AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus. SUMMARY OF BACKGROUND DATA: Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition. METHODS: Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables. RESULTS: Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus. CONCLUSIONS: In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management. LEVEL OF EVIDENCE: Level-III.

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVES: We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications. SUMMARY OF BACKGROUND DATA: Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions. METHODS: Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications. RESULTS: The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) (P<0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) (P<0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P=0.03) and wound complications (OR 9.47, P=0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications (P>0.05 for all). CONCLUSIONS: Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery. LEVEL OF EVIDENCE: 3.

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.

Abnormal Postoperative PROMIS Scores are Associated with Patient Satisfaction in Adult Spinal Deformity and Degenerative Spine Patients.

STUDY DESIGN: Retrospective review. OBJECTIVES: To evaluate 1) patient satisfaction after adult spine surgery; 2) associations between number of abnormal PROMIS domain scores and postoperative satisfaction; and 3) associations between normalization of a patient's worst preoperative PROMIS domain score and postoperative satisfaction. SUMMARY OF BACKGROUND DATA: Although "legacy" patient-reported outcome measures correlate with patient satisfaction after adult spine surgery, it is unclear whether PROMIS scores do. METHODS: We included 1119 patients treated operatively for degenerative spine disease (DSD) or adult spinal deformity (ASD) from 2014-2019 at our tertiary hospital who completed questionnaires preoperatively and at ≥1 postoperative timepoints up to 2 years. Postoperative satisfaction was measured in ASD patients using items 21 and 22 from the SRS 22-revised questionnaire and in DSD patients using the NASS Patient Satisfaction Index. "Worst" preoperative PROMIS domain was that with the greatest clinically negative deviation from the mean. "Normalization" was a postoperative score within 1 standard deviation of the general population mean. Multivariate logistic regression identified factors associated with satisfaction. RESULTS: Satisfaction was reported by 88% of DSD and 86% of ASD patients at initial postoperative follow-up; this proportion did not change during the first year after surgery. We observed an inverse relationship between postoperative satisfaction and number of abnormal PROMIS domains at all postoperative timepoints beyond 6 weeks. Only among ASD patients was normalization of the worst preoperative PROMIS domain associated with greater odds of satisfaction at all timepoints up to 1 year. CONCLUSION: The proportion of DSD and ASD patients satisfied postoperatively did not change from 6 weeks to 1 year. Normalizing the worst preoperative PROMIS domain and minimizing the number of abnormal postoperative PROMIS scores may reduce the number of dissatisfied patients. PROMIS data can guide perioperative patient management to improve satisfaction. LEVEL OF EVIDENCE: 3.

Systematic YouTube Review - Trigger Finger Release.

Background: With lack of regulation and incentivisation on YouTube for high-quality healthcare information, it is important to objectively evaluate the quality of information on trigger finger - a common condition for hand surgeon referral. Methods: YouTube was queried (11/21/2021) for videos on trigger finger release surgery. Videos were excluded if they were about unrelated topics or not in English. The most viewed 59 videos were categorised by source as physician or non-physician. Two independent reviewers quantified the reliability, quality and content of each video, with inter-rater reliability assessed using Kohen's Kappa test. Reliability was assessed using the Journal of the American Medical Association (JAMA) score. Quality was assessed using the DISCERN score with high-quality videos defined as those with scores in the sample upper 25th percentile. Content was assessed using the informational content score (ICS) with scores in the sample upper 25th percentile indicating more complete information. Two-sample t-tests and logistic regression were used to assess variations between sources. Results: Videos by physicians had higher DISCERN quality (42.6 ± 7.9, 36.4 ± 10.3; p = 0.02) and informational content (5.8 ± 2.6, 4.0 ± 1.7; p = 0.01) scores compared to those by non-physician sources. Videos by physicians were associated with increased odds of high-quality (Odds Ratio [OR] 5.7, 95% Confidence Interval [95% CI] 1.3-41.3) and provided more complete patient information (OR 6.3, 95% CI 1.4-48.9). The lowest DISCERN sub-scores for all videos were discussion of the uncertainties and risks associated with surgery. The lowest ICS for all videos were in the diagnosis of trigger finger (11.9%) and non-surgical prognosis (15.3%). Conclusions: Physician videos have more complete and higher quality information on trigger finger release. Additionally, discussion of treatment risks, areas of uncertainty, the diagnostic process, non-surgical prognosis and transparency on references used were identified as lacking content. Level of Evidence: Level III (Therapeutic).

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery.

BACKGROUND CONTEXT: Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse. PURPOSE: The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores. PATIENT SAMPLE: Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. OUTCOME MEASURES: PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience. METHODS: Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores. RESULTS: Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all). CONCLUSIONS: In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

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.

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery.

BACKGROUND CONTEXT: Patient activation is a patient's willingness to take independent actions to manage their own health care. PURPOSE: The goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: A single-institution, academic database of patients undergoing elective spine surgery. OUTCOME MEASURE: MCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety. METHODS: We retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function. RESULTS: Of the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08-6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20-8.57), and stage 4 (aOR:5.56, 95% CI:2.20-14.01) were more likely to achieve MCID. CONCLUSION: Patients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery.

BACKGROUND CONTEXT: Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients. PURPOSE: To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery. DESIGN: Retrospective review. PATIENT SAMPLE: Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained. OUTCOME MEASURES: The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute. METHODS: Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM. RESULTS: LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM. CONCLUSIONS: Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery. LEVEL OF EVIDENCE: III.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review.

BACKGROUND: Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI. OBJECTIVE: To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS: A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis. RESULTS: After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review. CONCLUSIONS: Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

Racial Disparities in Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVES: To synthesize previous studies evaluating racial disparities in spine surgery. METHODS: We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay. RESULTS: A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications. CONCLUSIONS: This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

No Difference in Two-Year Revisions Between Hybrid Fusion and Two-Level Anterior Discectomy and Fusion: A National Database Study.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: This study utilized a large national database to compare two-year revision rates, in addition to complications and costs, of hybrid surgery (HS) compared to two-level anterior cervical discectomy and fusion (ACDF). METHODS: This study used the PearlDiver Mariner dataset selecting for patients aged 18 and older who had at least 90-day active longitudinal follow-up who underwent two-level ACDF or two-level Hybrid surgery (single level ACDF and single level CDA). Patients with prior spinal trauma, infection, cancer, or posterior fusion were excluded. Primary outcomes measures were 90-day major and minor medical complications, ED visits, readmissions, as well as two-year revisions. Patients were also assessed for postoperative dysphagia, incidental durotomy, vascular injury, 90-day surgical site, and implant complications. Additionally, hospitalization and postoperative costs were evaluated. RESULTS: There were 4570 two-level ACDF surgeries and 888 hybrid surgeries. After matching the cohorts, no statistical differences in demographics were found. There were no differences in reoperation rates at all measured time points nor 2-year complications. HS had a lower incidence of major (1.6% vs 3.1%, P = .003) and minor complications (3.0% vs 4.6%, P = .009) than ACDF. 90-day readmission was lower in the HS cohort (2.8% vs 4.2%), P = .024. HS was associated with reduced hospitalization costs -$2614 (-$3916 to -$904, P < .001). 3516 patients had ACDF, and 699 had HS with at least 2 years of follow-up. CONCLUSION: Hybrid surgery is a safe and effective surgical treatment for cervical disease in appropriately selected patients.

Orthopaedic Surgeon Distribution in the United States.

BACKGROUND: There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors. METHODS: County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density. RESULTS: In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000 persons, respectively. Over the past 2 decades, there was a significant increase in the percentage of orthopaedic surgeons in metropolitan counties (77% in 2000 vs 93% in 2019, P < 0.001) and in the proportion of orthopaedic surgeons 55 years and older (32% in 2000 vs 39% in 2019, P < 0.001). Orthopaedic surgeon density increased with increasing median home value (P < 0.001) and median household income (P < 0.001). Counties with a higher percentage of persons in poverty (P < 0.001) and higher unemployment rate (P < 0.001) and nonmetropolitan (P < 0.001) and rural (P < 0.001) counties had a lower density of orthopaedic surgeons. On multivariable analysis, a model consisting of median home value (P < 0.001), rural counties (P < 0.001), percentage of noninsured persons (P < 0.001), and percentage of foreign-born persons (P < 0.001) predicted orthopaedic surgeon density. CONCLUSION: Access to orthopaedic surgeons in the United States in rural areas is decreasing over time. County-level socioeconomic factors such as wealth and urbanization were found to be closely related with surgeon density.

Emergency Department Visits for Ankle Fractures Through COVID-19: An Analysis of the National Electronic Injury Surveillance System.

Background: Societal changes that occurred during the COVID-19 pandemic may have altered the epidemiology of ankle fractures. The aim of this study was to assess trends in emergency department visits for ankle fractures from 2019 to 2020 in the United States. Methods: The National Electronic Injury Surveillance System (NEISS) database is a sample of hospitals in the United States stratified and weighted based on emergency department (ED) size, which was used to generate national estimates (NEs). The NEISS database was queried for patients who sustained an ankle fracture. Patients before COVID-19 (BC) (July 2019-December 2019) were compared to those during COVID-19 (DC) (July 2020-December 2020). Results: This study assessed 3350 (NE: 131,672) patients. Of these, 1683 (NE: 67,292) patients presented BC and 1667 (NE: 64,380) DC, representing a 4% decrease. The rate of alcohol-related ankle fractures increased (1.9% BC vs 2.6% DC; P < .001). The fraction of ankle fractures at school (3% BC vs 0.7% DC; P < .001) and during sports (19% BC vs 14% DC; P < .001) decreased. ED visits for ankle fracture leading to hospitalization marginally increased (23% BC vs 24% DC). The top 3 ankle fracture causes during COVID-19 were stairs (NE: 18,026, 28%), floors (ie, falling on floor) (NE: 4635, 7.2%), and skateboards (NE: 2832, 4.40%). The 3 largest increases in ankle fracture causes during COVID-19 were skateboards (+2.80%), floors (+1.10%), and powered scooters (+0.80%). Conclusion: There was a decrease in ankle fractures during the COVID-19 pandemic compared to the year before. Alcohol-related fractures increased as did fractures resulting in hospitalization. Ankle fractures caused by skateboards, powered scooters, and mopeds increased during COVID-19, whereas fewer occurred in school or during sports, consistent with restrictions to group activities. These findings may aid in proper health care budgeting in times of national and global crises. Level of Evidence: Level III, retrospective comparative study.

Increased Severity of Anemia Is Associated with Postoperative Complications following a Adult Spinal Deformity Surgery.

BACKGROUND: Anemia is a modifiable risk factor for postoperative complications following surgery. This study aimed to determine the impact of preoperative anemia severity on 30-day postoperative complications following adult spinal deformity (ASD) surgery. METHODS: Adults undergoing spinal fusion for ASD from 2012 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were substratified into 3 cohorts-non-anemia, mild anemia, and moderate-to-severe anemia-based on World Health Organization definitions. We assessed 30-day wound, cardiac, pulmonary, renal, and thromboembolic complications, as well as sepsis, mortality, postoperative transfusions, extended length of stay, and reoperation. Bivariate analyses and multivariable logistic regression were performed. RESULTS: Of 2173 patients, 1694 (78%) had no anemia, 307 (14%) had mild anemia, and 172 (8%) had moderate or severe anemia. Following adjustments, patients with mild anemia were more likely to have postoperative blood transfusions (odds ratio [OR] 1.80, P < 0.001) and extended length of stay (OR 1.43, P < 0.001). Patients with moderate-to-severe anemia were at increased risk of organ space infection (OR 3.27, P = 0.028), death (OR 13.15, P = 0.001), postoperative blood transfusion (OR 2.81, P < 0.001), and extended length of stay (OR 3.02, P < 0.001). CONCLUSIONS: We found a stepwise and approximately two-fold increase in the odds ratio of postoperative transfusion and length of stay with increasing severity of anemia. Moderate-to-severe anemia was associated with increased odds of death and organ space infection. Patients with moderate-to-severe anemia should be medically optimized before ASD surgery.

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.

AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery.

BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery. PURPOSE: To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery. STUDY DESIGN: Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included. OUTCOME MEASURES: Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold. RESULTS: Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge. CONCLUSIONS: First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

The Most-Cited Ankle Arthroplasty Implant Articles.

Background: Citation analysis is a useful way of evaluating the impact, importance, and merit of articles within a medical specialty. Our study identified and analyzed the most-cited articles on ankle arthroplasty implants to evaluate their importance in the field of ankle arthroplasty research. Methods: Using the keywords "ankle arthroplasty" and "ankle replacement" and the search period 1970-2021, we found 3728 articles on ankle arthroplasty implants in the Scopus, Web of Science, and MEDLINE/PubMed databases. We included original articles, reviews, clinical trials, and case reports in the study. We retrieved the 50 most-cited articles published during the time frame and then screened them for studies of specific ankle arthroplasty implants and their postoperative outcomes. We also recorded and analyzed the articles' subjects, authorship, journals, countries of origin, and years of publication. Results: The 50 most-cited articles were published between 1983 and 2014, with the majority (33) published between 2000 and 2010. They generated 9012 citations in the literature. The most-cited study accounted for 497 citations; the mean number of citations per article was 180.24 ± 76.24. Twenty-three (46%) of the articles addressed postoperative outcomes following a specific type of arthroplasty implant. Arthroplasty implant studies accounted for 4726 citations, or 52.4% of the citations of the 50 articles. The most frequently studied arthroplasty implant was STAR (15), followed by Agility (7), Buechel Pappas (5), and Salto (4). STAR accounted for 3311 citations, or 37% of the total citations of the 50 articles. Conclusion: Ankle arthroplasty research has made great progress in the past 2 decades, particularly in the area of postoperative outcomes of specific ankle implants, but continued research and publication on additional arthroplasty implants should become a priority. Level of Evidence: Level V, Review Article.

Preoperative duration of pain is associated with chronic opioid use after adult spinal deformity surgery.

PURPOSE: Few studies have explored the association between preoperative patient-reported measures and chronic opioid use following adult spinal deformity (ASD) surgery. We sought to explore the association between preoperative duration of pain, as well as other patient-reported factors, and chronic opioid use after ASD surgery. METHODS: We retrospectively reviewed our U.S. academic tertiary care hospital's database of ASD patients. We included patients 18 years or older who underwent arthrodesis of four or more spinal levels from January 2008 to February 2018, with 2-year follow-up. The primary outcome variable was chronic opioid use, defined as opioid use at both 1 and 2 years postoperatively. We analyzed patient characteristics; duration of preoperative pain (<4 years or ≥4 years); radiculopathy; preoperative Scoliosis Research Society-22r (SRS-22r) score; Oswestry Disability Index (ODI) value; and surgical characteristics. RESULTS: Of 119 patients who met the inclusion criteria, 93 (78%) were women, and mean ± standard deviation age was 59 ± 13. Sixty patients (50%) reported preoperative opioid use, and 35 (29%) reported chronic opioid use. Preoperative opioid use was associated with higher odds of chronic use (adjusted odds ratio, 5.9; 95% confidence interval 1.6-21), as was preoperative pain duration of ≥4 years (adjusted odds ratio, 3.3; 95% confidence interval 1.1-9.8). Patient characteristics, surgical variables, ODI value, and SRS-22r score were not significantly associated with chronic postoperative opioid use. CONCLUSION: Preoperative opioid use and duration of pain of ≥4 years were associated with higher odds of chronic opioid use after ASD surgery. LEVEL OF EVIDENCE: III.

Adoption of awake spine surgery - trends from a national registry over 14 years.

BACKGROUND CONTEXT: Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied. PURPOSE: To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States. STUDY DESIGN/SETTING: A retrospective observational study. PATIENT SAMPLE: Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019. OUTCOME MEASURES: The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019. METHODS: Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006. RESULTS: We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m2; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively). CONCLUSIONS: Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.