Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion.

INTRODUCTION: Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes. METHODS: A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates. RESULTS: Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications. DISCUSSION: This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.

Long-segment posterior cervical decompression and fusion: does caudal level affect revision rate?

OBJECTIVE: Posterior cervical decompression and fusion (PCDF) is a commonly performed procedure to address cervical myelopathy. A significant number of these patients require revision surgery for adjacent-segment disease (ASD) or pseudarthrosis. Currently, there is no consensus among spine surgeons on the inclusion of proximal thoracic spine instrumentation. This study investigates the benefits of thoracic extension in long-segment cervical fusions and the potential drawbacks. The authors compare outcomes in long-segment subaxial cervical fusion for degenerative cervical myelopathy with caudal vertebral levels of C6, C7, and T1. METHODS: A retrospective analysis identified 369 patients who underwent PCDF. Patients were grouped by caudal fusion level. Reoperation rates for ASD and pseudarthrosis, infection, and blood loss were examined. Data were analyzed with chi-square, 1-way ANOVA, and logistic regression. RESULTS: The total reoperation rate for symptomatic pseudarthrosis or ASD was 4.8%. Reoperation rates, although not significant, were lower in the C3-6 group (2.6%, vs 8.3% for C3-7 and 3.8% for C3-T1; p = 0.129). Similarly, rates of infection were lower in the shorter-segment fusion without achieving statistical significance (2.6% for C3-6, vs 5.6% for C3-7 and 5.5% for C3-T1; p = 0.573). The mean blood loss was documented as 104, 125, and 224 mL for groups 1, 2, and 3, respectively (p < 0.001). CONCLUSIONS: Given the lack of statistical difference in reoperation rates for long-segment cervical fusions ending at C6, C7, or T1, shorter fusions in high-risk surgical candidates or elderly patients may be performed without higher rates of reoperation.

Preoperative Sedative Use and Other Risk Factors for Continued Narcotic Use After Total Knee Arthroplasty: A Comprehensive Analysis of a Mandatory Database.

Opioids are used for pain control after total knee arthroplasty (TKA) and carry risk for abuse. Mandatory statewide databases have been created to monitor their use. The goal of this study was to identify patient risk factors for prolonged opioid use after TKA. The authors retrospectively reviewed a consecutive series of 676 primary TKA procedures performed between January 2017 and July 2017. Information on fulfillment of narcotic, sedative, benzodiazepine, and stimulant prescriptions was obtained from the Pennsylvania State Controlled Substance Monitoring website 6 months before and 1 year after the procedure. Bivariate and multivariate analyses were used to identify risk factors for the need for a second prescription and opioid use for longer than 6 months. Of this cohort, 30.3% used preoperative opioids, 60.5% filled a second opioid prescription, and 11.8% continued opioid use for longer than 6 months. Patients who had opioid use before the index procedure had more than 3-fold (odds ratio [OR], 3.29; P<.001) increased odds of filling a second opioid prescription and 8-fold (OR, 8.05; P<.001) increased odds of postoperative opioid use for longer than 6 months. Multivariate analysis was used to identify independent risk factors for requiring a second prescription, including discharge to a rehabilitation facility (OR, 2.77), bilateral procedures (OR, 1.88), preoperative narcotic use (OR, 1.70), and younger age (OR, 0.95). Independent risk factors for narcotic use for longer than 6 months included preoperative sedative (OR, 3.30) or narcotic use (OR, 1.49). This study identified several risk factors associated with prolonged narcotic use after TKA, including preoperative sedative use, and determined their relative weight. [Orthopedics. 2021;44(1):e50-e54.].

Overlapping Surgery Increases Operating Room Efficiency Without Adversely Affecting Outcomes in Total Hip and Knee Arthroplasty.

BACKGROUND: Several recent studies have demonstrated that overlapping surgeries in total hip (THA) and knee (TKA) arthroplasty do not increase the rates of complications, but whether this practice is cost-effective has yet to be addressed in the literature. The purpose of this study is to determine the effect of overlapping surgery on procedural costs and surgical productivity during THA and TKA. METHODS: We identified all patients undergoing primary THA or TKA from 2015 to 2018 by 18 surgeons at a single orthopedic specialty hospital. Procedural and personnel costs were calculated for each case using a time-driven activity-based costing algorithm. Overlap of surgical time by at least 30 minutes was used to define an overlapping procedure. We compared costs and outcomes between overlapping and nonoverlapping procedures, standardizing all costs to 8-hour time blocks. A multivariate regression analysis was performed to determine independent effect of overlapping procedures on costs and outcomes. RESULTS: Of the 4786 consecutive procedures, 968 (20.2%) overlapped by at least 30 minutes. Although overlapping rooms increased mean operative time by 8.3 minutes (P < .0001) and operating room personnel costs by $80 per case (<.0001), overlapping surgeons could perform significantly more procedures per 8 hours (7.6 vs 6.4; P < .0001), increasing total 8-hour profit margin by $1215 per procedure. There was no difference in 90-day readmission rate, length of stay, or rates of discharge home between the groups. CONCLUSION: Overlapping noncritical portions of procedures in primary THA and TKA appear to be both a safe practice and an effective strategy.

Understanding Opioid Use After Total Hip Arthroplasty: A Comprehensive Analysis of a Mandatory Prescription Drug Monitoring Program.

INTRODUCTION: Opioids remain the most prescribed medication after total hip arthroplasty (THA) despite the potential for abuse and adverse effects. Given the high rates of opioid abuse and potential adverse effects, the reporting of controlled substances is now mandatory in many statewide databases. This study aimed to use a mandatory statewide database to analyze opioid prescription patterns in postoperative THA patients and identify independent risk factors for those patients who need a second prescription and/or require prolonged use (>6 months). METHODS: We retrospectively reviewed a consecutive series of 619 primary THAs. Demographic and comorbidity information were collected for all patients. Narcotic prescription data (converted to morphine milligram equivalents) as well as prescription data for sedatives, benzodiazepines, and stimulants were collected from the State's Controlled Substance Monitoring websites 6 months before and 9 months after the index procedure. Bivariate and multivariate analyses were done for second prescription and continued use. RESULTS: Of the 619 patients who underwent THA, 34.9% (216/619) used preoperative opioids, 36.2% (224/619) filled a second opioid prescription, and 10.5% (65/619) had continued use past 6 months. Patients with preoperative opioids were at an approximately 4-fold increased odds of requiring a second script and 12 times odds of continued opioid use. In the multivariate analysis, independent risk factors for requiring a second prescription, in descending order of magnitude, included the use of any sedative or sleep aid prescription and preoperative narcotic use. Independent risk factors for continued narcotic use longer than 6 months after THA included preoperative narcotic use and increased length of stay. DISCUSSION: Several risk factors and their relative weight have been identified for continued narcotic consumption after THA. It is important for surgeons to consider these predisposing factors preoperatively during the informed consent process and for managing postoperative pain expectations.