/OLIF/LLIF are anticipated through 2050. By 2030, the estimated carrying capacity for ALIF/OLIF/LLIF expenditures is projected to reach approximately $75.6 million, constrained by CMS expenditure limits and market size. Prophet model projections indicate that expenditures for ALIF/OLIF/LLIF are expected to exceed this cap by the end of the decade.