Reverse total shoulder arthroplasty within 6 weeks of proximal humerus fracture is associated with the lowest risk of revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001). CONCLUSIONS: Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

No difference in 10-year survivorship of total shoulder arthroplasty vs. hemiarthroplasty for avascular necrosis of the humeral head.

BACKGROUND: Avascular necrosis (AVN) of the humeral head is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely, total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty), is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio because TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox proportional hazard modeling. χ2 analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. RESULTS: In total, 4825 patients undergoing TSA and 1969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = .017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = .148) and no difference in the observed etiologies for revision (P > .05 for all). CONCLUSION: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10 years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

The Association Between Oral Bone Mineral Density-Reducing Medications and the Risk of 2-Year Implant-Related Complications Following Total Knee Arthroplasty.

BACKGROUND: Certain medications interfere with the bone remodeling process and may potentially increase the risk of complications after total knee arthroplasty (TKA). As patients undergoing TKA may be taking these bone mineral density (BMD)-reducing medications, it is unclear as to whether and which medications impact TKA outcomes. Therefore, the purpose of this study was to observe the impact of various BMD-reducing medications on 2-year implant-related complications following TKA. METHODS: A retrospective analysis of patients undergoing primary TKA was conducted using a national administrative claims database. Patients were identified if they were taking any known BMD-reducing medication and were compared to control patients. To control for confounders associated with taking multiple agents, multivariable logistic regression analyses were conducted for each 2-year outcome (all-cause revision, loosening-indicated revision, and periprosthetic fracture--indicated revision), with the output recorded as odds ratios (ORs). RESULTS: In our study, 502,927 of 1,276,209 TKA patients (39.4%) were taking at least one BMD-reducing medication perioperatively. On multivariable analysis, medications associated with a higher likelihood of 2-year all-cause revision included first- and second-generation antipsychotics (SGAs) (OR: 1.42 and 1.26, respectively), selective serotonin reuptake inhibitors (SSRIs) (OR: 1.14), glucocorticoids (1.13), and proton pump inhibitors (PPIs) (OR: 1.23) (P < .05 for all). Medications associated with a higher likelihood of 2-year periprosthetic fracture included SGAs (OR: 1.51), SSRIs (OR: 1.27), aromatase inhibitors (OR: 1.29), and PPIs (OR: 1.42) (P < .05 for all). CONCLUSIONS: Of the drug classes observed, the utilization of perioperative PPIs, SSRIs, glucocorticoids, first-generation antipsychotics, and SGAs was associated with the highest odds of all-cause revision. Our findings suggest a relationship between these medications and BMD-related complications; however, further studies should seek to determine the causality of these relationships.

Increased Risk of 10-Year Revision Following Total Hip Arthroplasty for Femoral Neck Fracture.

BACKGROUND: As the incidence of femoral neck fractures (FNFs) increases with the aging population, understanding its impact on surgical outcomes is important to improving implant survival and patient satisfaction. Despite increasing use of total hip arthroplasty (THA) as management for FNF, few studies have examined long-term implant survivability. Thus, this study sought to determine the 10-years cumulative incidence of revision and indications for revision in patients undergoing THA for FNF in comparison to osteoarthritis. METHODS: Patients who underwent primary THA for FNF or osteoarthritis were identified using a national administrative claims database and propensity-score matched in a 1:2 ratio based on age, gender, the Charlson Comorbidity Index (CCI), smoking, obesity, and diabetes mellitus. Kaplan-Meier and Cox proportional hazards analyses were used to observe the cumulative incidence and risk of all-cause revision, periprosthetic joint infection (PJI), dislocation, mechanical loosening, and periprosthetic fracture (PPF) within 10 years of primary THA. In total, 19,735 patients who underwent THA for FNF and 39,383 patients who underwent THA for osteoarthritis were included. RESULTS: The 10-years cumulative incidences of all-cause revision (7.1 versus 4.9%), PJI (5.0 versus 3.3%), dislocation (6.8 versus 3.8%), mechanical loosening (3.1 versus 1.9%), and PPF (7.8 versus 4.0%) were significantly higher for those who underwent THA for FNF versus osteoarthritis. Femoral neck fractures were associated with higher risks of revision (hazard ratio [HR]: 1.6), PJI (HR: 1.7), dislocation (HR: 2.0), mechanical loosening (HR: 1.6), and PPF (HR: 2.2) (P < 0.001 for all). CONCLUSIONS: Despite the advantages of THA, femoral neck fractures remain a major risk factor for long-term complications. Tailored preoperative planning, surgical techniques, and postoperative bone health optimization in these patients may help minimize poor outcomes.

Declining Trends in Septic Revision Following Total Knee Arthroplasty From 2010 to 2019: A National Cohort Analysis.

INTRODUCTION: Periprosthetic joint infections (PJI) following total knee arthroplasty (TKA) are associated with high patient morbidity, mortality, and healthcare costs. Methods to reduce the burden of PJI have been shown to be efficacious on a small scale. On a national scale, it is unknown whether these methods have reduced PJI rates. METHODS: A retrospective trend analysis was conducted using a national database. The incidence of 2-year septic revision was observed for the entire cohort and patients who had high-risk co-morbidities from 2010 to 2019. A multivariable logistic regression was performed to compare the odds ratios of 2-year septic revision rates from 2011 to 2019 to the reference year of 2010. Linear regression was used to compare the change throughout this period in the overall and high-risk sub-analysis groups. RESULTS: Among the 860,185 patients, 5,589 underwent septic revision within 2 years. The 2-year septic revision rate decreased from 0.75% in 2010 to 0.69% in 2019 (compounded annual growth rate [CAGR] = -0.94%, P = 0.049). Multivariable logistic regressions demonstrated that the odds of septic revision in 2019 were significantly lower than those in 2010 (OR [odds ratio]: 0.83, 95% CI [confidence interval]: [0.70 to 0.96], P = 0.017). In high-risk patients, the septic revision rate decreased from 1.04 to 0.80% (CAGR = -2.80%, P = 0.004), specifically in those who had a history of psychoses, Medicaid insurance, anemia, heart failure, obesity, liver disease, tobacco use, and drug abuse (P < 0.05 for all). DISCUSSION: This study demonstrates a national reduction in the 2-year septic revision rate in all TKA patients, including patients considered at high risk for PJI. This suggests current preventative methods may be efficacious on a national scale in TKA. Further research is needed to identify more modalities to reduce the national incidence of this morbid and costly complication.

Reassessing Glycemic Control: A Novel Method for 90-Day Major Complication Stratification Based on Hemoglobin A1c and Same-Day Glucose Levels for Patients Undergoing Total Knee Arthroplasty.

INTRODUCTION: Glucose levels obtained on day of surgery may be predictive of complications following total knee arthroplasty (TKA). Established glucose thresholds for TKA are either non-specific or have low predictive power. Therefore, the purpose of this study was to create data-driven hemoglobin A1c (HbA1c) and same-day glucose thresholds associated with varying risks of 90-day major and surgical site infection (SSI) complications following TKA. METHODS: Stratum-specific likelihood ratio analysis was conducted to determine data-driven HbA1c and glucose strata associated with varying risks of 90-day major and SSI complications. Each strata was then propensity-score matched to the lowest strata based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disorder, and obesity. The risk ratio (RR) for complications in each stratum with respect to the lowest matched stratum was analyzed. RESULTS: Four data-driven HbA1c (%) strata (4.5 to 5.9, 6.0 to 6.4, 6.5 to 7.9, and 8.0+) and two same-day glucose (mg/dl) strata (60 to 189 and 190+) were identified that predicted 90-day major complications. When compared to the propensity-matched lowest strata (4.5 to 5.9%), the risk of 90-day major complications sequentially increased as the HbA1c (%) strata increased: 6.0 to 6.4 (RR: 1.23; P = 0.024), 6.5 to 7.9 (RR 1.38; P < 0.001), 8.0+ (RR 2.0; P < 0.001). When compared to the propensity-matched lowest strata (60 to 189 mg/dl), the 190+ mg/dl strata had a higher risk of 90-day major complications (RR: 1.18; P = 0.016). No HbA1c or same-day glucose strata had significantly different risks of 90-day SSI. CONCLUSION: The multiple strata identified for HbA1c demonstrate that a single HbA1c cut-off as identified in prior literature may be missing a larger picture for risk stratification. The threshold identified for same-day glucose can be utilized in day-of-surgery glycemic control guidelines to further reduce the risk of 90-day major complications.

The effect of smoking on 30-day complications following primary repair of Achilles tendon ruptures.

PURPOSE: There exists a gap in the knowledge of the impact of smoking on Achilles tendon rupture repair. This study evaluates perioperative and postoperative complications associated with smoking to allow for a more informed evaluation and discussion with the patients when considering the surgical management of Achilles tendon repair in this patient population. METHODS: The National Surgical Quality Improvement Program database was queried for patients undergoing Achilles tendon rupture repair from 2006 to 2019. Two patient cohorts were defined in this retrospective study: smokers and patients who did not smoke. The various patient demographics, medical comorbidities, and postoperative outcomes were compared using bivariate and multivariate analyses between the smoking and non-smoking groups. RESULTS: Of 4209 patients who underwent Achilles tendon repair, 3662 patients (87%) did not smoke, whereas 547 patients (13%) were smokers. Patients who were smokers were more likely to be younger and have a higher body mass index. Following multivariate analyses, those who smoked had an increased risk of experiencing wound dehiscence (OR 3.57; p = 0.013) and urinary tract infections (OR 1.21; p = 0.033) compared to non-smoking patients. CONCLUSION: Despite the rate of complications being relatively low in the short-term perioperative period, individuals who smoke should be counseled on the surgical risks they may experience following Achilles tendon repair, including wound dehiscence and urinary tract infections. Discussion preoperatively between the physician and patient who smoke can include ways in which postoperative care will be done to minimize the risk of adverse events, ultimately reducing costs for both the patient and the hospital.

Bleeding disorder increases the risks of complications following arthroscopic rotator cuff repair.

BACKGROUND: It is imperative to determine patients' risk factors prior to arthroscopic rotator cuff repair (ARCR), so that the physician and patient are both aware of the possible postoperative complications. However, the impact of bleeding disorders on a patient's short-term postoperative outcome has not yet been analyzed. METHODS: A national database was queried for patients undergoing ARCR from 2006 to 2018. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. In this analysis, outcomes including postoperative complications, hospital admission, extended length of stay, and mortality were compared between the two cohorts using bivariate and multivariate analyses. RESULTS: Of 33,374 patients undergoing ARCR, 32,849 patients (98.4%) did not have a bleeding disorder whereas 525 patients (1.6%) had a bleeding disorder. Following adjustment on multivariate analyses, patients with a bleeding disorder had an increased risk of postoperative transfusion (OR 8.11; p = 0.044), sepsis (OR 11.86; p = 0.003), hospital admission (OR 1.41; p = 0.008), and mortality (OR 8.10; p = 0.019). CONCLUSIONS: Patients with documented bleeding disorder have an increased risk of postoperative complications compared to patients without a bleeding disorder. Consequently, it is essential to recognize these risk factors to decrease postoperative complications to optimize patient outcomes and costs. LEVEL OF EVIDENCE: III.

Data-driven body mass index threshold associated with increased risk of 2-year periprosthetic joint infection following total shoulder arthroplasty.

BACKGROUND: Body mass index (BMI) is a modifiable risk factor for medical and infectious complications following total shoulder arthroplasty (TSA). Previous studies investigating BMI were limited to the conventional classification system, which may be outdated for modern day patients. Therefore, the purpose of this study was to identify BMI thresholds that are associated with varying risk of 90-day medical complications and 2-year prosthetic joint infection (PJI) following TSA. METHODS: A national database was utilized to identify 10,901 patients who underwent primary elective TSA from 2013 to 2022. Patients were only included if they had a BMI value recorded within 1 month prior to TSA. Separate stratum-specific likelihood ratio analyses, an adaptive technique to identify data-driven thresholds, were performed to determine data-driven BMI strata associated with varying risk of 90-day medical complications and 2-year PJI. The incidence rates of these complications were recorded for each stratum. To control for confounders, each BMI strata was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and diabetes mellitus to the lowest identified BMI strata for both outcomes of interest. The risk ratio (RR) and 95% confidence interval (CI) were recorded for each matched analysis. RESULTS: The average age and BMI of patients was 70.5 years (standard deviation ±9.8) and 30.7 (standard deviation ±6.2), respectively. Stratum-specific likelihood ratio analysis identified two BMI strata associated with differences in the rate of 2-year PJI: 19-39 and 40+. The same strata were identified for 90-day major complications. When compared to the matched BMI 19-39 cohort, the risk of 2-year PJI was higher in the BMI 40+ cohort (RR: 2.7; 95% CI 1.39-5.29; P = .020). After matching, there was no significant difference in the risk of 90-day major complications between identified strata (RR: 1.19, 95% CI: 0.86-1.64; P = .288). CONCLUSION: A data-driven BMI threshold of 40 was associated with a significantly increased risk of 2-year PJI following TSA. This is the first TSA study to observe BMI on a continuum and observe at what point BMI is associated with increased risk of 2-year PJI following TSA. Our identified BMI strata can be incorporated into risk-stratifying models for predicting both PJI and 90-day major complications to minimize both.

10-Year Cumulative Incidence and Indications for Revision Total Knee Arthroplasty Among Patients Who Have Sickle Cell Disease.

BACKGROUND: Literature regarding total knee arthroplasty (TKA) outcomes in sickle cell disease (SCD) is limited. Moreover, 10-year survivorship of SCD implants is unknown. This study aimed to observe 10-year cumulative incidence and indications for revision TKA in patients who did and did not have SCD. METHODS: Patients who underwent primary TKA were identified using a large national database. The SCD patients were matched by age, sex, and a comorbidity index to a control cohort in a 1:4 ratio. The 10-year cumulative incidence rates were determined using Kaplan-Meier survival analyses. Multivariable analyses were conducted using Cox proportional hazard modeling. Chi-squared analyses were conducted to compare indications for revision between cohorts. In total, 1,010 SCD patients were identified, 100,000 patients included in the unmatched control, and 4,020 patients included in the matched control. RESULTS: Compared to the unmatched control cohort, SCD patients exhibited higher 10-year all-cause revision (HR: 1.86; P < .001) with higher proportions of revisions for periprosthetic joint infection (PJI) (P < .001), aseptic loosening (P < .001), and hematoma (P < .001). Compared to the matched control, SCD patients had higher 10-year all-cause revision (Hazard Ratio (HR): 1.39; P = .034) with a higher proportion of revisions for PJI (P = .044), aseptic loosening (P = .003), and hematoma (P = .019). CONCLUSION: Independent of other comorbidities, SCD patients are more likely to undergo revisions for PJI, aseptic loosening, and hematoma compared to patients who do not have SCD. Due to the high-risk of these complications, perioperative and postoperative surgical optimization should be enforced in SCD patients.

Updates in the Impact of Chronic Systemic Inflammation on Vascular Inflammation by Positron Emission Tomography (PET).

PURPOSE OF REVIEW: In this review, we focus on the clinical and epidemiological studies pertaining to systemic and vascular inflammation by positron emission tomography (PET) in patients with chronic inflammatory conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), human immunodeficiency virus (HIV), and psoriasis to highlight the importance of chronic systemic inflammation on vascular inflammation by PET in these disease states. RECENT FINDINGS: Recent clinical and translation advancements have demonstrated the durable relationship between chronic systemic inflammation and cardiovascular disease (CVD). In chronic inflammatory states, this relationship is robustly evident in the form of increased vascular inflammation, yet traditional risk estimates often underestimate the subclinical cardiovascular risk conferred by chronic inflammation. PET has emerged as a novel, non-invasive imaging modality capable of both quantifying the degree of systemic and vascular inflammation and detecting residual inflammation prior to cardiovascular events. We begin by demonstrating the role of inflammation in the pathogenesis of atherosclerosis, discussing how PET has been utilized to measure systemic and vascular inflammation and their effect on subclinical atherosclerosis, and finally reviewing recent applications of PET in constructing improved risk stratification for patients at high risk for stroke and CVD.

Predicting prolonged hospital stay following hip dysplasia surgery in the pediatric population.

Previous studies have shown that minimizing the length of hospital stay (LOS) following surgical procedures reduces costs and can improve the patients' quality of life and satisfaction. However, this relationship has not been defined following operative treatment for developmental dysplasia of the hip (DDH). Therefore, the purpose of this study was to determine the most important nonmodifiable and modifiable factors that can predispose patients to require a prolonged LOS following hip dysplasia surgery. From 2012 to 2019, a national pediatric database was used to identify pediatric patients who underwent surgery for hip dysplasia. Demographic, clinical, and comorbidity variables were analyzed in a patient cohort who had a normal LOS versus one with an extended LOS using chi-square tests and analysis of variance. Statistically significant variables (P value <0.05) were inputted into an artificial neural network model to determine the level of importance. Out of 10,816 patients, 594 (5.5%) had a prolonged LOS following DDH surgery. The five most important variables to predict extended LOS following hip dysplasia surgery were increased operative time (importance = 0.223), decreased BMI (importance = 0.158), older age (importance = 0.101), increased preoperative international normalized ratio (importance = 0.096), and presence of cardiac comorbidities (importance = 0.077). Operative time, BMI, age, preoperative international normalized ratio, and cardiac comorbidities had the greatest effect on predicting prolonged LOS postoperatively. Evaluating factors that impact patients' LOS can help optimize costs and patient outcomes.

Pediatric Hip Dysplasia Surgery Outcomes by Pediatric Versus Nonpediatric Orthopedists.

Objectives Developmental dysplasia of the hip (DDH) encompasses a spectrum of abnormalities in the immature hip. Surgical intervention is indicated if conservative management fails. Despite the increased supply of pediatric orthopedic surgeons (POSs) over the last few decades, there continues to be a maldistribution of surgeons. The purpose of this study is to determine outcomes following surgical management of hip dysplasia by POSs compared to non-pediatric orthopedic surgeons. Methods Pediatric patients who underwent surgical treatment for hip dysplasia from 2012 to 2019 were identified using a large national database. Patient demographics, comorbidities, and postoperative complications were compared by pediatric versus nonpediatric-trained orthopedic surgeons. Bivariate and multivariable regression analyses were performed. Results Of the 10,780 pediatric patients who underwent hip dysplasia surgery, 10,206 patients (94.7%) were operated on by a POS, whereas 574 (5.3%) were operated on by a non-pediatric orthopedic surgeon. POSs were more likely to operate on patients with a higher American Society of Anesthesiologists class (p<0.001) and those with a greater number of medical comorbidities, including cardiac (p=0.001), gastrointestinal (p=0.017), and neurological (p<0.001). Following analysis using multivariable regression models to control for patient baseline characteristics, there were no differences in any postoperative complications between patients treated by pediatric-trained and nonpediatric-trained orthopedic surgeons. Conclusions Compared to non-pediatric orthopedic surgeons, POSs were more likely to operate on younger patients with increased medical comorbidities. However, there were no differences in postoperative complications following surgical management for DDH in patients treated by nonpediatric and pediatric orthopedic surgeons.

No Increased Risk of All-cause Revision up to 10 Years in Patients Who Underwent Bariatric Surgery Before Single-level Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: This study aimed to assess whether prior bariatric surgery (BS) is associated with higher 10-year surgical complication and revision rates in lumbar spine fusion compared with the general population and morbidly obese patients. BACKGROUND: Obesity accelerates degenerative spine processes, often necessitating lumbar fusion for functional improvement. BS is explored for weight loss in lumbar spine cases, but its impact on fusion outcomes remains unclear. Existing literature on BS before lumbar fusion yields conflicting results, with a limited investigation into long-term spine complications. METHODS: Utilizing the PearlDiver database, we examined patients undergoing elective primary single-level lumbar fusion, categorizing them by prior BS. Propensity score matching created cohorts from (1) the general population without BS history and (2) morbidly obese patients without BS history. Using Kaplan-Meier and Cox proportional hazard modeling, we compared 10-year cumulative incidence rates and hazard ratios (HRs) for all-cause revision and specific revision indications. RESULTS: Patients who underwent BS exhibited a higher cumulative incidence and risk of decompressive laminectomy and irrigation & debridement (I&D) within 10 years postlumbar fusion compared with matched controls from the general population [decompressive laminectomy: HR = 1.32; I&D: HR = 1.35]. Compared with matched controls from a morbidly obese population, patients who underwent BS were associated with lower rates of adjacent segment disease (HR = 0.31) and I&D (HR = 0.64). However, the risk of all-cause revision within 10 years did not increase for patients who underwent BS compared with matched or unmatched controls from the general population or morbidly obese patients (P > 0.05). CONCLUSIONS: Prior BS did not elevate the 10-year all-cause revision risk in lumbar fusion compared with the general population or morbidly obese patients. However, patients who underwent BS were associated with a lower 10-year risk of I&D when compared with morbidly obese patients without BS. Our study indicates comparable long-term surgical complication rates between patients who underwent BS and these control groups, with an associated reduction in risk of infectious complications when compared with morbidly obese patients. Although BS may address medical comorbidities, its impact on long-term lumbar fusion revision outcomes is limited.

Sickle Cell Disease Has No Impact on 10-Year Cumulative Incidence and Indications for Revision Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Patients with sickle cell disease (SCD) experience distinct physiological challenges that may alter surgical outcomes. There has been no research establishing 10-year lumbar fusion (LF) implant survivorship rates among individuals with SCD. This study aims to determine the 10-year cumulative incidence and indications for revision LF between patients with and without SCD. METHODS: A national database was queried to identify patients with and without SCD who underwent primary LF. SCD patients undergoing LF were propensity-score matched in a 1:4 ratio by age, gender, and Charlson Comorbidity Index (CCI) to a matched LF control. In total, 246 SCD patients were included along with 981 and 100,000 individuals in the matched and unmatched control cohorts, respectively. Kaplan-Meier survival analysis was utilized to determine the 10-year cumulative incidence rates of revision LF. Furthermore, multivariable analysis using Cox proportional hazard modeling was performed to compare indications for revisions and surgical complications between cohorts including hardware removal, drainage and evacuation, pseudoarthrosis, and mechanical failure. RESULTS: No significant differences were found in the cumulative incidence of 10-year all-cause revision LF between patients in the SCD cohort and either of the control cohorts (P > .05 for each). Additionally, there were no significant differences between the SCD cohort and either of the control cohorts in regards to the indications for revision or surgical complications in LF (P > .05 for each). CONCLUSIONS: This study indicates that SCD patients do not have increased risk for revision LF, nor any of its indications.

Higher 2-Year Cumulative Incidence of Mental Health Disorders Following Irrigation and Debridement in Primary Lumbar Fusion.

Introduction: Spinal fusion is an operation that is employed to treat spinal diseases. Surgical site infection (SSI) after lumbar fusion (LF) is a postoperative complication. SSI is treated with irrigation and debridement (I&D), which requires readmittance following discharge or prolonged hospital stays, which are deleterious to patients' mental health. The long-term relationship between treating SSI with I&D and patients' mental health is still understudied. Methods: Using the Mariner dataset from the PearlDiver Patient Records Database using Current Procedural Terminology and International Classification of Diseases procedure codes, retrospective cohort analysis was carried out. This study involved 445,480 patients who underwent LF with at least 2-year follow-up and were followed up for 2 years. Of the patients, 2,762 underwent I&D. Using univariate analysis employing Pearson Chi-square and Student t-test, where appropriate (Table 1), patient demographics between cohorts were gathered. 2-year cumulative incidence (CI) between LF and I&D cohorts was calculated using Kaplan-Meier analysis (Fig. 1, 2, 3). Cox proportional hazards were employed to observe significant differences in CI rates (Table 2). Results: For patients who received I&D, 2-year CI depression (HR: 1.72; 95% CI: 1.49-1.99; P<0.001) and stress (HR: 1.35; 95% CI: 1.02-1.79; P=0.035) rates were significantly higher than for those who did not. There was no statistically significant difference in 2-year CI anxiety rates between cohorts (HR: 0.92; 95% CI: 0.58-1.46; P=0.719). Conclusions: In conclusion, 16.8% of patients developed new-onset depression 2 years following I&D, in comparison to 10.3% of those who underwent LF. Patients who underwent I&D following LF were significantly more likely to experience depression and stress. To mitigate negative mental health outcomes, mental health services should be available to patients who underwent surgery.

Robot-navigated pedicle screw insertion can reduce intraoperative blood loss and length of hospital stay: analysis of 1,633 patients utilizing propensity score matching.

BACKGROUND CONTEXT: Navigation and robotic technologies have emerged as an alternative option to conventional freehand techniques for pedicle screw insertion. However, the effectiveness of these technologies in reducing the perioperative complications of spinal fusion surgery remains limited due to the small cohort size in the existing literature. PURPOSE: To investigate whether utilization of robotically navigated pedicle screw insertion can reduce the perioperative complications of spinal fusion surgery-including reoperations-with a sizeable cohort. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: Patients who underwent primary lumbar fusion surgery between 2019 and 2022. OUTCOME MEASURES: Perioperative complications including readmission, reoperation, its reasons, estimated blood loss, operative time, and length of hospital stay. METHODS: Patients' data were collected including age, sex, race, body mass index, upper-instrumented vertebra, lower-instrumented vertebra, number of screws inserted, and primary procedure name. Patients were classified into the following two groups: freehand group and robot group. The variable-ratio greedy matching was utilized to create the matched cohorts by propensity score and compared the outcomes between the two group. RESULTS: A total of 1,633 patients who underwent primary instrumented spinal lumbar fusion surgery were initially identified (freehand 1,286; robot 347). After variable ratio matching was performed with age, sex, body mass index, fused levels, and upper instrumented vertebrae level, 694 patients in the freehand group and 347 patients in robot groups were selected. The robot group showed less estimated blood loss (418.9±398.9 vs 199.2±239.6 ml; p<.001), shorter LOS (4.1±3.1 vs 3.2±3.0 days; p<.001) and similar operative time (212.5 vs 222.0 minutes; p=.151). Otherwise, there was no significant difference in readmission rate (3.6% vs 2.6%; p=.498), reoperation rate (3.2% vs 2.6%; p=.498), and screw malposition requiring reoperation (five cases, 0.7% vs one case, 0.3%; p=1.000). CONCLUSIONS: Perioperative complications requiring readmission and reoperation were similar between fluoroscopy guided freehand and robotic surgery. Robot-guided pedicle screw insertion can enhance surgical efficiency by reducing intraoperative blood loss and length of hospital stay without extending operative time.

Complex Orthopaedic Trauma Is Shifting Away From Level I to Non-Level I Trauma Centers: An Analysis of the National Trauma Data Bank.

INTRODUCTION: An increasing number of fellowship-trained orthopaedic trauma surgeons are working in non-Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non-Level I centers and its potential effect on patient outcomes. METHODS: Data from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non-Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non-Level I centers were recorded. RESULTS: Three hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non-Level I hospital. Per-hospital complication rates were consistently lower in non-Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non-Level I centers. DISCUSSION: This study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management.