The Statistical Fragility of Trials Comparing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion: A Meta Analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To assess the robustness of randomized controlled trials (RCTs) that compared cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic degenerative cervical pathology by using fragility indices.

SUMMARY OF BACKGROUND DATA

RCTs comparing these surgical approaches have shown that CDA may be equivalent or even superior to ACDF due to better preservation of normal spinal kinematics.

MATERIALS AND METHODS

RCTs reporting clinical outcomes after CDA versus ACDF for degenerative cervical disc disease were evaluated. Data for outcome measures were classified as continuous or dichotomous. Continuous outcomes included: Neck Disability Index, overall pain, neck pain, radicular arm pain, and modified Japanese Orthopedic Association scores. Dichotomous outcomes included: any adjacent segment disease (ASD), superior-level ASD, and inferior-level ASD. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively. The corresponding fragility quotient (FQ) and continuous FQ were calculated by dividing FI/CFI by sample size.

RESULTS

Twenty-five studies (78 outcome events) were included. Thirteen dichotomous events had a median FI of 7 [interquartile range (IQR): 3-10], and the median FQ was 0.043 (IQR: 0.035-0.066). Sixty-five continuous events had a median CFI of 14 (IQR: 9-22) and a median continuous FQ of 0.145 (IQR: 0.074-0.188). This indicates that, on average, altering the outcome of 4.3 patients out of 100 for the dichotomous outcomes and 14.5 out of 100 for continuous outcomes would reverse trial significance. Of the 13 dichotomous events that included a loss to follow-up data, 8 (61.5%) represented ≥7 patients lost. Of the 65 continuous events reporting the loss to follow-up data, 22 (33.8%) represented ≥14 patients lost.

CONCLUSION

RCTs comparing ACDF and CDA have fair to moderate statistical robustness and do not suffer from statistical fragility.

The cost-utility of intraoperative tranexamic acid in adult spinal deformity patients undergoing long posterior spinal fusion

PURPOSE

This study aims to evaluate the cost-utility of intraoperative tranexamic acid (TXA) in adult spinal deformity (ASD) patients undergoing long posterior (≥ 5 vertebral levels) spinal fusion.

METHODS

A decision-analysis model was built for a hypothetical 60-year-old adult patient with spinal deformity undergoing long posterior spinal fusion. A comprehensive review of the literature was performed to obtain event probabilities, costs and health utilities at each node. Health utilities were utilized to calculate Quality-Adjusted Life Years (QALYs). A base-case analysis was carried out to obtain the incremental cost and effectiveness of intraoperative TXA. Probabilistic sensitivity analysis was performed to evaluate uncertainty in our model and obtain mean incremental costs, effectiveness, and net monetary benefits. One-way sensitivity analyses were also performed to identify the variables with the most impact on our model.

RESULTS

Use of intraoperative TXA was the favored strategy in 88% of the iterations. The mean incremental utility ratio for using intraoperative TXA demonstrated higher benefit and lower cost while being lower than the willingness-to-pay threshold set at $50,000 per quality adjusted life years. Use of intraoperative TXA was associated with a mean incremental net monetary benefit (INMB) of $3743 (95% CI 3492-3995). One-way sensitivity analysis reported cost of blood transfusions due to post-operative anemia to be a major driver of cost-utility analysis.

CONCLUSION

Use of intraoperative TXAs is a cost-effective strategy to reduce overall perioperative costs related to post-operative blood transfusions. Administration of intraoperative TXA should be considered for long fusions in ASD population when not explicitly contra-indicated due to patient factors.

Life Expectancy After Treatment of Metastatic Bone Disease: An International Trend Analysis

INTRODUCTION

The decision to treat metastatic bone disease (MBD) surgically depends in part on patient life expectancy. We are unaware of an international analysis of how life expectancy among these patients has changed over time. Therefore, we asked (1) how has the life expectancy for patients treated for MBD changed over time, and (2) which, if any, of the common primary cancer types are associated with longer survival after treatment of MBD?

METHODS

We reviewed data collected from 2000 to 2022 in an international MBD database, as well as data used for survival model validation. We included 3,353 adults who underwent surgery and/or radiation. No patients were excluded. Patients were grouped by treatment date into period 1 (2000 to 2009), period 2 (2010 to 2019), and period 3 (2020 to 2022). Cumulative survival was portrayed using Kaplan-Meier curves; log-rank tests were used to determine significance at P < 0.05. Subgroup analyses by primary cancer diagnosis were performed.

RESULTS

Median survival in period 2 was longer than in period 1 ( P < 0.001). Median survival (at which point 50% of patients survived) had not been reached for period 3. Median survival was longer in period 2 for all cancer types ( P < 0.001) except thyroid. Only lung cancer reached median survival in period 3, which was longer compared with periods 1 and 2 ( P < 0.001). Slow-growth, moderate-growth, and rapid-growth tumors all demonstrated longer median survival from period 1 to period 2; only rapid-growth tumors reached median survival for period 3, which was longer compared with periods 1 and 2 ( P < 0.001).

DISCUSSION

Median duration of survival after treatment of MBD has increased, which was a consistent finding in nearly all cancer types. Longer survival is likely attributable to improvements in both medical and surgical treatments. As life expectancy for patients with MBD increases, surgical methods should be selected with this in mind.

LEVEL OF EVIDENCE

VI.

Development of a Novel Risk Stratification Score to Predict 30-Day Mortality in Cervical Trauma Patients: CLAAD Score

STUDY DESIGN

Case control.

OBJECTIVE

Traumatic cervical spine injuries are associated with a substantial risk of mortality. The aim of this study is to develop a novel mortality prediction model for patients with cervical trauma who require operative treatment.

SUMMARY OF BACKGROUND DATA

Patients with cervical spine trauma have a high risk of postoperative complications and mortality. There are few reliable systems that can accurately predict mortality after surgery for cervical spine trauma, and those that do exist are typically not specific to cervical trauma.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing surgery for cervical spine trauma. Univariate analyses were performed to identify variables associated with mortality. Variables that were found to be significant in the univariate models were compiled into a multivariable model. The final model was compared with the American Society of Anesthesiologists (ASA), a modified Charlson comorbidity index (mCCI), and the 5-factor modified frailty index (mFI-5) in respect to predicting 30-day mortality after cervical trauma. The score was then externally validated using the Nationwide Inpatient Sample (NIS) database.

RESULTS

Fifty-five (6.7%) of 822 patients did not survive 30 days after surgery. The final multivariable logistic regression model consisted of the following variables: circumferential fusion "C." long "L" fusion (more than 4 levels), anemia "A," age over 60 "A," and dialysis "D." The risk of mortality increased with increasing CLAAD score, with mortality rates of 0.9%, 3.1%, 7.4%, 22.7%, and 14.3% for scores of 0, 1, 2, 3, and 4, respectively. The CLAAD model had an AUC of 0.73 for predicting mortality after cervical trauma.

CONCLUSIONS

The CLAAD score is a simple and effective system that can help identify patients at risk of increased mortality within 30 days of cervical trauma.

LEVEL OF EVIDENCE

Level III.

Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020

PURPOSE

Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement.

METHODS

Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program.

RESULTS

From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level.

CONCLUSIONS

Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted.

LEVEL OF EVIDENCE

III.

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index

INTRODUCTION

The purpose of this study was to evaluate the ability of the Pathologic Fracture Mortality Index (PFMI) to predict the risk of 30-day morbidity after pathologic fracture fixation and compare its efficacy with those of the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5).

METHODS

Cohorts of 1,723 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020 and 159 patients from a tertiary cancer referral center who underwent fixation for impending or completed pathologic fractures of long bones were retrospectively analyzed. National Surgical Quality Improvement Program morbidity variables were categorized into medical, surgical, utilization, and all-cause. PFMI, ASA, mCCI, and mFI-5 scores were calculated for each patient. Area under the curve (AUC) was used to compare efficacies.

RESULTS

AUCs predicting all-cause morbidity were 0.62, 0.54, and 0.56 for the PFMI, ASA, and mFI-5, respectively. The PFMI outperformed the ASA and mFI-5 in predicting all-cause ( P < 0.01), medical ( P = 0.01), and utilization ( P < 0.01) morbidities. In the 2005 to 2012 subset, the PFMI outperformed the ASA, mFI-5, and mCCI in predicting all-cause ( P = 0.01), medical ( P = 0.03), and surgical ( P = 0.05) morbidities but performed similarly to utilization morbidity ( P = 0.19). In our institutional cohort, the AUC for the PFMI in morbidity stratification was 0.68. The PFMI was associated with all-cause (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.12 to 1.51; P < 0.001), medical (OR, 1.19; 95% CI, 1.03 to 1.40; P = 0.046), and utilization (OR, 1.32; 95% CI, 1.14 to 1.52; P < 0.001) morbidities but not significantly associated with surgical morbidity (OR, 1.21; 95% CI, 0.98 to 1.49; P = 0.08) in this cohort.

DISCUSSION

The PFMI is an advancement in postoperative morbidity risk stratification of patients with pathologic fracture from metastatic disease.

LEVEL OF EVIDENCE

III.

Open Access Publication in Total Knee Arthroplasty Is Associated With Increased Social Media Attention, but Is Not Associated With Increased Citations

BACKGROUND

Open access (OA) publication is growing in total joint arthroplasty literature. While OA manuscripts are free to view, these publications require a fee from authors. This study aimed to compare social media attention and citation rates between OA and non-OA publications in the total knee arthroplasty (TKA) literature.

METHODS

There were 9,606 publications included, with 4,669 (48.61%) as OA articles. The TKA articles were identified from 2016 to 2022. Articles were grouped as OA or non-OA and Altmetric Attention Score (AAS), a weighted count of social media attention, and the Mendeley readership were analyzed using negative binomial regressions while adjusting for days since publication.

RESULTS

The OA articles had greater mean AAS (13.45 versus 8.42, P = .012) and Mendeley readership (43.91 versus 36.72, P < .001). OA was not an independent predictor of number of citations when compared to non-OA articles (13.98 versus 13.63, P = .914). Subgroup analysis of studies in the top 10 arthroplasty journals showed OA was not an independent predictor of AAS (13.51 versus 9.53, P = .084) or number of citations (19.51 versus 18.74, P = .495) but was an independent predictor of Mendeley readership (49.05 versus 40.25, P < .003).

CONCLUSION

The OA publications in the TKA literature were associated with increased social media attention, but not overall citations. This association was not observed among the top 10 journals. Authors may use these results to weigh the relative importance of readership, citations, and online engagement to the cost of OA publication.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI.

METHODS

Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status.

RESULTS

We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Predicting Mortality Following Odontoid Fracture Fixation in Elderly Patients: CAADS-16 Score

STUDY DESIGN

Retrospective Review of a National Database.

INTRODUCTION

By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear.

METHODS

The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality.

RESULTS

608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively.

CONCLUSIONS

This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.

Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty

BACKGROUND AND OBJECTIVES

Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare.

METHODS

We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare.

RESULTS

A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures.

CONCLUSION

Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.

ChatGPT Performs at the Level of a Third-Year Orthopaedic Surgery Resident on the Orthopaedic In-Training Examination

Introduction

Publicly available AI language models such as ChatGPT have demonstrated utility in text generation and even problem-solving when provided with clear instructions. Amidst this transformative shift, the aim of this study is to assess ChatGPT's performance on the orthopaedic surgery in-training examination (OITE).

Methods

All 213 OITE 2021 web-based questions were retrieved from the AAOS-ResStudy website (https://www.aaos.org/education/examinations/ResStudy). Two independent reviewers copied and pasted the questions and response options into ChatGPT Plus (version 4.0) and recorded the generated answers. All media-containing questions were flagged and carefully examined. Twelve OITE media-containing questions that relied purely on images (clinical pictures, radiographs, MRIs, CT scans) and could not be rationalized from the clinical presentation were excluded. Cohen's Kappa coefficient was used to examine the agreement of ChatGPT-generated responses between reviewers. Descriptive statistics were used to summarize the performance (% correct) of ChatGPT Plus. The 2021 norm table was used to compare ChatGPT Plus' performance on the OITE to national orthopaedic surgery residents in that same year.

Results

A total of 201 questions were evaluated by ChatGPT Plus. Excellent agreement was observed between raters for the 201 ChatGPT-generated responses, with a Cohen's Kappa coefficient of 0.947. 45.8% (92/201) were media-containing questions. ChatGPT had an average overall score of 61.2% (123/201). Its score was 64.2% (70/109) on non-media questions. When compared to the performance of all national orthopaedic surgery residents in 2021, ChatGPT Plus performed at the level of an average PGY3.

Discussion

ChatGPT Plus is able to pass the OITE with an overall score of 61.2%, ranking at the level of a third-year orthopaedic surgery resident. It provided logical reasoning and justifications that may help residents improve their understanding of OITE cases and general orthopaedic principles. Further studies are still needed to examine their efficacy and impact on long-term learning and OITE/ABOS performance.

Association of Neighborhood Socioeconomic Deprivation With Utilization and Costs of Anterior Cervical Discectomy and Fusion

STUDY DESIGN

A retrospective analysis.

OBJECTIVE

The aim of our study was to analyze the association of Area Deprivation Index (ADI) with the utilization and costs of elective anterior cervical discectomy and fusion (ACDF) surgery.

SUMMARY OF BACKGROUND DATA

ADI, a comprehensive neighborhood-level measure of socioeconomic disadvantage, has been shown to be associated with worse perioperative outcomes in a variety of surgical settings.

MATERIALS AND METHODS

The Maryland Health Services Cost Review Commission Database was queried to identify patients who underwent primary elective ACDF between 2013 and 2020 in the state. Patients were stratified into tertiles by ADI, from least disadvantaged (ADI1) to most disadvantaged (ADI3). The primary endpoints were ACDF utilization rates per 100,000 adults and episode-of-care total costs. Univariable and multivariable regression analyses were performed.

RESULTS

A total of 13,362 patients (4984 inpatient and 8378 outpatient) underwent primary ACDF during the study period. In our study, there were 2,401 (17.97%) patients residing in ADI1 neighborhoods (least deprived), 5974 (44.71%) in ADI2, and 4987 (37.32%) in ADI3 (most deprived). Factors associated with increased surgical utilization were increasing ADI, outpatient surgical setting, non-Hispanic ethnicity, current tobacco use, and diagnoses of obesity and gastroesophageal reflux disease. Factors associated with lower surgical utilization were: non-white race, rurality, Medicare/Medicaid insurance status, and diagnoses of cervical disk herniation or myelopathy. Factors associated with higher costs of care were increasing ADI, older age, Black/African American race, Medicare or Medicaid insurance, former tobacco use, and diagnoses of ischemic heart disease and cervical myelopathy. Factors associated with lower costs of care were outpatient surgical setting, female sex, and diagnoses of gastroesophageal reflux disease and cervical disk herniation.

CONCLUSIONS

Neighborhood socioeconomic deprivation is associated with increased episode-of-care costs in patients undergoing ACDF surgery. Interestingly, we found greater utilization of ACDF surgery among patients with higher ADI.

LEVEL OF EVIDENCE

3.

Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score

PURPOSE

Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease.

METHODS

Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05.

RESULTS

Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76.

CONCLUSIONS

The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis.

LEVEL OF EVIDENCE

Prognostic level III.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF).

METHODS

A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05.

RESULTS

Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05).

CONCLUSION

Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Laminectomy vs Fusion for Intradural Extramedullary Tumors

BACKGROUND

Laminectomy (LA) and LA with fusion (LAF) have been demonstrated as surgical techniques that treat intradural extramedullary tumors (IDEMTs). The purpose of the present study was to compare the rate of 30-day complications following LA vs LAF for IDEMTs.

METHODS

Patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients undergoing LA for IDEMTs were substratified into 2 cohorts: those who received LAF and those who did not. In this analysis, preoperative patient characteristics and demographic variables were assessed. 30-day wound, sepsis, cardiac, pulmonary, renal, and thromboembolic complications, as well as mortality, postoperative transfusions, extended length of stay, and reoperation, were assessed. Bivariate analyses, including χ ² and t tests, and multivariable logistical regression were performed.

RESULTS

Of 2027 total patients undergoing LA for IDEMTs, 181 (9%) also had fusion. There were 72/373 (19%) LAF in the cervical region, 67/801 (8%) LAF in the thoracic region, and 42/776 (5%) LAF in the lumbar region. Following adjustment, patients who received LAF were more likely to have increased length of stay (OR 2.73, P < 0.001) and increased rate of postoperative transfusion (OR 3.15, P < 0.001). Patients undergoing LA in the cervical spine for IDEMTs tended to receive additional fusion (P < 0.001).

CONCLUSIONS

Increased length of stay and rate of postoperative transfusion were associated with LAF for IDEMTs. LA in the cervical spine for IDEMTs was associated with additional fusion.

LEVEL OF EVIDENCE: 3

Comparing five equations to calculate estimated glomerular filtration rate to predict acute kidney injury following total joint arthroplasty

BACKGROUND

Acute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations.

RESULTS

Seven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation.

CONCLUSIONS

Preoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients.

Return to work after adult spinal deformity surgery

PURPOSE

To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work.

METHODS

Using a multicenter database of patients treated surgically for ASD from 2008 to 2015, we identified 188 patients (mean age 51 ± 15 years) who self-reported as employed preoperatively and had 2-year follow-up. Per the ASD-Surgical and Radiographical Invasiveness Index (ASD-SR), 118 patients (63%) underwent high-invasiveness (HI) surgery (ASD-SR ≥ 100) and 70 (37%) had low-invasiveness (LI) surgery (ASD-SR < 100). Patients who self-reported ≥ 75% normal level of work/school activity were considered to be working full time. Chi-squared and Fisher exact tests were used to compare categorical variables (α = .05).

RESULTS

Preoperatively, 69% of employed patients worked full time. Postoperatively, 15% of employed patients were full time at 6 weeks, 70% at 6 months, 83% at 1 year, and 84% at 2 years. Percentage of employed patients working full time at 2 years was greater than preoperatively (p < .001); percentage of patients returning to full time at 6 weeks was lower in the HI (5%) than in the LI group (19%) (p = .03), a difference not significant at later points.

CONCLUSIONS

Most adults returned to full-time work after ASD surgery. A smaller percentage of patients in the HI group than in the LI group returned to full-time work at 6 weeks. Patients employed full time preoperatively will likely return to full-time employment after ASD surgery.

LEVEL OF EVIDENCE

III.

The "kickstand rod" technique for correction of coronal malalignment: two-year clinical and radiographic outcomes

PURPOSE

Restoring coronal alignment in spine deformity patients has been shown to play an important role in improving patient reported outcomes (PRO). Recently, the "kickstand rod" (KSR) technique was developed as a novel coronal correction method in complex spine deformity cases. The goal of the present study was to assess outcomes of this technique at two years of follow-up.

METHODS

Consecutive, unique adult patients who underwent KSR constructs for coronal spinal malalignment between 2015 and 2019 with a minimum 2 year clinical and radiographic follow-up were identified. A KSR construct includes a more laterally placed iliac screw and additional rod that effectively depresses the ipsilateral ilium/pelvis for coronal correction, while serving as a buttress to prevent future loss of correction. Outcomes included revision for instrumentation-related complications, radiographic alignment, and PROs.

RESULTS

Twenty patients were included with a mean age of 54 years [range: 20-73 years]. Mean follow-up time was 2.5 years [range: 2.0-5.0]. Mean number of levels fused was 17.3 [range: 10-24]. There were significant improvements in coronal alignment (CVA: 5.8 cm ± 2.6 cm vs. 1.7 cm ± 1.5 cm), sagittal alignment (SVA: 5.6 cm ± 5.9 cm vs. 1.6 cm ± 2.5 cm) and major Cobb angle (55º ± 32 vs. 26º ± 21) maintained at 2 years (p < 0.05). One patient experienced an asymptomatic fracture at the shank of the KSR iliac screw. There were significant improvements in Oswestry Disability Index and SRS-22 domains (p < 0.05).

CONCLUSION

The KSR technique is a safe and effective method for correcting coronal malalignment in complex spinal deformity patients with no revisions specific for the KSR or iliac screw and significantly improved PROs at a minimum two-year follow-up.

Comparative Risk Stratification for Prediction of Early Postoperative Morbidity and Mortality after Open Fixation of Periarticular Lower Extremity Fractures

Category:

Trauma; Ankle; Hindfoot

Introduction/Purpose:

The standardized identification of patients who are at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures.

Methods:

Query of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database yielded 65,529 patients who underwent periarticular hip, knee, and ankle fracture repair from 2010-2019. We collected patient demographics and preoperative risk factors. To generate our risk stratification systems, 60% of patients were randomly designated as the development cohort and analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE and mortality. A nomogram analysis was then conducted to assign scores for each risk factor and generate two points-based risk stratification systems, for AE and mortality. To validate our models, the systems were applied to the remaining 40% of patients (the validation cohort) and tested for predictive ability.

Results:

In total, 13,212 patients (20.2%) experienced any AE and 3,613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for each of the following in both risk stratification systems: fracture type (+4 hip, +2 knee, +0 ankle), male gender (+1), age (>=80 years +5, 60-79 years +3, 40-59 years +2), functionally dependent (+2), anemia (+2 for AE, +1 for mortality), pulmonary disease (+3 for AE, +1 for mortality), congestive heart failure (+3 for AE, +2 for mortality), and end- stage renal disease (+3 for AE, +1 for mortality). Corticosteroid use (+1), hypertension (+1), and insulin-dependent diabetes (+2) were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4-79.5% and mortality from 0.08- 54.4%.

Conclusion:

Fracture type, male gender, age >=40 years, corticosteroid use, functional dependence, anemia, hypertension, insulin-dependent diabetes, pulmonary disease, congestive heart failure, and end-stage renal disease can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient.

Racial Disparities in Early Adverse Events and Unplanned Readmission after Open Fixation of Below- Knee Fractures

Category:

Trauma; Ankle; Hindfoot; Other

Introduction/Purpose:

Race-based differences in the surgical management of hip fractures are well-established. Studies assessing these disparities for below-knee fractures have yet to be conducted despite their high volume. Our purpose was to determine whether 1) early postoperative complications and 2) time to surgery for operative fixation of below-knee fractures differ for black versus white patients, and to assess whether disparities exist between fracture subtypes.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients (>=18 years) undergoing open fixation of below-knee fractures between 2010-2019. This yielded 9,172 patients; 1,120 (12%) were black. We collected patient demographics and preoperative risk factors. Primary outcomes were 30-day postoperative complications and time to surgical fixation. Fractures were further subclassified as tibia and/or fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures. Nearest-neighbor propensity score matching in a 1:1 ratio was applied to compare outcomes by race. Alpha = 0.05.

Results:

After matching, we identified 1,120 white patients with equal propensity scores as our black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0-2.0) of experiencing any early adverse event when compared with matched white counterparts. Blacks also had 1.9 times higher odds (95% CI: 1.2-3.0) of requiring unplanned readmission within 30 days of operative fixation. Fifty-eight black patients (5.3%) required short-term readmission, compared with 351 white patients (4.5%) - 32 (2.9%) in the matched cohort. The most common reasons for readmission were wound, gastrointestinal, thromboembolic, and recurrent musculoskeletal complications for both races. There were no significant differences by race in time to surgery. Fracture subtype was not associated with postoperative complications or time to surgery in the multivariable analysis.

Conclusion:

Racial disparities in the early postoperative course after open fixation of below-knee fractures exist, with significantly higher rates of early adverse events and unplanned readmission for black versus white patients that persist after propensity matching. These trends may be secondary to a host of community- and hospital-level factors, illustrating the importance of interventions that consider the differences between hip and non-hip fractures and increase resources to vulnerable areas.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis

BACKGROUND

The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA).

METHODS

Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery.

RESULTS

A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group.

CONCLUSION

Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.

Preoperative Hypoalbuminemia Is Associated With Early Morbidity and Mortality After Revision Total Hip Arthroplasty

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P<.025. A total of 2492 revision THAs with complete data were identified, of which 486 (20%) had preoperative hypoalbuminemia. Preoperative hypoalbuminemia increased the absolute risk of a major complication by 15.3% compared with patients with revision THA without hypoalbuminemia (30% vs 14.7%, P<.001). Patients with preoperative hypoalbuminemia also had nearly a 7-fold higher incidence of death (3.3%) compared with those with revision THA without preoperative hypoalbuminemia (0.5%, P<.001). After logistic regression, the odds of having a major complication after revision THA with preoperative hypoalbuminemia within 30 days were increased by 80% (odds ratio, 1.8; 95% CI, 1.4-2.3; P<.001), and the odds of death within 30 days were increased by 210% (odds ratio, 3.1; 95% CI, 1.2-7.8; P=.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [Orthopedics. 2022;45(5):281-286.].

Early Postoperative Complications in Total Hip and Knee Arthroplasty Before and During the COVID-19 Pandemic: A Retrospective Analysis of 38,234 Patients

Background

The outcomes of total joint arthroplasty during the coronavirus disease 2019 (COVID-19) pandemic are unknown. We sought to compare early postoperative complications in total hip arthroplasty (THA) and total knee arthroplasty (TKA) prior to and during the COVID-19 pandemic.

Methods

Patients in the American College of Surgeons National Surgical Quality Improvement Program database who had THA or TKA in the latter halves (July to December) of 2019 and 2020 were identified. Patients were divided into pre-COVID-19 (2019) and during-COVID-19 (2020) cohorts. Propensity score matching and logistic regression were used to detect correlations between operative period and outcomes. Statistical significance was set at α = 0.05.

Results

A total of 38,234 THA and 61,956 TKA patients were included. There was a significantly higher rate of outpatient procedures in 2020 than that in 2019 for both THA (41.68% vs 6.59%, P < .001) and TKA (41.68% vs 7.56%, P < .001). On matched analysis, surgery in 2020 had lower odds of hospital stay for >1 day (THA: odds ratio [OR] 0.889; P < .001) (TKA: OR 0.644; P < .001) and nonhome discharge (THA: 0.655; P < .001) (TKA: 0.497; P < .001). There was also increased odds of superficial surgical site infection in THA (OR 1.272; P = .040) and myocardial infarction in TKA patients (OR 1.488; P = .042) in 2020 compared to those in 2019. There was no difference in the 15 other outcomes assessed.

Conclusions

Total joint arthroplasty surgery remains safe despite the COVID-19 pandemic. A statistically significant increase was detected in superficial surgical site infection and myocardial infarction risk during 2020 compared to 2019; however, the clinical significance of this is questionable. A shift away from inpatient stay was also present, possibly reflecting efforts to minimize nosocomial exposure to COVID-19.

Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery

STUDY DESIGN

A cost-utility analysis study.

OBJECTIVE

This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established.

MATERIALS AND METHODS

A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score <-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model.

RESULTS

Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF.

CONCLUSIONS

Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.

Comparative risk stratification for prediction of early postoperative morbidity and mortality after open fixation of periarticular lower extremity fractures

INTRODUCTION

The identification of patients at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures.

METHODS

Query of the NSQIP database yielded 65,529 patients who underwent periarticular lower extremity repair from 2010 to 2019. To generate our risk stratification systems, 60% of patients were randomly analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE or mortality. A nomogram analysis was then conducted to assign scores for each risk factor. To validate our models, the systems were tested for predictive ability using the remaining 40% of patients.

RESULTS

In total, 13,212 patients (20.2%) experienced any AE and 3613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for the following in both risk stratification systems: fracture type, male gender, age, functional dependence, anemia, pulmonary disease, congestive heart failure, and end-stage renal disease. Corticosteroid use, hypertension, and insulin-dependent diabetes were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4 to 79.5% and mortality from 0.08 to 54.4%.

CONCLUSION

Fracture type and preoperative characteristics can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient.

LEVEL OF EVIDENCE

Therapeutic IV.

Total Knee Arthroplasty after Anterior Cruciate Ligament Reconstruction

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Factors associated with RVU generation in common sports medicine procedures

INTRODUCTION

Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based.

METHODS

We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour.

RESULTS

Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time.

CONCLUSION

wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Laminectomy Versus Laminectomy with Fusion for Intradural Extramedullary Tumors: A Systematic Review and Meta-Analysis

OBJECTIVE

The primary objective of our systematic review and meta-analysis was to systematically compare the reported outcomes between laminectomy and laminectomy with fixation/fusion (LF) for the treatment of intradural extramedullary tumors (IDEMTs). Our secondary objective was to compare the outcomes between different laminectomy exposure techniques.

METHODS

PubMed and Embase were queried for literature on laminectomy and LF for IDEMTs. Reports of transforaminal approaches, interlaminar approaches, corpectomy, pediatrics patients, intramedullary tumors, technical studies, animal or cadaver studies, and literature reviews were excluded. The outcome measures recorded were pain, neurologic function, functional independence, cerebrospinal fluid leak, and wound infection. Where possible, the laminectomy technique (partial laminectomy [PL] vs. total laminectomy [TL]) was specified. Stata, version 17, was used for the fixed effects inverse variance meta-analysis.

RESULTS

Of 1849 reports assessed, 17 were included. The meta-analysis revealed that laminectomy (PL or TL) resulted in higher rates of postoperative sagittal instability compared with LF (odds ratio, 1.81; P < 0.001). No differences in any other postoperative outcome were observed between laminectomy and LF (P = 0.44). The systematic review also revealed no differences in postoperative pain, neurologic function, or functional independence or disability between PL and TL. Some evidence suggested that TL might result in greater rates of sagittal instability compared with PL.

CONCLUSIONS

No differences between LF, PL, or TL in pain, neurologic deficit, functional independence, cerebrospinal fluid leak, or wound infection were reported. Laminectomy had greater odds of sagittal instability compared with LF. Patients with preoperative sagittal instability requiring extensive removal of the posterior spinal column to achieve adequate resection of large tumors might benefit from LF.

Growing Racial Disparities in the Utilization of Adult Spinal Deformity Surgery: An Analysis of Trends From 2004 to 2014

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States.

SUMMARY OF BACKGROUND DATA

Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients.

METHODS

Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status.

RESULTS

From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both).

CONCLUSION

Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

The BTK Safety Score: A Novel Scoring System for Risk Stratifying Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty

Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p < 0.001) and CCI (0.599; p < 0.001). The BTK Safety Score developed and validated in our study can be used by surgeons and perioperative teams to risk stratify patients undergoing si-BTKA. Future work is needed to assess this scoring system's ability to predict long-term functional outcomes.

Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database

BACKGROUND

Racial disparities in outcomes after orthopaedic surgery have been well-documented in the fields of arthroplasty, trauma, and spine surgery; however, little research has assessed differences in outcomes after surgery for oncologic musculoskeletal disease. If racial disparities exist in the treatment of patients with pathologic long bone fractures, then they should be identified and addressed to promote equity in patient care.

QUESTIONS/PURPOSES

(1) How do wait times between hospital admission and operative fixation for pathologic fractures of long bones differ between Black and non-Hispanic white patients, after controlling for confounding variables using propensity score matching? (2) How does the proportion of patients with 30-day postoperative complication differ between these groups after controlling for confounding variables using propensity score matching?

METHODS

Using the National Surgical Quality Improvement Program database, we analyzed 828 patients who underwent fixation for pathologic fractures from 2012 to 2018. This database not only provides a large enough sample of pathologic long bone fracture patients to conduct the present study, but also it contains variables such as time from hospitalization to surgery that other national databases do not. After excluding patients with incomplete data (4% of the initial cohort), 775 patients were grouped by self-reported race as Black (12% [94]) or white (88% [681]). Propensity score matching using a 1:1 nearest-neighbor match was then used to match 94 Black patients with 94 white patients according to age, gender, BMI, American Society of Anesthesiologists physical status classification, anemia, endstage renal disease, independence in performing activities of daily living, congestive heart failure, and pulmonary disease. The primary outcome of interest was the number of days between hospital admission and operative fixation, which we assessed using a Poisson regression and report as an incidence risk ratio. The secondary outcomes were the occurrences of major 30-day postoperative adverse events (failure to wean off mechanical ventilation, cerebrovascular events, renal failure, cardiovascular events, reoperation, death), minor 30-day adverse events (reintubation, wound complications, pneumonia, and thromboembolic events), and any 30-day adverse events (defined as the pooling of all adverse events, including readmissions). These outcomes were analyzed using a bivariate analysis and logistic regression with robust estimates of variance and are reported as odds ratios. Because any results on disparities rely on rigorous control of other baseline demographics, we performed this multivariable approach to ensure we were controlling for confounding variables as much as possible.

RESULTS

After controlling for potentially confounding variables such as age and gender, we found that Black patients had a longer mean wait time (incidence risk ratio 1.5 [95% CI 1.1 to 2.1]; p = 0.01) than white patients. After controlling for confounding variables, Black patients also had greater odds of having any postoperative adverse event (OR 2.1 [95% CI 1.1 to 3.8]; p = 0.02), including readmission (OR 3.3 [95% CI 1.5 to 7.6]; p = 0.004).

CONCLUSION

The racial disparities in pathologic long bone fracture care found in our study may be attributed to fundamental racial biases, as well as systemic socioeconomic disparities in the US healthcare system. Identifying and eliminating the racial, socioeconomic, and sociocultural biases that drive these disparities would improve care for patients with orthopaedic oncologic conditions. One possible way to reduce these disparities would be to implement standardized surgical care pathways for pathological long bone fractures across different institutions to minimize variation in important aspects of care, such as time to surgical fixation. Further insight is needed on the types of standardized care pathways and the implementation mechanisms that are most effective.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion.  PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients.

METHODS

The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05).

RESULTS

Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients.

CONCLUSIONS

Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.

COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The primary aim was to compare length of stay (LOS) and discharge disposition of adult spinal deformity (ASD) patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, reoperations, readmissions, and unplanned emergency department (ED) visits.

SUMMARY OF BACKGROUND DATA

ASD patients often require extended LOS and non-routine discharge. Given resource limitations during the Coronavirus Disease 2019 (COVID-19) pandemic and caution regarding hospital stays, surgeons modified standard postoperative protocols to minimize patient exposure.

METHODS

We identified all patients who underwent elective thoracolumbar ASD surgery with more than or equal to five levels fusion at a tertiary care center during two distinct time intervals: July to December 2019 (Pre-COVID, N = 60) and July to December 2020 (During-COVID, N = 57). Outcome measures included LOS and discharge disposition (home vs. non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors.

RESULTS

Patients who underwent ASD surgery during the pandemic were younger (61 vs. 67 yrs) and had longer fusion constructs (nine vs. eight levels) compared with before the pandemic (P < 0.05 for both). On bivariate analysis, patients undergoing surgery during the pandemic had shorter LOS (6 vs. 9 days) and were more likely to be discharged home (70% vs. 28%) (P < 0.05 for both). After controlling for age and levels fused on multivariable regression, patients who had surgery during the pandemic had shorter LOS (IRR = 0.83, P = 0.015) and greater odds of home discharge (odds ratios [OR] = 7.2, P < 0.001). Notably, there were no differences in major complications, reoperations, readmissions, or ED visits between the two groups.

CONCLUSION

During the COVID-19 pandemic, LOS for patients undergoing thoracolumbar ASD surgery decreased, and more patients were discharged home without adversely affecting complication or readmission rates. Lessons learned during the pandemic may help improve resource utilization without negatively influencing short-term outcomes.Level of Evidence: 3.

Persistent sleep disturbance after spine surgery is associated with failure to achieve meaningful improvements in pain and health-related quality of life

BACKGROUND CONTEXT

Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery.

PURPOSE

To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018.

OUTCOME MEASURES

Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery.

METHODS

Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05.

RESULTS

Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80).

CONCLUSION

One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery.

Proximal Humerus Fracture-Open Reduction Internal Fixation With an Expandable Intramedullary Nitinol Scaffold

SUMMARY

For the treatment of proximal humerus fractures, the intramedullary nitinol scaffold is a novel implant that has gained popularity and demonstrated promising 1-year outcomes as an alternative to bone grafting for providing intramedullary structural support to the humeral head. The aim of this video is to demonstrate the insertion of this device safely, while highlighting potential pitfalls, in a 67-year-old patient with a displaced, varus angulated 2-part proximal humerus fracture.

The Five-item Modified Frailty Index is Predictive of 30-day Postoperative Complications in Patients Undergoing Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery.

SUMMARY OF BACKGROUND DATA

The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions.

METHODS

Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes.

RESULTS

After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased.

CONCLUSION

The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.

How is staging of ALIF following posterior spinal arthrodesis to the pelvis related to functional improvement in patients with adult spinal deformity?

STUDY DESIGN

Retrospective cohort.

OBJECTIVES

To compare postoperative functional improvement in patients who underwent staged versus non-staged anterior-posterior spinal arthrodesis for adult spinal deformity (ASD). In patients with ASD, spinal arthrodesis can be performed in 2 stages to avoid the physiologic insult of a lengthy surgery. The association between staged surgery and postoperative functional improvement has not been well studied.

METHODS

We included 87 patients (59 women) with ASD who underwent anterior-posterior spinal arthrodesis of > 5 levels with fixation to the pelvis from 2010-2014. Primary outcomes were the frequency of achieving at least a minimal clinically important difference (MCID) in the Scoliosis Research Society-22r (SRS-22r) Activity domain and the timeframe in which it was achieved. The secondary outcome was patient satisfaction (SRS-22r Patient Satisfaction domain). A Cox proportional hazard model was used to compare functional improvement over time between staged and non-staged groups. Our study was powered to detect a relative hazard ratio of 0.53, β = 0.20. α = 0.05.

RESULTS

The frequency of achieving an MCID in SRS-22r Activity score did not differ significantly between the staged group (33/41 patients) and the non-staged group (34/46 patients) (hazard ratio 0.74; 95% confidence interval 0.41-1.36). Median times to achieving an MCID in SRS-22r Activity score were 191 days (interquartile range: 86-674) in the staged group and 181 days (interquartile range: 72-474) in the non-staged group (p = .75). The staged and non-staged groups had similar SRS-22r Patient Satisfaction scores at 3-9 months postoperatively and at final follow-up (both, p > .05).

CONCLUSION

Patients with ASD who underwent staged anterior-posterior spinal arthrodesis within 3 months after index surgery were similarly likely to experience functional improvement in the same timeframe as patients who underwent non-staged surgery. Patient satisfaction did not differ significantly between staged and non-staged groups.

LEVEL OF EVIDENCE

III.

Caudally directed upper-instrumented vertebra pedicle screws associated with minimized risk of proximal junctional failure in patients with long posterior spinal fusion for adult spinal deformity

BACKGROUND CONTEXT

It is unknown whether upper instrumented vertebra (UIV) pedicle screw trajectory and UIV screw-rod angle are associated with development of proximal junctional kyphosis (PJK) and/or proximal junctional failure (PJF).

PURPOSE

To determine whether (1) the cranial-caudal trajectory of UIV pedicle screws and (2) UIV screw-vertebra angle are associated with PJK and/or PJF after long posterior spinal fusion in patients with adult spinal deformity (ASD).

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

We included 96 patients with ASD who underwent fusion from T9-T12 to the pelvis (>5 vertebrae fused) between 2008 and 2015.

OUTCOME MEASURES

Pedicle screw trajectory was measured as the UIV pedicle screw-vertebra angle (UIV-PVA), which is the mean of the two angles between the UIV superior endplate and both UIV pedicle screws. (Positive values indicate screws angled cranially; negative values indicate screws angled caudally.) We measured UIV rod-vertebra angle (UIV-RVA) between the rod at the point of screw attachment and the UIV superior endplate.

METHODS

During ≥2-year follow-up, 38 patients developed PJK, and 28 developed PJF. Mean (± standard deviation) UIV-PVA was -0.9° ± 6.0°. Mean UIV-RVA was 87° ± 5.2°. We examined the development of PJK and PJF using a UIV-PVA/UIV-RVA cutoff of 3° identified by a receiver operating characteristic curve, while controlling for osteoporosis, age, sex, and preoperative thoracic kyphosis.

RESULTS

Patients with UIV-PVA ≥3° had significantly greater odds of developing PJK (odds ratio 2.7; 95% confidence interval: 1.0-7.1) and PJF (odds ratio 3.6; 95% confidence interval: 1.3-10) compared with patients with UIV-PVA <3°. UIV-RVA was not significantly associated with development of PJK or PJF.

CONCLUSIONS

In long thoracic fusion to the pelvis for ASD, UIV-PVA ≥3° was associated with 2.7-fold greater odds of PJK and 3.6-fold greater odds of PJF compared with UIV-PVA <3°. UIV-RVA was not associated with PJK or PJF.

LEVEL OF EVIDENCE

III.

Using Predictive Modeling and Supervised Machine Learning to Identify Patients at Risk for Venous Thromboembolism Following Posterior Lumbar Fusion

STUDY DESIGN

Retrospective review.

OBJECTIVE

To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology.

METHODS

Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic.

RESULTS

13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.001), and comparable to that of the XGBoost algorithm (P > 0.05).

CONCLUSION

Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.

A guide to resecting tumors of the sciatic notch

Sciatic notch tumors are rare and have numerous etiologies. Tumor presentation varies widely and no uniform recommendations exist for approaching resection. Most studies on the topic have been small case series, with the approach dictated by surgeon experience and comfort. We provide an overview of surgical approaches for resecting sciatic notch tumors reported in the literature, as well as a conceptual framework for application of these approaches based on standard oncologic principles. The advantages and disadvantages of each approach are described on the basis of anatomic location of the tumor. For tumors that span the notch with intra- and extra-pelvic extension, notchplasty is a novel technique that provides superior visualization and access for en-bloc excision.

Treatment of Neck Pain with Opioids in the Primary Care Setting: Trends and Geographic Variation

OBJECTIVE

Neck pain is a leading cause of years lived with disability and is often managed with opioid medications in primary care settings, though this is contraindicated by national guidelines. The aim of this study was to determine the prevalence of opioid prescription for neck pain at a primary care visit and to analyze the geographic variation and trends in opioid prescriptions between 2011 and 2017.

METHODS

Using a prescription drug claims database, we identified 591,961 adult patients who presented for neck pain in primary care settings between 2011 and 2017. Patients who had outpatient specialty visits within 1 year before presentation, a concomitant diagnosis of a non-musculoskeletal cause of neck pain, or preexisting chronic opioid use were excluded.

RESULTS

The mean age of the patients was 45 ± 12 years, and 64% were female. Fifteen percent of patients were prescribed opioids within 30 days of their encounter. Eleven percent of patients were prescribed moderate- to high-dose opioids (>20 morphine milligram equivalents). From 2011-2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions given to first time presenters to an outpatient clinic for neck pain was highest in Mississippi (20%) and lowest in New Mexico (6%) (P < 0.001). In 2017, the proportion of both overall opioid prescriptions and moderate- to high-dose prescriptions was highest in the Midwest (10.4%) and lowest in the Northeast (4.9%). The proportion of patients with filled opioid prescriptions declined between 2011 (19%) and 2017 (13%) (P < 0.001), and the proportion of patients with moderate- to high-dose prescriptions declined from 2011 (13%) to 2017 (8%) (P < 0.001). first-time presenters of neck pain to an outpatient clinic.

CONCLUSIONS

Opioid medication use for neck pain in the primary care setting is significant. Although opioid prescriptions are declining, there remains a need for further standardization in prescription practices.

The CARDE-B Scoring System Predicts 30-Day Mortality After Revision Total Joint Arthroplasty

BACKGROUND

There exists a substantial risk of having a perioperative complication after revision total joint arthroplasty (TJA). The complex shared decision-making between surgeon and patient would benefit from a high-fidelity tool to identify patients at risk for mortality after revision TJA. Therefore, we developed the CARDE-B score. CARDE-B is an acronym for congestive heart failure, albumin or malnutrition (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index <25 kg/m2. We developed and validated the CARDE-B score to determine the risk of death within 30 days of a revision TJA.

METHODS

A total of 13,118 revision TJAs (40% hip and 60% knee) from the National Surgical Quality Improvement Program (NSQIP) database were analyzed. A simple 1-point scoring system, CARDE-B, was created for predicting 30-day mortality after revision TJA, based on a logistic regression model. The CARDE-B scoring system assigns 1 point to each criterion in the acronym: congestive heart failure, albumin (<3.5 mg/dL), renal failure on dialysis, dependence for daily living, elderly (>65 years of age), and body mass index of <25 kg/m2. The CARDE-B scoring system was compared with 2 commonly utilized scores: American Society of Anesthesiologists (ASA) physical status classification and the 5-factor modified frailty index (mFI-5). The area under the curve (AUC) was used to assess the accuracy of each model. The Hosmer-Lemeshow test was used to assess goodness of fit. Finally, the Nationwide Inpatient Sample (NIS) was used for external validation of the CARDE-B score in 19,153 patients who underwent revision TJA in 2017.

RESULTS

Eighty-eight patients (0.7%) did not survive 30 days after revision TJA. The AUC for the logistic regression model was 0.88 in both the derivation and internal validation samples using NSQIP. The predicted probability of 30-day mortality after revision TJA increased stepwise from <0.01% for a CARDE-B score of 0 points to 39% for a CARDE-B score of 5 points. The AUC for the CARDE-B score predicting 30-day mortality after revision TJA was 0.85. This was more accurate (p < 0.001) than the ASA physical status classification (AUC, 0.77) and the mFI-5 (AUC, 0.67). The AUC for the CARDE-B score in the NIS external validation set was 0.75. The Hosmer-Lemeshow p value for goodness of fit was 0.34, indicating goodness of fit in the external validation sample.

CONCLUSIONS

The CARDE-B score is a simple system that predicts the risk of death within 30 days of a revision TJA, offering surgeons and patients a valuable and validated risk-stratification tool.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology

STUDY DESIGN

Retrospective review of an administrative database.

OBJECTIVES

The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.

METHODS

Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.

RESULTS

In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001.

CONCLUSION

Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.

Geographic Variation in Physician Payments from Private Insurers for Commonly Performed Inpatient Orthopaedic Surgeries in the United States

We investigated geographic variation in percentage of private insurance payments to United States physicians for commonly performed orthopaedic procedures. We queried a private administrative claims database for patients who underwent inpatient total knee arthroplasty (TKA), total hip arthroplasty (THA), single-level anterior cervical discectomy and fusion (ACDF), and posterior lumbar fusion (PLF) from 2010 to 2017. Percentage of total payments to physician (PPP) was calculated by dividing physician payments by total payments. Analysis of variance was used to determine geographic differences in PPP. A total of 542,530 patients were included, mean age was 55 ± 8. PPP significantly varied between states for all four procedures (p < 0.001); Colorado and Alabama had the lowest and highest PPP, respectively. There was a significant annual decrease in PPP across all regions in all procedures. There was significant variation in percentage of total payments to physicians across geographic regions in the United States for TKA, THA, ACDF and PLF. (Journal of Surgical Orthopaedic Advances 30(1):014-019, 2021).

Chronic Opioid Use Following Lumbar Discectomy: Prevalence, Risk Factors, and Current Trends in the United States

Objective

Lumbar discectomy is commonly performed for symptomatic lumbar disc herniation. We aimed to examine prescribing patterns and risk factors for chronic opioid use following lumbar discectomy.

Methods

Using a private insurance claims database, patients were identified who underwent primary lumbar discectomy from 2010–2015 and had 1-year of continuous enrollment postoperatively. Patients were excluded with spinal fusion. The strength of opioid prescriptions was quantified using morphine milligram equivalents daily (MMED). Univariate and multivariate logistic regression models were built to examine risk factors associated with chronic postoperative opioid use.

Results

A total of 5,315 patients were included in the study (mean age, 59 years; 50% female). 1,198 of patients (23%) used chronic opioids postoperatively. Chronic opioid use declined significantly from 27% in 2010 to 17% in 2015, p < 0.001. In addition, there were significantly fewer patients receiving high and very high-dose opioid prescriptions from 2010–2015, p < 0.001. The median duration that patients used opioids postoperatively was 211 days in 2010 (interquartile range [IQR], 29–356 days), and decreased significantly to 44 days (IQR, 10–294 days) in 2015. The strongest factors associated with chronic opioid use were preoperative opioid use (odds ratio [OR], 4.0), drug abuse (OR, 2.6), depression (OR, 1.6), surgery in the west (OR, 1.6) or south (OR, 1.6), anxiety (OR, 1.5), or 30-day readmission (OR, 1.4).

Conclusion

Chronic opioid use following primary lumbar discectomy has declined from 2010–2015. A variety of factors are associated with chronic opioid use. Preoperative recognition of some of these risk factors may aid in perioperative management and counseling.

Synthetic Cages Associated With Increased Rates of Revision Surgery and Higher Costs Compared to Allograft in ACDF in the Nonelderly Patient

Objective

The aim of this study was to compare all-cause reoperation rates and costs in nonelderly patients treated with anterior cervical discectomy and fusion (ACDF) with structural allograft versus synthetic cages for degenerative pathology.

Methods

We queried a private claims database to identify adult patients (≤ 65 years) who underwent single-level ACDF in a hospital setting using either structural allograft or a synthetic cage (polyetheretherketone, metal, or hybrid device), from 2010 to 2016. The rate of all-cause reoperations at 2 years were compared between the 2 groups. Index hospitalization costs and 90-day complication rates were also compared. Significance was set at p < 0.05.

Results

A total of 26,754 patients were included in the study. 11,514 patients (43%) underwent ACDF with structural allograft and 15,240 (57%) underwent ACDF with a synthetic cage. The patients in the allograft group were younger and more likely to be male. There was no significant difference between the 2 groups with respect to 90-day complications including: wound dehiscence, dysphagia, dysphonia, and hematoma/seroma. In the 2-year postoperative period, the synthetic cage group had a significantly higher rate of allcause reoperation compared to the allograft group (9.1% vs. 8.0%, p = 0.002). Index hospitalization costs were significantly higher in the synthetic cage group compared to those in the allograft group ($23,475 vs. $20,836, p < 0.001).

Conclusion

Structural allograft is associated with lower all-cause reoperation rates and lower index costs in nonelderly patients undergoing ACDF surgery for degenerative pathology. It is important to understand this data as we transition toward value-based care.

Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective review.

OBJECTIVE

To identify national trends in postoperative opioid prescribing practices after posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Opioids are an important component of pain management after PSF for AIS. Given the national opioid crisis, it is important to understand opioid prescribing practices in these patients.

METHODS

Using a commercial prescription drug claims database, we identified AIS patients who underwent PSF from 2010 to 2016 and who were prescribed opioids postoperatively. An initial prescription at hospital discharge of ≥ 90 morphine milligram equivalents daily (MMED) was used to identify patients at risk of overdose according to the US Centers for Disease Control and Prevention (CDC) guidelines. Prescriptions for skeletal muscle relaxants were also identified. α = 0.05.

RESULTS

We included 3762 patients (75% female) with a mean (± standard deviation) age of 15 ± 2.1 years. 56% of patients filled only 1 opioid prescription after discharge, and 44% had ≥ 1 refills. 91% of opioid prescriptions were for hydrocodone (median strength, 43 MMED; mean strength, 65 ± 270 MMED) or oxycodone formulations (median strength, 60 MMED; mean strength, 79 ± 174 MMED). 82% of prescriptions complied with CDC guidelines (< 90 MMED). Overall, 612 patients (16%) filled ≥ 1 prescription for skeletal muscle relaxants, the most common being cyclobenzaprine (45%) and methocarbamol (29%). The percentage of patients filling > 1 prescription declined from 54% in 2010 to 31% in 2016 (p < 0.001). The proportion of patients receiving prescriptions for ≥ 90 MMED was highest in the West (29%) and lowest in the South (16%) (p < 0.001).

CONCLUSION

Most opioid prescriptions after PSF in patients with AIS comply with CDC guidelines. Temporal and geographic variations show an opportunity for standardizing opioid prescribing practices in these patients.

LEVEL OF EVIDENCE

III.

Correction to: Opioid prescribing practices after posterior spinal arthrodesis for adolescent idiopathic scoliosis

The original version of this article unfortunately contained a mistake.