Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly.

BACKGROUND: Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. METHODS: Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. RESULTS: Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. CONCLUSION: The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

Trends in Hospital and Surgeon Charges and Reimbursements for Revision Total Knee Arthroplasty.

BACKGROUND: The relationship between surgeon and hospital charges and reimbursements for revision total knee arthroplasty (TKA) has not been well examined. The objective of this study is to report trends and variations in hospital charges and payments compared to surgeons for stage 1 (S1) vs stage 2 (S2) septic revision TKA and aseptic revision (AR) TKA. METHODS: The 5% Medicare sample was used to capture hospital and surgeon data for revision TKA from 2005 to 2014. The charge multiplier (CM) and ratio of hospital to surgeon charges, and the payment multiplier (PM) and ratio of hospital to surgeon payments were calculated. Year-to-year variation and regional trends in-patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. RESULTS: In total, 4570 AR, 1323 S1, and 863 S2 TKA patients were included. CM increased for all cohorts: 8.1-13.8 for AR (P < .001), 21.0-22.5 (P = .07) for S1, and 11.8-22.0 (P < .001) for S2. PM followed a similar trend, increasing 8.1-13.8 (P < .001) for AR, 19.8-27.3 (P = .005) for S1, and 14.7-30.7 (P < .001) for S2. Surgeon reimbursement decreased for all cohorts. LOS decreased for AR (3.8-2.8 days), S1 (12.8-6.9 days), and S2 (4.5-3.9 days). Charlson Comorbidity Index remained stable for AR patients but increased significantly for S1 and S2 cohorts. CONCLUSION: Hospital charges and payments relative to the surgeons have significantly increased for revision TKA in the setting of stable or increasing patient complexity and decreasing LOS.

Reimbursements for Revision Total Hip Arthroplasty Have Increased for Hospitals but Not for Surgeons.

BACKGROUND: With increases in total hip arthroplasty procedures the need for revision total hip arthroplasty (rTHA) has increased as well. This study aims to analyze the trends in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for rTHA for aseptic revisions, stage 1 and stage 2 revisions. METHODS: The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 4449 patients undergoing aseptic revision, 517 for stage 1 revision, and 300 for stage 2 revision in between the years 2004 and 2014. Two values were calculated: (1) the ratio of hospital to surgeon charges (CM) and (2) the ratio of hospital to surgeon payments (PM). Year-to-year variation and trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), CM, and PM were evaluated. RESULTS: The mean CCI for aseptic revisions and stage 1 revisions did not significantly change (P < .088 and P < .063). The CCI slightly increased for stage 2 revisions (P < .04). The mean LOS decreased significantly over time in all 3 procedure types. The CM increased by 39% (P < .02) in aseptic revisions, 109% in stage 1 revisions (P < .001) but did not significantly change in stage 2 revisions (P < .877). PM for aseptic revisions increased around 103% (P < .001), 107% for stage 1 revisions (P < .001), and 9.7% for stage 2 revisions (P < .176). CONCLUSION: Hospital charges and payments relative to surgeon charges and payments have increased substantially for THA aseptic revisions, stage 1 revisions, and stage 2 revisions despite stable patient complexity and decreasing LOS.

Surgeon Reimbursement Unchanged as Hospital Charges and Reimbursements Increase for Total Joint Arthroplasty.

BACKGROUND: Despite increasing demands on physicians and hospitals to increase value and reduce unnecessary costs, reimbursement for healthcare services has been under downward pressure for several years. This study aimed to analyze the trend in hospital charges and payments relative to corresponding surgeon charges and payments in a Medicare population for total hip (THA) and knee arthroplasty (TKA). METHODS: The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 56,228 patients who underwent primary THA and 117,698 patients who underwent primary TKA between 2005 and 2014. Two values were calculated: (1) the charge multiplier (CM), the ratio of hospital to surgeon charges and (2) the payment multiplier (PM), the ratio of hospital to surgeon payments. Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. RESULTS: Hospital charges were significantly higher than surgeon charges and increased substantially for both THA (CM increased from 8.7 to 11.5, P < .0001) and TKA (CM increased from 7.9 to 11.4, P < .0001). PM followed a similar trend, increasing for both THA and TKA (P < .0001). LOS decreased significantly for both THA and TKA (P < .0001), while Charlson Comorbidity Index remained stable. Both CM (r2 = 0.84 THA, 0.90 TKA) and PM (r2 = 0.75 THA, 0.84 TKA) were strongly negatively associated with LOS. CONCLUSION: Hospital charges and payments relative to surgeon charges and payments have increased substantially for THA and TKA despite stable patient complexity and decreasing LOS.

Urinary Self-Catheterization is Not Associated with Increased Risk of Major Complications Following Total Hip and Knee Arthroplasty.

BACKGROUND: The objective of this study is to evaluate urinary self-catheterization as a potential risk factor for postoperative complications following total hip (THA) and knee (TKA) arthroplasty procedures. METHODS: Self-catheterization patients who underwent total joint arthroplasty from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visit, infection, revision, and dislocation for THA or arthrofibrosis for TKA were calculated, as well as cost and length of stay. Self-catheterizing patients were then compared to a 4:1 matched control cohort using a logistic regression analysis to control for confounding factors. RESULTS: Sixty-nine patients underwent THA, and 128 patients who underwent TKA and who actively self-catheterized at the time of surgery were identified. Self-catheterization was not associated with infection, emergency room visits, readmissions, revision surgery, arthrofibrosis, or cost compared to the 4:1 matched control cohort. However, self-catheterization was associated with significantly longer length of stay (difference for THA = 1.91 days, confidence interval = 0.97-2.86, P < .001; difference for TKA = 0.61, odds ratio = 0.16-1.06, P = .01). CONCLUSION: Self-catheterization does not appear to be associated with increased risk of major complications following total joint arthroplasty with the numbers available in this study. Reassurance can be given regarding concerns for infection and other complications following surgery in this patient population.

Hospital and Surgeon Reimbursement Trends for Femoral Neck Fractures Treated With Hip Hemiarthroplasty and Total Hip Arthroplasty.

BACKGROUND: The economic impact of hip fractures on the health care system continues to rise with continued pressure to reduce unnecessary costs while maintaining quality patient care. This study aimed to analyze the trend in hospital charges and payments relative to surgeon charges and payments in a Medicare population for hip hemiarthroplasty and total hip arthroplasty (THA) for femoral neck fracture. METHODS: The 5% Medicare sample database was used to capture hospital and surgeon charges and payments related to 32,340 patients who underwent hemiarthroplasty and 4323 patients who underwent THA for femoral neck fractures between 2005 and 2014. Two values were calculated: (1) charge multiplier (CM, ratio of hospital to surgeon charges), and (2) payment multiplier (PM, ratio of hospital to surgeon payments). Year-to-year variation and regional trends in patient demographics, Charlson Comorbidity Index (CCI), length of stay (LOS), 90-day and 1-year mortality, CM, and PM were evaluated. RESULTS: Hospital charges were significantly higher than surgeon charges and increased substantially for hemiarthroplasty (CM of 13.6 to 19.3, P < .0001) and THA (CM of 9.8 to 14.9, P = .0006). PM followed a similar trend for both hemiarthroplasty (14.9 to 20.2; P = .001) and THA (11.9 to 17.4; P < .0001). LOS decreased significantly for hemiarthroplasty (3.78 to 3.37d; P < .0001) despite increasing CCI (6.36 to 8.39; P = .018), whereas both LOS (3.71 to 3.79 days; P = .421) and CCI (5.34 to 7.08; P = .055) remained unchanged for THA. CONCLUSION: Hospital charges and payments relative to surgeon charges and payments have increased substantially for hemiarthroplasty and THA performed for femoral neck fractures.

Hypogonadism Is Associated With Increased Risks of Postoperative Complications Following Total Hip Arthroplasty.

BACKGROUND: Despite being a relatively common problem among aging men, hypogonadism has not been previously studied as a potential risk factor for postoperative complications following total hip arthroplasty (THA). METHODS: In total, 3903 male patients with a diagnosis of hypogonadism who underwent primary THA from 2006 to 2012 were identified using a national insurance database and compared to 20:1 matched male controls using a logistic regression analysis. RESULTS: Hypogonadism was associated with an increased risk of major medical complications (odds ratio [OR] 1.24, P = .022), urinary tract infection (OR 1.43, P < .001), wound complications (OR 1.33, P = .011), deep vein thrombosis (OR 1.64, P < .001), emergency room visit (OR 1.24, P < .001), readmission (OR 1.14, P = .015), periprosthetic joint infection (OR 1.37 and 1.43, P < .05), dislocation (OR 1.51 and 1.48, P < .001), and revision (OR 1.54 and 1.56, P < .001) following THA. A preoperative diagnosis of hypogonadism was associated with increased total reimbursement and charges by $390 (P < .001) and $4514 (P < .001), respectively. CONCLUSION: The diagnosis of hypogonadism is associated with an elevated risk of postoperative complications and increased cost of care following primary THA. Data from this study should influence the discussion between the patient and the provider prior to undergoing joint replacement and serve as the basis for further research.

Preoperative Pain Management: Is Tramadol a Safe Alternative to Traditional Opioids Before Total Hip Arthroplasty?

BACKGROUND: Preoperative opioid use has been associated with worse clinical outcomes and higher rates of prolonged opioid use following lower extremity arthroplasty. Tramadol has been recommended for management of osteoarthritis-related pain; however, outcomes following total hip arthroplasty (THA) in patients taking tramadol in the preoperative period have not been well described. The aim of this study is to examine the effect of preoperative tramadol use on postoperative outcomes in patients undergoing elective THA. METHODS: A total of 5304 patients who underwent primary THA for degenerative hip pathology from 2008 to 2014 were identified using the Humana Claims Database. Patients were grouped by preoperative pain management modality into 3 mutually exclusive populations including tramadol, traditional opioid, or nonopioid only. A multivariate logistic regression was used to evaluate all postsurgical outcomes of interest. RESULTS: Tramadol users had an increased risk of developing prolonged narcotic use (odds ratio [OR], 2.17; confidence interval [CI], 1.89-2.49; P < .001) following surgery compared to nonopioid-only users. When compared to traditional opioid use, tramadol use was associated with decreased risk of subsequent 90-day minor medical complications (OR, 0.75; CI, 0.62-0.90; P = .002), emergency department visits (OR, 0.70; CI, 0.57-0.85; P < .001), and prolonged narcotic use (OR, 0.43; CI, 0.37-0.49; P < .001). Traditional opioid use significantly increased length of stay by 0.20 days (P = .001) when compared to tramadol use. CONCLUSION: Preoperative tramadol use is associated with prolonged opioid use following THA but is not associated with other postoperative complications. Patients taking tramadol preoperatively appear to have a lower risk of postoperative complications compared to patients taking traditional opioids preoperatively.

Normal Pressure Hydrocephalus Is Associated With Increased Risks of Postoperative Complications Following Total Knee and Total Hip Arthroplasty.

BACKGROUND: Normal pressure hydrocephalus (NPH) has not been studied as a potential risk factor for postoperative complications after primary total knee (TKA) and total hip arthroplasty (THA). METHODS: Nearly 2000 patients with a diagnosis of NPH who underwent TKA or THA from 2005 to 2014 were identified in a national insurance database and compared to 10:1 matched controls using a logistic regression analysis. RESULTS: NPH was associated with an increased risk of hospital readmission, emergency room visit, and infection following TKA (odds ratio 1.48-2.70, all P < .01). NPH was associated with an increased risk of hospital readmission, emergency room visit, and dislocation following THA (odds ratio 2.40-2.50, all P < .01). NPH was also associated with significantly higher costs and hospital length of stay following both procedures. CONCLUSION: The diagnosis of NPH is associated with an elevated risk of postoperative complications and increased resource utilization following TKA and THA.

Patients With Multiple Sclerosis are at Increased Risk for Postoperative Complications Following Total Hip and Knee Arthroplasty.

BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease affecting the central nervous system. Patients with MS are living longer due to improved medical therapy and thus the demand for arthroplasty in this population will increase. The objective of this study is to evaluate MS as a potential risk factor for postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Patients with a diagnosis of MS who underwent THA or TKA from 2005 to 2014 were identified in a national insurance database. Rates of death, hospital readmission, emergency room visits, infection, revision, and dislocation (for THA) or stiffness (for TKA) were calculated, in addition to cost and length of stay. MS patients were then compared to a matched control population. RESULTS: In total, 3360 patients who underwent THA and 6436 patients who underwent TKA with a history of MS were identified and compared with 10:1 matched control cohorts without MS. The MS group for both TKA and THA had significantly higher incidences of hospital readmission (THA odds ratio [OR] 2.05, P < .001; TKA OR 1.99, P < .001), emergency room visits (THA OR 1.41, P < .001; TKA OR 1.66, P < .001), and infection (THA OR 1.35, P = .001; TKA OR 1.32, P < .001). MS patients who underwent THA had significantly higher rates of revision (OR 1.35, P = .001) and dislocation (OR 1.52, P < .001). Diagnosis of MS was also associated with significantly higher costs and hospital length of stay for patients undergoing both TKA and THA. CONCLUSION: A diagnosis of MS is associated with increased risk of postoperative complications and higher costs following both THA and TKA.

Is osteonecrosis due to systemic lupus erythematosus associated with increased risk of complications following total hip arthroplasty?

PURPOSE: As the medical treatment of systemic lupus erythematosus (SLE) has evolved, the rate of total hip arthroplasty (THA) in SLE patients has increased, with osteonecrosis (ON) being the primary indication for arthroplasty in a quarter of cases. Comparative literature evaluating outcomes following THA for patients with SLE and ON versus patients with non-SLE-related ON or patients with osteoarthritis (OA) is limited. The goal of the present study was to investigate the current trend in SLE patients undergoing THA and compare complications following THA for ON with SLE, ON without SLE, and OA. METHODS: The PearlDiver patient records database ( www.pearldiverinc.com , Colorado Springs, CO), a for-fee insurance-based patient records database, was utilized for this study. Two hundred forty-four patients who underwent THA for ON associated with SLE were identified and compared to control cohorts of 7836 patients with ON without SLE and 64,235 patients with OA using a multivariate analysis. RESULTS: We found patients with SLE undergoing THA for ON experienced lower rates of infection and revision but a higher rate of medical complications compared to patients undergoing THA for non-SLE ON diagnoses. Patients with SLE undergoing THA for ON experienced decreased rates of infection but increased rates of transfusion and medical complications compared to patients undergoing THA for OA. CONCLUSIONS: Our data demonstrate that THA can be safely performed on SLE patients with ON without significantly increased morbidity compared to that in patients with non-SLE-associated ON or patients with OA.

Outcomes following Total Hip Arthroplasty for Femoral Head Osteonecrosis in Patients with History of Solid Organ Transplant.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients with solid organ transplant (SOT) are at increased risk of postoperative complications after THA for osteoarthritis. The objective of the present study is to evaluate SOT as a potential risk factor for complication after THA for ONFH. METHODS: This is a retrospective study that identified patients with SOT who underwent THA for ONFH from 2005 to 2014 in a national insurance database and compared them to 5:1 matched controls without transplant. Subgroup analyses of patients with renal transplant (RT) and those with non-RT were also analyzed. A logistic regression analysis was used to compare rates of mortality, hospital readmission, emergency room (ER) visits, infection, revision, and dislocation while controlling for confounders. Differences in hospital charges, reimbursement, and length of stay (LOS) were also compared. RESULTS: 996 patients with SOT who underwent THA were identified and compared to 4,980 controls. SOT patients experienced no increased risk of early postoperative complications compared to controls. Solid organ transplant was associated with higher resource utilization and LOS. Renal transplant patients were found to have significantly higher risk of hospital readmission at 30 days (odds ratio [OR] 1.77; p = 0.001) and 90 days (OR 1.62; p < 0.001) and hospital LOS (p < 0.001), but had lower risk of infection (OR 0.65; p = 0.030). Non-RT patients had higher rate of ER visits at 30 days (OR 2.26; p = 0.004) but lower rates of all-cause revision (OR 0.22; p = 0.043). CONCLUSIONS: Patients with history of SOT undergoing THA for ONFH utilize more hospital resources with longer LOS and greater risk of readmission but are not necessarily at an increased risk of early postoperative complications.

Outcomes Following Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients on Hemodialysis.

BACKGROUND: Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients on hemodialysis (HD) are at increased risk for complications after THA for osteoarthritis, however there is limited information on outcomes of THA for ONFH in patients on HD. With increasing prevalence of chronic kidney disease (CKD) requiring HD, studies are needed to characterize the risk of complications in these patients. Therefore, the purpose of this study was to evaluate HD as a potential risk factor for complication after THA in patients with ONFH on HD. METHODS: Patients on HD with ONFH who underwent THA with at least 2 years of follow-up were identified using a combination of ICD-9 and CPT codes in a national insurance database. A 10:1 matched control cohort of patients with ONFH not on HD was created for comparison. A logistic regression analysis was used to evaluate rates of death, hospital readmission, emergency room (ER) visit, infection, revision, and dislocation between cohorts. Differences in hospital charges, reimbursement, and length of stay between the two groups were also assessed. RESULTS: One thousand one hundred thirty-seven patients on HD who underwent THA for ONFH were compared to a matched control cohort of 11,182 non-HD patients who underwent THA for ONFH. Patients on HD experienced higher rates of death (HD 4.1%, non-HD 0.9%; odds ratio [OR] 3.35, p < 0.01), hospital readmission (HD 16.1%, non-HD 5.9%; OR 2.69, p < 0.01) and ER visit (HD 10.4%, non-HD 7.4% OR 1.5, p < 0.01). Hemodialysis was not associated with higher risk of infection, revision, or dislocation, but was associated with significantly higher charges (p < 0.01), reimbursement (p < 0.01), and hospital length of stay (p < 0.01). CONCLUSIONS: While patients on HD do not have increased risk of implant-related complications, they are at increased risk of developing medical complications following THA for ONFH and subsequently may require more resources. Orthopedic surgeons and nephrologists should be cognizant of the increased risk in this population to provide appropriate preoperative counseling and enhanced perioperative medical management. LEVEL OF EVIDENCE: Therapeutic Level III.

Increased Reimbursement for Surgical Fixation of Hip Fractures: The Difference Between the Hospital and the Surgeon.

OBJECTIVES: To evaluate trends and variations in hospital charges and payments relative to surgeon charges and payments for surgical treatment of hip fractures in the US Medicare population. METHODS: Hospital and surgeon charges and payments after treatment of hip fractures by closed reduction and percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or intramedullary nail (IMN), along with corresponding patient demographics, 90-day and 1-year mortality, Charlson Comorbidity Index (CCI), and length of stay (LOS) from 2005 to 2014 were captured from the 5% Medicare Standard Analytic Files. The ratio of hospital to surgeon charges (CM: Charge Multiplier) and the ratio of hospital to surgeon payments (PM: Payment Multiplier) were calculated for each year and region of the United States and trended over time. Correlations between the CM and PM and LOS were evaluated using a Pearson correlation coefficient (r). RESULTS: Three thousand twenty-eight patients who underwent CRPP and 25,341 patients who underwent ORIF/IMN were included. The CM for CRPP increased from 10.1 to 15.6, P < 0.0001. The CM for ORIF/IMN increased from 11.9 to 17.2, P < 0.0001. The PM for CRPP increased from 15.1 to 19.2, P < 0.0001. The PM for ORIF/IMN increased from 11.5 to 17.4, P < 0.0001. CONCLUSIONS: Hospital charges and payments have continually increased relative to surgeon charges and payments for treatment of hip fractures despite decreasing LOS.

Postoperative Venous Thromboembolism and other Complications after Anatomic Total Shoulder Arthroplasty in Patients With a History of Prostate or Breast Cancer.

INTRODUCTION: As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS: Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS: Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION: Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.

Unplanned Immediate Return to Operating Room After Spine Surgery: Significance of Immediate Postoperative Radiographs.

STUDY DESIGN: Retrospective analysis; single center data. OBJECTIVE: The purpose of this study is to look at the utility and relevance of immediate postoperative radiographs in providing vital information leading to immediate revision after spine surgery. SUMMARY OF BACKGROUND DATA: Immediate postoperative radiographs are routinely obtained in the recovery room after spine surgery to verify the level, alignment of the spine, implant position, and the adequacy of the procedure. However, with the ability to utilize intraoperative fluoroscopy imaging for the same purpose, the requirement for immediate postoperative radiographs needs to be validated. The purpose of this study is to look at the utility and relevance of these postoperative radiographs in providing critical information that may warrant immediate intervention. METHODS: Retrospective analysis of all spine surgeries (elective and emergent), performed at a single center from 2011 to 2016, was done and cases returning to operating room within 48 hours were identified. Indication of immediate revision was reviewed and utility of immediate postoperative radiographs in guiding immediate revision was analyzed. RESULTS: A total of 1804 elective and urgent spinal surgeries were performed by seven surgeons. Twenty-two patients returned to operating room within 48 hours of their index procedures. Of these 22 cases, only two patients were noted to have positive findings on recovery room radiographs. The findings of suboptimal spinal alignment or failed instrumentation led to the immediate revision in both cases. Both cases involved instrumentation at cervicothoracic region and intraoperative imaging provided only limited visualization. CONCLUSION: Routine recovery room radiographs played a role in the decision to emergently return to the operating room in 0.10% (2/1804) cases at our institution. The potential benefit of immediate recovery room radiographs after spine surgery should be weighed against the added healthcare cost and patient discomfort associated with obtaining these radiographs routinely. Imaging may be delayed to a more elective time without any significant risk in majority of spine cases. LEVEL OF EVIDENCE: 3.

Risk of Surgical Site Infection and Mortality Following Lumbar Fusion Surgery in Patients With Chronic Steroid Usage and Chronic Methicillin-Resistant Staphylococcus aureus Infection.

STUDY DESIGN: A retrospective database analysis among Medicare beneficiaries OBJECTIVE.: The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion. SUMMARY OF BACKGROUND DATA: Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail. METHODS: The PearlDiver insurance-based database (2005-2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated. RESULTS: Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13-3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33-1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41-2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61-9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20-28.46, P < 0.001) but did not significantly impact mortality. CONCLUSION: Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion. LEVEL OF EVIDENCE: 3.

Perioperative hemoglobin A1c as a predictor of deep infection following single-level lumbar decompression in patients with diabetes.

BACKGROUND CONTEXT: Although multiple studies have cited that diabetes mellitus as a risk factor decreased functional outcomes, increased infectious complications, and overall increased reoperation rate following degenerative lumbar spinal surgery, few have investigated how perioperative glycemic control influences such complications. PURPOSE: The primary goal of the present study was to use a national database to evaluate the association of perioperative glycemic control as demonstrated by hemoglobin A1c (HbA1c) levels in patients with diabetes undergoing primary, single-level decompression without concomitant fusion with the incidence of deep postoperative infection requiring operative irrigation and debridement. Our secondary objective was to calculate a threshold level of HbA1c above which the risk of postoperative infection after lumbar decompression increases significantly in patients with diabetes. STUDY DESIGN/SETTING: This is a retrospective case control database study, with Level III evidence. PATIENT SAMPLE: This study comprised private-payer patients with diabetes mellitus undergoing single-level lumbar decompression with an HbA1c laboratory value recorded in the database within 3 months of surgery. OUTCOME MEASURES: The outcome examined in this study was deep infection following primary, single-level lumbar decompression requiring surgical intervention. Postoperative infection within 1 year of the index primary, single-level lumbar decompression was assessed using Current Procedural Terminology (CPT) procedure codes and the International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes. METHODS: The Humana private-payer dataset from the PearlDiver database was used for this study. The database was queried for patients with diabetes mellitus undergoing primary, single-level lumbar decompression surgery using CPT codes. Patients with a diagnosis of diabetes mellitus who had an HbA1c level drawn within 3 months before or after their surgical date were then selected to form the study group using the ICD-9 diagnostic codes. Patients were then divided into groups based on their HbA1c level by increments of 0.5 mg/dL. The incidence of deep infection requiring operative intervention within 1 year for each HbA1c group was then identified using CPT and ICD-9 codes. A receiver operating characteristic (ROC) and area under the curve (AUC) analysis was performed to determine an optimal threshold value of the HbA1c above which the risk of postoperativeinfection was significantly increased. The threshold value was tested using a multivariable binomial logistic regression analysis. RESULTS: A total of 5,194 patients who underwent primary, single-level lumbar decompression with diabetes and a perioperative HbA1c recorded within 3 months of surgery were included in the study. The rate of infection ranged from a low of 0.5% up to 3.5% for patients with an HbA1c level >11.0 mg/dL (p=.012). The inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (p=.01, AUC=0.71, specificity=70%, sensitivity=53%). After controlling for patient demographics and medical comorbidities, patients with an HbA1c level of 7.5 mg/dL or above had a significantly higher risk for deep infection compared with patients below this threshold (odds ratio: 2.9, 95% confidence interval: 1.8-4.9, p<.0001). CONCLUSIONS: The risk of deep postoperative infection requiring surgical intervention following single-level lumbar decompression in patients with diabetes mellitus increases as the perioperative HbA1c increases. The ROC and multivariable regression analyses determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of deep postoperative infection following lumbar decompression.