Size and morphology of the coracoid and glenoid in pediatric and adolescent patients: implications for Latarjet procedure.

Background: Glenohumeral instability is a challenging problem in children and adolescents. For patients with anterior glenoid bone loss, the Latarjet procedure is an effective treatment option. However, concerns about coracoid size and morphology may limit its utilization within this patient population. The purpose of this study was to establish normative data on coracoid and glenoid size and morphology among a large cohort of adolescent patients and describe the anatomic relationships with demographic factors. Methods: This is a retrospective cross-sectional study of a consecutive series of 584 patients aged 12-21 years after a chest computed tomography scan for non-shoulder related trauma at a single level I trauma center. Demographic characteristics were collected from the electronic medical record, and the following coracoid anatomic measurements were obtained from computed tomography scans: coracoid length, coracoid thickness, coracoid width, glenoid height, and glenoid width. The ratio of coracoid thickness to glenoid width was calculated to estimate the percent bone loss that could be addressed with a traditional Latarjet coracoid transfer. To ensure reliability among 3 reviewers, all measured the same 25 scans and inter-rater reliability was excellent with all Kappa coefficients >0.81. The remaining scans were divided equally and assessed separately by these reviewers. Correlation coefficients were used to quantify the relationships between all anatomic measures and the age, weight, and height of individuals. Growth curves for each measurement were modeled using quantile regression with height and height∗height as predictors. Additionally, we stratified the growth curves by sex, when significant. Of the 584 subjects, 55% were male, and average age was 19 years (range 12, 21). Results: All growth curves illustrated increase anatomic size across the height range of 145-190 cm. The growth curve including all patients (Fig. 1) illustrated that the 50% percentile of median coracoid length increased from approximately 28 to 32 mm. In addition to height, sex was a significant predictor for coracoid width and glenoid width. The median coracoid width increased from approximately 9.5 to 10.2 mm for females compared to an increased width from approximately 10 to 11 mm for males. The median glenoid width for females increased from approximately 21 to 25 mm and for males the median glenoid width increased from just under 22 to 25.5 mm. Conclusions: Among children and adolescents, coracoid and glenoid size are correlated with patient height. These data can help guide patient selection for the Latarjet procedure.

Concomitant open distal clavicle excision is associated with greater improvement in range of motion without increased risk of acromial stress fracture after reverse total shoulder arthroplasty: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the effect of concomitant open distal clavicle excision (DCE) on postoperative clinical outcomes and incidence of acromial and scapular stress fractures (ASFs) in patients with symptomatic acromioclavicular joint osteoarthritis (ACJ OA) undergoing reverse total shoulder arthroplasty (RTSA). METHODS: A single-surgeon retrospective cohort study was conducted including patients who underwent primary elective RTSA with or without DCE from 2015 to 2019 with a minimum 6-month follow-up period. Shoulder active range of motion (AROM) and visual analog scale (VAS) pain were recorded preoperatively and postoperatively. ASFs and other adverse events were identified using postoperative notes and/or radiographs. Characteristics and outcomes were compared between the RTSA and RTSA-DCE groups. RESULTS: Forty-six RTSA patients (mean age, 67.9±8.7 years; 60.9% male; mean follow-up, 24.9±16.6 months) and 70 RTSA-DCE patients (mean age, 70.2±8.9 years; 20.0% male; mean follow-up, 22.7±12.9 months) were included. There were no significant intergroup differences in rates of ASF (RTSA, 0.0% vs. RTSA-DCE, 1.4%; P=1.00), stress reactions (RTSA, 8.7% vs. RTSA-DCE, 11.4%; P=0.76), reoperation, revision, or infection (all P>0.05), or in pre-to-postoperative reduction in VAS pain (P=0.17) at latest follow-up. However, the RTSA-DCE group had greater pre-to-postoperative improvement in flexion AROM (RTSA, 43.7°±38.5° vs. RTSA-DCE, 59.5°±33.4°; P=0.03) and internal rotation (IR) AROM (P=0.02) at latest follow-up. CONCLUSIONS: Concomitant DCE in RTSA improves shoulder flexion and IR AROM, alleviates shoulder pain, and does not increase the risk of ASFs. Level of evidence: III.

Operative management of gouty tophi in the region of the olecranon: a case series.

Background: Tophaceous gout affecting the olecranon region can result in local discomfort, skin ulceration, secondary infection, and considerable disability if left untreated. However, there are limited reports of outcomes, including postoperative complications and recurrence after surgical excision of tophaceous gout deposits at the elbow. The aim of this study is to present our surgical technique and minimum one-year outcomes after surgical excision of tophaceous gout involving the elbow. Methods: A retrospective chart review was performed on all patients from a single surgeon's practice who underwent surgical excision of gouty tophi of the elbow between January 2016 and December 2019. The indications for surgical excision of tophi included failure of medical management, presence of skin ulceration, and/or large gouty tophi. The relevant data pertaining to patient demographics, preoperative findings, intraoperative findings, surgical pathology reports, and short-term postoperative complications were collected through retrospective chart review. Patients were subsequently contacted for a follow-up telehealth visit to assess recurrence of gouty tophi, functional outcomes, and range of motion (ROM) measurements. Results: Six male patients underwent 7 total procedures (1 bilateral elbow) during the study period. The mean age of the cohort at the time of surgery was 56.0 ± 7.1 years (range: 45.3-63.5). The mean size of the swelling in 2 maximum dimensions was 5.8 × 3.4 cm. There were no intraoperative or immediate postoperative wound complications. There was no recurrence of gouty tophi at a mean follow-up time of 30.8 months (range: 14.0-43.5). Patients reported physiologic ROM (mean flexion-extension arc of 2°-134°) with no pain at final follow-up. Conclusion: Surgical treatment of tophaceous gout of the elbow is associated with a low risk of wound complication and recurrence.

The Latarjet-Patte Procedure Past, Present, and Future.

The Latarjet-Patte procedure has a long and storied history that predates shoulder arthroscopy, but its popularity has increased over the past two decades as a treatment for anterior glenohumeral instability with bone loss. Transfer of the coracoid process and conjoint tendon to the anteroinferior glenoid creates a triple-blocking effect that is both static and dynamic, lending it biomechanical superiority over alternative bone block techniques. Patients undergoing the Latarjet-Patte procedure have low rates of recurrent instability compared to arthroscopic soft-tissue stabilization procedures, particularly in the setting of glenoid- and humeral-sided bone loss. A number of technical innovations have been developed in recent years to improve the efficacy of this procedure and to reduce its potential complications, although their associated learning curves and potential for widespread adoption remain unclear. In this article, we review the history, indications, outcomes, and future of this surgical technique.

Internal hemipelvectomy with ischiectomy, partial acetabulectomy, and femoral head and neck excision in a cat with a pelvic osteochondroma.

CASE DESCRIPTION: A 2-year-old 5.1-kg (11.2-lb) castrated male Siberian cat was examined because of a history of an abnormal right pelvic limb gait and a 4- to 5-month history of progressive constipation. Radiographs obtained by the referring veterinarian showed an osteoproductive and osteolytic bony lesion that involved the right ischium and filled the obturator foramen. CLINICAL FINDINGS: A hard mass was palpable in the right inguinal area, and rectal examination revealed a smooth bony mass on the ventral aspect of the right pelvic floor with marked reduction in the pelvic canal space. A 3.9 × 3 × 4.6-cm, mineralized mass bridging the right obturator foramen was present on CT images. The ventral component of the mass was slightly larger than its dorsal component, and lysis of the right pubic bone was present. There was no obvious soft tissue involvement. TREATMENT AND OUTCOME: A limb salvage procedure involving internal hemipelvectomy with ipsilateral ischiectomy, contralateral partial ischiectomy, ipsilateral partial acetabulectomy, and femoral head and neck excision was performed. Histologic examination revealed that the mass was an osteochondroma. The cat recovered well and had good functional limb use immediately after surgery. The cat was still alive 1 year after surgery with good limb use. CLINICAL RELEVANCE: Internal hemipelvectomy involving ischiectomy, partial acetabulectomy, and femoral head and neck excision can result in a good functional outcome in cats if the procedure is planned appropriately with a full understanding of the regional anatomy and adherence to surgical oncologic principles.

Survival time of juvenile dogs with oral squamous cell carcinoma treated with surgery alone: A Veterinary Society of Surgical Oncology retrospective study.

OBJECTIVE: To report the signalment, staging, surgical treatment, and survival time of juvenile dogs treated surgically for oral squamous cell carcinoma (OSCC). STUDY DESIGN: Retrospective study. ANIMALS OR SAMPLE POPULATION: Twenty-five dogs, <2 years of age with OSCC treated with surgery. METHODS: Cases were solicited from the Veterinary Society of Surgical Oncology. Data retrieved included sex, breed, age, weight, clinical signs, tumor location, preoperative diagnostics and staging, histopathological diagnosis with margin evaluation, disease-free interval, and date and cause of death. A minimum follow-up time of 3 months was required for inclusion. RESULTS: Eighteen dogs were <12 months of age, and seven were <24 months. Various breeds were represented, with a mean body weight of 22.3 ± 14.4 kg. No dogs had evidence of metastatic disease prior to surgery. All dogs underwent partial maxillectomy or mandibulectomy. Histological margins were complete in 24 dogs and incomplete in one. No dogs had evidence of metastatic disease or tumor recurrence. The median follow-up time was 1556 days (92 to 4234 days). All dogs were alive at the last follow-up except for one documented death, due to dilated cardiomyopathy. Median disease-specific survival time was not reached. CONCLUSION: The prognosis after wide surgical excision of OSCC in juvenile dogs was excellent. CLINICAL SIGNIFICANCE: OSCC in juvenile dogs can be effectively treated with surgery alone.

Preoperative autologous blood donation and transfusion in dogs undergoing elective surgical oncology procedures with high risk of hemorrhage.

OBJECTIVE: To describe preoperative autologous blood donation (PABD) and transfusion in dogs undergoing elective surgical oncology procedures with a high risk of intraoperative hemorrhage. STUDY DESIGN: Prospective study. ANIMALS: Twelve dogs. METHODS: Dogs undergoing surgical oncology procedures associated with a high risk of hemorrhage were enrolled. Blood was collected a minimum of 6 days before surgery and separated into fresh frozen plasma (FFP) and packed red blood cells (pRBC). Dogs received FFP at the start of surgery and pRBC intraoperatively when hemorrhage ensued. The mean packed cell volume/total solids (PCV/TS) were calculated on the day of PABD preoperatively, immediately postoperatively, and 24 hours after transfusion. The dogs were monitored for transfusion-related adverse reactions, including hyperthermia, hypotension, tachycardia, bradycardia, pale mucous membranes, prolonged capillary refill time, or tachypnea/dyspnea. RESULTS: Dogs enrolled in the study underwent mandibulectomy, maxillectomy, chest wall resection, and liver lobectomy. Ten of the 12 dogs that underwent PABD received autologous transfusion at first signs of hemorrhage intraoperatively. Iatrogenic anemia was noted in two dogs (PCV 30% and 31%). The mean PCV/TS levels on the day of blood collection, preoperatively, immediately postoperatively (after transfusion), and 24 hours posttransfusion were 45.1%/7.1 g/dL, 42.2%/6.73 g/dL, 33.2%/5.42 g/dL, and 36.5%/5.65 g/dL, respectively. No dog developed transfusion-related complications. CONCLUSION: Preoperative autologous blood donation was well tolerated and led to uneventful autologous transfusion in 10 of 12 dogs. CLINICAL SIGNIFICANCE: Preoperative autologous blood donation and autologous transfusion are feasible for dogs undergoing elective surgical procedures with a high risk of hemorrhage.

A Preferred Vendor Model Reduces the Costs of Sports Medicine Surgery.

PURPOSE: To report on our institution's first year of experience with a preferred vendor program for implants and disposables for sports medicine surgery. METHODS: Cost and utilization data for implants and disposables were analyzed for knee and shoulder sports medicine surgeries performed during the 2-year period including the 12 months preceding the start of the contract (contract year 0 [CY0] and the first 12 months of the contract period (CY1). The costs of grafts and biological therapies were excluded. Utilization of the preferred vendor's products, operative time, and per-case costs were compared between the 2 time periods and adjusted for patient factors and case mix. RESULTS: Utilization of the preferred vendor's shavers (0% to 94%, P < .001) and radiofrequency ablation wands (0% to 91%, P < .001) increased significantly in CY1 (n = 5,068 cases) compared with CY0 (n = 5,409 cases), with a small but significant increase in use of the preferred vendor's implants (64% to 67%, P = .023). There was no significant difference in mean operative time between CY0 and CY1 (P = .485). Mean total per-case implant and disposable costs decreased by 12% (P < .001) in CY1 versus CY0. CONCLUSION: Our institution was able to reduce the costs of sports medicine surgery with the implementation of a preferred single-vendor program for implants and disposables. This program had widespread surgeon adoption and did not have any detrimental effect on operating room efficiency. LEVEL OF EVIDENCE: III, retrospective comparative study.

Influence of speaker's gender on speaker introductions at the 2018 ACVS Surgical Summit.

OBJECTIVE: To evaluate whether formality of introduction differed between male vs female speakers at the 2018 American College of Veterinary Surgeons (ACVS) scientific meeting and identify other variables that predisposed introducers or chairs to informal introduction. STUDY DESIGN: Observational study. SAMPLE POPULATION: Thirteen session chairs introducing 68 lectures (41 by females, 27 by males) by 63 speakers. METHODS: Observers recorded the session introducer, speaker, and whether speakers were introduced with a formal or informal title. Information evaluated included type of oral presentation; introducer gender, year, and country of graduation from veterinary school; speaker gender; whether the speaker was a resident; and speaker's year of graduation. RESULTS: Female speakers were introduced by their first name in 9 of 41 introductions compared to in 1 of 27 introductions for male speakers. This difference reached statistical significance when data independence was assumed (P = .043); however, this significance was narrowly lost when data clustering on session introducer was controlled for (P = .067). CONCLUSION: In this study, female speakers were more likely than male speakers to be introduced by their first and last names rather than with their professional title at a recent ACVS scientific meeting. IMPACT: Additional research is required to determine the effect of this type of subordinate language and gender bias in veterinary surgery.

Tibial Shaft Fractures in Workers Compensation and No-Fault Insurance Is There a Difference in Resource Utilization?

BACKGROUND: Workers Compensation claims have been previously associated with inferior clinical outcomes. However, variation in inpatient stays for orthopedic trauma injuries according to insurance type has not been previously examined. METHODS: We investigated the differences according to insurance for tibial shaft fractures in regard to length of stay and disposition. Using the New York SPARCS database, we identified 1,856 adult non-elderly patients with an isolated tibial shaft fracture who underwent surgery. Patients were stratified by insurance type, including private, Medicaid, Workers Compensation, and no-fault, which covers medical expenses related to automobile or pedestrian accidents. RESULTS: Compared to private insurance (mean: 2.7 days), length of stay was longer for no-fault (mean: 3.9 days; adjusted difference +33%, p < 0.001) and Medicaid (mean: 3.5 days; adjusted difference +22%, p < 0.001), but not significantly different for Workers Compensation (mean: 3.5 days; adjusted difference +4%, p = 0.474). Compared to private insurance (rate: 3.5%), disposition to a facility was significantly higher for no-fault (rate: 10.1%; adjusted odds ratio [OR] = 3.3, p < 0.001) and Medicaid (rate: 7.6%; OR = 2.2, p = 0.003), but was not significantly different for Workers Compensation (rate: 6.3%; OR = 1.8, p = 0.129). CONCLUSIONS: Patients with no-fault insurance, but not Workers Compensation, are subject to longer hospital stays and are more likely to be discharged to a facility following operative fixation of an isolated tibial shaft fracture. These findings suggest that financial, social, and legal factors influence medical care for patients involved in automobile accidents with no-fault insurance.

Preferred Single-Vendor Program for Total Joint Arthroplasty Implants: Surgeon Adoption, Outcomes, and Cost Savings.

BACKGROUND: In total joint arthroplasty, variation in implant use can be driven by vendor relationships, surgeon preference, and technological advancements. Our institution developed a preferred single-vendor program for primary hip and knee arthroplasty. We hypothesized that this initiative would decrease implant costs without compromising performance on quality metrics. METHODS: The utilization of implants from the preferred vendor was evaluated for the first 12 months of the contract (September 1, 2017, to August 31, 2018; n = 4,246 cases) compared with the prior year (September 1, 2016, to August 31, 2017; n = 3,586 cases). Per-case implant costs were compared using means and independent-samples t tests. Performance on quality metrics, including 30-day readmission, 30-day surgical site infection (SSI), and length of stay (LOS), was compared using multivariable-adjusted regression models. RESULTS: The utilization of implants from the preferred vendor increased from 50% to 69% (p < 0.001), with greater use of knee implants than hip implants from the preferred vendor, although significant growth was seen for both (from 62% to 81% for knee, p < 0.001; and from 38% to 58% for hip, p < 0.001). Adoption of the preferred-vendor initiative was greatest among low-volume surgeons (from 22% to 87%; p < 0.001) and lowest among very high-volume surgeons (from 61% to 62%; p = 0.573). For cases in which implants from the preferred vendor were utilized, the mean cost per case decreased by 23% in the program's first year (p < 0.001), with an associated 11% decrease in the standard deviation. Among all cases, there were no significant changes with respect to 30-day readmission (p = 0.449) or SSI (p = 0.059), while mean LOS decreased in the program's first year (p < 0.001). CONCLUSIONS: The creation of a preferred single-vendor model for hip and knee arthroplasty implants led to significant cost savings and decreased cost variability within the program's first year. Higher-volume surgeons were less likely to modify their implant choice than were lower-volume surgeons. Despite the potential learning curve associated with changes in surgical implants, there was no difference in short-term quality metrics. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Limb-shortening limb salvage (LSLS) in a cat with metatarsal osteosarcoma.

The objective of this report was to document a successful partial limb amputation surgery in a cat with metatarsal osteosarcoma (OSA) including the use of pad grafts from the amputated foot. Limb shortening of the hindlimb through a partial amputation resulted in excellent limb function and usage. The patient retained functional use of the limb after surgery, with no lameness. There was no evidence of metastasis or local recurrence seen 323 days post-surgery. Limb shortening partial amputation is a reasonable option and can result in excellent limb use after surgery despite a significant loss in limb length.

Intervention pour raccourcir et sauver un membre chez un chat atteint d'un ostéosarcome métatarsien. L'objectif du présent rapport consistait à documenter une chirurgie d'amputation partielle réussie chez un chat atteint d'un ostéosarcome métatarsien y compris l'usage de greffes des coussinets du pied amputé. Le raccourcissement du membre postérieur par une amputation partielle a donné d'excellents résultats pour la fonction et l'usage du membre. Le patient a conservé l'usage fonctionnel du membre après la chirurgie, sans boiterie. Il n'y avait aucun signe de métastase ni de récurrence locale lors d'un examen 323 jours après la chirurgie. L'amputation partielle et le raccourcissement du membre sont une option raisonnable et peuvent produire une excellente utilisation du membre après la chirurgie malgré une perte importante de la longueur du membre.(Traduit par Isabelle Vallières).

Association of Magnet Nursing Status With Hospital Performance on Nationwide Quality Metrics.

INTRODUCTION: Magnet Recognition is the highest distinction a healthcare organization can receive for excellence in nursing. Although Magnet status is generally associated with superior clinical outcomes and patient satisfaction, its association with performance on nationwide quality metrics is currently unknown. METHODS: Within a propensity score-matched cohort, we compared performance on the Hospital-Acquired Condition Reduction Program (HACRP), Hospital Value-Based Purchasing (VBP), and Hospital Readmissions Reduction Program (RRP) initiatives. RESULTS: The mean HACRP total performance score was inferior at Magnet versus non-Magnet hospitals (p < .001), and HACRP penalties were more likely to be levied against Magnet hospitals (p = .003). There was no significant difference according to Magnet status for VBP penalties after correcting for multiple comparisons (p = .049). There were no significant difference in RRP penalties according to Magnet status (p = .999). CONCLUSIONS: Magnet hospitals performed worse on a number of hospitalwide quality metrics tied to reimbursement by the Centers for Medicare and Medicaid Service. Although Magnet hospitals are known for superior nursing care and organizational support for safety and quality improvement, this is not captured within these composite measures of quality, which can be influenced at many levels of care. These data underscore the need for comprehensive quality improvement across multiple domains of care outside of nursing. LEVEL OF EVIDENCE: Level III, retrospective study.

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty.

BACKGROUND: For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? METHODS: The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. RESULTS: Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections. CONCLUSIONS: Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. LEVEL OF EVIDENCE: Level III: prognostic study.

Cost-Effectiveness of Preoperative Smoking Cessation Interventions in Total Joint Arthroplasty.

BACKGROUND: Smoking is associated with adverse outcomes after total joint arthroplasty (TJA), including periprosthetic joint infection (PJI). Although preoperative smoking cessation interventions may help reduce the risk PJI, the short-term cost-effectiveness of these programs remains unclear. METHODS: Decision analysis was used to evaluate the cost-effectiveness of a preoperative smoking cessation intervention over a 90-day TJA episode of care. Costs and probabilities were derived from literature review and published Medicare data. Thresholds for cost and efficacy of the intervention were determined using sensitivity analysis. RESULTS: In our model, the average 90-day cost was $32 less for patients enrolled in a mandatory smoking cessation intervention ($23,457) compared with patients who were not ($23,489). In sensitivity analyses, the smoking cessation intervention was cost-saving vs no intervention when the short-term cost of PJI was greater than $95,410, the rate of PJI was reduced by at least 25% for former vs current smokers, the cost of the intervention was less than $219, or the success rate of the intervention was greater than 56%. CONCLUSION: Smoking cessation interventions prior to TJA can increase the value of care and are an important public health initiative. Routine referral to smoking cessation interventions should be considered for smokers indicated for TJA. LEVEL OF EVIDENCE: Level II, economic and decision analyses.

Day of Admission is Associated With Variation in Geriatric Hip Fracture Care.

INTRODUCTION: The transition to bundled payment reimbursement for geriatric hip fractures has incentivized the identification of avoidable inefficiencies in the cost and quality of care. Although a "weekend effect" has been described with regard to hip fracture mortality, measures of efficiency according to the day of hip fracture admission are currently unclear. METHODS: We identified 62,303 patients aged 65 years or older with a primary diagnosis of femoral neck or intertrochanteric hip fracture in the New York Statewide Planning and Research Cooperative System between 2009 and 2014. Outcome measures included preoperative delay, postoperative length of stay (LOS), and cost of admission. RESULTS: Preoperative delay was longer for weekend admissions, but shorter for admissions on Wednesday, Thursday, and Friday. Postoperative LOS was longer for admissions on Tuesday, Wednesday, and Thursday. Discharge rates varied considerably according to the day of admission, ranging from 12% to 43% by hospital day 4 and 53% to 72% by hospital day 6. No differences in cost according to day of admission were found once preoperative delay and postoperative LOS were accounted for. DISCUSSION: Notable variation exists in hospitalizations for geriatric hip fracture depending on the day of admission. Our data suggest the presence of a weekend effect, in which changes in staffing of surgical, medical, and ancillary services lead to increased waiting times for surgery for new admissions and delays in discharge of early- and mid-week admissions. LEVEL OF EVIDENCE: Level III, retrospective study.

Costs and complications of increased length of stay following adolescent idiopathic scoliosis surgery.

Accelerated discharge protocols for scoliosis surgery have recently been described in the literature. There are limited data describing the association of length of stay (LOS) during the index admission with postoperative outcomes. We sought to define the economic and clinical implications of an additional 1 day in the hospital for scoliosis surgery. The Statewide Planning and Research Cooperative System database was used to identify patients with adolescent idiopathic scoliosis who underwent spinal fusion from 1 October 2007 to 30 September 2012 at high-volume institutions (>20 cases/year) in the state of New York. Regression models were adjusted for age, sex, race, insurance, comorbidity score, and perioperative complications during the index admission. Among the 1286 patients with AIS who underwent spinal fusion, the mean LOS was 4.90 days [95% confidence interval (CI)=4.84-4.97; SD=1.19]. In the perioperative period, 605 (47.05%) underwent transfusion and 202 (15.71%) had problems with pain control. An additional 1 day in the hospital was associated with $11 033 (95% CI=7162-14 904; P<0.001) in insurance charges, $5198 (95% CI=4144-6252; P<0.001) in hospital costs, 28% increased risk (odds ratio=1.28; 95% CI=1.01-1.63; P=0.041) of all-cause 90-day readmission, and a 57% increased risk (odds ratio=1.57; 95% CI=1.13-2.17; P=0.007) of returning to the operating room within 90 days. Increased LOS during the index admission scoliosis surgery is associated with higher costs and an increased risk of 90-day postoperative complications. Protocols to decrease LOS for this surgery have potential benefits to patients, hospitals, and insurers. Level of Evidence: Level III, retrospective comparative study.

Risk Factors for Cerebrospinal Fluid Leak Following Anterior Cervical Discectomy and Fusion.

STUDY DESIGN/SETTING: This was a retrospective cohort study. PURPOSE: The purpose of this study was to examine the association between postoperative cerebrospinal fluid (CSF) leak and anterior cervical discectomy and fusion (ACDF). Specifically, we evaluated: (1) demographic risk factors; (2) comorbid risk factors; (3) indications for surgery; and (4) lengths of stay. SUMMARY OF BACKGROUND DATA: CSF leak is a rare but serious complication of ACDF. Currently, there is a paucity of literature describing the risk factors for CSF leak following ACDF. METHODS: The Nationwide Inpatient Sample was used to identify all patients who underwent cervical fusion using the anterior approach with excision of intervertebral disc between 1998 and 2010. Patients who had a diagnosis of ossification of the posterior longitudinal ligament in the cervical region were excluded. All patients who had a CSF leak were identified. Demographics and comorbidities were compared via χ analysis, and logistic regression to calculate the odds of having a CSF leak. RESULTS: Of the 1,261,140 patients identified, 3048 patients (0.24%) had a postoperative CSF leak. Patients who were between the ages of 55 and 69 years (P=0.038) and 70 years or older (P=0.001) were at an increased risk of CSF leak compared with patients who were aged 40-54 years. Non-white race (P=0.021), obesity, (P<0.001) and hypertension (P=0.025) were associated with an increased risk of CSF leak, but diabetes (P=0.966) and hyperlipidemia (P=0.226) were not. Herniated disc diagnosis was associated with decreased risk of CSF leak (P=0.032), but cervical spondylosis with myelopathy patients had an increased risk (P<0.001). Patients with CSF leak had a mean length of stay of 6.0 days compared with 2.1 days among controls. CONCLUSIONS: Surgical candidates who are older and non-white should be counseled of their increased risk for CSF leak in preoperative planning. Patients who are obese and have hypertension may benefit from medical optimization before surgery. LEVEL OF EVIDENCE: Level III.

Are HCAHPS Scores Higher for Private vs Double-Occupancy Inpatient Rooms in Total Joint Arthroplasty Patients?

BACKGROUND: Private hospital rooms have a number of potential advantages compared to shared rooms, including reduced noise and increased control over the hospital environment. However, the association of room type with patient experience metrics in total joint arthroplasty (TJA) patients is currently unclear. METHODS: For private versus shared rooms, we compared our institutional Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in patients who underwent primary TJA over a 2-year period. Regression model odds ratios (ORs) were adjusted for surgeon, date of surgery, and length of stay. RESULTS: Patients in private rooms were more likely to report a top-box score for overall hospital rating (85.6% vs 79.4%, OR = 1.53, P = .011), hospital recommendation (89.3% vs 83.0%, OR = 1.78, P = .002), call button help (76.0% vs 68.7%, OR = 1.40, P = .028), and quietness (70.4% vs 59.0%, OR = 1.78, P < .001). There were no significant differences on surgeon metrics including listening (P = .225), explanations (P = .066), or treatment with courtesy and respect (P = .396). CONCLUSION: For patients undergoing TJA, private hospital rooms were associated with superior performance on patient experience metrics. This association appears specific for global and hospital-related metrics, with little impact on surgeon evaluations. With the utilization of HCAHPS data in value-based initiatives, placement of TJA patients in private rooms may lead to increased reimbursement and higher hospital rankings. LEVEL OF EVIDENCE: Level III, retrospective cohort.

Knee dislocation with popliteal artery disruption: A nationwide analysis from 2005 to 2013.

OBJECTIVE: Few have compared short-term outcomes following knee dislocations with or without concomitant popliteal artery disruption (PAD). METHODS: The Nationwide Inpatient Sample was used to identify 2175 patients admitted for knee dislocation from 2005 to 2013 (concomitant PAD: n = 210/9.7%; without: n = 1965/90.3%). RESULTS: Patients with PAD were younger, more often male, Black and Hispanic, and with Medicaid (all p ≤ 0.013). PADs were associated with 11.0-times higher odds of increased LOS (95%CI, 6.6-18.4) and 2.8-times higher odds of experiencing any complication (95%CI, 2.03-3.92). Female sex was a protective factor against increased LOS, (OR = 0.65; 95%CI, 0.48-0.88). CONCLUSION: High suspicion index should be maintained for concomitant vascular injuries following knee dislocations.