Single-level posterior cervical foraminotomy associated with increased incidence of early postoperative wound infection rates relative to anterior cervical discectomy with fusion and cervical disc arthroplasty.

Background: To date, there are no studies comparing perioperative outcomes of cervical radiculopathy patients managed by anterior cervical discectomy with fusion (ACDF), cervical disc arthroplasty (CDA), or posterior cervical foraminotomy (PCF). To assess if there were differences in perioperative outcomes between cervical radiculopathy patients who can be appropriately treated with ACDF, CDA, or PCF. Methods: Patients diagnosed with cervical radiculopathy who underwent a single-level ACDF, CDA, or PCF between 2012 and 2019 were retrospectively identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology (CPT) codes. Patients were subsequently stratified into those who underwent ACDF, CDA, or PCF, and propensity score-matched to adjust for differences in patient demographics/characteristics. Differences were assessed in terms of operative time, healthcare utilization metrics (reoperations, readmissions, lengths-of-stay), as well as medical and surgical complications. Results: A total of 18,614 cervical radiculopathy patients undergoing surgery were identified (ACDF: n=15,862; CDA: n=1,731; PCF: n=1,021). After 1:1 propensity score matching (n=535 each), there were no differences in characteristics in patients undergoing ACDF, CDA, or PCF (P>0.05). PCF patients had statistically higher rates of reoperation (2.1%) than ACDF (0.4%), CDA (0.6%) patients (P=0.010). PCF patients also experienced higher rates of superficial infection (P=0.001), and deep infection (P=0.007), relative to ACDF and CDA patients. There were no other significant differences in medical/surgical complications between the ACDF, CDA, or PCF patients. Conclusions: Cervical radiculopathy patients undergoing PCF are associated with higher rates of perioperative infection and overall reoperation than ACDF or CDA. Further research is required to elucidate the mechanism behind this association.

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.].

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis.

BACKGROUND: As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS: The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed. RESULTS: A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost. CONCLUSION: Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Trends in industry-sponsored research in plastic surgery since implementation of the Sunshine Act.

Financial contributions from industry for physician-led research have been historically challenging to study in plastic surgery. However, as mandated by the Physician Payments Sunshine Act of 2013, the Open Payments Database (OPD) has increased transparency in payments from industry to physicians. This study aimed to analyze trends in industry-sponsored research funding for plastic surgeons. Using the OPD, research payments from industry made to plastic surgeons from 2014 to 2018 were examined. Total payments and number of payments were recorded by recipient's census region (e.g., Northeast, Midwest, South, West) and therapeutic area (e.g., breast prosthetics/reconstruction, wound healing/tissue engineering, software/instrumentation, biologics, cosmetics/injectables). Payments totaled across 5 years in each therapeutic area for each region were also analyzed. Location of company U.S. headquarters and therapeutic area were recorded. Statistical analyses were performed using SAS 9.4. Brown-Mood test, t test, Kruskal-Wallis, Mann-Whitney, and linear regression tests were used. Aggregated over 5 years, the greatest payment value was allocated to wound healing/tissue engineering, whereas the number of payments was highest in breast prosthetics/reconstruction. Private plastic surgeons receive significantly higher payments compared to academic plastic surgeons. With such findings, greater transparency and additional years of OPD data may provide further insight into industry influence on physician-led research in plastic surgery.

Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery.

Venous thromboembolism (VTE) is an uncommon but highly morbid and potentially preventable complication in children. This study aimed to characterize the incidence of, and risk factors for, VTE in children undergoing orthopedic surgery. A retrospective analysis was performed using the 2012 to 2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Patient demographics, comorbidities, operative variables, and perioperative outcomes were compared between patients who did and did not develop a VTE. In total, 81,490 pediatric patients who underwent orthopedic surgery were identified. Of those, the mean±SD age was 9.7±4.8 years, and 50.1% were male. Sixty patients (0.07%) developed a postoperative VTE. On multivariate regression, demographic and surgical variables associated with a VTE were ages 16 to 18 years (P=.002; compared with ages 11 to 15 years), American Society of Anesthesiologists (ASA) classes III and V (P=.003; compared with ASA classes I and II), preoperative blood transfusion (P<.001), arthrotomy (P<.001), and femur fracture (P<.001). Postoperative adverse events occurring prior to a VTE were also assessed. Controlling for patient factors, independent risk factors for VTE included any adverse event (P<.001), major adverse events (P<.001), minor adverse events (P<.001), reoperation (P<.001), and readmission (P<.001). This study identified an incidence of VTE of 0.07% in a population of more than 80,000 children undergoing orthopedic surgery. The identification of risk factors for VTE in this patient population raises the issue of VTE prophylaxis for select high-risk subpopulations. [Orthopedics. 2022;45(1):31-37.].

COVID-positive ankle fracture patients are at increased odds of perioperative surgical complications following open reduction internal fixation surgery.

INTRODUCTION: Ankle fractures have continued to occur through the COVID pandemic and, regardless of patient COVID status, often need operative intervention for optimizing long-term outcomes. For healthcare optimization, patient counseling, and care planning, understanding if COVID-positive patients undergoing ankle fracture surgery are at increased risk for perioperative adverse outcomes is of interest. METHODS: The COVID-19 Research Database contains recent United States aggregated insurance claims. Patients who underwent ankle fracture surgery from April 1st, 2020 to June 15th, 2020 were identified. COVID status was identified by ICD coding. Demographics, comorbidities, and postoperative complications were extracted based on administrative data. COVID-positive versus negative patients were compared with univariate analyses. Propensity-score matching was done on the basis of age, sex, and comorbidities. Multivariate regression was then performed to identify risk factors independently associated with the occurrence of 30-day postoperative adverse events. RESULTS: In total, 9,835 patients undergoing ankle fracture surgery were identified, of which 57 (0.58%) were COVID-positive. COVID-positive ankle fracture patients demonstrated a higher prevalence of comorbidities, including: chronic kidney disease, diabetes, hypertension, and obesity (p<0.05 for each). After propensity matching and controlling for all preoperative variables, multivariate analysis found that COVID-positive patients were at increased risk of any adverse event (odds ratio [OR] = 3.89, p = 0.002), a serious adverse event (OR = 5.48, p = 0.002), and a minor adverse event (OR = 3.10, p = 0.021). DISCUSSION: COVID-positive patients will continue to present with ankle fractures requiring operative intervention. Even after propensity matching and controlling for patient factors, COVID-positive patients were found to be at increased risk of 30-day perioperative adverse events. Not only do treatment teams need to be protected from the transmission of COVID in such situations, but the increased incidence of perioperative adverse events needs to be considered.

Clinical Characteristics and Perioperative Complication Profiles of COVID-19-Positive Patients Undergoing Hip Fracture Surgery.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic disease has imposed an unprecedented degree of stress on healthcare systems. This study aimed to understand whether COVID-19 positivity is associated with an increased risk of adverse outcomes after geriatric hip fracture surgery. METHODS: From a national administrative claims data set, patients who underwent hip fracture surgery from April 1, 2020, to December 1, 2020 were selected for analysis. COVID-19-positive status was assessed by the emergency International Classification of Diagnoses, 10th Revision, COVID-19 code within 2 weeks before the surgery. Demographic, comorbidity, and 30-day postoperative adverse event information were extracted. Logistic regression before and after 10:1 propensity matching was performed to identify patient risk factors associated with the occurrence of postoperative adverse events. RESULTS: Of 42,002 patients who underwent hip fracture surgery, 678 (1.61%) were identified to be positive for COVID-19 infection. No significant differences in age, sex, and procedure type were found between COVID-19-positive and COVID-19-negative groups, but the COVID-19-positive patients demonstrated a higher incidence of several comorbidities. These differences were no longer significant after matching. After matching, the COVID-19-positive group had a higher incidence of any, serious, and minor adverse events (P < 0.001 for all). Controlling for preoperative variables, COVID-19 positivity was associated with an increased risk of experiencing any adverse events (odds ratio [OR] = 1.62, 95% confidence interval [95% CI] = [1.37 to 1.92], P < 0.001), serious adverse events (OR = 1.66, 95% CI = [1.31 to 2.07], P < 0.001), and minor adverse events (OR = 1.59, 95% CI = [1.34 to 1.89], P < 0.001). DISCUSSION: After matching and controlling for confounding variables, COVID-19-positive hip fracture patients had increased odds of multiple postoperative events. Clinicians caring for this vulnerable geriatric population should be mindful of this risk to improve the care for these patients during the ongoing global pandemic.

Orthopaedic Foot and Ankle Surgeon Industry Compensation Reported by the Open Payments Database.

Background. The current study aims to characterize and explore trends in Open Payments Database (OPD) payments reported to orthopaedic foot and ankle (F&A) surgeons. OPD payments are classified as General, Ownership, or Research. Methods. General, Ownership, and Research payments to orthopaedic F&A surgeons were characterized by total payment sum and number of transactions. The total payment was compared by category. Payments per surgeon were also assessed. Median payments for all orthopaedic F&A surgeons and the top 5% compensated were calculated and compared across the years. Medians were compared through Mann-Whitney U tests. Results. Over the period, industry paid over $39 million through 29,442 transactions to 802 orthopaedic F&A surgeons. The majority of this payment was General (64%), followed by Ownership (34%) and Research (2%). The median annual payments per orthopaedic F&A surgeon were compared to the 2014 median ($616): 2015 ($505; P = .191), 2016 ($868; P = .088), and 2017 ($336; P = .084). Over these years, the annual number of compensated orthopaedic F&A surgeons increased from 490 to 556. Averaged over 4 years, 91% of the total orthopaedic F&A payment was made to the top 5% of orthopaedic F&A surgeons. The median payment for this group increased from $177 000 (2014) to $192 000 (2017; P = .012). Conclusion. Though median payments to the top 5% of orthopaedic F&A surgeons increased, there was no overall change in median payment over four years for all compensated orthopaedic F&A surgeons. These findings shed insight into the orthopaedic F&A surgeon-industry relationship.Levels of Evidence: III, Retrospective Study.

Hospital Discharge Within a Day After Total Knee Arthroplasty Does Not Affect 1-Year Complications Compared With Rapid Discharge.

INTRODUCTION: In patients undergoing total knee arthroplasty (TKA), it is unclear whether a difference in complication rates exists between patients discharged the day of surgery compared with subsequent postoperative days. METHODS: Data were collected from the PearlDiver Patient Records Database from 2007 to 2017. Subjects were identified using International Classification of Diseases codes. Eligible patients were stratified into the following three groups: (1) same day discharge (<24 hours postoperatively), (2) rapid discharge (1 to 2 days), and (3) traditional discharge (3 to 4 days) based on the length of stay. RESULTS: In total, 84,864 patients were identified as having undergone primary TKA. The incidence of same day discharge, rapid discharge, and traditional discharge was 2.36% (2,004/84,864), 28.56% (24,235/84,864), and 69.08% (58,625/84,864), respectively. After adjustment, no notable differences were observed in the overall complication and revision rates between the same day discharge group and either the rapid discharge or the traditional discharge group. On multivariate analysis, patients in the rapid discharge cohort were less likely to require manipulation under anesthesia or develop periprosthetic joint infection when compared with the traditional discharge group at 1 year postoperatively. CONCLUSIONS: For those who qualify after careful selection, same day and rapid discharge TKA may be a feasible alternative to the traditional inpatient TKA. LEVEL OF EVIDENCE: A level 3 retrospective, prognostic study.

Postoperative bracing practices after elective lumbar spine surgery: A questionnaire study of U.S. spine surgeons.

BACKGROUND: There is limited data available on the use of orthoses across varying elective spine surgeries. When previously studied in 2009, inconsistent lumbar postoperative bracing practices were reported. The present study aimed to provide a ten-year update regarding postoperative bracing practices after elective lumbar surgery among United States (U.S.) spine surgeons. METHODS: A questionnaire was distributed to attendees of the Lumbar Spine Research Society Annual Meeting (April 2019). The questionnaire collected demographic information, and asked surgeons to identify if they used orthoses postoperatively after ten elective lumbar surgeries. Information regarding type of brace, duration of use, and reason for bracing was also collected. Chi-square tests and one-way analysis of variance (ANOVA) were used for comparisons. RESULTS: Seventy-three of 88 U.S. attending surgeons completed the questionnaire (response rate: 83%). The majority of respondents were orthopaedic surgery-trained (78%), fellowship-trained (84%), and academic surgeons (73%). The majority of respondents (60%) did not use orthoses after any lumbar surgery. Among the surgeons who braced, the overall bracing frequency was 26%. This rate was significantly lower than that reported in the literature ten years earlier (p<0.0001). Respondents tended to use orthoses most often after stand-alone lateral interbody fusions (43%) (p<0.0001). The average bracing frequency after lumbar fusions (34%) was higher than the average bracing frequency after non-fusion surgeries (16%) (p<0.0001). The most frequently utilized brace was an off the shelf lumbar sacral orthosis (66%), and most surgeons braced patients to improve pain (42%). Of surgeons who braced, most commonly did so for 2-4 months (57%). CONCLUSION: Most surgeon respondents did not prescribe orthoses after varying elective lumbar surgeries, and the frequency overall was lower than a similar study conducted in 2009. There continues to be inconsistencies in postoperative bracing practices. In an era striving for evidence-based practices, this is an area needing more attention.

Use of intraoperative navigation for posterior spinal fusion in adolescent idiopathic scoliosis surgery is safe to consider.

PURPOSE: The use of image-guided stereotactic navigation is increasing in use in treating AIS; however, no studies have investigated perioperative outcomes and short-term adverse events compared with non-navigated procedures. The aim of the present study is to use a large national pediatric database to assess the rate of utilization of intraoperative navigation in pediatric patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis (AIS) and to compare thirty-day outcomes of navigated vs. non-navigated surgery. METHODS: The NSQIP-Pediatric database was queried for cases of posterior fusion for AIS. Patients were stratified by whether or not a concurrent code for stereotactic navigation was used (CPT 61,783). Year of procedure, demographics, comorbidities, operative variables and perioperative adverse outcomes were abstracted and assessed using univariate and multivariate analysis. RESULTS: Overall, 12,739 non-navigated patients and 340 navigated patients were identified. The use of navigation increased from 0.5% of cases in 2012 to 5.2% of cases in 2018. Demographics, comorbidities, and number of levels fused did not differ between navigated and non-navigated patients. Navigated cases were on average 41 min longer than non-navigated cases (268.6 vs. 309.6 min p < 0.001), with 9.84% more cases requiring transfusion (65.0% vs 75.6%, p < 0.001). Hospital stay for navigated cases was an average of 0.4 days shorter (3.9 days vs 4.3 days, p = 0.001). On multivariate analysis, navigated cases had higher odds of prolonged surgery (OR = 2.13, p < 0.001) and lower odds of prolonged length of stay (OR = 0.28, p < 0.001). CONCLUSION: Although the use of navigation for AIS posterior fusion was associated with longer operative time, post-operative hospital stay was shorter and other perioperative adverse outcomes were not significantly different between groups.

Patients' and Physicians' Knowledge of Radiation Exposure Related to Spine Surgery.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: Examine patients' and physicians' estimates of radiation exposure related to spine surgery. SUMMARY OF BACKGROUND DATA: Patients are commonly exposed to radiation when undergoing spine surgery. Previous studies suggest that patients and physicians have limited knowledge about radiation exposure in the outpatient setting. This has not been assessed for intraoperative imaging. METHODS: A questionnaire was developed to assess awareness/knowledge of radiation exposure in outpatient and intraoperative spine care settings. Patients and surgeons estimated chest radiograph (CXR) equivalent radiation from: cervical and lumbar radiographs (anterior-posterior [AP] and lateral), computed tomography (CT), magnetic resonance imaging (MRI), intraoperative fluoroscopy, and intraoperative CT (O-arm). Results were compared to literature-reported radiation doses. RESULTS: Overall, 100 patients and 26 providers completed the survey. Only 31% of patients were informed about outpatient radiation exposure, and only 23% of those who had undergone spine surgery had been informed about intraoperative radiation exposure. For lumbar radiographs, patients and surgeons underestimated CXR-equivalent radiation exposures: AP by five-fold (P < 0.0001) and seven-fold (P < 0.0001), respectively, and lateral by three-fold (P < 0.0001) and four-fold (P = 0.0002), respectively. For cervical CT imaging, patients and surgeons underestimated radiation exposure by 18-fold (P < 0.0001) and two-fold (P = 0.0339), respectively. For lumbar CT imaging, patients and surgeons underestimated radiation exposure by 31-fold (P < 0.0001) and three-fold (P = 0.0001), respectively. For intraoperative specific cervical and lumbar imaging, patients underestimated radiation exposure for O-arm by 11-fold (P < 0.0001) and 22-fold (P = 0.0002), respectively. Surgeons underestimated radiation exposure of lumbar O-arm by three-fold (P = 0.0227). CONCLUSION: This study evaluated patient and physician knowledge of radiation exposure related to spine procedures. Underestimation of radiation exposure in the outpatient setting was consistent with prior study findings. The significant underestimation of intraoperative cross-sectional imaging (O-arm) is notable and needs attention in the era of increased use of such technology for imaging, navigation, and robotic spine surgery. LEVEL OF EVIDENCE: 4.

Thirty-Day Readmissions After Aseptic Revision Total Hip Arthroplasty: Rates, Predictors, and Reasons Vary by Surgical Indication.

BACKGROUND: Revision total hip arthroplasty (rTHA) is performed for different surgical indications. With increasing attention being focused to minimize readmission risk, the National Surgical Quality Improvement Program (NSQIP) was used to assess 30-day readmissions after rTHA for 3 aseptic indications. METHODS: Patients undergoing rTHA were identified in the 2013-2017 NSQIP and classified as being performed for osteolysis/aseptic loosening, recurrent dislocation, or periprosthetic fracture. Rates and predictors of 30-day readmission were determined by indication. Reasons for readmission were also assessed as being either related or unrelated to the surgical site. RESULTS: Of 6104 patients meeting inclusion criteria, osteolysis/aseptic loosening represented 46% of the revisions (readmission rate: 6.2%), recurrent dislocation represented 33.2% (readmission rate: 10.9%), and periprosthetic fractures represented 20.9% (readmission rate: 9.3%). These readmission rates represented statistically significant variation across the 3 indications (P < .0001). On multivariate analysis, demographic, procedural, and postoperative predictors of readmission varied by indication. The osteolysis/aseptic loosening and periprosthetic fracture cohorts had surgical site-related readmissions in 43.9% and 42.4% of readmitted cases, respectively. On the contrary, readmissions after rTHA performed for recurrent dislocation were mostly surgical site-related (63.3%) and driven primarily by a postoperative dislocation. Further multivariate analysis showed that the rTHA indication of recurrent dislocation itself was the strongest predictor (odds ratio, 3.34; P < .0001) of a postoperative dislocation leading to a 30-day readmission. CONCLUSION: Thirty-day readmissions varied from 6.2% to 10.9% based on surgical indication for aseptic rTHA. Reasons for readmission also differed across the 3 cohorts. These findings may aid postoperative care pathways and protocol optimization.

Industry Payments to Orthopedic Spine Surgeons Reported by the Open Payments Database: 2014-2017.

STUDY DESIGN: This was a retrospective study of publicly available data. OBJECTIVE: The objective of this study was to characterize and assess trends in Open Payments Database (OPD) industry payments reported to orthopedic spine surgeons from 2014 to 2017. SUMMARY OF BACKGROUND DATA: There have been a lack of studies characterizing OPD industry payments to orthopedic spine surgeons over the 4 full years of data available. MATERIALS AND METHODS: General industry payments made to orthopedic spine surgeons from 2014 to 2017 were characterized by year with analysis of: number of compensated surgeons, median payment per surgeon, top strata of compensated surgeons, and subtype (ie, food/beverage). Research and Ownership Payments were characterized by median payment per surgeon. Mann-Whitney U tests were used to compare payments. RESULTS: For General Payments, the number of compensated orthopedic spine surgeons increased from 1539 in 2014 to 1673 in 2017. Later year median General Payments per surgeon were compared with the 2014 median ($1051): 2015 ($1070: P=0.375), 2016 ($1263: P=0.012), and 2017 ($978: P=0.561). In 2014, the top 10% of compensated orthopedic spine surgeons received 89% of the total General compensation to orthopedic spine surgeons, top 5% received 79%, and the top 1% received 55%. The median General Payment for these 3 top strata remained similar over the 4 years evaluated (P>0.05). For subtype analyses, the median aggregate General Payment for "education" increased (P=0.002) across the years. Finally, it was determined that the median payment per surgeon for Research and Ownership Payment categories remained stable across the time period (P>0.05). CONCLUSIONS: Many expected industry payments to surgeons to decrease under public scrutiny of the OPD, but the present study showed no net change in median payment (General, Research, and Ownership) over the years studied. In the age of greater transparency, these findings shed insight into the orthopedic spine surgeon-industry relationship. LEVEL OF EVIDENCE: Level III.

High, As Well As Low, Preoperative Platelet Counts Correlate With Adverse Outcomes After Elective Posterior Lumbar Surgery.

STUDY DESIGN: Retrospective cohort study of prospectively collected data. OBJECTIVE: Assess correlation between preoperative platelet counts and postoperative adverse events after elective posterior lumbar surgery procedures. SUMMARY OF BACKGROUND DATA: Preoperative low platelet counts have been correlated with adverse outcomes after posterior lumbar surgery. Nonetheless, the effect of varying platelet counts has not been studied in detail for a large patient population, especially on the high end of the platelet spectrum. METHODS: Patients who underwent elective posterior lumbar surgery were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Preoperative platelet counts were considered relative to 30-day perioperative adverse outcomes. Patients were classified into platelet categories based on determining upper and lower bounds on when the adverse outcomes crossed a relative risk of 1.5. Univariate and multivariate analyses compared 30-day postoperative complications, readmissions, operative time, and hospital length of stay between those with low, normal, and high platelet counts. RESULTS: In total, 137,709 posterior lumbar surgery patients were identified. Using the relative risk threshold of 1.5 for the occurrence of any adverse event, patients were divided into abnormally low (≤140,000/mL) and abnormally high (≥447,000/mL) platelet cohorts. The abnormally low and high platelet groups were associated with higher rates of any, major, minor adverse events, transfusion, and longer hospital length of stay. Furthermore, the abnormally low platelet counts were associated with a higher risk of readmissions. CONCLUSION: The data-based cut-offs for abnormally high and low platelet counts closely mirrored those found in literature. Based on these definitions, abnormally high and low preoperative platelet counts were associated with adverse outcomes after elective posterior lumbar surgery. These findings facilitate risk stratification and suggest targeted consideration for patients with high, as well as low, preoperative platelet counts. LEVEL OF EVIDENCE: 3.

Characteristics and Predictors of HCAHPS Nonresponse After Spine Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess nonresponder biases for the HCAHPS survey following spine surgery. SUMMARY OF BACKGROUND DATA: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a publicly reported patient satisfaction survey. In addition to having the potential of impacting a hospital's reputation, it is directly linked to government reimbursement. However, it is known that a minority of patients return this survey, and it is expected that there are nonresponder biases. METHODS: All adult inpatient spine surgery patients at a single institution between January 2013 and August 2017 at a single institution were selected for retrospective analysis. Patient demographics and perioperative outcomes were assessed as potential predictors of not returning HCAHPS surveys. Univariate and multivariate analyses were performed. RESULTS: Of 5517 spine surgeries analyzed, 1505 (27.3%) patients returned the HCAHPS survey. Response rate was variable based on patient characteristics (with statistically significant differences based on age, functional status, race, and American Society of Anesthesiologists score) but not variable based on anatomic region of the spine surgery. Multivariate analysis revealed that patients who did not return the HCAHPS survey were more likely to be black/African American (OR = 2.8, P < 0.001), have a higher American Society of Anesthesiologists score (OR 1.76, P < 0.001), and have had a major adverse event (OR = 1.66; P = 0.001), minor adverse event (OR = 2.50; P < 0.001), discharged to a destination other than home (OR = 2.16, P < 0.001), hospital readmission (OR = 2.58; P < 0.001), and a long hospital length of stay (OR = 1.28, P = 0.001). CONCLUSION: For spine surgery patients, patient characteristics and perioperative outcomes were found to be significantly associated with the nonresponder bias for HCAHPS surveys. Although the potential resultant bias in HCAHPS scores cannot be directly determined, this must be considered in interpreting the results of such satisfaction surveys given that less than one-third of patients actually completed this survey in the study population. LEVEL OF EVIDENCE: 3.

Admission NarxCare Narcotics Scores are not Associated With Adverse Surgical Outcomes or Self-reported Patient Satisfaction Following Elective Spine Surgery.

STUDY DESIGN: Retrospective cohort study OBJECTIVE.: The aim of this study was to investigate how elective spine surgery patient preoperative opioid use (as determined by admission NarxCare narcotics use scores) correlated with 30-day perioperative outcomes and postoperative patient satisfaction. SUMMARY OF BACKGROUND DATA: The effect of preoperative narcotics usage on postoperative outcomes and patient satisfaction following spine surgery has been of question. The NarxCare platform analyzes the patients' state Physician Drug Monitoring Program (PDMP) records to assign numerical scores that approximate a patient's overall opioid drug usage. METHODS: Elective spine surgery cases performed at a single institution between October 2017 and March 2018 were evaluated. NarxCare narcotics use scores at the time of admission were assessed. Patient characteristics, as well as 30-day adverse events, readmissions, reoperations, and mortality, were abstracted from the medical record. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data were also abstracted when available.Cases were binned based on the following ranges of admission NarxCare scores: 0, 1 to 99, 100 to 299, 300 to 499, and 500+. Multivariate logistic regressions were performed to compare the odds of having an adverse events, readmission, reoperation, and mortality between the different narcotics groups. One-way analysis of variance analyses were performed to compare HCAHPS survey response rates and HCAHPS survey results between the different narcotics score groups. RESULTS: In total, 346 patients met criteria for inclusion in the study (NarxScore 0: n = 74, 1-99: n = 58, 300-499: n = 117, and 500+: n = 21). Multivariate logistic regressions did not detect statistically significant differential odds of experiencing adverse events, readmission, reoperation, or mortality between the different groups of admissions narcotics scores. Analyses of variance did not detect statistically significant differences in HCAHPS survey response rates, total HCAHPS scores, or HCAHP subgroup scores between the different narcotics score groups. CONCLUSION: Although there are many reasons to address preoperative patient narcotic utilization, the present study did not detect perioperative outcome differences or patient satisfaction based on the narcotic use scores as stratified here. LEVEL OF EVIDENCE: 3.

Surgical Treatment of Septic Shoulders: A Comparison Between Arthrotomy and Arthroscopy.

PURPOSE: To compare the efficacy, as measured through the rate of reoperation, and rates of other 30-day perioperative complications between arthrotomy and arthroscopy for the treatment of septic native shoulders in a national patient population. METHODS: Patients who were diagnosed with septic arthritis in a native shoulder and underwent irrigation and debridement through arthrotomy or arthroscopy were identified in the 2005-2016 National Surgical Quality Improvement Program database. Patient preoperative characteristics were characterized. Rate of reoperation, a proxy used to measure treatment efficacy, and other perioperative complications were compared between the 2 procedures. RESULTS: In total, 100 patients undergoing shoulder arthrotomy and 155 patients undergoing shoulder arthroscopy for septic shoulder were identified. On univariate analysis, there were no statistically significant differences in patient preoperative characteristics, operative time (60 vs. 48 minutes, P = .290), length of stay (7.5 vs. 6.6 days, P = .267), or time to reoperation (8.9 vs. 7.2 days, P = .594) between the 2 surgical groups. On multivariate analysis controlling for patient characteristics, there were no statistically significant differences in risk of reoperation (relative risk [RR] = 1.914, 99% confidence interval [CI] = 0.730-5.016, P = .083), any adverse events (RR = 1.254, 99% CI = 0.860-1.831, P = .122), minor adverse events (RR = 1.304, 99% CI = 0.558-3.047, P = .421), serious adverse events (RR = 1.306, 99% CI = 0.842-2.025, P = .118), or readmission (RR = 0.999, 99% CI = 0.441-2.261, P = .998) comparing arthrotomy with arthroscopy. CONCLUSIONS: By demonstrating similar rates of reoperation, other postoperative complications, and 30-day readmissions, the current study suggests that arthrotomy and arthroscopic surgery have similar efficacy in treating septic shoulders. However, owing to the small sample size, there is still the possibility of a type II error. LEVEL OF EVIDENCE: Level III, therapeutic retrospective comparative study.

Assessment of Nonresearch Industry Payments to Otolaryngologists in 2014 and 2015.

Objective To characterize, describe, and compare nonresearch industry payments made to otolaryngologists in 2014 and 2015. Additionally, to describe industry payment variation within otolaryngology and among other surgical specialties. Study Design Retrospective cross-sectional database analysis. Setting Open Payments Database. Subjects and Methods Nonresearch payments made to US otolaryngologists were characterized and compared by payment amount, nature of payment, sponsor, and census region between 2014 and 2015. Payments in otolaryngology were compared with those in other surgical specialties. Results From 2014 to 2015, there was an increase in the number of compensated otolaryngologists (7903 vs 7946) and in the mean payment per compensated otolaryngologist ($1096 vs $1242), as well as a decrease in the median payment per compensated otolaryngologist ($169 vs $165, P = .274). Approximately 90% of total payments made in both years were attributed to food and beverage. Northeast census region otolaryngologists received the highest median payment in 2014 and 2015. Compared with other surgical specialists, otolaryngologists received the lowest mean payment in 2014 and 2015 and the second-lowest and lowest median payment in 2014 and 2015, respectively. Conclusion The increase in the mean payment and number of compensated otolaryngologists can be explained by normal annual variation, stronger industry-otolaryngologist relationships, or improved reporting; additional years of data and improved public awareness of the Sunshine Act will facilitate determining long-term trends. The large change in disparity between the mean and median from 2014 to 2015 suggests greater payment variation. Otolaryngologists continue to demonstrate limited industry ties when compared with other surgical specialists.