Injury patterns and risk factors for orthopaedic trauma from snowboarding and skiing: a national perspective.

PURPOSE: Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports. METHODS: The National Trauma Data Bank was queried for patients presenting to emergency departments due to injuries sustained from skiing and snowboarding during 2011 and 2012. Patient demographics, comorbidities, and injury patterns were tabulated and compared between skiing and snowboarding. Risk factors for increased injury severity score and lack of helmet use were identified using multivariate logistic regression. RESULTS: Of the 6055 patients identified, 55.2 % were skiers. Sixty-one percent had fractures. Lower extremity fractures were the most common injury and occurred more often in skiers (p < 0.001). Upper extremity fractures were more common in snowboarders, particularly distal radius fractures (p < 0.001). On multivariate analysis, increased injury severity was independently associated with age 18-29, 60-69, 70+, male sex, a positive blood test for alcohol, a positive blood test for an illegal substance, and wearing a helmet. Lack of helmet use was associated with age 18-29, 30-39, smoking, a positive drug test for an illegal substance, and snowboarding. CONCLUSIONS: Young adults, the elderly, and those using substances were shown to be at greater risk of increased injury severity and lack of helmet use. The results of this study can be used clinically to guide the initial assessment of these individuals following injury, as well as for targeting preventive measures and education. LEVEL OF EVIDENCE: Prognostic Level III.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data.

BACKGROUND: National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies. QUESTIONS/PURPOSES: (1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events? METHODS: Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with > 10% rate of missing data were removed from the regression; among variables with ≤ 10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database. RESULTS: Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists. CONCLUSIONS: Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled. CLINICAL RELEVANCE: Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Discharge to Inpatient Facilities After Total Hip Arthroplasty Is Associated With Increased Postdischarge Morbidity.

BACKGROUND: Discharge disposition accounts for significant variability in costs after elective total hip arthroplasty (THA). Therefore, institutions must evaluate the short-term clinical outcomes associated with postdischarge care options. The present study intends to characterize the associations between short-term morbidity after primary THA and discharge destination. METHODS: Primary elective unilateral THA cases performed for osteoarthritis were identified in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2014. Propensity scores were used to adjust for selection bias in discharge destination, based on demographics, obesity class, preoperative functional status, modified Charlson comorbidity index, American Society of Anesthesiologists (ASA) class, and the presence of predischarge complications. Propensity-adjusted multivariate logistic regressions were used to examine associations between discharge destination and postdischarge complications, controlling for selection bias based on observable patient characteristics. RESULTS: Among 54,837 THA cases included in the study, 40,576 (74%) were discharged home, and 14,261 (26%) were discharged to inpatient facilities. In multivariate propensity-adjusted analyses, patients discharged to continued inpatient care after THA were more likely to have septic complications (odds ratio, 2.34; 95% confidence interval, 1.58-3.45), urinary complications (1.51; 1.21-1.90), readmission (1.44; 1.29-1.59), wound complications (1.31; 1.09-1.57), and respiratory complications (1.93; 1.21-3.07). CONCLUSION: Discharge to continued inpatient care following THA is associated with increased odds of postdischarge morbidity and unplanned readmission, after propensity score adjustment for predischarge characteristics. Additional research is needed on the impact of devoting resources toward facilitating discharge to home after THA.

Is Outpatient Total Hip Arthroplasty Safe?

BACKGROUND: Safety data for outpatient total hip arthroplasty (THA) remains scarce. METHODS: The present study retrospectively reviews prospectively collected data from the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program Database. Patients who underwent THA were categorized by day of hospital discharge to be outpatient (length of stay [LOS] 0 days) or inpatient (LOS 1-5 days). Those with extended LOS beyond 5 days were excluded. To account for baseline nonrandom assignment between the study groups, propensity score matching was used. The propensity matched populations were then compared with multivariate Poisson regression to compare the relative risks of adverse events during the initial 30 postoperative days including readmission. RESULTS: A total of 63,844 THA patients were identified. Of these, 420 (0.66%) were performed as outpatients and 63,424 (99.34%) had LOS 1-5 days. Outpatients tended to be younger, male, and to have fewer comorbidities. After propensity score matching, outpatients had no difference in any of 18 adverse events evaluated other than blood transfusion, which was less for outpatients than those with a LOS of 1-5 days (3.69% vs 9.06%, P < .001). CONCLUSION: After adjusting for potential confounders using propensity score matching and multivariate logistic regression, patients undergoing outpatient THA were not at greater risk of 30 days adverse events or readmission than those that were performed as inpatient procedures. Based on the general health outcome measures assessed, this data supports the notion that outpatient THA can appropriately be considered in appropriately selected patients.

Which Pediatric Orthopaedic Procedures Have the Greatest Risk of Adverse Outcomes?

BACKGROUND: Quality improvement in orthopaedic surgery has received increasing attention; however, there is insufficient information available about the perioperative safety of many common pediatric orthopaedic procedures. This study aimed to characterize the incidence of adverse events in a national pediatric patient sample to understand the risk profiles of common pediatric orthopaedic procedures, and to identify patients and operations that are associated with increased rates of adverse outcomes. METHODS: A retrospective cohort study was conducted using the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Pediatric patients who underwent 29 different orthopaedic procedures were identified in the 2012 NSQIP Pediatric database. The occurrence of any adverse event, infection, return to the operating room, and readmission within 30 days, were reported for each procedure. Multivariate regression was then used to identify the association of patient and operative characteristics with the occurrence of each adverse outcome. RESULTS: A total of 8975 pediatric patients were identified. Supracondylar humerus fracture fixation was the most common procedure performed in this sample (2274 patients or 25.57% of all procedures), followed by posterior spinal fusion (1894 patients or 21.10% of all procedures). Adverse events occurred in 352 patients (3.92% of all patients). Four deaths were noted (0.04% of all patients), which only occurred in patients with nonidiopathic scoliosis undergoing spinal fusion. Infections occurred in 143 patients (1.59%), and 197 patients (2.19%) were readmitted within 30 days. Multiple patient characteristics and procedures were found to be associated with each adverse outcome studied. CONCLUSIONS: Spinal fusion, multiaxial external fixation, and fasciotomy were procedures associated with increased rates of adverse outcomes within 30 days. Patients with obesity, ASA class ≥3, and impaired cognitive status also had increased rates of adverse outcomes. The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlight areas for quality improvement. LEVEL OF EVIDENCE: Level III-Prognostic.

Injuries Associated with Subdural Hematoma: A Study of the National Trauma Data Bank.

Of 92030 patients with subdural hematoma (SDH) in the National Trauma Data Bank (NTDB), 55729 had fall mechanisms of injury (61%), while 36301 had other traumatic mechanisms (nonfall, 39%). For nonfall mechanisms, the three associated injuries with the highest incidence were: skull fractures (43.3%), rib/sternum injuries (25.0%), and thoracic organ injuries (24.0%). For fall mechanisms, the three associated injuries with the highest incidence were: skull fractures (19.0%), spinal injuries (7.1%), and upper extremity fractures (6.8%). Mortality was associated with age and most studied associated injuries (odds ratios ofup to 2.04). 'This study conveys an important clinical point: even though traditional teaching highlights the risk of noncontiguous spine fractures in patients with a known spine fracture, the risk of a noncontiguous spine fracture is higher when dealing with a patient with SDH. This is underscored by the fact that mortality is higher for SDH patients with other associated injuries.

How do Orthopaedic Devices Change After Their Initial FDA Premarket Approval?

BACKGROUND: The FDA approves novel, high-risk medical devices through the premarket approval (PMA) process based on clinical evidence supporting device safety and effectiveness. Devices subsequently may undergo postmarket modifications that are approved via one of several PMA supplement review tracks, usually without additional supporting clinical data. While orthopaedic devices cleared via the less rigorous 510(k) pathway have been studied previously, devices cleared through the PMA pathway and those receiving postmarket PMA supplements warrant further investigation. QUESTIONS/PURPOSES: We asked: What are (1) the types of original orthopaedic devices receiving FDA PMA approval, (2) the number and rate of postmarket device changes approved per device, (3) the types of PMA supplement review tracks used, (4) the types of device changes approved via the various review tracks, and (5) the number of device recalls and market withdrawals that have occurred for these devices? METHODS: All original PMA-approved orthopaedic devices between January 1982 and December 2014 were identified in the publically available FDA PMA database. The number of postmarket device changes approved, the PMA supplement review track used, the types of postmarket changes, and any FDA recalls for each device were assessed. RESULTS: Seventy original orthopaedic devices were approved via the FDA PMA pathway between 1982 and 2014. These devices included 34 peripheral joint implants or prostheses, 18 spinal implants or prostheses, and 18 other devices or materials. These devices underwent a median 6.5 postmarket changes during their lifespan or 1.0 changes per device-year (interquartile range, 0.4-1.9). The rate of new postmarket device changes approved per active device, increased from less than 0.5 device changes per year in 1983 to just fewer than three device changes per year in 2014, or an increase of 0.05 device changes per device per year in linear regression analysis (95% CI, 0.04-0.07). Among the 765 total postmarket changes, 172 (22%) altered device design or components. The majority of the design changes were reviewed via either the real-time review track (n = 98; 57%), intended for minor design changes, or the 180-day review track (n = 71; 41%), intended for major design changes. Finally, a total of 12 devices had FDA recalls at some point during their lifespan, two being for hip prostheses with high revision rates. CONCLUSIONS: Relatively few orthopaedic devices undergo the FDA PMA process before reaching the market. Orthopaedic surgeons should be aware that high-risk medical devices cleared via the FDA's PMA pathway do undergo considerable postmarket device modification after reaching the market, with potential for design "drift," ie, shifting away from the initially tested and approved device designs. CLINICAL RELEVANCE: As the ultimate end-users of these devices, orthopaedic surgeons should be aware that even among high-risk medical devices approved via the FDA's PMA pathway, considerable postmarket device modification occurs. Continued postmarket device monitoring will be essential to limit patient safety risks.

Variation in Resource Utilization for Patients With Hip and Pelvic Fractures Despite Equal Medicare Reimbursement.

BACKGROUND: Medicare currently reimburses hospitals for inpatient admissions with "bundled" payments based on patient Diagnosis-related Groups (DRGs) regardless of true hospital costs. At present, DRG 536 (fractures of the hip and pelvis) includes a broad spectrum of patients with orthopaedic trauma, likely with varying inpatient resource utilization. With the growing incidence of fractures in the elderly, inadequate reimbursements from Medicare for certain patients with DRG 536 may lead to growing financial strain on healthcare institutions caring for these patients with higher costs. QUESTIONS/PURPOSES: The purposes of the study were to determine whether (1) inpatient length of stay; (2) intensive care unit stay; and (3) ventilator time differ among subpopulations with Medicare DRG 536. METHODS: A total of 56,683 patients, 65 years or older, with fractures of the hip or pelvis were identified in the 2011 and 2012 National Trauma Data Bank. This clinical registry contains data on trauma cases from more than 900 participating trauma centers, allowing analysis of resource utilization in centers across the United States. Patients were grouped in the following subgroups: hip fractures (n = 35,119), nonoperative pelvic fractures (n = 15,506), acetabulum fractures, operative and nonoperative, (n = 7670), and operative pelvic fractures (n = 682). Total inpatient length of stay, intensive care unit (ICU) stay, and ventilator time were compared across groups using multivariate analysis that controlled for hospital factors. RESULTS: After controlling for patient and hospital factors, difference in inpatient length of stay was -0.2 days for patients with nonoperative pelvis fractures compared with inpatient length of stay for patients with hip fractures (95% CI, -0.4 to -0.1 days; p = 0.001); 1.7 days for patient with acetabulum fractures (95% CI, 1.4-1.9 days; p < 0.001); and 7.7 days for patients with operative pelvic fractures (95% CI, 7.0-8.4 days; p < 0.001). The difference in ICU length of stay for patients with nonoperative pelvis fractures was 0.8 days compared with ICU length of stay for patients with hip fractures (95% CI, 0.7-0.9 days; p < 0.001); 1.9 days for patients with acetabulum fractures (95% CI, 1.8-2.1 days; p < 0.001); and 6.3 days for patients with operative pelvic fractures (95% CI, 5.9-6.7 days; p < 0.001). The difference in mechanical ventilation time for patients with nonoperative fractures was 0.5 days compared with ventilation time for patients with hip fractures (95% CI, 0.4-0.6 days; p < 0.001); 1.1 days for patients with acetabulum fractures (95% CI, 1.0-1.2 days; p < 0.001); and 3.9 days for patients with operative fractures (95% CI, 2.5-3.2 days; p < 0.001). CONCLUSIONS: In our current multitiered trauma system, certain centers will see higher proportions of patients with acetabulum and operative pelvic fractures. Because hospitals are reimbursed equally for these subgroups of Medicare DRG 536, centers that care for a greater proportion of patients with more-complex pelvic trauma will experience lower financial margins per trauma patient, limiting their potential for growth and investment compared with competing institutions that may not routinely see patients with high-energy trauma. Because of this, we believe reevaluation of this Medicare Prospective Payment System DRG is warranted. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

How Much Do Adverse Event Rates Differ Between Primary and Revision Total Joint Arthroplasty?

BACKGROUND: It is not known which adverse events occur more commonly following revision than following primary total joint arthroplasty. METHODS: Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 2011 to 2013 as part of the America College of Surgeons National Surgical Quality Improvement Program were identified. Rates of adverse events were compared between patients undergoing primary and patients undergoing revision procedures with adjustments for demographic and comorbidity characteristics. RESULTS: In total, 48307 THA patients and 70605 TKA patients met inclusion criteria. Of the THA patients, 43247 (89.5%) underwent primary procedures, while 5060 (10.5%) underwent revision procedures. Of the TKA patients, 65694 (93.0%) underwent primary procedures, while 4911 (7.0%) underwent revision procedures. Patients undergoing revision procedures had higher rates of systemic sepsis (for THA, 0.3% vs 0.1%, adjusted relative risk [RR], 3.5; 95% confidence interval [CI], 1.7-7.0; P < .001; for TKA, 0.3% vs 0.1%, adjusted RR, 3.0; 95% CI, 1.7-5.2, P < .001), deep incisional surgical site infection (for THA, 1.3% vs 0.3%, adjusted RR, 4.3; 95% CI, 3.2-5.8, P < .001; for TKA, 0.7 vs 0.2%, RR, 4.0; 95% CI, 2.7-5.9, P < .001), and organ/space infection (for THA, 1.8% vs 0.2%, RR, 7.4; 95% CI, 5.4-10.0, P < .001; for TKA, 1.1% vs 0.1%, adjusted RR, 7.5; 95% CI, 5.4-10.6, P < .001). Patients undergoing revision procedures did not have higher rates of pulmonary embolism or deep vein thrombosis (P ≥ .05 for each). CONCLUSIONS: Public reporting of adverse events should be interpreted in the context of the differences between primary and revision procedures, and reimbursement systems should reflect the greater amount of postoperative care that patients undergoing revision procedures require.

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data.

BACKGROUND: Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments. QUESTIONS/PURPOSES: We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons? MATERIALS AND METHODS: We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual. RESULTS: A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34-619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons. CONCLUSIONS: Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings. LEVEL OF EVIDENCE: Level III, Economic and Decision Analysis.

Computer-Assisted Navigation Is Associated With Decreased Rates of Hardware-Related Revision After Instrumented Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To (1) define utilization trends for navigated instrumented posterior lumbar fusion (PLF), (2) compare reasons and rates of revision at 30-day, 60-day, 90-day, and 1-year follow-up, and (3) compare 90-day perioperative complications between navigated versus conventional instrumented PLF. METHODS: Patients who underwent navigated or conventional instrumented PLF were identified from the Humana insurance database using the PearlDiver Patient Records between 2007-2017. Usage of navigation was characterized. Patient demographics and operative characteristics (number of levels fused, interbody usage) were compared between the 2 treatment groups. Propensity score matching was done and comparisons were made for revision rates at different follow-up periods (categorized by reasons) and other 90-day perioperative complications. RESULTS: This study included 1,648 navigated and 23 429 conventional instrumented PLF. Navigated cases increased over the years studied to approximately 10% in 2017. Statistical analysis after propensity score matching revealed significantly lower rates of hardware-related revision at 90-day follow-up in the navigated cohort (0.49% versus 1.15%, P = .033). At 1-year follow-up, the navigated cohort continued to have significantly lower rates of hardware-related revision (1.70% versus 2.73%, P = .044) as well as all cause revision (2.67% versus 4.00%, P = .032). There were no statistical differences between the 2 cohorts in any of the 90-day perioperative complications studied, such as cellulitis and blood transfusion (P > .05 for all). CONCLUSIONS: These findings suggest that navigation is associated with reductions in hardware-related revisions after instrumented PLF. However, these results should be interpreted cautiously in the setting of potential confounding by other unmeasured variables.

Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study is to determine how often patients with degenerative cervical myelopathy (DCM) and initially treated with cervical steroid injections (CSI) and to determine whether these injections provide any benefit in delaying ultimate surgical treatment. METHODS: All patients with a new diagnosis of DCM, without previous cervical spine surgery or steroid injections, were identified in PearlDiver, a large insurance database. Steroid injection and surgery timing was identified using Current Procedural Terminology (CPT) codes. Multivariate logistic regression identified associations with surgical treatment. RESULTS: A total of 686 patients with DCM were identified. Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%). All patients underwent eventual surgical treatment. Median time from initial DCM diagnosis to surgery was 75.5 days (mean 351.6 days; standard deviation 544.9 days). Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections, OR = 1.44, P < .001) and at each examined time point through 5 years (OR = 2.01, P < .001). In multivariate analysis comparing injection types, none of the 3 injection types were associated with decreased odds of surgery within 1 month of diagnosis. CONCLUSIONS: While cervical steroid injections continue to be commonly performed in patients with DCM, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of DCM.

The Role of Vertebral Body Tethering in Treating Skeletally Immature Scoliosis.

This is a critical analysis of a study by Hoernschemeyer et al, "Anterior Vertebral Body Tethering for Adolescent Scoliosis with Growth Remaining: A Retrospective Review of 2 to 5-Year Postoperative Results" (J Bone Joint Surg Am, 2020;102[13]:1169-1176), that assessed the clinical and radiographic outcomes of vertebral body tethering (VBT) in the treatment of adolescent scoliosis. The authors demonstrated successful treatment in 74% of patients, based on radiographic outcomes and avoidance of subsequent posterior spinal fusion. Nearly a quarter of patients required revision surgery. Almost half suffered a broken tether, although the effects of such complications are not fully understood. The study provided valuable information for determining which patients are reasonable candidates for VBT and emphasizes several questions surrounding this novel technology that remain unanswered. This analysis discusses the study's strengths and weaknesses, suggests potential directions of future research, and examines the potential indications for VBT.

Preoperative opioids before adult spinal deformity surgery associated with increased reoperations and high rates of chronic postoperative opioid use at 3-year follow-up.

PURPOSE: To determine the association of preoperative opioid prescriptions with reoperations and postoperative opioid prescriptions after adult spina deformity (ASD) surgery. With the current opioid crisis, patients undergoing surgery for ASD are at particular risk for opioid-related complications due to significant preoperative disability and surgical morbidity. No previous studies consider preoperative opioids in this population. METHODS: A retrospective cohort study of patients undergoing posterior spinal fusion (7 or more levels) for ASD was performed. All patients had at least 3 years of postoperative follow-up 3 years postoperatively. Prescriptions for 4 different opioid medications (hydromorphone, oxycodone, hydrocodone, and tramadol) were identified within 3 months preoperatively and up to 3 years postoperatively. Multivariate regression was utilized to determine the association of preoperative use with reoperations and with postoperative opioid use, controlling for both patient and surgery-related confounding factors. RESULTS: A total of 743 patients were identified and 59.6% (443) had opioid prescriptions within 3 months preoperatively. Postoperative opioid prescriptions were identified in 66.9% of patients at 12 months postoperatively, and in 54.8% at 36 months postoperatively. The 3-year reoperation rate was 11.0% in patients without preoperative prescriptions, 16.0% in patients with preoperative any opioid prescriptions (P = 0.07), and 34.8% in patients with preoperative hydromorphone prescriptions (P < 0.01). In multivariate analysis, preoperative opioid prescriptions were associated with increased reoperations (odds ratio [OR]: 1.62, P = 0.04), and chronic postoperative opioid use (OR: 4.40, P < 0.01). Preoperative hydromorphone prescriptions had the strongest association with both reoperations (OR: 4.96; P < 0.01) and chronic use (OR: 5.19: P = 0.03). CONCLUSION: In the ASD population, preoperative opioids are associated with both reoperations and chronic opioid use, with hydromorphone having the strongest association. Further investigation of the benefits of preoperative weaning programs is warranted.

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression. METHODS: A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance. RESULTS: A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant (P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant (P = .053). CONCLUSIONS: Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates.

STUDY DESIGN: Retrospective cohort comparison study. OBJECTIVE: The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA: Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF. MATERIALS AND METHODS: Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups. RESULTS: In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%). CONCLUSIONS: The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures. LEVEL OF EVIDENCE: Level III.

Reoperations after primary and revision lumbar discectomy: study of a national-level cohort with eight years follow-up.

BACKGROUND CONTEXT: Published rates for disc reherniation following primary discectomy are around 6%, but the ultimate reoperation outcomes in patients after receiving revision discectomy are not well understood. Additionally, any disparity in the outcomes of subsequent revision discectomy (SRD) versus subsequent lumbar fusion (SLF) following primary/revision discectomy remains poorly studied. PURPOSE: To determine the 8-year SRD/SLF rates and time until SRD/SLF after primary/revision discectomy respectively. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Patients undergoing primary or revision discectomy, with records in the PearlDiver Patient Records Database from the years 2010 to 2019. OUTCOME MEASURES: Subsequent surgery type and time to subsequent surgery. METHODS: Patients were grouped into primary or revision discectomy cohorts based off of the nature of "index" procedure (primary or revision discectomy) using ICD9/10 and CPT procedure codes from 2010 to 19 insurance data sets in the PearlDiver Patient Records Database. Preoperative demographic data was collected. Outcome measures such as subsequent surgery type (fusion or discectomy) and time to subsequent surgery were collected prospectively in PearlDiver Mariner database. Statistical analysis was performed using BellWeather statistical software. A Kaplan-Meier survival analysis of time to SLF/SRD was performed on each cohort, and log-rank test was used to compare the rates of SLF/SRD between cohorts. RESULTS: A total of 20,147 patients were identified (17,849 primary discectomy, 2,298 revision discectomy). The 8-year rates of SRD (6.1% in revision cohort, 4.8% in primary cohort, p<.01) and SLF (10.4% in revision cohort, 6.2% in primary cohort, p<.01) were higher after revision versus primary discectomy. Time to SLF was shorter after revision versus primary discectomy (709 vs. 886 days, p<.01). After both primary and revision discectomy, the 8-year rate of SLF (10.4% in revision cohort, 6.2% in primary cohort, p<.01) is greater than SRD (6.1% in revision cohort, 4.8% in primary cohort, p<.01). CONCLUSIONS: Compared to primary discectomy, revision discectomy has higher rates of SLF (10.4% vs. 6.2%), and faster time to SLF (2.4 vs. 1.9 years) at 8-year follow up.

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion?

BACKGROUND CONTEXT: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown. PURPOSE: To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology STUDY DESIGN/SETTING: Retrospective Cohort Study PATIENT SAMPLE: Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage OUTCOME MEASURES: Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF) METHODS: Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT. RESULTS: A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p = .017) and SF-12 PCS (41.5 vs. 50.0, p = .035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24). CONCLUSIONS: While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful.

Minimally Invasive Lumbar Decompression Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion for Treatment of Low-Grade Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: A retrospective cohort comparison study. OBJECTIVE: To compare perioperative outcomes, radiographic parameters, and patient-reported outcome measures (PROMs) between minimally invasive unilateral laminotomy with bilateral decompression (MIS-ULBD) versus MIS transforaminal lumbar interbody fusion (MIS-TLIF) for treatment of low-grade lumbar degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: While lumbar degenerative spondylolisthesis is a common condition, optimal surgical treatment remains controversial. Newer MIS techniques, which preserve bone, paraspinal musculature, and posterior midline stabilizers, are thought to reduce the risk of iatrogenic instability and may obviate the need for fusion. However, few comparative studies of MIS techniques for low-grade lumbar degenerative spondylolisthesis currently exist. MATERIALS AND METHODS: Consecutive patients with low-grade (Meyerding grade I or II) lumbar degenerative spondylolisthesis treated with single-level MIS-ULBD or MIS-TLIF were identified retrospectively from a prospectively collected spine surgery registry from April 2017 to November 2021. Perioperative outcomes, radiographic data, and PROMs were assessed. RESULTS: A total of 188 patients underwent either MIS-ULBD or MIS-TLIF (79 MIS-ULBD and 109 MIS-TLIF). Patients who underwent MIS-ULBD tended to be older, had higher Charlson Comorbidity Index, lower mean percentage back pain, higher percentage of L4/L5 pathology, shorter operative time, lower estimated blood loss, and lower postoperative pain ( P <0.05). In both groups, there were statistically significant improvements at one year for five of the six PROMs studied: Oswestry Disability Index (ODI), visual analog scale (VAS)-back pain, VAS-leg pain, Short Form 12 Physical Component Score (SF12-PCS), and Patient-Reported Outcomes Measurement Information System (PROMIS) ( P <0.05). On multivariate analysis controlling for confounders, there were no associations between procedure type and achieving minimal clinically important difference at one year in any of the PROMs studied. CONCLUSIONS: The current study suggests that both MIS-ULBD and MIS-TLIF result in significant improvements in pain and physical function for patients with low-grade lumbar degenerative spondylolisthesis. LEVEL OF EVIDENCES: 3.

Demographics and Medical Comorbidities as Risk Factors for Increased Episode of Care Costs Following Lumbar Fusion in Medicare Patients.

The objective was to evaluate medical comorbidities and surgical variables as independent risk factors for increased health care costs in Medicare patients undergoing lumbar fusion. Care episodes limited to lumbar fusions were retrospectively reviewed on the Centers of Medicare and Medicaid Innovation (CMMI) Bundled Payment for Care Improvement (BPCI) reimbursement database at a single academic institution. Total episode of care cost was also collected. A multivariable linear regression model was developed to identify independent risk factors for increased total episode of care cost, and logistic models for surgical complications and readmission. A total of 500 Medicare patients were included. Risk factors associated with increased total episode of care cost included transforaminal interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) (ß = $5,399, P < 0.001) and ALIF+PLF (AP) fusions (ß = $24,488, P < 0.001), levels fused (ß = $3,989, P < 0.001), congestive heart failure (ß = $6,161, P = 0.022), hypertension with end-organ damage (ß = $10,138, P < 0.001), liver disease (ß = $16,682, P < 0.001), inpatient complications (ß = $4,548, P = 0.001), 90-day complications (ß = $10,012, P = 0.001), and 90-day readmissions (ß = $15,677, P < 0.001). The most common surgical complication was postoperative anemia, which was associated with significantly increased costs (ß = $18,478, P < 0.001). Female sex (OR = 2.27, P = 0.001), AP fusion (OR = 2.59, P = 0.002), levels fused (OR = 1.45, P = 0.005), cerebrovascular disease (OR = 4.19, P = 0.003), cardiac arrhythmias (OR = 2.32, P = 0.002), and fluid electrolyte disorders (OR = 4.24, P = 0.002) were independent predictors of surgical complications. Body mass index (OR = 1.07, P = 0.029) and AP fusions (OR = 2.87, P = 0.049) were independent predictors of surgical readmission. Among medical comorbidities, congestive heart failure, hypertension with end-organ damage, and liver disease were independently associated with a significant increase in total episode of care cost. Interbody devices were associated with increased admission cost.