Utilizing a comprehensive machine learning approach to identify patients at high risk for extended length of stay following spinal deformity surgery in pediatric patients with early onset scoliosis.

PURPOSE: Early onset scoliosis (EOS) patient diversity makes outcome prediction challenging. Machine learning offers an innovative approach to analyze patient data and predict results, including LOS in pediatric spinal deformity surgery. METHODS: Children under 10 with EOS were chosen from the American College of Surgeon's NSQIP database. Extended LOS, defined as over 5 days, was predicted using feature selection and machine learning in Python. The best model, determined by the area under the curve (AUC), was optimized and used to create a risk calculator for prolonged LOS. RESULTS: The study included 1587 patients, mostly young (average age: 6.94 ± 2.58 years), with 33.1% experiencing prolonged LOS (n = 526). Most patients were female (59.2%, n = 940), with an average BMI of 17.0 ± 8.7. Factors influencing LOS were operative time, age, BMI, ASA class, levels operated on, etiology, nutritional support, pulmonary and neurologic comorbidities. The gradient boosting model performed best with a test accuracy of 0.723, AUC of 0.630, and a Brier score of 0.189, leading to a patient-specific risk calculator for prolonged LOS. CONCLUSIONS: Machine learning algorithms accurately predict extended LOS across a national patient cohort and characterize key preoperative drivers of increased LOS after PSIF in pediatric patients with EOS.

Pediatric Hip Dysplasia Surgery Outcomes by Pediatric Versus Nonpediatric Orthopedists.

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

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

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

Long-Term Patient Outcomes for Treatment of Difficult Osteochondral Lesions of the Talus with Particulated Juvenile Allograft Cartilage Implantation ± Calcaneal Autograft: A Cohort Study.

BACKGROUND: Osteochondral lesions of the talus (OCLT) are common injuries that can be difficult to treat. To date, long-term patient reported outcome measures (PROMs) of patients with particulated juvenile allograft cartilage implantation with or without calcaneal autograft have not been compared. METHODS: Thirteen patients with difficult to treat OCLTs underwent arthroscopic-assisted implantation of particulated juvenile allograft cartilage (DeNovo NT®) with or without autogenous calcaneal bone grafting by a single surgeon. Calcaneal bone graft use was determined by lesion size > 150 mm2 and/or deeper than 5 mm. Patients were evaluated using physical examination, patient interviews, and PROMs. RESULTS: When comparing patients in regards to calcaneal bone graft implantation, no difference in age, BMI, pre-operative PROMs, or follow-up was noted, however, calcaneal bone graft patients did have a significantly larger lesion size (188.5 ± 50.9 vs. 118.7 ± 29.4 mm2 respectively; p value = 0.027). VAS and FAAM ADL scores during final follow-up improvement did not significantly differ between cohorts. The FAAM Sports score improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.032). The AOFAS score improvement did not differ between cohorts (p value = 0.944), however, the SF-36 PCS improved significantly more for the DeNovo alone group compared to the bone graft cohort (p value = 0.038). No intraoperative/perioperative complications were observed with calcaneal bone grafting. CONCLUSION: While patients followed over the course of ~ 8 years after implantation of particulated juvenile allograft cartilage (DeNovo NT®) with/without autogenous calcaneal bone graft had positive post-operative PROMs, patients without calcaneal bone graft had significantly greater improvement in functional outcome scores. Whether these differences are due to graft incorporation or larger lesion size is unclear. LEVEL OF EVIDENCE: III, retrospective cohort study.

Comparing pediatric femoral shaft fracture repair patient outcomes between pediatric and non-pediatric orthopedic surgeons.

INTRODUCTION: While pediatric femoral shaft fractures account for less than 2% of all fractures in children, they are the most common pediatric fracture requiring hospitalization. Management of pediatric femoral shaft fractures is challenging, with various treatment options relating to severity and patient age. The last few decades have seen an increased supply of pediatric orthopedic surgeons (POS) along with increased referral rates. However, there continues to be a maldistribution of POS throughout the country. This study sought to determine outcomes following femoral shaft fracture repair by POS compared to non-pediatric trained orthopedic surgeons. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried to identify pediatric patients who underwent open treatment of femoral shaft fracture from 2012 to 2019. Differences in patient demographics, comorbidities, and postoperative complications were assessed and compared between patients who were treated by pediatric subspecialty-trained orthopedic surgeons and those treated by non-pediatric orthopedic surgeons. Bivariate and multivariable regression analyses were utilized. RESULTS: Of the 5862 pediatric patients who underwent femoral shaft fracture treatment, 4875 (83.2%) had their surgeries performed by a POS whereas 987 (16.8%) were operated on by a non-pediatric surgeon. POS were more likely to operate on patients with a higher American Society of Anesthesiologists classification (p < 0.001) and those with medical comorbidities, including gastrointestinal (p = 0.022) and neurological (p < 0.001). After controlling for baseline patient characteristics on multivariable regression analysis, patients treated by non-pediatric orthopaedic surgeons are at an increased risk of prolonged hospital stay (OR 2.595; p < 0.001) when compared to patients operated on by POS. CONCLUSION: The results indicated that patients undergoing surgical treatment for a femoral shaft fracture by a non-pediatric trained orthopedic surgeon were at increased risk of a prolonged hospital stay compared to those being treated by POS. Additionally, POS were more likely to operate on more difficult patients with increased comorbidities.

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

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

Risks of chronic steroid or immunosuppressive therapy on total shoulder arthroplasty patients.

Introduction: Patients on chronic corticosteroids/immunosuppressants (SI) undergoing orthopaedic surgery are at an increased risk for surgical complications and worse outcomes. However, whether or not chronic preoperative SI use increases the risk for 30-day complications in patients undergoing primary total shoulder arthroplasty (SA) has yet to be explored. Methods: From 2006 to 2019, the National Surgical Quality Improvement Program (NSQIP) database was used to identify all patients who underwent primary SA (anatomic TSA and reverse TSA). Patients were stratified into two cohorts: chronic preoperative SI users and those without use. Bivariate and multivariate analyses were utilized in this study. Results: Of the 26,979 patients who underwent primary SA, 25,656 (95.1%) patients did not have SI usage whereas 1323 (4.9%) patients had chronic preoperative SI usage. Following adjustment on multivariate analyses, compared to the non-SI usage cohort, patients who used SI had an increased risk of urinary tract infections (UTIs) (OR 1.87; p = 0.009) and septic shock (OR 7.14; p = 0.002). There were no differences in mortality between the two cohorts (p = 0.058). Discussion and Conclusion: Chronic pre-operative SI use is an independent risk factor for septic shock and UTIs following primary SA. Surgeons and patients should be aware of these risks to better inform patient counseling and surgical decision making.

The Effect of Steroid Use on Complications after Distal Radius Fracture Repair.

Background Distal radius fractures (DRFs) are the most common fracture of the upper extremity. Given that steroids are one of the most commonly prescribed drugs and are usually prescribed for chronic conditions, steroid use represents a key factor to consider in how to optimize perioperative outcomes. Questions/Purposes The purpose of this study was to investigate if there are differences in perioperative outcomes for patients undergoing DRF open reduction and internal fixation based on preoperative steroid use. Patients and Methods Adult patients who underwent operative treatment for DRF from 2007 to 2018 were identified in a national database. Patients were divided into two cohorts as follows: (1) no steroid usage and (2) preoperative steroid usage. In this analysis, various postoperative complications, as well as extended length of stay and reoperation, were assessed. Bivariate analyses and multivariable logistical regression were performed. Results Among a total of 16,505 patients undergoing operative treatment for DRF, 16,145 patients (97.8%) did not have steroid usage and 360 (2.2%) had steroid usage. Following adjustment, an increased risk of extended length of hospital stay greater than 3 days (odds ratio [OR] = 1.646; p = 0.012) was seen in the steroid usage group compared with those who did not use steroids within 30 days of surgery. Conclusion Preoperative steroid use is associated with increased length of stay over 3 days after DRF open reduction and internal fixation surgery but is not associated with any of the other complications that were assessed in this study. Level of Evidence This is a Level III, retrospective study.

Risk Factors for 30-Day Unplanned Re-Operation in Pediatric Upper Extremity Surgery: A National Surgical Quality Improvement Program (NSQIP)-Pediatric Analysis.

Introduction The unplanned re-operation rate has been used as one marker of procedure quality in numerous surgical sub-fields. The purpose of this study was to determine independent risk factors for unplanned re-operations within 30 days following pediatric upper extremity surgery. Methods Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. The procedures included percutaneous fixation of supracondylar humerus fractures, open treatment of humeral condylar fractures, tendon sheath incision, repair of syndactyly, and reconstruction of polydactyly. Patients were categorized by those who had unplanned return to the operating room within 30 days and patients who did not. Patient demographics, clinical characteristics, and medical co-morbidities were evaluated for their association with re-operation using bivariate and multivariate analysis. Results A total of 27,536 pediatric patients underwent primary upper extremity surgeries; of these, 290 (1.1%) required an unplanned re-operation. After controlling for potential confounding variables on multivariable regression analysis, American Society of Anesthesiologists (ASA) class III-V (OR 15.89; p<0.001), inpatient procedure (OR 1.29; p=0.044), emergent/urgent triage (OR 3.75; p<0.001), longer operative time (OR 1.01; p<0.001), and prolonged hospital stay (OR 1.01; p=0.010) were independent predictors for re-operation. Conclusion This study demonstrates that the national rate of 30-day unplanned re-operation in pediatric upper extremity surgeries is low overall. The greatest risk factors for unplanned re-operation were ASA class III-V, inpatient setting, emergent/urgent triage, longer operative time, and prolonged hospital stay. This knowledge can help further improve patient outcomes through risk stratification and preoperative planning.

Forearm Pronation at Foot Contact: A Biomechanical Motion-Capture Analysis in High School and Professional Pitchers.

Background: It has previously been speculated that baseball pitchers who display excessive forearm pronation at foot contact (FC) have a higher propensity toward ulnar collateral ligament injury and subsequent surgery. Purpose: To evaluate the association between degree of forearm pronation/supination at FC and throwing arm kinetics in high school and professional pitchers, at both the individual (intrapitcher) and the group (interpitcher) level. Study Design: Descriptive laboratory study. Methods: High school (n = 41) and professional (n = 196) pitchers threw 8 to 12 fastballs while being assessed with a 3-dimensional motion-capture system (480 Hz). Pitchers at each playing level were divided into a supination or pronation subgroup depending on degree of forearm pronation at FC. Regression models were built to observe the relationship between forearm pronation at FC and kinetic and kinematic parameters of interest. Results: At both the individual and the group level of high school and professional pitchers, there was no significant correlation between forearm pronation at FC and elbow varus torque (P min = .21). For every 10° increase in forearm pronation at FC in the individual high school pitcher, elbow flexion at FC decreased by 5°, whereas maximum elbow extension velocity was achieved 0.6% later in the pitch. In addition, elbow medial force increased by 4.1 N and elbow varus torque increased by 0.8 N·m for every 10° increase in forearm supination at FC. For every 10° increase in forearm supination in the individual professional pitcher, ball velocity increased by 0.5 m/s, shoulder external rotation at FC decreased by 11°, and elbow medial force decreased by 5.5 N. Conclusion: Supination- or pronation-predominant forearm motion during the pitch did not significantly differ between playing levels. Excessive forearm pronation at FC was not a significant risk factor for increased throwing arm kinetics for high school or professional pitchers. There was a weak positive association between forearm supination at FC and elbow varus torque in the individual high school pitcher. Ultimately, coaches and pitchers may be better served by redirecting their focus to other mechanical aspects of the pitch that may have stronger associations with injury risk implications as well as performance.

Metabolic Syndrome: Is Arthroscopic Rotator Cuff Repair Safe in This Patient Population?

Purpose Metabolic syndrome is associated with postoperative morbidity and mortality in surgical patients. With the increased use of arthroscopic techniques for rotator cuff repair (RCR), it is important to identify the impact this disorder has on surgical patients. The purpose of this study is to evaluate the clinical impact of metabolic syndrome on outcomes following arthroscopic RCR. Methods The 2006-2019 National Surgical Quality Improvement Program database was queried for adult patients who underwent arthroscopic RCR. Two patient groups were categorized: patients with metabolic syndrome and patients without metabolic syndrome. Demographics, comorbidities, and 30-day postoperative outcomes were compared using bivariate and multivariate analyses. Results Of 40,156 patients undergoing arthroscopic RCR, 36,391 did not have metabolic syndrome and 3,765 had metabolic syndrome. After adjusting for differences in baseline characteristics between the two groups, those with metabolic syndrome had an increased risk of developing renal complications and cardiac complications, as well as requiring hospital admission postoperatively and hospital readmission. Conclusion Metabolic syndrome is an independent risk factor for developing renal and cardiac complications, as well as requiring overnight hospital admission and hospital readmission. Providers should understand the need for preoperative evaluation and surveillance of these patients following their surgery to minimize the risk of poor outcomes.

Preoperative Dehydration Increases the Risk of Extended Length of Hospital Stay Following Total Ankle Arthroplasty.

INTRODUCTION: The effects of preoperative dehydration on outcomes following total ankle arthroplasty (TAA) remain unknown. Therefore, the purpose of this study is to evaluate the association between dehydration and postoperative complications for patients undergoing TAA. METHODS: Patients undergoing TAA from 2007 to 2019 were identified in the National Surgical Quality Improvement Program (NSQIP) database. A preoperative serum blood urea nitrogen/creatinine (BUN/Cr) greater than 20 was used to define preoperative dehydration. Patients were stratified into 2 cohorts: patients who were dehydrated (BUN/Cr > 20) and patients without dehydration (BUN/Cr ≤ 20). In this analysis, various postoperative outcomes were assessed with bivariate and multivariate analyses. RESULTS: In total, 1033 patients underwent TAA and had their serum BUN and Cr values recorded. For both BUN and Cr, the patients in this study had their serum values recorded a mean of 15 days before their surgery. A total of 588 patients (56.9%) did not have dehydration preoperatively and 445 patients (43.1%) were dehydrated. Following adjustment on multivariate analysis, an increased risk of extended length of hospital stay (odds ratio [OR] = 1.457; p = 0.024) was seen in the dehydrated group compared with those who were noted to be well hydrated. CONCLUSION: As fluid intake is one modifiable preoperative variable that can be easily monitored during elective procedures, it is important for physicians to be aware of patients who are dehydrated and adjust their fluids appropriately to optimize postoperative outcomes. LEVELS OF EVIDENCE: Level III: Retrospective cohort study.

Risks of Immunosuppressive Therapy in Patients Undergoing Open Reduction Internal Fixation for Ankle Fractures.

Chronic steroid and immunosuppressant use have been shown to increase the risk for postoperative complications in orthopedic surgery. Further understanding of the risks of immunosuppression is necessary to aid in risk stratification and patient counseling. However, these risks have not yet been explored in ankle fracture patients. Thus, the purpose of this study is to determine whether patients taking immunosuppressives are at an increased risk for morbidity and mortality following open reduction and internal fixation (ORIF) of ankle fractures. Patients undergoing operative treatment for ankle fractures from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were categorized based on their use of immunosuppressive medications. Postoperative outcomes assessed included superficial surgical site infections, deep surgical site infections, organ space infections, wound dehiscence, pneumonia, unplanned intubation, pulmonary embolism, urinary tract infection, renal failure, blood transfusion requirement, deep vein thrombosis, sepsis, cardiac arrest, extended length of hospital stay, readmission, reoperation, and mortality. Univariate and multivariate analyses were performed. In total, 10,331 patients underwent operative treatment for ankle fracture. Total 10,153 patients (98.3%) were not taking immunosuppressants and 178 (1.7%) were taking these medications. In multivariate analysis, patients taking immunosuppressants were at increased risk of pulmonary embolism (odds ratio [OR] 4.382; p = .041) and hospital readmission (OR 2.131; p = .021). Use of immunosuppressive medications is an independent risk factor for pulmonary embolism and readmission following ORIF for ankle fractures. Notably, no association with wound complications, infections, or sepsis was identified.

Evaluating the association between race and complications following pediatric upper extremity surgery.

Race can influence perioperative care and outcomes in adult and pediatric orthopedic surgery. However, no prior study has evaluated any associations between race and complications following upper extremity surgery in pediatric patients. Thus, the purpose of this study was to evaluate whether there are any differences in risks for complications, readmission, or mortality following upper extremity surgery between African American and Caucasian pediatric patients. Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were categorized into two cohorts: patients who were Caucasian and patients who were African American. Differences in demographics, comorbidities, and postoperative complications were assessed and compared between the two-patient population using bivariate and multivariable regression analyses. Of the 25 848 pediatric patients who underwent upper extremity surgeries, 21 693 (83.9%) were Caucasian, and 4155 (16.1%) were African American. Compared to Caucasian patients, African American patients were more likely to have a higher American Society of Anesthesiologists classification ( P < 0.001), as well as pulmonary comorbidities ( P < 0.001) and hematologic disorders ( P = 0.004). Following adjustment on multivariable regression analysis to control for baseline characteristics, there were no differences in any postoperative complications between Caucasian and African American patients. In conclusion, African American pediatric patients are not at an increased risk for postoperative complications compared to Caucasian patients following upper extremity surgery. Race should not be used independently when evaluating patient risk for postoperative complications. Level of Evidence: III.

Racial disparities in readmission rates following surgical treatment of pediatric developmental dysplasia of the hip.

PURPOSE: Across orthopedic subspecialties, significant racial disparities have been identified with regard to postoperative outcomes. Despite these findings among adult patients, the literature assessing these disparities within pediatric orthopedics is limited. The purpose of this study was to determine the independent predictors for unplanned readmission following surgical treatment of developmental dysplasia of the hip. METHODS: Pediatric patients undergoing hip dysplasia surgery from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Two patient groups were defined: patients who had unplanned hospital readmission within 30 days of surgery and patients who were not readmitted. Clinical characteristics assessed included gender, race, and American Society of Anesthesiologists (ASA) class. Risk factors for complications were assessed using bivariate and multivariate analysis. RESULTS: Of 6561 pediatric patients undergoing surgical treatment for hip dysplasia, 540 (8.2%) had unplanned readmission. On bivariate analysis, non-white race (Black, Asian, Hispanic, American Indian, and Native Hawaiian), an ASA class of III, IV, or V, pulmonary, renal, neurological, and gastrointestinal comorbidities, as well as immune disease, steroid use, and nutritional support were significantly associated with unplanned readmission (p < 0.05 for all). After controlling for confounding variables on multivariate analysis, non-white race (OR 1.46; p = 0.042) and ASA class of III-V (OR 2.21; p = 0.002) were found to be independent predictors for readmission. CONCLUSION: Clinicians should be advised of the increased readmission rates observed in non-white patients and those of higher ASA scores. Further work is needed to combat existing disparities within pediatric orthopedics.

The association between anesthesia type and postoperative outcomes in patients receiving primary total shoulder arthroplasty.

PURPOSE: There has been interest to investigate optimal anesthetic techniques for primary total shoulder arthroplasty (TSA). In this study, we investigate if there are differences in postoperative complications in patients receiving (1) regional alone; (2) general alone; and (3) regional plus general anesthesia for primary TSA. METHODS: Patients undergoing primary TSA from 2014 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: general anesthesia, regional anesthesia, and general anesthesia combined with regional anesthesia. Thirty-day complications were assessed using bivariate and multivariate analyses. RESULTS: Of 13,386 total patients undergoing TSA, 9079 patients (67.8%) had general anesthesia, 212 (1.6%) had regional anesthesia, and 4095 (30.6%) had general anesthesia combined with regional anesthesia. There were no significant differences in postoperative complications between the general anesthesia group and the regional anesthesia group. Following adjustment, an increased risk of extended length of hospital stay was seen in the combined general and regional anesthesia group compared to those who only had general anesthesia (p = 0.001). CONCLUSION: General versus regional versus general plus regional anesthesia have no difference in postoperative complications in patients receiving primary total shoulder arthroplasty. However, addition of regional anesthesia to general anesthesia is associated with increased length of stay. LEVEL OF EVIDENCE: III.

The Effects of Chronic Steroid Use on Postoperative Complications Following Thyroidectomy.

BACKGROUND: Patients undergoing thyroidectomy are sometimes on chronic steroids for underlying disease. This study examined the postoperative risk profile of thyroidectomy patients on chronic steroids. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) database who underwent thyroidectomy were sorted by presence or absence of chronic steroid use. Clinicodemographics, comorbidities, and postoperative complications were recorded and compared between the two. Univariate and multivariate analyses compared the groups and calculated odds ratios (OR). RESULTS: We identified 42,857 patients. 41,903 (97.8%) patients were not on chronic steroids, while 954 (2.2%) were. Most underwent total thyroidectomy (18,748, 43.75%) or total lobectomy (16,323, 38.09%). Following univariate and multivariate analyses, patients on chronic steroids had increased risk of postoperative bleeding and transfusions (OR = 0.375, p = 0.046, 95% CI 0.223-0.988), open wound infection (OR = 0.226, p < 0.001, 95% CI 0.117-0.437), pulmonary embolism (OR = 0.312, p = 0.034, 95% CI 0.106-0.918), and ventilator use > 48 h (OR = 0.401, p < 0.008, 95% CI 0.205-0.785). CONCLUSIONS: Chronic steroid use prior to thyroidectomy is an independent risk factor for multiple postoperative complications, namely postoperative bleeding and transfusions, open wound infection, pulmonary embolism, and ventilator use over 48 h. Patients on chronic steroids should be medically optimized before thyroidectomy to reduce the risk of potentially life-threatening complications.

Mortality and morbidity following operative management of tibial shaft fractures in octogenarians.

PURPOSE: As the geriatric population continues to grow, the incidence of tibial shaft fractures in octogenarians is projected to increase. There is significant variation in the functional and physiologic status within the geriatric population. The purpose of this study is to compare the complications following operative treatment of tibial shaft fractures for patients who are 65- to79-year-old compared to patients who are 80- to 89-year-old. METHODS: Data were collected through the National Surgical Quality Improvement Program database for the years 2007-2018. All isolated tibial shaft fractures that were treated with open reduction internal fixation (ORIF) or intramedullary nail (IMN) were identified. Patients were divided into a 65- to 79-year-old group and an 80-to 89-year-old group. Primary and secondary outcomes were studied and included 30-day mortality. Univariate and multivariate analyses were performed with a significance set at p < 0.05. RESULTS: In total, 434 patients with tibial shaft fractures were included in the study. Of these, 333 were 65- to 79-year-old and 101 were 80- to 89-year-old (Table 1). On multivariate analysis, there was no significant difference in complication rates between the two cohorts. CONCLUSION: After controlling for demographics and comorbidities, age was not independently associated with 30-day mortality or any other peri-operative complications between patients aged 80 to 89 and patients aged 65 to 79 following operative management of tibial shaft fractures. In appropriately selected octogenarian patients, operative management of tibial shaft fractures represents a relatively safe treatment modality that may promote early rehabilitation.

Evaluating the association between pulmonary abnormalities and complications following pediatric hip dysplasia surgery.

PURPOSE: Developmental dysplasia of the hip (DDH) encompasses a wide range of abnormal hip development and is a common condition in the pediatric population. Congenital pulmonary abnormalities are typically mild in the pediatric population but can be associated with severe comorbid conditions. The purpose of this study was to analyze the effect of structural pulmonary/airway abnormalities on the incidence of postoperative complications following surgical management of DDH. METHODS: From 2012 to 2019, the National Surgical Quality Improvement Program-Pediatric database was utilized to identify pediatric patients undergoing surgical treatment for hip dysplasia. Patients were stratified into two groups: patients with a structural pulmonary/airway abnormality and patients without a pulmonary abnormality. Patient demographics, comorbidities, and postoperative complications were compared between the two cohorts with the use of various statistical analyses, including bivariate and multivariate analyses. RESULTS: Of the 10,853 patients who underwent surgical treatment for hip dysplasia, 10,157 patients (93.6%) did not have a structural pulmonary/airway abnormality whereas 696 (6.4%) had an airway abnormality. Following adjustment on multivariate analysis, patients with a structural pulmonary abnormality had an increased risk of cardiac arrest requiring cardiopulmonary resuscitation (OR 2.342; p = 0.045). CONCLUSION: The results indicated that patients with a structural pulmonary abnormality had an increased risk of cardiac arrest requiring cardiopulmonary resuscitation compared to those without a pulmonary abnormality. Ensuring appropriate preoperative evaluation with a multidisciplinary team and close monitoring postoperatively is important to prevent the risk of severe outcomes in this vulnerable patient population.

Extended length of stay in diabetic octogenarians following revision total hip arthroplasty.

PURPOSE: Past research has shown diabetic patients, including those of geriatric age, to be at an increased risk of postoperative complications following various surgeries, including revision total hip arthroplasty (rTHA). However, whether these risks are disproportionately greater in octogenarian patients has not been well investigated. This study aimed to determine whether diabetic octogenarians are at an increased risk of postoperative complications following rTHA. METHODS: The national surgical quality improvement program database was used to identify all diabetic patients who underwent rTHA from 2007 to 2018. Patients were divided into two groups: an aged 65 to 79 cohort and an aged 80 to 89 cohort. Patient demographics, comorbidities, and postoperative complications were assessed and compared between the two aged cohorts, with the utilization of bivariate and multivariate analyses. RESULTS: Of the 1184 diabetic patients who underwent rTHA, 906 (76.5%) patients were in the aged 65 to 79 cohort and 278 (23.5%) patients were in the aged 80 to 89 cohort. After adjusting for patient demographics and medical comorbidities, compared to patients in the aged 65 to 79 group, diabetic patients who were 80 to 89 years old were found to have an increased risk of extended length of hospital stay (OR 1.67; p = 0.017). CONCLUSION: Diabetic octogenarian patients have an increased risk for a prolonged hospital stay following rTHA relative to their younger diabetic geriatric counterparts. Orthopedic surgeons should be aware of these increased risks to properly educate diabetic octogenarians and assist in surgical management decision making in these patients considering rTHA.