Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention.

OBJECTIVES: To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. DESIGN: Retrospective cohort study. SETTING: Three academic Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. OUTCOME MEASURES AND COMPARISONS: Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS: Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS: Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures.

INTRODUCTION: The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. METHODS: The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. RESULTS: Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. DISCUSSION: Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

Mental Robustness May Be Associated With Improved Physical Function in Bilateral Total Knee Arthroplasty Patients.

BACKGROUND: In accordance with the high incidence of bilateral knee osteoarthritis, many patients have undergone bilateral total knee arthroplasty (BTKA). Whether patients undergo bilateral procedures in a staged or simultaneous fashion, the physical and mental burden of undergoing 2 major orthopedic procedures is considerable. The aims of this study were to (1) investigate differences between minimal clinically important difference (MCID) achievement between staged versus simultaneous BTKA, and (2) identify the patient variables, specifically mental scores, that were associated with MCID achievement in patients undergoing BTKA. METHODS: Simultaneous and staged BTKA patients within a single health care network from 2016 to 2021 were retrospectively reviewed. Patient demographics, surgery details, and Patient-Reported Outcome Measurement Information System Physical Function Short Forms 10a (PROMIS PF10a), PROMIS Mental scores, and Knee Disability Osteoarthritis Outcome Scores (KOOS) were reviewed. Preoperative and postoperative patient-reported outcome measures were collected before the first total knee arthroplasty (TKA) and after the second TKA, respectively, in staged BTKA patients. The final cohort consisted of 249 patients, with an average age of 66 years (range, 21 to 87), 63% women, and an average body mass index of 32 (range, 20 to 52), at a mean follow-up of 1.1 years (range, 0.5 to 2.4). Multivariate regressions were performed on MCID PF10a and KOOS achievement, as well as whether the BTKA was performed simultaneously versus staged. RESULTS: A preoperative PROMIS Mental score in the upper 2 quartiles was associated with MCID PF10a achievement in BTKA. Men and surgeries performed at an Academic Medical Center were negatively associated with the achievement of MCID KOOS. Interestingly, those who underwent simultaneous BTKA were less likely to achieve MCID KOOS than those who underwent a staged BTKA. CONCLUSIONS: Preoperative mental robustness may be positively associated with improved physical function outcome in BTKA patients.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease.

Background: Following orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology. Methods: The 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD. Results: After weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality. Conclusions: After matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Effects of anode position on pedicle screw testing during lumbosacral spinal fusion surgery.

OF BACKGROUND DATA: Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements. PURPOSE: To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws). STUDY DESIGN: Prospective cohort study. Tertiary medical center. PATIENT SAMPLE: Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement. METHODS: Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. R2 coefficients of correlation were determined, and variances were compared with F-tests. RESULTS: A total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an R2 of 0.96. Comparisons between the four anode locations demonstrated R2 values ranging from 0.76 to 0.87. F-tests comparing thresholds between each anode site demonstrated all groups not to be statistically different. CONCLUSION: The current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.

Chondrosarcoma patient characteristics, management, and outcomes based on over 5,000 cases from the National Cancer Database (NCDB).

INTRODUCTION: Chondrosarcoma, although relatively uncommon, represents a significant percentage of primary osseous tumors. Nonetheless, there are few large-cohort, longitudinal studies of long-term survival and treatment outcomes of chondrosarcoma patients and none using the National Cancer Database (NCDB). METHODS: Chondrosarcoma patients were identified from the 2004-2015 NCDB datasets and divided on three primary tumor sites: appendicular, axial, and other. Demographic, treatment, and long-term survival data were determined for each group. Multivariate Cox analysis and Kaplan-Meier survival curves were generated to assess long-term survival over time for each. RESULTS: In total, 5,329 chondrosarcoma patients were identified, of which 2,686 were appendicular and 1,616 were axial. Survival was higher among the appendicular cohort than axial at 1-year, 5-year, and 10-year (89.52%, 75.76%, and 65.24%, respectively). Multivariate Cox analysis identified patients in the appendicular cohort to have significantly greater likelihood of death with increasing age category, distant metastases at presentation, and male sex (p<0.001 for each). Best outcomes for seen for those undergoing surgical treatment (p<0.001). Patients in the axial cohort were with increased likelihood of death with increasing age category and distant metastases (p<0.001), while surgical treatment with or without radiation were associated with a significant decrease (p<0.001). Kaplan-Meier survival analysis showed worst survival for the axial cohort (p<0.001) and patients with distant metastases at presentation (p<0.001). Survival was not significantly different between older (2004-2007) and more recent years (2012-2016) (p = 0.742). CONCLUSIONS: For both appendicular and axial chondrosarcomas, surgical treatment remains the mainstay of treatment due to its continued superiority for the long-term survival of patients, although advancements in survival over the last decade have been insignificant. Presence of distant metastases and axial involvement are significant, poor prognostic factors perhaps because of difficulty in surgical excision or extent of disease.

Underweight patients are the highest risk body mass index group for perioperative adverse events following stand-alone anterior lumbar interbody fusion.

BACKGROUND CONTEXT: Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts. PURPOSE: The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases. OUTCOME MEASURES: Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality. METHODS: Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/m3), were calculated. Multivariate analysis was then performed controlling for patient factors. RESULTS: In total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI<18.5 kg/m3) and super morbidly obese (>50 kg/m3), however, multivariate risks for adverse events and postoperative infection were elevated for underweight patients beyond those found in any other BMI category. No effect was noted in these identical variables between normal, overweight, obese class 1, or even obese class 2 patients. Multivariate analysis also found overweight patients to show a slightly protective trend against mortality while the super morbidly obese had elevated odds. CONCLUSIONS: Underweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.

The Unmet Need for Orthopaedic Services Among American Indian and Alaska Native Communities in the United States.

ABSTRACT: Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.

Characteristics, Management, and Outcomes of Patients With Osteosarcoma: An Analysis of Outcomes From the National Cancer Database.

INTRODUCTION: Previous studies about osteosarcoma patient characteristics, management, and outcomes have limited patient numbers, combine varied tumor types, and/or are older studies. METHODS: Patients with osteosarcoma from the 2004 to 2015 National Cancer Database data sets were separated into axial, appendicular, and other. Demographic and treatment data as well as 1-, 5-, and 10-year survival were determined for each group. A multivariate Cox analysis of patient variables with the likelihood of death was performed, and the Kaplan Meier survival curves were generated. RESULTS: Four thousand four hundred thirty patients with osteosarcoma (3,435 appendicular, 810 axial, and 185 other) showed survival at 1-year, 5-year, and 10-year and was highest among the appendicular cohort (91.17%, 64.43%, and 58.58%, respectively). No change in survival was seen over the periods studied. The likelihood of death was greater with increasing age category, distant metastases, and treatment with radiation alone but less with appendicular primary site, treatment with surgery alone, or surgery plus chemotherapy. DISCUSSION: Despite advances in tumor management, surgical excision remains the best predictor of survival for osteosarcomas. No difference was observed in patient survival from 2004 to 2015 and, as would be expected, distant metastases were a poor prognostic sign, as was increasing age, male sex, and axial location.

The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database.

INTRODUCTION: American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention. METHODS: 1999-2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications. RESULTS: Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999-2004 to 60.92% in 2011-2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16-30 cases: OR = 0.91; 95% CI: 0.85-0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61-0.76; p<0.001). Femoral neck hip fractures were associated with increased odds of surgical complications. DISCUSSION: Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.

Long-term Corticosteroid Use Independently Correlates With Complications After Posterior Lumbar Spine Surgery.

With the increasing medical complexity of patients undergoing posterior lumbar surgery, more patients are pharmacologically immunosuppressed to manage chronic conditions. The effects of immunosuppression have become of greater interest across multiple surgical specialties. The goal of the current study was to investigate whether long-term corticosteroid use is independently associated with perioperative adverse outcomes among patients undergoing posterior lumbar surgery. Patients who underwent elective posterior lumbar spine surgery (decompression and/or fusion) were identified in the 2005-2016 National Surgical Quality Improvement Program (NSQIP) database. Patient factors, surgical factors, and 30-day perioperative outcomes for patients taking long-term corticosteroids were compared with those for patients who were not taking these drugs. Propensity matching and multivariate analysis were used to evaluate comparable patients while controlling for potentially confounding variables. In total, 140,519 patients undergoing posterior lumbar spine surgery were identified. Of these, 5243 (3.73%) were taking corticosteroids. After propensity matching and controlling for age, sex, body mass index, functional status, American Society of Anesthesiologists class, and surgical procedure, those taking corticosteroids were at greater risk for any adverse event (odds ratio, 1.45), a serious adverse event (odds ratio, 1.57), a minor adverse event (odds ratio, 1.47), infection (odds ratio, 1.48), reoperation (odds ratio, 1.48), and readmission (odds ratio, 1.47) (P≤.001 for each). The findings confirmed that long-term corticosteroid use is associated with significant increases in perioperative adverse outcomes for patients undergoing elective posterior lumbar surgery, even with matching and controlling for potentially confounding variables. These findings can guide patient counseling and preemptive interventions before surgery for this patient population. [Orthopedics. 2021;44(3):172-179.].

Underweight patients are an often under looked "At risk" population after undergoing posterior cervical spine surgery.

BACKGROUND: Body Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery. METHODS: Patients undergoing elective posterior cervical spine surgery were abstracted from the 2005-2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5-24.9 kg/m2). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health. RESULTS: A total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI < 18.5 kg/m2) were the highest among any category of patients along the BMI spectrum. These patients experienced increased odds of any adverse event (Odds Ratio (OR) = 1.67, p = 0.008, major adverse events (OR=2.08, p = 0.001), post-operative infection (OR = 1.95, p = 0.002), and reoperation (OR = 1.84, p = 0.020). Interestingly, none of the overweight or obese categories were found to be correlated with increased risk of adverse event categories other than super-morbidly obese patients (BMI>50.0 kg/m2) for post-operative infection (OR = 1.54, p = 0.041). CONCLUSIONS: The current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.

The Continued Utility and Viability of Dakin's Solution in Both High- and Low-resource Settings.

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin's solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin's solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin's solution for modern wound care.

Addressing Supply Chain Management Issues in Cost-effective Maternal and Pediatric Global Surgery: A Call to Action.

Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework.

Underweight patients are at just as much risk as super morbidly obese patients when undergoing anterior cervical spine surgery.

BACKGROUND CONTEXT: Past studies have focused on the association of high body mass index (BMI) on spine surgery outcomes. These investigations have reported mixed conclusions, possible due to insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (e.g. underweight, overweight, and obese). Few studies have considered outcomes of patients with low BMI. PURPOSE: To analyze how anterior cervical spine surgery outcomes track with World Health Organization categories of BMI to better assess where along the BMI spectrum patients are at risk for adverse perioperative outcomes. DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients undergoing elective anterior cervical spine surgery were abstracted from the 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program database. OUTCOME MEASURES: Thirty-day adverse events, hospital readmissions, postoperative infections, and mortality. METHODS: Patients undergoing anterior cervical spine procedures (anterior cervical discectomy and fusion, anterior cervical corpectomy, cervical arthroplasty) were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Patients were then aggregated into modified World Health Organization categories of BMI. Odds ratios of adverse outcomes, normalized to average risk of normal weight subjects (BMI 18.5-24.9 kg/m2), were calculated. Multivariate analyses were then performed on aggregated adverse outcome categories controlling for demographics (age, sex, functional status) and overall health as measured by the American Society of Anesthesiologists classification. RESULTS: In total, 51,149 anterior cervical surgery patients met inclusion criteria. Multivariate analyses revealed the odds of any adverse event to be significantly elevated for underweight and super morbidly obese patients (Odds Ratios [OR] of 1.62 and 1.55, respectively). Additionally, underweight patients had elevated odds of serious adverse events (OR=1.74) and postoperative infections (OR=1.75) and super morbidly obese patients had elevated odds of minor adverse events (OR=1.72). Relative to normal BMI patients, there was no significant elevation for any adverse outcomes for any of the other overweight/obese categories, in fact some had reduced odds of various adverse outcomes. CONCLUSIONS: Underweight and super morbidly obese patients have the greatest odds of adverse outcomes after anterior cervical spine surgery. The current study identifies underweight patients as an at-risk population that has previously not received significant focus. Physicians and healthcare systems should give additional consideration to this population, as they often already do for those at the other end of the BMI spectrum.

Postoperative Pressure Ulcers After Geriatric Hip Fracture Surgery Are Predicted by Defined Preoperative Comorbidities and Postoperative Complications.

INTRODUCTION: The current study sought to determine the factors predictive of postoperative pressure ulcer development by analyzing extensive multicenter outcomes data from the 2016 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. METHODS: The 2016 NSQIP Participant Use File and Hip Fracture Procedure Targeted file were used to identify the risk factors for the development of postoperative pressure ulcers after hip fracture surgery in a geriatric cohort. Multivariate regressions were performed to identify preoperative comorbidities and postoperative complications that are risk factors for developing postoperative pressure ulcers. RESULTS: Of 8,871 geriatric hip fracture patients included in the study cohort, 457 (5.15%) developed pressure ulcers. Multivariate regressions identified the following preoperative risk factors for developing a postoperative pressure ulcer (in order of decreasing relative risk): preoperative sepsis, elevated platelet count, insulin-dependent diabetes, and preexisting pressure ulcer. Multivariate regressions also identified the following postoperative complications as risk factors for developing a postoperative pressure ulcer: postoperative sepsis, postoperative pneumonia, urinary tract infection, and postoperative delirium. DISCUSSION: The identified preoperative factors and postoperative complications should help guide quality improvement programs.

Readmissions After Distal Radius Fracture Open Reduction and Internal Fixation: An Analysis of 11,124 Patients.

PURPOSE: Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database. METHODS: Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses. RESULTS: Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery. CONCLUSION: This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Dialysis Dependence Is Associated With Significantly Increased Odds of Perioperative Adverse Events After Geriatric Hip Fracture Surgery Even After Controlling for Demographic Factors and Comorbidities.

Previous studies evaluating the risk of perioperative adverse events after hip fracture surgery for dialysis-dependent patients are either institutional cohort studies or limited by patient numbers. The current study uses the National Surgical Quality Improvement Program database's large national patient population and 30-day follow-up window to address these weaknesses. METHODS: National Surgical Quality Improvement Program databases (2006 to 2016) were queried for patients aged 60 years or older who underwent hip fracture surgery. Differences in 30-day outcomes based on preoperative dialysis dependence were compared using risk-adjusted logistic regression and coarsened exact matching for adverse events, need for revision surgery, readmission, and mortality. The proportion of adverse events that occurred before versus after discharge was also assessed. RESULTS: A total of 288 dialysis-dependent and 16,392 non-dialysis-dependent patients met the inclusion criteria. Matched populations controlling for demographic factors (ie, age, sex, body mass index, and functional status) and overall health (American Society of Anesthesiologists class) found dialysis-dependent patients to be associated with significantly greater odds of any adverse event (odds ratio [OR] = 1.90), major adverse event (OR = 1.77), and unplanned readmission (OR = 2.48). Increased odds of minor adverse event (OR = 1.05), return to the operating room (OR = 1.66), and death (OR = 1.42) within 30 postoperative days were also found but were not statistically significant. DISCUSSION: Even after controlling for demographics and health status, geriatric dialysis patients undergoing surgery for hip fracture are at significantly greater odds of adverse outcomes. Because of increased risks for geriatric dialysis patients undergoing surgery for hip fracture, surgical caution, patient counseling, and heightened surveillance must be observed throughout the perioperative period for this fragile population. Furthermore, hospitals and physicians must take the increased risks associated with dialysis into account when considering bundled payment reimbursement strategies and resource allocation for hip fracture care.