Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample.

Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p = .015) and overall complications (56.8%, p < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.

Early complications of acromioclavicular joint reconstruction requiring reoperation.

PURPOSE: Prior studies have reported high complication rates with acromioclavicular joint reconstruction (ACJR). However, many of these reports have suffered from small sample sizes and inclusion of older surgical techniques. The purpose of this study was to determine the rates of early complications requiring reoperation in patients treated with ACJR. METHODS: From 2007 to 2011, patients who were treated with ACJR were identified using the PearlDiver database, a large insurance database in the USA. The following reoperations were then queried from this patient cohort: irrigation and debridement within 30 days of index surgery, manipulation under anaesthesia (MUA) of the shoulder joint within 3 months of index surgery, and revision ACJR, distal clavicle excision, and removal of hardware within 6 months of index surgery. RESULTS: In total, 2106 patients treated with ACJR were identified. The reoperation rates for irrigation and debridement, MUA, revision ACJR, distal clavicle excision, and removal of hardware were 2.6, 1.3, 4.2, 2.8, and 6.2 %, respectively. Patients ≥35 years of age and females more likely to undergo a reoperation after ACJR. Specifically, patients ≥35 years of age were more likely to undergo MUA and revision ACJR, while patients ≥50 years of age were more likely to undergo an irrigation and debridement. Females were more likely than males to undergo revision ACJR and distal clavicle excision. CONCLUSIONS: Older patients and females were more likely to experience postoperative complications requiring reoperations, including revision ACJR, distal clavicle excision, and irrigation and debridement. By analysing a large cohort of patients across multiple centres and providers, this study provides valuable insight into the recent complication profiles of ACJR, allowing surgeons to appropriately counsel patients on the risks of these procedures. LEVEL OF EVIDENCE: IV.

Preoperative Interventions and Charges in the 2-Year Period Before Unicompartmental Knee Arthroplasty: What Happens Before Surgery.

BACKGROUND: This study investigated preoperative interventions and their costs in the 2-year period before a patient undergoing a unicompartmental knee arthroplasty (UKA). METHODS: A retrospective cohort analysis of patients undergoing UKA between 2009 and 2011 was conducted using the PearlDiver Patient Record Database to track inpatient and outpatient billing records. RESULTS: One thousand eight hundred forty-one patients from Medicare and 4704 patients from United Healthcare underwent UKA between 2009 and 2011. In the 2 years before UKA, the per patient average charge was $3919.96 for Medicare patients and $5219.14 for United Healthcare patients, with 21.7% of Medicare-associated charges and 28.2% of United Healthcare-associated charges occurring within 3 months of surgery. In the 2-year period before surgery, 65.5% of Medicare patients and 53.6% of United Healthcare patients received an intra-articular injection, with 29.1% (Medicare) and 46.0% (United Healthcare) of these injections occurring within 3 months of surgery. In addition, 15.1% of Medicare patients and 20.7% of United Healthcare patients underwent an arthroscopy, with between 32.4% and 43.8% of these occurring in the final 6 months before UKA. CONCLUSION: Preoperative interventions (ie, imaging, procedures, physical therapy, and injections) occur at a high frequency in close proximity to UKA resulting in substantial costs. The development of algorithms to guide management of these patients is critical in reducing costs before UKA.

Trends analysis of rhBMP utilization in single-level posterior lumbar fusion (PLF) in the United States.

PURPOSE: A retrospective database review was carried out to evaluate the trends and demographics of rhBMP utilization in single-level posterior lumbar fusion (PLF) in the United States. METHODS: Patients who underwent single-level PLF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN, USA), a national database of orthopaedic insurance records. The year of procedure, age, gender, and region of the United States were recorded for each patient. Results were reported for each variable as the incidence of procedures identified per 100,000 patients searched in the database. RESULTS: Totally 5158 patients had single-level PLF in this study. The average rate of single-level PLF with rhBMP utilization maintained at a relatively stable level (19.1-23.5%) from 2005 to 2009, but sharply decreased to 6.8% in 2010 and 6.9% in 2011. The overall incidence of single-level PLF without rhBMP (1.37 cases per 100,000 patients) was more than five times of the incidence of single-level PLF with rhBMP (0.27 cases per 100,000 patients) (P < 0.01). The average rate of single-level PLF with rhBMP utilization is highest in Midwest (18.7%), followed by West (18.4%), South (16.4%) and Northeast (11.5%). The highest incidence of single-level PLF with rhBMP was observed in the group aged 70-74 years with an incidence of 0.33 per 100,000 patients. CONCLUSIONS: The incidence of rhBMP utilization in single-level PLF increased from 2006 to 2009, but dropped to a low level in 2010 and 2011. The Northeast region had the lowest incidence of rhBMP utilization. The group aged 70-74 years trended to have the higher incidence of single-level PLF with rhBMP utilization.

Kinetic magnetic resonance imaging analysis of lumbar segmental motion at levels adjacent to disc herniation.

PURPOSE: A retrospective radiographic study was carried out to analyze the effect of lumbar disc herniation on the kinetic motion of adjacent segments. METHODS: A total of 162 patients with low back pain or radicular pain in the lower limbs without a prior history of surgery were evaluated using kinetic magnetic resonance imaging. Translational motion, angular variation, and disc height were measured at each segment from L1-L2 to L5-S1. Other factors including the degree of disc degeneration, age, gender, and vertebral segment location were analyzed to determine any predisposing risk factors for segmental instability adjacent to disc herniations. RESULTS: Spinal levels above the disc herniation exhibited, on average, a 6.4 % increase in translational motion per mm of disc herniation (P = 0.496) and a 21.4 % increase in angular motion per mm herniation (P = 0.447). Levels below the herniation demonstrated a 5.2 % increase in translational motion per mm of disc herniation (P = 0.428) and a decrease of 10.7 % in angular motion per mm (P = 0.726). The degree of disc degeneration had no significant correlation with adjacent level motion. Similarly, disc herniation was not significantly correlated with disc height at adjacent levels, although there was a significant relationship between gender and adjacent segment disc height. CONCLUSIONS: Although disc height, translational motion, and angular variation are significantly affected at the level of a disc herniation, no significant changes are apparent in adjacent segments. Our results indicate that herniated discs have no effect on range of motion at adjacent levels regardless of the degree of disc degeneration or the size of disc herniation, suggesting that the natural progression of disc degeneration and adjacent segment disease may be separate, unrelated processes within the lumbar spine.

Trends associated with distal biceps tendon repair in the United States, 2007 to 2011.

BACKGROUND: Current studies investigating surgical treatment of distal biceps tendon tears largely consist of small, retrospective case series. The purpose of this study was to investigate the current patient demographics, surgical trends, and postoperative complication rates associated with operative treatment of distal biceps tendon tears using a large database of privately insured, non-Medicare patients. METHODS: Patients who underwent surgical intervention for distal biceps tendon tears from 2007 to 2011 were identified using the PearlDiver database. Demographic and surgical data as well as postoperative complications were reviewed. Statistical analysis was performed using linear regression analysis and χ(2) tests, with statistical significance set at P < .05. RESULTS: A total of 1443 patients underwent surgical treatment for distal biceps tendon tears. Men and patients aged 40 to 59 years accounted for 98% and 72% of the cohort, respectively. Regarding surgical technique, reinsertion to the radial tuberosity was preferred (95%) over tenodesis to the brachialis (5%) (P < .01). In total, revision surgery for tendon rerupture occurred in 5.4% of treated patients. The incidence of revision surgery for rerupture in acute and chronic distal biceps tears was 5.1% and 7.0%, respectively (P = .36). Postoperative infection and peripheral nerve injury rates were 1.1% and 0.6%, respectively. CONCLUSION: Surgeons strongly preferred anatomic reinsertion to the radial tuberosity for treatment, regardless of the chronicity of the injury. Postoperative complication rates were similar to those found in prior studies, although the true rate of rerupture may be higher than previously thought.

Preoperative Interventions and Charges Before Total Knee Arthroplasty.

BACKGROUND: The cost effectiveness of total knee arthroplasty (TKA) has been well established, but little data exist regarding preoperative interventions and their costs. The purpose of this study was to examine preoperative interventions and their associated charges within the 2-year period before TKA. METHODS: A retrospective cohort analysis of patients undergoing TKA between 2007 and 2011 was conducted using the PearlDiver Patient Record Database. Patients' inpatient and outpatient billing records were tracked over the 2-year period before receiving a TKA. RESULTS: A total of 35,596 patients from Medicare and 47,064 from United Healthcare underwent TKA from 2009 to 2011. In the 2-year period before TKA, the per patient average charge was $3545.82 for Medicare and $3281.57 for United Healthcare. In the 2-year period before TKA, 21.4% (Medicare) and 23.3% (United Healthcare) of all patients received a magnetic resonance imaging, with between 31.9% (Medicare) and 45.6% (United Healthcare) of these occurring within 3 months of surgery (P < .05). During this same period, 49.4% (Medicare) and 63.2% (United Healthcare) of all patients received an intra-articular injection, with between 29.4% (Medicare) and 44.8% (United Healthcare) of these occurring within 3 months of surgery (P < .05). CONCLUSION: Interventions and costs before TKA occur largely within 6 months preoperatively, with a substantial portion occurring within 3 months. These interventions may not be clinically or cost effective for certain patients, such as those with moderate-to-severe osteoarthritis. Foregoing these interventions and opting to perform TKA earlier may reduce costs and prevent unnecessary tests and procedures.

Demographic Trends and Complication Rates in Arthroscopic Elbow Surgery.

PURPOSE: To investigate demographic trends in elbow arthroscopy over time, as well as to query complication rates requiring reoperation associated with these procedures. METHODS: The Current Procedural Terminology (CPT) billing codes of patients undergoing elbow arthroscopy were searched using a national insurance database. From the years 2007 to 2011, over 20 million orthopaedic patient records were present in the database with an orthopaedic International Classification of Diseases, Ninth Revision diagnosis code or CPT code. Our search for procedures and the corresponding CPT codes for the elbow included diagnostic arthroscopy, loose body removal, synovectomy, and debridement. The type of procedure, date, gender, and region of the country were identified for each patient. In addition, the incidence of reoperation for infection, stiffness, and nerve injury was examined. RESULTS: There was a significant increase in arthroscopic elbow procedures over the study period. Male patients accounted for 71% of patients undergoing these procedures. Of the elbow arthroscopy patients, 22% were aged younger than 20 years, 25% were aged 20 to 39 years, 47% were aged 40 to 59 years, and 6% were aged 60 years or older. Other than synovectomy, there were regional variations in the incidence of each procedure type. The overall rate of reoperation was 2.2%, with specific rates of 0.26% for infection, 0.63% for stiffness, and 1.26% for nerve injury. It should be noted that because only the complications requiring reoperation are recorded in the database, these numbers are lower than the overall complication rate. CONCLUSIONS: Overall, the incidence of elbow arthroscopy in this patient population is relatively low and appears to be increasing slightly over time. In the database used in this study, elbow arthroscopy procedures were most commonly performed in male patients and in patients aged 40 to 59 years, with regional variation in the incidence of the different procedures. Furthermore, the rate of complications requiring reoperation was low, with a nerve operation being the most common reoperation performed. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Utilization and Costs of Postoperative Physical Therapy After Rotator Cuff Repair: A Comparison of Privately Insured and Medicare Patients.

PURPOSE: To evaluate the utilization and charges related to physical therapy (PT) after rotator cuff repair in privately insured and Medicare patients and between arthroscopic and open/mini-open repair techniques. METHODS: The PearlDiver insurance database was queried for patients receiving postoperative PT using Current Procedural Terminology codes. Data were available from 2007 to 2011 for United Healthcare and from 2005 to 2011 for Medicare patients. Patients undergoing arthroscopic (CPT 29827) or open/mini-open approaches (CPT 23410, 23412, 23420) were identified in both populations. Utilization was determined by both the percentage of patients with at least one postoperative PT-related code and the average number of encounters per patient. Per-patient average charge was determined by dividing total charges within the billing period by the patient total. RESULTS: A total of 365,891 patients undergoing rotator cuff repair were identified. There was an increase in the number of arthroscopic repairs (+29.1%, P = .027, United Healthcare; +78.9%, P < .001, Medicare) and a decrease in the number of open/mini-open repairs (-18.2%, P = .038, United Healthcare; -18.2%, P < .001, Medicare) across the study period. At 6 months postoperatively, PT utilization was greater in the United Healthcare groups (82.9% arthroscopic, 81.0% open/mini-open) than in the Medicare groups (41.8% arthroscopic, 43.2% open/mini-open). Utilization-weighted per-patient average charge was comparable among all 4 groups, with slightly higher charges in the United Healthcare groups ($3,376 arthroscopic, $3,251 open/mini-open) compared with the Medicare groups ($2,940 arthroscopic, $2,807 open/mini-open). The United Healthcare groups had a greater number of utilization-weighted billed encounters (36.1 for open/mini-open, 9.5 for arthroscopic) than their Medicare counterparts (12.8 open/mini-open, 16.7 arthroscopic). CONCLUSIONS: Utilization of PT after rotator cuff repair is substantially higher in privately insured than in Medicare patients. Utilization rates appear to be comparable between surgical approaches. Per-patient costs were comparable irrespective of surgical approach and insurance modality. LEVEL OF EVIDENCE: Level IV, economic.

Demographic trends in arthroscopic and open biceps tenodesis across the United States.

BACKGROUND: The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. METHODS: A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient's age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. RESULTS: There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P = .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P = .009; P = .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. CONCLUSION: Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes.

Operative versus nonoperative treatment of acute Achilles tendon rupture: An analysis of 12,570 patients in a large healthcare database.

BACKGROUND: The purpose of this study was to compare the latest patient demographics and rerupture rates of operative versus nonoperative treatment of acute Achilles tendon rupture in the United States. METHODS: Patients undergoing treatment of an acute Achilles tendon rupture from 2007 to 2011 were identified by cross-referencing ICD-9-CM and CPT codes through the PearlDiver Patient Record Database. RESULTS: In total, 12,570 patients were treated for an acute Achilles tendon rupture. The ratio of operative to nonoperative treatment increased from 1.41 to 1.65. Males were more likely to undergo surgery than females. There were no significant differences in short-term rerupture rate for operative (2.1%) versus nonoperative (2.4%) treatment. CONCLUSIONS: The proportion of patients who received operative treatment for an acute Achilles tendon rupture increased slightly during the 5 year period, suggesting that surgeons in the United States have been slower to adopt nonoperative treatment than their European counterparts.

What is the frequency of vascular injury after knee dislocation?

BACKGROUND: Vascular injury secondary to an acute knee dislocation is a known complication. However, there exist wide discrepancies in the reported rate of vascular injury in this setting. QUESTIONS/PURPOSES: Using a large private insurance database, we determined the frequency of vascular injury in knee dislocations across year of diagnosis, age, sex, and US geographic region and the proportion of these injuries requiring surgical repair. METHODS: The PearlDiver database, which contains records from 11 million orthopaedic patients, was searched using ICD-9 diagnostic codes for all knee dislocation events from 2004 to 2009. Within this subset, we identified which knee dislocations had an associated vascular injury ICD-9 code. Patients were stratified by year of diagnosis, age, sex, and US geographic region, and Current Procedural Terminology codes were used to identify the subset of patients with vascular injury requiring surgical repair. Differences in frequency across demographic groups and over time were analyzed with Poisson regression analysis. RESULTS: Among the 8050 limbs with knee dislocation identified over the study period, 267 had a concomitant vascular injury for an overall frequency of 3.3%. Males were found to have an increased risk of vascular injury compared to females (odds ratio = 2.59, p < 0.001). Additionally, patients aged 20 to 39 years had a higher risk of vascular injury when compared to those aged 0 to 19 years (odds ratio = 1.93, p = 0.001), 40 to 59 years (odds ratio = 1.57, p = 0.014), and 60 years or older (odds ratio = 2.81, p = 0.036). There were no differences in vascular injury frequency across US geographic regions or diagnosis year. Thirty-four of the 267 cases of vascular injury (13%) underwent surgical treatment. CONCLUSIONS: This is the largest study, to our knowledge, that analyzes the proportion of knee dislocations that result in vascular injury. Our data suggest that there is a lower frequency of vascular injury associated with knee dislocation and a lower proportion of vascular injuries undergoing surgical treatment than previously reported. These findings may support a more selective angiography protocol to screen for vascular injury, rather than performing this invasive diagnostic test on all knee dislocations, as has been done historically. Future large-scale and prospective studies should analyze factors that may predispose to vascular injuries after knee dislocation and determine which patients should be screened for vascular injury after knee dislocation. LEVEL OF EVIDENCE: Level IV, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

The role of tactile feedback in grip force during laparoscopic training tasks.

BACKGROUND: Laparoscopic minimally invasive surgery has revolutionized surgical care by reducing trauma to the patient, thereby decreasing the need for medication and shortening recovery times. During open procedures, surgeons can directly feel tissue characteristics. However, in laparoscopic surgery, tactile feedback during grip is attenuated and limited to the resistance felt in the tool handle. Excessive grip force during laparoscopic surgery can lead to tissue damage. Providing additional supplementary tactile feedback may allow subjects to have better control of grip force and identification of tissue characteristics, potentially decreasing the learning curve associated with complex minimally invasive techniques. METHODS: A tactile feedback system has been developed and integrated into a modified laparoscopic grasper that allows forces applied at the grasper tips to be felt by the surgeon's hands. In this study, 15 subjects (11 novices, 4 experts) were asked to perform single-handed peg transfers using these laparoscopic graspers in three trials (feedback OFF, ON, OFF). Peak and average grip forces (newtons) during each grip event were measured and compared using a Wilcoxon ranked test in which each subject served as his or her own control. RESULTS: After activating the tactile feedback system, the novice subject population showed significant decreases in grip force (p < 0.003). When the system was deactivated for the third trial, there were significant increases in grip force (p < 0.003). Expert subjects showed no significant improvements with the addition of tactile feedback (p > 0.05 in all cases). CONCLUSION: Supplementary tactile feedback helped novice subjects reduce grip force during the laparoscopic training task but did not offer improvements for the four expert subjects. This indicates that tactile feedback may be beneficial for laparoscopic training but has limited long-term use in the nonrobotic setting.

Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States.

BACKGROUND: Intraoperative neuromonitoring (ION), such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP), and electromyography (EMG), is used to detect impending neurological injuries during spinal surgery. To date, little is known about the trends in the use of ION for scoliosis surgery in the United States. METHODS: A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. RESULTS: There were 3618 patients who had scoliosis surgery during the study period. Intraoperative neuromonitoring was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (P < .0001). Multimodal ION was used more commonly than unimodal ION (64.6% versus 35.4%). The most commonly used modality was combined SSEP and EMG, while the least used modality was MEP only. Neurological injuries occurred in 1.8 and 2.0% of patients that had surgery with and without ION, respectively (P = .561). Intraoperative neuromonitoring was used most commonly in patients <65 years of age and in the Northeastern part of the United States (age P = .006, region P < .0001). CONCLUSIONS: The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in nonelderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.

Spine Degenerative Conditions and Their Treatments: National Trends in the United States of America.

STUDY DESIGN: Retrospective database study. OBJECTIVE: Low back and neck pain are among the top leading causes of disability worldwide. The aim of our study was to report the current trends on spine degenerative disorders and their treatments. METHODS: Patients diagnosed with lumbar or cervical spine conditions within the orthopedic subset of Medicare and Humana databases (PearlDiver). From the initial cohorts we identified subgroups based on the treatment: fusion or nonoperative within 1 year from diagnosis. Poisson regression was used to determine demographic differences in diagnosis and treatment approaches. RESULTS: Within the Medicare database there were 6 206 578 patients diagnosed with lumbar and 3 156 215 patients diagnosed with cervical degenerative conditions between 2006 and 2012, representing a 16.5% (lumbar) decrease and 11% (cervical) increase in the number of diagnosed patients. There was an increase of 18.5% in the incidence of fusion among lumbar patients. For the Humana data sets there were 1 160 495 patients diagnosed with lumbar and 660 721 patients diagnosed with cervical degenerative disorders from 2008 to 2014. There was a 33% (lumbar) and 42% (cervical) increases in the number of diagnosed patients. However, in both lumbar and cervical groups there was a decrease in the number of surgical and nonoperative treatments. CONCLUSIONS: There was an overall increase in both lumbar and cervical conditions, followed by an increase in lumbar fusion procedures within the Medicare database. There is still a burning need to optimize the spine care for the elderly and people in their prime work age to lessen the current national economic burden.

Trends Analysis of rhBMP2 Utilization in Single-Level Anterior Lumbar Interbody Fusion in the United States.

STUDY DESIGN: Retrospective case study. OBJECTIVE: To evaluate the trends and demographics of recombinant human bone morphogenetic protein 2 (rhBMP2) utilization in single-level anterior lumbar interbody fusion (ALIF) in the United States. METHODS: Patients who underwent single-level ALIF from 2005 to 2011 were identified by searching ICD-9 diagnosis and procedure codes in the PearlDiver Patient Records Database (PearlDiver Technologies, Fort Wayne, IN), a national database of orthopedic insurance records. The year of procedure, age, gender, and region of the United States were analyzed for each patient. RESULTS: A total of 921 patients were identified who underwent a single-level ALIF in this study. The average rate of single-level ALIF with rhBMP2 utilization increased (35%-48%) from 2005 to 2009, but sharply decreased to 16.7% in 2010 and 15.0% in 2011. The overall incidence of single-level ALIF without rhBMP2 (0.20 cases per 100 000 patients) was more than twice of the incidence of single-level ALIF with rhBMP2 (0.09 cases per 100 000 patients). The average rate of single-level ALIF with rhBMP2 utilization is highest in West (41.4%), followed by Midwest (33.3%), South (26.5%) and Northeast (22.2%). The highest incidence of single-level ALIF with rhBMP2 was observed in the group aged less than 65 years (compared with any other age groups, P < .001), with an incidence of 0.21 per 100 000 patients. CONCLUSIONS: The incidence of rhBMP2 utilization in single-level ALIF increased from 2006 to 2009, but decreased in 2010 and 2011. The Northeast region had the lowest incidence of rhBMP2 utilization. The group aged less than 65 years trended to have the higher incidence of single-level ALIF with rhBMP2 utilization.

Postoperative Complications Associated With rhBMP2 Use in Posterior/Posterolateral Lumbar Fusion.

STUDY DESIGN: Retrospective database review. OBJECTIVE: Posterior/posterolateral lumbar fusion (PLF) is an effective treatment for a variety of spinal disorders; however, variations in surgical technique have different complication profiles. The aim of our study was to quantify the frequency of various complications in patients undergoing PLF with and without human recombinant bone morphogenetic protein 2 (rhBMP2). METHODS: We queried the orthopedic subset of the Medicare database (PearlDiver) between 2005 and 2011 for patients undergoing PLF procedures with and without rhBMP2. Complication and reoperation rates were analyzed within 1 year of the index procedure. Complications assessed include: acute renal failure, deep vein thrombosis, dural tear, hematoma, heterotopic ossification, incision and drainage, cardiac complications, nervous system complications, osteolysis, pneumonia, pseudarthrosis, pulmonary embolism, radiculopathy, respiratory complications, sepsis, urinary retention, urinary tract infection, mechanical, and wound complications. Chi-square analysis was used to calculate the complication differences between the groups. RESULTS: Our data revealed higher overall complication rates in patients undergoing PLF with rhBMP2 versus no_rhBMP2 (76.9% vs 68.8%, P < .05). Stratified by gender, rhBMP2 males had higher rates of mechanical complications, pseudarthrosis, and reoperations compared with no_rhBMP2 males (P < .05), whereas rhBMP2 females had higher rates of pseudarthrosis, urinary tract infection, and urinary retention compared with no_rhBMP2 females (P < .05). CONCLUSION: Our data revealed higher overall complication rates in PLF patients given rhBMP2 compared with no_rhBMP2. Furthermore, our data suggests that rhBMP2-associated complications may be gender specific.

Regression of Anterior Disk-Osteophyte Complex Following Cervical Laminectomy and Fusion for Cervical Spondylotic Myelopathy.

STUDY DESIGN: A retrospective case-control study. OBJECTIVE: To investigate whether posterior cervical laminectomy and fusion modifies the natural course of anterior disk-osteophyte complex in patients with multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Dorsal migration of the spinal cord is the main purported mechanism of spinal cord decompression following cervical laminectomy and fusion but other potential mechanisms have received scant attention in the literature. This study was conducted to investigate whether cervical laminectomy and fusion affects the size of anterior disk-osteophyte complex. METHODS: The medical records and radiographic imaging of 44 patients who underwent cervical laminectomy and fusion for cervical spondylotic myelopathy between 2006 and 2013 were analyzed. The size of the anterior disk-osteophyte complex was measured preoperatively and postoperatively on MR images taken at an interval of >3 months apart. A control group consisted of 20 nonoperatively treated advanced cervical spondylosis patients. Patients in the control met the same inclusion and exclusion criteria and also had sequential magnetic resonance imaging (MRI) taken at an interval of >3 months apart. RESULTS: The nonoperative and operative groups were statistically similar in the pertinent patient demographics and characteristics including sex, age, time to second MRI, size of anterior disk-osteophyte complex on baseline MRI, mean number of levels affected, and percentage of patients with T2 signal change. As expected the mJOA scores were significantly lower in the operative versus nonoperative cohort (13.6 vs. 16.5, P<0.01). A significant decrease in the size of anterior disk osteophyte was observed in the operative group postoperatively (P<0.01). In comparison, there was no statistically significant change in the size of the anterior disk-osteophyte complex in the control group (P>0.05). The magnitude of the change in disk size between the 2 groups was statistically significant (P<0.01). CONCLUSIONS: The findings of this study suggest that regression of anterior disk-osteophyte complex occurs following cervical laminectomy and fusion, and likely provides another mechanism of spinal cord decompression.

Surgical Approach and Anesthetic Modality for Carpal Tunnel Release: A Nationwide Database Study With Health Care Cost Implications.

Background: Carpal tunnel release (CTR) is commonly performed for carpal tunnel syndrome once conservative treatment has failed. Operative technique and anesthetic modality vary by surgeon preference and patient factors. However, CTR practices and anesthetic trends have, to date, not been described on a nationwide scale in the United States. Methods: The PearlDiver Patient Records Database was used to search Current Procedural Terminology codes for elective CTR from 2007 to 2011. Anesthetic modality (eg, general and regional anesthesia vs local anesthesia) and surgical approach (eg, endoscopic vs open) were recorded for this patient population. Cost analysis, patient demographics, regional variation, and annual changes in CTR surgery were evaluated. Results: We identified 86 687 patients who underwent carpal tunnel surgery during this 5-year time period. In this patient sample, 80.5% of CTR procedures were performed using general or regional anesthesia, compared with 19.5% of procedures performed using local anesthesia; 83.9% of all CTR were performed in an open fashion, and 16.1% were performed using an endoscopic technique. Endoscopic surgery was on average $794 more expensive than open surgery, and general or regional anesthesia was $654 more costly than local anesthesia. Conclusions: In the United States, open CTR under local anesthesia is the most cost-effective way to perform a CTR. However, only a small fraction of elective CTR procedures are performed with this technique, representing a potential area for significant health care cost savings. In addition, regional and age variations exist in procedure and anesthetic type utilized.