Epidemiology of Achilles tendon injuries in collegiate level athletes in the United States.

BACKGROUND: Achilles injuries are devastating injuries, especially for competitive athletes. No studies have examined the outcomes of Achilles injuries in NCAA athletes. Therefore, a better characterization and understanding of the epidemiology is crucial. METHODS: Achilles injuries across 16 sports among NCAA men and women during the 2004-2005 to 2013-2014 academic years were analyzed using the NCAA Injury Surveillance Program (NCAA-ISP). Achilles tendon injury rate (IR) per 100,000 athlete-exposures (AEs), operative rate, annual injury rate trends, reinjury rates, mechanism of injury, in-season status (pre/regular/post season), and time loss distributions were compiled and calculated. A sub-analysis of comparing gender and injury mechanism was also performed for both all injuries and severe injuries. RESULTS: Overall, N = 255 Achilles injuries were identified with an injury rate (IR) of 2.17 (per 100,000 AEs). These injuries occurred most often in women's gymnastics (IR = 16.73), men's basketball (IR = 4.26), and women's basketball (IR = 3.32), respectively. N = 52 injuries were classified as severe injuries which have higher median time loss (48 days) and higher operative rate (65.4%). For severe Achilles injuries, female athletes had higher operative (77.8% vs. 58.8%) and higher time loss compared to male athletes (96 days vs. 48 days). Contact mechanisms were associated with a higher season-ending injury rate. CONCLUSION: Overall, 20.4% of Achilles injuries were considered severe with 65.6% operative rate. About 73.1% were season-ending injuries, and the remaining athletes have a median time loss of 48 days. Severe Achilles injuries create significant impact on playing time and career for NCAA athletes.

Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes. METHODS: Twenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12±3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded. RESULTS: The percutaneous ZO showed a significant improvement (p<0.0001) in preoperative to postoperative FFI (from 65±9 to 8±12) and VAS (from 9±1 to 1±2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks. CONCLUSIONS: ZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications. LEVEL OF EVIDENCE: III, retrospective case series.

New Paradigms in the Continuum of Spine Care: From Newborns to Elderly Patients.

The evaluation and management of spinal disorders is complex and constantly evolving. Back pain and spinal deformity are substantial contributors to hospital and outpatient physician visits even for young patients. With new insights into the etiology, clinical presentation, and evaluation, children can be more accurately diagnosed and treated. Patients with adolescent idiopathic scoliosis may undergo selective fusion to preserve motion segments, and in some cases, vertebral body tethering or other growth-modification techniques may provide correction with motion preservation in this rapidly changing specialty. The understanding of spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope) and sagittal balance as they relate to clinical health status has provided surgeons with valuable guidance when managing pediatric and adult spinal deformity. An evidence-based approach to the management of spinal disorders across the continuum of ages has the goal of improving the value of care through optimization of outcomes and limitation of costs and complications. There are new paradigms in the management of spinal disorders and evidence-based approaches to the evaluation and management of patients across the ages.

Favorable Outcome Twenty-Two Months after Delbet Type Ib Capital Femoral Transepiphyseal Fracture and Posterior Column Acetabular Fracture in a Fifteen-Year-Old Male.

Case: A fifteen-year-old male patient sustained a posteriorly dislocated right capital femoral Delbet type Ib epiphyseal fracture-separation and a right acetabular posterior column fracture after a low-energy trip and fall. The capital femoral epiphysis was closed reduced and fixed with cannulated screws on an urgent basis. He underwent acetabular osteosynthesis via a Kocher-Langenbeck approach two days thereafter. Twenty-two months after injury, he was weight-bearing on the right lower extremity without radiologic evidence of avascular necrosis or clinical evidence of pain or functional deficit. Conclusion: Fracture-separation of the capital femoral epiphysis comprises only 8% of skeletally immature femoral neck fractures in the Delbet and Colonna classification. Prognosis is worse with ipsilateral hip dislocation due to the risk of avascular necrosis from disruption of the medial femoral circumflex artery. Urgent referral to a trauma center and treatment by appropriate specialists enables good long-term results after this uncommon traumatic injury pattern.

Complications After Percutaneous Osteotomies of the Calcaneus.

Background: Open hindfoot surgery is associated with a relatively high rate of complications, including neurovascular injuries and wound healing problems compared with percutaneous techniques. However, there is a scarcity of literature describing the outcomes of these percutaneous techniques given their relatively recent adoption. The present study aims to assess the rate of postoperative complications for 3 commonly performed percutaneous calcaneal osteotomies. Methods: One hundred eighteen patients (unilateral feet) were treated with one of 3 common percutaneous calcaneal osteotomies. Sixty-five patients (55.1%) were treated with a medializing calcaneal osteotomy for hindfoot valgus, 32 patients with a Zadek osteotomy (27.1%) for insertional Achilles tendinopathy, and 21 patients (17.8%) with a modified Dwyer osteotomy for hindfoot varus. Fisher exact test was used to assess for associations between categorical variables. Results: The mean age was 46.2 years and there was a mean follow-up of 16.1 months. The overall rate of postoperative complications was 3.4% (n = 4), and no significant differences were found between the different osteotomy types. Complications included 2 cases (1.7%) of transient neuritis, 1 case of prolonged wound drainage (0.8%), and 1 nonunion (0.8%). None of the complications were associated with any recorded preoperative comorbidity. Discussion: In this series, we found that percutaneous calcaneal osteotomies are a safe alternative method for the treatment of conditions involving the hindfoot. The rate of postoperative complications may be less when compared to the reported rates of open hindfoot correction and should be considered in patients with a traditionally high risk of developing a postoperative complication. Level of Evidence: Level IV, retrospective analysis.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis.

BACKGROUND: The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis. HYPOTHESIS: Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis. PATIENTS AND METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI). RESULTS: In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization. DISCUSSIONS: Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status. LEVEL OF EVIDENCE: III.

Distraction Arthroplasty as Acute and Definitive Treatment for Open Ankle Fracture Dislocation.

A 73-year-old woman with significant medical comorbidities presented with a grade I open left ankle fracture dislocation. Distraction arthroplasty was used as a definitive treatment for this injury. The patient tolerated the procedure and had no postoperative complications. The external fixator was removed at 6 months. The patient maintained good ankle function at the 1-year postoperative visit. Distraction arthroplasty is a viable acute and definitive treatment option for ankle fracture in patients with significant medical comorbidities. [Orthopedics. 2021;44(1):e148-e150.].

Opioid Consumption and Time to Return to Work After Percutaneous Osteotomy in Foot Surgery.

Surgeries involving the foot and ankle are painful procedures, with many patients unwilling to discontinue prescribed narcotics at 3 months postoperatively. Percutaneous techniques allow for smaller incisions and minimal soft tissue disruption. Fifty consecutive patients underwent outpatient percutaneous foot surgery. Data were collected on pain medication taken and time to return to work. A mean of 3.3 tablets of oxycodone were consumed during the first 2 weeks. No patient was taking narcotics after 2 weeks. Mean time to return to work was 18.9 days. Percutaneous foot and ankle surgery led to a significant reduction in narcotic consumption. [Orthopedics. 2020;43(4):e334-e337.].

Resection Arthroplasty: Current Indications and Tips.

Resection arthroplasty for metatarsalgia is a selective procedure primarily indicated for patients with rheumatoid arthritis. These patients present with significant forefoot deformities, poor bone quality, and loss of soft tissue integrity. Resection of the metatarsal heads and correction of lesser toe deformities improve pain and decrease transfer metatarsalgia. Patients with concurrent hallux valgus may benefit from a lapidus procedure or hallux metatarsophalangeal fusion in an effort to improve outcomes and decrease incidence of recurrent hallux valgus. In rare cases, diabetics with neuropathy may require resection arthroplasty in the setting of forefoot deformities recalcitrant to other modalities.

Failure of Fixation With Nickel-Titanium Staples in First Metatarsophalangeal Arthrodesis With Hallux Valgus Deformity.

First metatarsophalangeal (MTP) joint arthrodesis is a treatment option for patients with arthritic hallux valgus (HV). Nickel-titanium staples allow continuous compression throughout the fusion site and have been shown to achieve successful union in many procedures. However, their efficacy has not been tested in patients with underlying HV deformity. Three cases of severe HV deformity that underwent first MTP arthrodesis with 2 nickel-titanium staples placed 60° from each other and had failure are reported. The authors believe this construct does not provide adequate rotational control for first MTP arthrodesis in patients with severe HV deformity. [Orthopedics. 2019; 42(4):e402-e404.].

Predictive Factors and Rates of Fusion in Minimally Invasive Transforaminal Lumbar Interbody Fusion Utilizing rhBMP-2 or Mesenchymal Stem Cells.

BACKGROUND: Several fusion adjuncts exist to enhance fusion rates during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The objective of this study was to compare fusion rates in patients undergoing MI-TLIF with either rhBMP-2 or cellularized bone matrix (CBM). METHODS: We conducted a single surgeon retrospective cohort study of patients who underwent MI-TLIF with either rhBMP-2 or CBM placed in an interbody cage. Single and multilevel procedures were included. Fusion was assessed on computed tomography scans at 12-month follow-up by an independent, blinded, board-certified neuroradiologist. Fusion rates and rate of revision surgery were compared with a Fisher exact test between the 2 groups. A multivariate regression analysis was performed to identify patient factors that were predictive of radiographic nonunion after MI-TLIF. RESULTS: A total of 93 fusion levels in 78 patients were reviewed. Thirty-nine patients received CBM, and 39 patients received rhBMP-2. The patients receiving rhBMP-2 were older on average (61.4 vs 55.6, P = .03). The overall fusion rate was 68% in the CBM group (32/47 levels) and 78% in the rhBMP-2 group (36/46) (P = .35). Only preoperative hypertension was predictive of radiographic nonunion (odds ratio = 3.5, P = .05). There were 3 smokers in the CBM group and 4 smokers in the BMP group, and 1 in each group experienced radiographic pseudarthrosis. A total of 4 patients, 3 in the CBM group and 1 in the BMP group (P = .61), required revision for symptomatic pseudarthrosis. All of these patients had a single-level index procedure. CONCLUSIONS: There were no differences in radiographic fusion and rate of revision surgery in patients who underwent MI-TLIF with either rhBMP-2 or CBM as fusion adjuncts. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Both rhBMP-2 and CBMs can be used as effective fusion adjuncts without any clear advantage of one over the other.

Safety and Effectiveness of Talus Subchondroplasty and Bone Marrow Aspirate Concentrate for the Treatment of Osteochondral Defects of the Talus.

Eleven patients with symptomatic talus osteochondral defects who underwent subchondroplasty with bone marrow aspirate concentrate injection were retrospectively reviewed. Foot and Ankle Outcome Score and visual analog scale pain score were recorded preoperatively and at the 1-year postoperative visit. The mean osteochondral defect size was 1.3×1.4 cm. The weight-bearing visual analog scale pain score improved from a mean of 7.8 to 1.8, and the Foot and Ankle Outcome Score improved from a mean of 67.1 to 89.6. At 1-year follow-up, 10 patients reported they would have the procedure again. Subchondroplasty and bone marrow aspirate concentrate injection offered good pain relief for talus osteochondral defects. The procedure allows immediate weight bearing postoperatively and does not compromise future treatments. [Orthopedics. 2018; 41(5):e734-e737.].

The Effect of Parkinson's Disease on Patients Undergoing Lumbar Spine Surgery.

STUDY DESIGN: Retrospective Database Analysis. OBJECTIVE: The purpose of this study was to assess characteristics and outcomes of patients with Parkinson's disease (PD) undergoing lumbar spine surgery for degenerative conditions. METHODS: The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on ICD-9-CM procedural codes for lumbar spine surgery and substratified to degenerative diagnoses. Incidence and baseline patient characteristics were determined. Multivariable analysis was performed to determine independent risk factors increasing incidence of lumbar fusion revision in PD patients. RESULTS: PD patients account for 0.9% of all degenerative lumbar procedures. At baseline, PD patients are older (70.7 versus 58.9, p < 0.0001) and more likely to be male (58.6% male, p < 160.0001). Mean length of stay (LOS) was increased in PD patients undergoing lumbar fusion (5.1 days versus 4.0 days, p < 0.0001) and lumbar fusion revision (6.2 days versus 4.8 days, p < 180.0001). Costs were 7.9% (p < 0.0001) higher for lumbar fusion and 25.2% (p < 0.0001) higher for lumbar fusion revision in PD patients. Multivariable analysis indicates that osteoporosis, fluid/electrolyte disorders, blood loss anemia, and insurance status are significant independent predictors of lumbar fusion revision in patients with PD. CONCLUSION: PD patients undergoing lumbar surgery for degenerative conditions have increased LOS and costs when compared to patients without PD.

Comparing the Incidence of Index Level Fusion Following Minimally Invasive Versus Open Lumbar Microdiscectomy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine the incidence of index level fusion following open or minimally invasive lumbar microdiscectomy. METHODS: We conducted a retrospective review of 174 patients with a symptomatic single-level lumbar herniated nucleus pulposus who underwent microdiscectomy via a mini-open approach (MIS; 39) or through a minimally invasive dilator tube (135). Outcomes of interest included revision microdiscectomy and the ultimate need for index level fusion. Continuous variables were analyzed with independent sample t test, and χ2 analysis was used for categorical data. A multivariate regression analysis was performed to identify predictive factors for patients that required index level fusion after lumbar microdiscectomy. RESULTS: There was no difference in patient demographics in the open and MIS groups aside from length of follow-up (60.4 vs 40.03 months, P < .0001) and body mass index (24.72 vs 27.21, P = .03). The rate of revision microdiscectomy was not statistically significant between open and MIS approaches (10.3% vs 10.4%, P = .90). The rate of patients who ultimately required index level fusion approached significance, but was not statistically different between open and MIS approaches (10.3% vs 4.4%, P = .17). Multivariate regression analysis indicated that the need for eventual index level fusion after lumbar microdiscectomy was statistically predicted in smokers and those patients who underwent revision microdiscectomy (P < .05) in both open and MIS groups. CONCLUSIONS: Our results suggest a low likelihood of patients ultimately requiring fusion following microdiscectomy with predictors including smoking status and a history of revision microdiscectomy.

Short-Term Complications of Anterior Fixation of Odontoid Fractures.

STUDY DESIGN: Retrospective study. OBJECTIVE: Anterior fixation of odontoid fracture has been associated with high morbidity and mortality in small, single institution series. Identifying risk factors may improve risk stratification and highlight factors that could be optimized preoperatively. The objective of this study was to determine the 30-day complication rate following anterior fixation of odontoid fractures and to identify associated risk factors among patients in a large national database. METHODS: Patients who underwent anterior fixation were identified in the American College of Surgeons National Quality Improvement Program database (ACS NSQIP) from 2007 to 2012. Patient demographics, medical comorbidities, perioperative complications, and postoperative complications up to 30 days were analyzed by univariate and multivariate analysis. RESULTS: Overall, 103 patients met criteria for the study. The average age was 73.9 years and patients were predominantly white (85.4%). Cardiac comorbidity was common (66.0%), as were dependent functional status (14.6%) and bleeding disorders (13.6%). Complications occurred in 37.9% of patients, and mortality was high (6.8%). Age, white race, and history of bleeding disorders were independently predictive of complications in the multivariate analysis. The postoperative hospital stay was >5 days for 45.6% of patients. CONCLUSION: In a large, multicenter database study, anterior fixation of odontoid fracture was associated with high morbidity and mortality. Although advanced age was associated with increased risk of complications, patients undergoing anterior fixation were older, on average, than in prior studies. Bleeding disorder was a potentially modifiable risk factor for complications that could be optimized prior to surgery.

The Impact of Resident Involvement in Elective Posterior Cervical Fusion.

STUDY DESIGN: Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery. SUMMARY OF BACKGROUND DATA: Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest. RESULTS: A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023). CONCLUSION: The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity. LEVEL OF EVIDENCE: 3.

Incidence and Risk Factors for 30-Day Unplanned Readmissions After Elective Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective study of prospectively collected data. OBJECTIVE: To perform a multiinstitutional assessment on the incidence and risk factors for unplanned readmissions following elective posterior lumbar fusion (PLF) surgery. SUMMARY OF BACKGROUND DATA: Understanding what may drive rehospitalizations is a necessary step toward higher quality care. Identifying risk factors for unplanned readmission is especially important for elective PLF, which is a common procedure that is known to be associated with significant adverse events. METHODS: Adult patients undergoing PLF were identified using current procedure terminology (CPT) from the American College of Surgeons National Surgical Quality Improvement Program. Both descriptive and comparative statistics were performed for patient characteristics, clinical factors, and postoperative complications. Subsequently, a step-wise multivariate logistic regression was employed. RESULTS: Of the 2301 patients who met inclusion criteria for this study, 117 were unplanned readmissions (5.1%). These occurred at a mean of 15.9 days (range: 3-30 days) after surgery. The risk-adjusted analysis revealed that bleeding disorder (odds ratio, OR = 2.8, confidence intervals, CI = 1.0-7.6, P = 0.043), insulin dependent diabetes (OR = 2.5, CI = 1.4-4.4, P = 0.004), and total length of stay > 5 days (OR = 1.8, CI = 1.2-2.8, P = 0.009) were independent predictors for unplanned readmission. Significant postoperative complications included wound complications (OR = 27.6, CI = 13.9-54.8, P < 0.0001), pulmonary embolism and/or deep vein thrombosis/thrombophlebitis (OR = 11.9, CI = 5.0-28.5, P < 0.0001), sepsis (OR = 8.5, CI = 2.3-32.1, P = 0.002), and urinary tract infections (OR = 2.4, CI = 0.9-6.9, P = 0.094). CONCLUSION: The unplanned readmission rate for patients undergoing PLF was low, but this study's findings of potentially modifiable risk factors suggest that substantial improvement with this quality metric is possible. LEVEL OF EVIDENCE: N/A.

Accuracy of Percutaneous Pedicle Screw Placement: Does Training Level Matter?

STUDY DESIGN: In vitro human cadaveric surgical technique study. OBJECTIVE: To assess the accuracy of percutaneous pedicle screw placement in a human cadaveric model using standard fluoroscopic guidance technique, compared across varying levels of experience. SUMMARY OF BACKGROUND DATA: The current literature varies widely in the reported frequency of facet violation during placement of percutaneous pedicle screws. However, as of yet there are no studies examining the effect that training level has on accuracy of placement. MATERIALS AND METHODS: Four surgeons with differing levels of training (PGY-2, PGY-4, fellow, attending) were evaluated on their accuracy of percutaneous placement of screws in a uniform manner. Each of the 10 cadavers was instrumented from L1 to S1 bilaterally, for a total of 120 screws. Specimens were dissected to evaluate for facet and pedicle wall violations. These were then recorded and analyzed to evaluate for correlation among participating surgeons, laterality, spinal level, and cadaver body mass index. RESULTS: Of 120 screws placed, there were 35 total violations [26 superior articular facet violations (21.7%), 5 intra-articular facet joint violations (4.2%), and 4 pedicle breaches (3.3%)]. Among the trainees there was no difference in the likelihood of causing a violation (P=0.8863) but there was a difference when compared with the attending surgeon (P=0.0175). Laterality (P=0.1598), spinal level (P=0.3536), and body mass index (P=0.8547) did not correlate with the likelihood of a violation. CONCLUSIONS: Surgeons of differing training levels are able to safely and accurately place lumbar pedicle screws in a percutaneous manner, with a low likelihood of facet and pedicle wall violations.

Impact of Glycemic Control on Morbidity and Mortality in Adult Idiopathic Scoliosis Patients Undergoing Spinal Fusion.

STUDY DESIGN: This is a retrospective analysis of administrative database. OBJECTIVE: To elucidate the effect of glycemic control on surgical outcomes of middle-aged and elderly idiopathic scoliosis patients undergoing spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Diabetes mellitus (DM) is a condition thought to adversely affect outcomes of spine surgery. However, no study has stratified glycemic control levels and their impact on outcome for idiopathic scoliosis patients receiving a spinal fusion surgery. Previous studies may have reported higher than true rates of complications for controlled diabetic patients, who are the majority of diabetic patients. MATERIALS AND METHODS: The Nationwide Inpatient Sample was queried from years 2002 to 2011. We extracted idiopathic scoliosis patients older than 45 years of age that received spinal fusion and analyzed complications and outcomes variables among 3 cohorts: nondiabetic patients, controlled diabetics, and uncontrolled diabetics. Multivariate analyses were used to assess whether glycemic control was a risk factor for adverse postoperative outcomes. RESULTS: Controlled diabetics had significantly increased rates of acute renal failure (ARF), while uncontrolled diabetics had significantly increased rates of acute postoperative hemorrhage. In multivariate analyses controlling for patient factors and comorbidities, controlled DM was found to be an independent predictor of ARF [odds ratio (OR), 1.863; 95% confidence interval (CI), 1.346-2.579; P=0.0002), and uncontrolled DM was found to be a significant risk factor for acute postoperative hemorrhage (OR, 2.182; 95% CI, 1.192-3.997; P=0.0115), ARF (OR, 4.839; 95% CI, 1.748-13.392; P=0.0024), deep vein thrombosis (OR, 5.825; 95% CI, 1.329-25.522, P=0.0194) and in-patient mortality (OR, 8.889; 95% CI, 1.001-78.945; P=0.0499). CONCLUSIONS: Controlled DM was found to be a risk factor for ARF in adult idiopathic scoliosis patients undergoing spinal fusion surgery, while uncontrolled DM was shown to be a risk factor for postoperative hemorrhage, ARF, deep vein thrombosis, and mortality. The present study provides valuable data for better informed consent for patients with diabetes considering surgery for idiopathic scoliosis. LEVEL OF EVIDENCE: Level III.

Effect of Surgeon Volume on Complications, Length of Stay, and Costs Following Anterior Cervical Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To identify the association between surgeon volume and inpatient complications, length of stay, and costs associated with ACF. SUMMARY OF BACKGROUND DATA: Increased surgeon volume may be associated with improved outcomes after surgical procedures. However, there is a lack of information on the effect of surgeon volume on short-term outcomes after anterior cervical fusion (ACF). METHODS: A retrospective cohort study of ACF patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Surgeon volume was divided into three categories, volume <25th percentile, 25th to 74th percentile, and ≥75th percentile of surgeon volume. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital costs between surgeon volume categories. RESULTS: A total of 419,212 ACF patients were identified. The 25th percentile for volume was 5 cases per year, and the 75th percentile for volume was 67 cases per year. Volume <25th percentile was associated with increased rates of any adverse event (odd ratio, OR 3.8, P < 0.001), and multiple individual complications including death (OR 2.5, P=0.014), myocardial infarction (OR4.4, P < 0.001), sepsis (OR 4.1, P < 0.001), and surgical site infection (OR 4.0, P < 0.001). Notably, volume ≥75th percentile was associated with decreased rates of any adverse event (OR 0.7, P < 0.001) and death (OR 0.6, P = 0.028). On multivariate analysis, length of stay was significantly increased by 2.3 days (P < 0.001) for surgeons <25th percentile of volume and was decreased by 0.3 days for surgeons with volume ≥75th percentile. Hospital costs were $4569 more for surgeons with <25th percentile of volume and $1213 less for surgeons with ≥75th percentile volume. CONCLUSION: In this nationally representative sample, surgeons with volume <25th percentile had significantly increased complications, length of stay, and costs. Conversely, surgeons with ≥75th percentile volume experienced decreased complications, length of stay, and costs. LEVEL OF EVIDENCE: 4.