Stable Clinical and Radiological Outcomes at Medium and over 5 Year Follow Up of Calcaneus Fracture Open Reduction Internal Fixation Using a Sinus Tarsi Approach.

The sinus tarsi approach is increasingly growing in popularity for open reduction internal fixation of calcaneus fractures. Multiple studies have demonstrated favorable short-term results compared to the traditional extensile L incision, however long-term data over 5 years is currently limited to a single retrospective case series. Following local ethical approval, all patients who had completed a minimum 5 years from time of operation were contacted with a Standardized Telephone Questionnaire completed. This followed a previous retrospective chart review, with follow up telephone or clinic consultation performed by Davey et al. of this cohort at mean 35 months. Thirty-four fractures (31 patients) completed minimum 5 year follow up from the eligible group of 54 fractures (49 patients). Regarding functional outcomes, a significant improvement in mean Maryland Foot Score was observed between short- (mean 35.8 months) and medium-term (mean 81.9 months) of 77.6 (SD 15.0) to 86 (SD 7.9) (p = .0082). There was no significant difference in postoperative and long term radiographic Bohler's angle (p = .9683). Eleven feet (32%) proceeded to require reoperation, with removal of metal performed in 10 (29%), fusion in 2 (6%), and skin grafting following wound breakdown for 1 (3%). Four feet (12.9%) experienced post operative wound complications, including 3 (9.68%) cases of infection and 2 (6.45%) of delayed wound healing. This study demonstrated stable clinical and radiographic outcomes over 5 years following Calcaneus Fracture Open Reduction Internal Fixation using a sinus tarsi approach, supporting its continued usage when treating intraarticular calcaneus fractures for which operative intervention is indicated.

Clinical Trial Outcomes in Urology: Assessing Early Discontinuation, Results Reporting and Publication in ClinicalTrials.Gov Registrations 2007-2019.

PURPOSE: Clinical trials require significant resources, but benefits are only realized after trial completion and dissemination of results. We comprehensively assessed early discontinuation, registry results reporting, and publication by trial sponsor and subspecialty in urology trials. MATERIALS AND METHODS: We assessed trial registrations from 2007 to 2019 on ClinicalTrials.gov and publication data from PubMed®/MEDLINE®. Associations between sponsor or subspecialty with early discontinuation were assessed using Cox proportional hazards and results reporting or publication with logistic regression at 3 years after completion. RESULTS: Of 8,636 trials 3,541 (41.0%) were completed and 999 (11.6%) were discontinued. Of completed trials 26.9% reported results and 21.6% were published. Sponsors included academic institutions (53.1%), industry (37.1%) and the U.S. government (9.8%). Academic-sponsored (adjusted HR 0.81, 95% CI 0.69-0.96, p=0.012) and government-sponsored trials (adjusted HR 0.62, 95% CI 0.49-0.78, p <0.001) were less likely than industry to discontinue early. Government-sponsored trials were more likely to report (adjusted OR 1.72, 95% CI 1.17-2.54, p=0.006) and publish (adjusted OR 1.89, 95% CI 1.23-2.89, p=0.004). Academic-sponsored trials were less likely to report (adjusted OR 0.65, CI:0.48-0.88, p=0.006) but more likely to publish (adjusted OR 1.72, 95% CI 1.25-2.37, p <0.001). These outcomes were similar across subspecialties. However, endourology was more likely to discontinue early (adjusted HR 2.00, 95% CI 1.53-2.95, p <0.001), general urology was more likely to report results (adjusted OR 1.54, 95% CI 1.13-2.11, p=0.006) and andrology was less likely to publish (adjusted OR 0.53, 95% CI 0.35-0.81, p=0.003). CONCLUSIONS: Sponsor type is significantly associated with trial completion and dissemination. Government-sponsored trials had the best performance, while industry and academic-sponsored trials lagged in completion and results reporting, respectively. Subspecialty played a lesser role. Lack of dissemination remains a problem for urology trials.

Simultaneous bilateral total hip arthroplasty-a survey of Irish orthopaedic surgeons' practice.

BACKGROUND: Bilateral total hip arthroplasty may be performed simultaneously (SIMTHA) or in two staged operations. AIM: To assess attitudes towards and utilization of SIMTHA in Irish orthopaedic practice, and to assess patient and surgeon factors which are associated with the management of bilateral hip arthritis. METHODS: A 16-question electronic survey (Google Forms) was distributed via email to consultant Irish orthopaedic surgeons who perform total hip arthroplasty, followed by a reminder 1 month later. A p value < 0.05 was considered significant. RESULTS: There were 53 responses from arthroplasty surgeons, with 28% reporting they never perform SIMTHA, 26% have performed ≤ 5 SIMTHA, and 46% do ≥ 1 SIMTHA per year. Amongst the 15 surgeons who do not do SIMTHA, 60% reported a preference for staged arthroplasty, 20% felt it was not feasible in their institution, and a third reported a lack of experience with SIMTHA. There was a significant association between not performing SIMTHA and years of consultant experience (p = 0.002). There were no institutional guidelines on eligibility criteria for SIMTHA. The most common time interval for staged bilateral arthroplasty was 6-12 weeks (60%). Overall, 56% of surgeons felt SIMTHA is underutilised in the Irish healthcare system; this was associated with greater SIMTHA volume (p = 0.023). CONCLUSION: Half of the Irish arthroplasty surgeons report SIMTHA is a regular aspect of their practice. Performing SIMTHA is associated with greater arthroplasty volume, more recent consultant appointments, and a perception that the operation is underutilised.

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty.

BACKGROUND: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. AIMS: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years. METHODS: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. RESULTS: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. CONCLUSIONS: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

Shoulder arthroplasty in the setting of previous stabilization surgery: a systematic review of matched case control studies at minimum 2 years follow-up.

Background: Anterior shoulder instability causes considerable patient morbidity and the volume of shoulder stabilization surgery being performed annually is rising. Despite stabilization surgery, instability arthropathy in the long-term may arise requiring consideration of shoulder arthroplasty. This study evaluated the outcomes of shoulder arthroplasty following previous stabilization surgery with their associated changes in bony anatomy or soft tissue structure. Methods: A systematic review was performed as per Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines to identify all studies reporting outcomes of shoulder arthroplasty in the setting of previous stabilization surgery. Studies of >10 patients with a minimum of 24 months follow-up were included. Results: Overall, 377 shoulder arthroplasties composed of 247 anatomical total shoulder arthroplasties (aTSAs), 102 reverse total shoulder arthroplasties (RTSAs), and 28 hemiarthroplasties (HAs) were reported across 14 included studies at mean age 55.4 years, with 203 compared to 451 control shoulders in 7 matched case-control studies. The mean interval from arthroplasty to stabilization procedure was 19.7 years, with 27.2% of patients having undergone multiple procedures and 39.5% bone transfer procedures. Improvements in patient outcomes were observed both for patients who had underwent aTSA or RTSA, with the American Shoulder and Elbow Surgeons score the most commonly used scoring system. Across matched studies comparing to control, large improvements in American Shoulder and Elbow Surgeons were seen for both aTSA and RTSA implants, 38.1-80.5 and 34.9-82.3, which compared to control groups 38.0-85.5 and 35.5-82.3, respectively. There were differences observed in complication profiles between aTSA and RTSA procedures, with lower revision rates in the short-term to medium-term for RTSA implants in present literature. A significantly higher rate of aTSA revision was observed compared to matched control patients undergoing aTSA for primary osteoarthritis without previous stabilization surgery, 9.4% (13/139) vs. 4.1% (11/269) (P = .044). Aseptic loosening posed a particular challenge in the aTSA group, with significantly higher rates of 5.0% (7/139 f = 54.6 months) compared to control 0.74% (2/269 f = 49.1 months, P = .0088). No significant difference in infection rate was observed between matched study and control groups, 1.5% vs. 2.2% (P = .76). Conclusion: Shoulder arthroplasty may improve functional outcomes for patients experiencing instability arthropathy with a history of stabilization surgery. Careful consideration of potential complications is warranted both in surgical planning and patient counselling given the altered anatomy and biomechanics, with significantly higher revision and loosening rates observed following aTSA compared to control.

Total Hip Arthroplasty in the Setting of Post-Traumatic Arthritis Following Acetabular Fracture: A Systematic Review.

Background: Acetabular fractures are frequently associated with post-traumatic arthritis (PTA), for which total hip arthroplasty (THA) has emerged as the established procedure. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival of delayed THA for patients with PTA following acetabular fracture. Methods: A systematic review was performed in December 2021 as per Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines to identify all studies reporting outcomes of delayed THA performed for PTA with a history of acetabular fracture. From an initial screen of 893 studies, 29 studies which met defined inclusion criteria including minimum 12 months of follow-up and minimum 10 THA were included in the final review. Results: A total of 1220 THA were reported across 29 studies, with 1174 THA completing a minimum of 1-year follow-up at a mean of 86 months. All 29 studies reported upon complications, with a control included in 6 for comparison. Higher complication rates were observed both in patients who had prior open reduction internal fixation and conservative treatment, most notably infection which was observed following 3.6% THA. The total joint revision rate was 9.7%. An improvement was noted in all 25 studies which recorded patient-reported outcomes, with a mean rise in the Harris hip score from 45 to 86 across 18 studies. Conclusions: THA may reduce reported pain levels and improve functional outcomes in selected patients experiencing PTA following acetabular fractures. There is an increased risk of complications, necessitating careful consideration when planning the operation and open discussion with prospective patients and caregivers.

Total Hip Arthroplasty in Patients With Neurological Conditions: A Systematic Review.

Background: As operative techniques and implant design have evolved over time, total hip arthroplasty (THA) is increasingly being carried out for patients with neurological impairment. This patient group places unique surgical challenges to the arthroplasty surgeon, which may include contractures, instability, and altered muscular tone. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival following THA for patients with neurological conditions affecting the hip. Thus, we aim to support orthopaedic surgeon decision-making when considering and planning THA for these patients. Methods: A systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed/Medline OVID, Cochrane, and Embase databases. All studies reporting the outcomes of THA in the neurological population which met defined inclusion criteria were included. Results: From an initial screen of 1820 studies, 45 studies with a total of 36,251 THAs were included in the final selection. All 45 studies reported complication rates, with controls included in 16 for comparison. High complication rates were observed following THA in the neurologically impaired population, most notably dislocation with observed rates up to 10.6%. An improvement was noted in all 36 studies (1811 THAs) which reported upon patient-reported outcomes. Conclusions: THA may be beneficial in the selected patients with neurological conditions, to reduce pain and improve function. There is an increased risk of complications which require careful consideration when planning the operation and open discussion with prospective patients and caregivers before proceeding with surgery.

Increasing hip fracture volume following repeated lockdowns: an Irish multicentre study of periods pre-Covid, during Covid lockdown and following vaccination.

BACKGROUND: Older age groups were identified as a high-risk cohort for Covid-19 and thus were a focus of lockdown measures enacted internationally. Resultant decreased social mobility and physical activity levels are associated with sarcopenia, which may lead to increased risk of hip fracture upon resuming social integration and physical activities after easing of lockdown restrictions. AIMS: Our aim was to compare the incidence of hip fractures during the period following vaccination with subsequent relaxation of restrictions, to those prior to and during the Covid pandemic. METHODS: A multicentre retrospective cohort study was performed consisting of all patients presenting with a "hip" fracture to 3 regional trauma units over the relevant time periods in 2019, 2020 and 2021. Tallaght, Galway and Waterford University Hospitals are large academic teaching hospitals with a combined mixed urban and rural catchment of over 1 million people. FINDINGS: Four-hundred-fourteen patients in total were included in the final analysis, with 133 eligible hip fractures observed proceeding to operative treatment across the study period in 2019, 132 in 2020 and 149 in 2021, representing a 12.88% increase. Demographic data revealed similar patient cohorts with respect to age and gender, fracture pattern and treatment. CONCLUSIONS: An increase in hip fracture volume was observed during the period post vaccination with subsequent relaxation of restrictions and increased social mobility, compared to those prior to and during the Covid pandemic. These findings have implications for hospital planning and orthopaedic resourcing as we navigate our way forward past the Covid-19 Pandemic.

Surgical Site Infection in the Intensive Care Setting After Posterior Spinal Fusion: A Case Series Highlighting the Microbial Profile, Risk Factors, and the Importance of Comorbid Disease Burden.

BACKGROUND: Most posterior spinal fusion (PSF) patients do not require admission to an intensive care unit (ICU), and those who do may represent an underinvestigated, high-risk subpopulation. OBJECTIVE: To identify the microbial profile of and risk factors for surgical site infection (SSI) in PSF patients admitted to the ICU postoperatively. METHODS: We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015 and collected demographic, clinical, and procedural data. Comorbid disease burden was quantified using the Charlson Comorbidity Index (CCI). We performed multivariable logistic regression to identify risk factors for SSI, readmission, and reoperation. RESULTS: Anemia, more levels fused, cervical surgery, and cerebrospinal fluid leak were positively associated with ICU admission, and minimally invasive surgery was negatively associated. The median time to infection was equivalent for ICU patients and non-ICU patients, and microbial culture results were similar between groups. Higher CCI and undergoing a staged procedure were associated with readmission, reoperation, and SSI. When stratified by CCI into quintiles, SSI rates show a strong linear correlation with CCI ( P = .0171, R = 0.941), with a 3-fold higher odds of SSI in the highest risk group than the lowest (odds ratio = 3.15 [1.19, 8.07], P = .032). CONCLUSION: Procedural characteristics drive the decision to admit to the ICU postoperatively. Patients admitted to the ICU have higher rates of SSI but no difference in the timing of or microorganisms that lead to those infections. Comorbid disease burden drives SSI in this population, with a 3-fold greater odds of SSI for high-risk patients than low-risk patients.

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative.

Background Clear, accurate written documentation plays an important role in the handover of medical information, helping to improve care efficiency and avoid medical errors. Both HSE and the Irish National Orthopaedic Models of Care guidelines include key documentation standards for admission notes. Standardised medical admission proforma can help improve documentation standards, but their usage across Irish orthopaedic units is limited to three centres. We evaluated whether an admission proforma improved the documentation standards of acute orthopaedic trauma admission notes within our regional trauma unit. Methods Cycle 1 consisted of a retrospective review of 50 consecutive acute orthopaedic trauma admissions. Exclusion criteria included planned admissions, age <16 years, spinal or pelvic trauma, and 'hip' fractures for whom an existing proforma was in use. Cycle 2 consisted of a prospective review of 50 consecutive acute trauma admissions using the new proforma. Each cycle was scored against a pre-determined checklist incorporating Irish Health Service Executive and Orthopaedic Models of Care documentation standards, with results collated and statistical analysis then performed using Fisher's exact test. Findings Significant improvements in admission note compliance with national documentation were observed. This encompassed multiple domains including clinical identification, e.g., consultant identification (78% to 100% p=0.0005), clinical history, time of injury (72% to 100% p=0.0001), medical history, smoking status (86% to 100% p=0.0001), and patient assessment, vital signs (28% to 70% p=0.0001). Conclusion Improvements in admission note compliance with national documentation standards followed the introduction of a standardised proforma. These findings may encourage the introduction of similar proforma in other units, with potential benefits in patient care.

Virtual fracture clinic reduces patient X-ray volume for common wrist and ankle fractures.

BACKGROUND: Virtual fracture clinics (VFC) have been widely adopted worldwide as part of the changes in healthcare delivery during the COVID-19 pandemic. They have been shown to be a safe and effective method of delivering trauma care for injuries which do not require immediate intervention or specialist management, whilst maintaining high levels of patient satisfaction. AIMS: Our aim was to evaluate whether VFCs reduce the volume of X-rays performed for common fractures of the wrist and ankle. METHODS: A retrospective cohort review was performed. The pre-VFC group consisted of 168 wrist and 108 ankle referrals from March to September 2019. The VFC group included 75 wrist and 68 ankle referrals, during the period March to September 2020. The total number of X-ray images, carried out within a 3-month period for each fracture was summated, with statistical analysis performed following fracture pattern classification. FINDINGS: A statistically significant decrease in mean X-rays was observed for isolated stable fracture patterns, such as non-displaced distal radius, - 0.976 (p = 0.00025), and Weber A ankle fractures, - 0.907 (p = 0.000013). A reduction was also observed for more complex fracture patterns such as dorsally displaced distal radius, - 0.701 (p = 0.129) and Weber B ankle fractures, - 0.786 (p = 0.235), though not achieving statistical significance. CONCLUSIONS: Virtual fracture clinics can reduce X-ray frequency for common stable wrist and ankle fractures, with resultant benefits for both patients and healthcare systems. These benefits may be sustained in patient care beyond the current COVID-19 pandemic.

Inflammatory bowel disease induces inflammatory and pre-neoplastic changes in the prostate.

BACKGROUND: Inflammatory bowel disease (IBD) has been implicated as a risk factor for prostate cancer, however, the mechanism of how IBD leads to prostate tumorigenesis is not known. Here, we investigated whether chronic intestinal inflammation leads to pro-inflammatory changes associated with tumorigenesis in the prostate. METHODS: Using clinical samples of men with IBD who underwent prostatectomy, we analyzed whether prostate tumors had differences in lymphocyte infiltrate compared to non-IBD controls. In a mouse model of chemically-induced intestinal inflammation, we investigated whether chronic intestinal inflammation could be transferred to the wild-type mouse prostate. In addition, mouse prostates were evaluated for activation of pro-oncogenic signaling and genomic instability. RESULTS: A higher proportion of men with IBD had T and B lymphocyte infiltration within prostate tumors. Mice with chronic colitis showed significant increases in prostatic CD45 + leukocyte infiltration and elevation of three pro-inflammatory cytokines-TIMP-1, CCL5, and CXCL1 and activation of AKT and NF-kB signaling pathways. Lastly, mice with chronic colitis had greater prostatic oxidative stress/DNA damage, and prostate epithelial cells had undergone cell cycle arrest. CONCLUSIONS: These data suggest chronic intestinal inflammation is associated with an inflammatory-rich, pro-tumorigenic prostatic phenotype which may explain how gut inflammation fosters prostate cancer development in men with IBD.

Mode I and II Wear in Ceramic on Ceramic Total Hip Arthroplasty: A Case Report.

INTRODUCTION: Elective total hip arthroplasty (THA) is a common procedure and has been associated with favorable outcomes in both elderly and younger patients. A variety of implant and articular components exist so to allow surgeons to make a patient-specific choice with the intent of maximizing both patient outcomes and implant survival.The utilization of ceramic bearing surfaces during THA has become increasingly prevalent, with their tribological profile conveying favorable wear and osteolysis-resistant properties. Typically, ceramic articulating components are most susceptible to failure through brittle fracture or complications such as squeaking. CASE REPORT: This case describes a 68-year-old Caucasian male who underwent revision of ceramic on ceramic THA due to pain, with intraoperative analysis revealing evidence of gross Mode I acetabular ceramic component wear with a resultant Mode II wear articulation between the ceramic femoral head and acetabular liner. CONCLUSION: Wear between ceramic implants in THA is infrequently reported, and as such awareness of this uncommon phenomena as well as its potential causative factors is important when considering either primary or revision THA involving ceramic bearing components.

Informed Written Consent for Orthopaedic Trauma in the Emergency Setting at a Tertiary Referral Centre: A Closed-Loop Audit.

Introduction The purpose of this investigation was to perform an audit of the standards of consent forms in which patients sign prior to operative intervention for orthopaedic trauma in an emergency setting in our institution, with comparison to the 'Orthopaedic Surgical Consent' standards, as set by the American Association of Orthopaedic Surgeons (AAOS). If required, the investigator aimed to close the loop in this audit by educating orthopaedic surgeons on the necessary standards of obtaining written consent for orthopaedic trauma. Methods Following being granted approval by our institutional audit committee, a pre-intervention cycle was performed to assess the quality of consent obtained in written format using electronic patient records in consecutive patients over a four-week period. Following the analysis of this data, an education session was provided for all orthopaedic doctors responsible for obtaining informed written consent from patients who are planned to undergo operative management of a soft tissue or bony injury by the trauma and orthopaedic service in the emergency setting. Thereafter, a post-intervention cycle was performed with subsequent descriptive analysis using the GraphPad software. Results In the pre-intervention audit cycle, all included (n = 107) consent forms (100%) correctly included the patient's name, date of birth (DOB) and institutional board number (BN). However, only 79 consent forms (74.5%) were completed without using abbreviations or acronyms of any kind, whilst 81 consent forms (76.4%) were completed without correctly stating the side or site of the planned intervention. In the post-intervention cycle, all included (n = 40) consent forms (100%) correctly included the patient's name, DOB and institutional BN. Additionally, a total of 37 consent forms (92.5%) were correctly completed without using abbreviations or acronyms of any kind (74.5% versus 92.5%, p = 0.02). Furthermore, a total of 39 consent forms (97.5%) were completed correctly stating the side or site of the planned intervention (76.4% versus 97.5%, p = 0.0015). Conclusion This closed-loop audit found that the quality of informed consent obtained by orthopaedic surgeons in the emergency setting might potentially be significantly improved with at least one virtual education session. Such simple education sessions may potentially improve the documentation of the planned potential operative intervention by orthopaedic surgeons for cases of orthopaedic trauma to ensure patient safety is optimised. As the turnover of non-consultant hospital doctors is high in university teaching hospitals, regular education sessions on such topics may introduce a cultural shift in maintaining high standards when marking and consenting patients in the emergency setting.

Surgical Site Infection, Readmission, and Reoperation After Posterior Long Segment Fusion.

STUDY DESIGN: Retrospective case series. OBJECTIVE: We sought to identify risk factors associated with surgical site infection (SSI) after posterior long segment spinal fusion (PLSF). SUMMARY OF BACKGROUND DATA: Patients who undergo PLSF may be at elevated risk of SSI. Identifying factors associated with SSI in these operations can help risk stratify patients and tailor management. METHODS: We analyzed PLSFs-seven or more levels-at our institution from 2000 to 2015. Data on patients' clinical characteristics, procedural factors, and antimicrobial management were collected. Multivariable analysis identified factors independently associated with outcomes of interest. RESULTS: In 628 cases, SSI was associated with steroid use (P = 0.024, odds ratio [OR] = 2.54) and using cefazolin (P < 0.001, OR = 4.37) or bacitracin (P = 0.010, OR 3.49) irrigation, as opposed to gentamicin or other irrigation. Gram-positive infections were more likely with staged procedures (P = 0.021, OR 4.91) and bacitracin irrigation (P < 0.001, OR = 17.98), and less likely with vancomycin powder (P = 0.050, OR 0.20). Gram-negative infections were more likely with a history of peripheral arterial disease (P = 0.034, OR = 3.21) or cefazolin irrigation (P < 0.001, OR 25.47). Readmission was more likely after staged procedures (P = 0.003, OR = 3.31), cervical spine surgery (P = 0.023, OR = 2.28), or cefazolin irrigation (P = 0.039, OR = 1.85). Reoperation was more common with more comorbidities (P = 0.022, OR 1.09), staged procedures (P < 0.001, OR = 4.72), cervical surgeries (P = 0.013, OR = 2.36), more participants in the surgery (P = 0.011, OR = 1.06), using cefazolin (P < 0.001, OR = 3.12) or bacitracin (P = 0.009, OR = 3.15) irrigation, and higher erythrocyte sedimentation rate at readmission (P = 0.009, OR = 1.04). Washouts were more likely among patients with more comorbidities (P = 0.013, OR = 1.16), or who used steroids (P = 0.022, OR = 2.92), and less likely after cervical surgery (P = 0.028, OR = 0.24). Instrumentation removal was more common with bacitracin irrigation (p = 0.013, OR = 31.76). CONCLUSION: Patient factors, whether a procedure is staged, and choice of antibiotic irrigation affect the risk of SSI and ensuing management required.Level of Evidence: 4.

Comparison of inpatient versus post-discharge venous thromboembolic events after spinal surgery: A single institution series of 6869 consecutive patients.

STUDY DESIGN: retrospective chart review. OBJECTIVE: We aimed to determine the perioperative risk factors that lead to inpatient or post-discharge venous thromboembolism (VTE) events after spinal surgery. SUMMARY OF BACKGROUND DATA: While many studies relate the risk factors in a post-surgical setting to the incidence of VTE, this study aims to separate these VTE into inpatient and post-discharge categories to examine timing and risk factors. METHODS: We analyzed 6869 patients from 2009 to 2015 using Current Procedural Technology codes from a single tertiary academic institution. Patients were stratified based on occurrence and setting of VTE then controlled for perioperative characteristics with exclusion criteria being patients undergoing minor spine surgeries or secondary procedures. RESULTS: In 170 VTE events, these factors were associated with increased risk for: Inpatient DVT only: IVC filter (OR 6.380 [3.414-11.924]), longer length of hospital stay (OR 1.083 [1.047-1.120]), a prior history of DVT (OR 3.640 [1.931-6.856]). Post-discharge DVT only: history of PE (OR 45.142 [6.785-300.351]), having a corpectomy (OR 26.670 [3.477-204.548]), and having an osteotomy (OR 18.877 [1.129-315.534]). Inpatient PE only: surgery >4 h (OR 30.820, p < 0.001), fracture (OR 6.913, p = 0.004), IVC filter (OR 3.135, p = 0.029). Post-discharge PE only: corpectomy (OR 541.271, p = 0.009), foraminotomy (OR 40.137, p = 0.013), EBL > 500cc (OR 2467.798, p = 0.002). Time to onset of VTE events was significantly longer for patients undergoing osteotomy (7.43 days) than for patients with fracture (4.28 days), which is consistent with our findings that fracture was an independent predictor of inpatient VTE, and osteotomy was an independent predictor of post-discharge VTE (p = 0.018). CONCLUSIONS: Time-to-VTE varies between types of surgeries. Some risk factors are independently associated with VTE at all times during the 30-day postoperative period, while other factors are only associated with either inpatient or post-discharge VTE. Those patients with high-risk features for post-discharge VTE merit increased study for thromboprophylaxis management.

Trends in national utilization of posterior lumbar fusion and 30-day reoperation and readmission rates from 2006-2016.

OBJECTIVE: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016. METHODS: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders. RESULTS: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients. CONCLUSION: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time.

Medicaid Expansion Did not Improve Time to Treatment for Young Patients With Metastatic Renal Cell Carcinoma.

INTRODUCTION: The absence of health insurance coverage has been associated with worse outcomes for patients with metastatic renal cell carcinoma (mRCC). Medicaid expansion in the United States was an important provision of the Affordable Care Act, which increased the number of low-income individuals eligible for Medicaid starting in January 2014 in several states. The effect of Medicaid expansion on access to healthcare for patients with mRCC is unknown. MATERIALS AND METHODS: We performed a retrospective cohort study of 6844 patients aged < 65 years with mRCC at diagnosis within the National Cancer Database. We compared the time to treatment and the rates of no insurance before (2012-2013) and after (2015-2016) expansion between patients living in states that had and had not expanded Medicaid using difference-in-difference (DID) analyses. DIDs were calculated using linear regression analysis with adjustment for sociodemographic covariates. RESULTS: The rate of no insurance did not change in the expansion states compared with the nonexpansion states (DID, -0.55%; 95% confidence interval, -3.32% to 2.21%; P = .7). The percentage of patients receiving treatment within 60 days of diagnosis had increased in the expansion states from 43% to 49% and in the nonexpansion states from 42% to 46% after expansion. No change was found in treatment within 60 days of diagnosis among all patients (DID, 2.81%; 95% confidence interval, -2.61% to 8.22%; P = .3). CONCLUSIONS: Medicaid expansion was not associated with improved healthcare access for patients with mRCC as reflected by timely treatment. Future work should assess the association between Medicaid expansion and oncologic outcomes.

Using artificial intelligence (AI) to predict postoperative surgical site infection: A retrospective cohort of 4046 posterior spinal fusions.

OBJECTIVES: Machine Learning and Artificial Intelligence (AI) are rapidly growing in capability and increasingly applied to model outcomes and complications within medicine. In spinal surgery, post-operative surgical site infections (SSIs) are a rare, yet morbid complication. This paper applied AI to predict SSIs after posterior spinal fusions. PATIENTS AND METHODS: 4046 posterior spinal fusions were identified at a single academic center. A Deep Neural Network DNN classification model was trained using 35 unique input variables The model was trained and tested using cross-validation, in which the data were randomly partitioned into training n = 3034 and testing n = 1012 datasets. Stepwise multivariate regression was further used to identify actual model weights based on predictions from our trained model. RESULTS: The overall rate of infection was 1.5 %. The mean area under the curve (AUC), representing the accuracy of the model, across all 300 iterations was 0.775 (95 % CI [0.767,0.782]) with a median AUC of 0.787. The positive predictive value (PPV), representing how well the model predicted SSI when a patient had SSI, over all predictions was 92.56 % with a negative predictive value (NPV), representing how well the model predicted absence of SSI when a patient did not have SSI, of 98.45 %. In analyzing relative model weights, the five highest weighted variables were Congestive Heart Failure, Chronic Pulmonary Failure, Hemiplegia/Paraplegia, Multilevel Fusion and Cerebrovascular Disease respectively. Notable factors that were protective against infection were ICU Admission, Increasing Charlson Comorbidity Score, Race (White), and being male. Minimally invasive surgery (MIS) was also determined to be mildly protective. CONCLUSION: Machine learning and artificial intelligence are relevant and impressive tools that should be employed in the clinical decision making for patients. The variables with the largest model weights were primarily comorbidity related with the exception of multilevel fusion. Further study is needed, however, in order to draw any definitive conclusions.