General Versus Neuraxial Anesthesia in Revision Surgery for Periprosthetic Joint Infection.

BACKGROUND: The purpose of this study was to compare neuraxial and general anesthesia in revision surgery for periprosthetic joint infection (PJI). METHODS: Patients undergoing revision arthroplasty for PJI were identified in the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program databases. Thirty-day outcomes were compared between general and neuraxial anesthesia. Propensity-score matching and multivariate analysis were used to control patient and procedural variables. RESULTS: Neuraxial anesthesia was used in 1511 (16.8%) cases and general anesthesia in 7468 (83.2%) cases. Neuraxial anesthesia had a lower risk of any adverse event (odds ratio [OR] 0.70, P < .001), serious adverse events (OR 0.77, P < .001), and minor adverse events (OR 0.66, P < .001). Among 875 reoperations and 1351 readmissions, two had a diagnosis of intraspinal abscess, both occurring after general anesthesia. CONCLUSIONS: Neuraxial anesthesia was associated with a lower risk of adverse events when compared to general anesthesia in revision surgery for PJI.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures.

PURPOSE: The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. RESULTS: In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate. CONCLUSIONS: Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The chromatin remodeling complex Swi/Snf regulates splicing of meiotic transcripts in Saccharomyces cerevisiae.

Despite its relatively streamlined genome, there are important examples of regulated RNA splicing in Saccharomyces cerevisiae, such as splicing of meiotic transcripts. Like other eukaryotes, S. cerevisiae undergoes a dramatic reprogramming of gene expression during meiosis, including regulated splicing of a number of crucial meiosis-specific RNAs. Splicing of a subset of these is dependent upon the splicing activator Mer1. Here we show a crucial role for the chromatin remodeler Swi/Snf in regulation of splicing of meiotic genes and find that the complex affects meiotic splicing in two ways. First, we show that Swi/Snf regulates nutrient-dependent downregulation of ribosomal protein encoding RNAs, leading to the redistribution of spliceosomes from this abundant class of intron-containing RNAs (the ribosomal protein genes) to Mer1-regulated transcripts. We also demonstrate that Mer1 expression is dependent on Snf2, its acetylation state and histone H3 lysine 9 acetylation at the MER1 locus. Hence, Snf2 exerts systems level control of meiotic gene expression through two temporally distinct mechanisms, demonstrating that it is a key regulator of meiotic splicing in S. cerevisiae. We also reveal an evolutionarily conserved mechanism whereby the cell redirects its energy from maintaining its translational capacity to the process of meiosis.

Industry Payments to Pediatric Orthopaedic Surgeons Reported by the Open Payments Database: 2014 to 2017.

BACKGROUND: The Open Payments Database (OPD), mandated by the Sunshine Act, is a national registry of physician-industry transactions. Payments are reported as either General, Research, or Ownership payments. The current study aims to investigate trends in OPD General payments reported to pediatric orthopaedic surgeons from 2014 to 2017. METHODS: General industry payments made to pediatric orthopaedic surgeons (as identified by OPD) were characterized by median payment, payment subtype, and census region. As fewer Research and Ownership payments were made, only payment totals for these categories were determined. General payment data were analyzed for trends using the nonparametric Mann-Whitney U test. RESULTS: For General payments, there was an increase in the number of compensated pediatric orthopaedists from 2014 to 2017 (324 vs. 429). Of those compensated, there was no significant change in median payment per compensated surgeon ($201 vs. $197; P=0.82). However, a large percentage of total General payment dollars in pediatric orthopaedics were made to the top 5% of compensated pediatric orthopaedists each year (average 71% of total General industry compensation). For this top 5% group, median General payment per compensated surgeon increased from 2014 ($14,624) to 2017 ($32,752) (P=0.006). A significant increase in median subtype aggregate payment per surgeon was observed in the education (P<0.001) and royalty/license (P=0.031) subtypes; a significant decrease was observed for travel/lodging payments (P=0.01). Midwest pediatric orthopaedists received the highest median payment across all years studied. Few payments for research and ownership were made to pediatric orthopaedists. Four-year aggregate payment totals were $18,151 and $3,223,554 for Research and Ownership payments, respectively. CONCLUSIONS: Many expected payments to surgeons to decrease when put under the public scrutiny of the OPD. Not only was this decrease not observed for General payments to pediatric orthopaedic surgeons during the 2014 to 2017 period, but also the median General payment to the top 5% increased. These findings are important to note in the current era of increased transparency. LEVEL OF EVIDENCE: Level III.

Abnormally High, as Well as Low, Preoperative Platelet Counts Correlate With Adverse Outcomes and Readmissions After Elective Total Knee Arthroplasty.

BACKGROUND: Laboratory studies are routinely performed as a part of the preoperative workup for a total knee arthroplasty (TKA). The ramifications of abnormal preoperative platelet counts remain uncharacterized in large, multicenter patient populations. METHODS: Patients who underwent elective primary TKA were identified in the 2011-2015 National Surgical Quality Improvement Program database. Risk of 30-day postoperative complications was calculated as a function of preoperative platelet counts. Patients were characterized as having a normal platelet count, abnormally low platelet count, and abnormally high platelet count based on relative risk calculations. Univariate and multivariate analyses were performed to associate abnormal platelet counts with patient demographics, operative variables, 30-day postoperative complications, and readmissions. RESULTS: In total, 140,073 patients who underwent elective TKA were identified. Using the relative risk threshold of 1.5 for any adverse event, abnormally low and abnormally high platelet count thresholds were set at ≤116,000/mL and ≥492,000/mL, respectively. Multivariate analyses revealed low platelet counts to be associated with higher rates of any, major, and minor adverse events and longer length of stay. Analogously, high platelet counts were associated with higher rates of any and minor adverse events and longer length of stay. CONCLUSION: The present study employed a large patient sample size and showed that elective TKA patients with abnormally high, as well as low, platelet counts are at increased risk of postoperative adverse outcomes. Focused attention needs to be paid to TKA patients with preoperative abnormal platelet counts for optimization and postoperative care. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Severe Acute Respiratory Syndrome Coronavirus 2 Did Not Substantially Impact Injury Patterns or Performance of Players in the National Basketball Association From 2016 to 2021.

Purpose: To perform a descriptive epidemiologic analysis of National Basketball Association (NBA) injuries from 2016 to 2021, to evaluate the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019, or COVID-19) on injury patterns and performance statistics, and to determine the effect of infection with SARS-CoV-2 on individual performance statistics. Methods: Injury epidemiology in the NBA from the 2016 to 2021 seasons was collected using a comprehensive online search. Injuries and time missed were categorized by injury location and type. Player positions and timing of injury were recorded. Performance statistics were collected including traditional game statistics and Second Spectrum (speed, distance) statistics. Comparisons were made over seasons and comparing the pre-COVID-19 pandemic seasons to the pandemic era seasons. Players diagnosed with COVID-19 were analyzed for changes in performance in the short or long term. Results: Of the 3,040 injuries captured, 1,880 (61.84%) were in the lower extremity. Guards (77.44%) and forwards (75.88%) had a greater proportion of soft-tissue injuries (P < .001) than centers. Guards had the highest proportion of groin (3.27%, P = .001) and hamstring (6.21%, P < .001) injuries. Despite minor differences on a per-season basis, there were no differences in injury patterns identified between pre-COVID-19 and COVID-19 eras. Of players diagnosed with COVID-19 during the NBA Bubble, there were no detriments in short- or long-term performance identified, including traditional game statistics and speed and distance traveled. Conclusions: In the NBA seasons from 2016 to 2021, most injuries were to the lower extremity. The SARS-CoV-2 pandemic did not substantially impact injury patterns in the NBA, including locations of injury and type of injury (bony or soft tissue). Furthermore, infection with SARS-CoV-2 does not appear to have a significant impact on performance in basketball-specific or speed and distance measures. Level of Evidence: Level IV, prognostic case series.

Physical Therapy Utilization After Single-level Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Characterize physical therapy (PT) utilization following single-level posterior lumbar fusion (PLF). SUMMARY OF BACKGROUND DATA: PLF is a common procedure that is increasing in frequency. After such surgeries, PT may be considered to facilitate mobilization and return to activities. However, the usage of such therapy has not been well-characterized in the literature. MATERIALS AND METHODS: Patients undergoing single-level PLF were identified from the 2010 to 2021 PearlDiver administrative database. These patients were stratified based on usage of therapy, home versus outpatient therapy, and timing of therapy within the year after surgery. To determine predictors of therapy, patient characteristics were determined and multivariable regressions were performed. RESULTS: A total of 213,240 patients undergoing single-level PLF were identified, of which therapy was done in the year after surgery for 63,231 (29.0%, of which home therapy accounted for 16.5% of therapy visits). Of those who utilized PT, the average number of visits was 10.6±10.6. Home therapy peaked within the first month after surgery and outpatient therapy peaked at month two. Factors associated with any PT following PLF in decreasing odds ratio (OR) were having commercial insurance (OR: 1.68), being from the Northeast (OR: 1.41), age (OR: 1.13 for 70+ of age) female sex (OR: 1.09), and ECI (OR: 1.04 per point) ( P <0.001 for all). Of those who received therapy, factors associated with home PT utilization were being from the Northeast (OR: 2.55), age (OR: 1.91 for 70+ of age), Medicaid insurance (OR: 1.48), female sex (OR: 1.39), and interbody fusion (OR:1.07) ( P <0.001 for all). CONCLUSIONS: After single-level PLF, the minority of patients received home or outpatient PT. Of those who did, there was significant variation in the number of visits, with nonmedical factors such as insurance plan and geographic region being strongly associated suggesting room for more consistent practice patterns. LEVEL OF EVIDENCE: Level 3.

Postoperative spine surgical site infections: high rate of failure of one-stage irrigation and debridement.

BACKGROUND CONTEXT: Following spine surgery, postoperative surgical site infection (SSI) is a rare but potentially devastating complication. Previous studies have assessed risk factors for spine SSI and one aimed to develop risk stratification tool to assess management options, but this tool has not been externally validated or regularly used. PURPOSE: The current study aimed to investigate the rate of SSI following elective spine surgery, surgical management pursued, and success of traditionally utilized one-stage of irrigation and debridement (I&D) with closure over drains. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: Adult, elective spine surgeries performed at a single academic institution between 2013 and 2021 were evaluated. Patients who developed SSI requiring surgical intervention were identified. OUTCOME MEASURES: Those who underwent initial management with I&D and closure over drains were assessed for need of subsequent I&D (considered failure of initial infection management). METHODS: Of spine surgeries meeting inclusion criteria, those with SSI were identified and management was characterized. For those who did and did not fail attempted one stage I&D with closure over drains, pre-operative and surgical variables from the index procedure as well as infection characteristics were assessed and compared with univariable and multivariable analyses. RESULTS: Of 11,023 elective spine surgeries, SSI was identified for 76 (0.7%). For initial management, I&D with closure over drains was used for 66 (86.8%) while I&D and wound vacuum management was used 10 (13.2%). Failure of attempted one stage I&D (requiring subsequent I&D procedure) was identified for 18 (27% of those undergoing I&D and closure over drains). Of multiple patient, surgical, and infection characteristics, the only factor identified as independently predictive of one stage I&D failure was presence of bacteremia (odds ratio [OR] 38.3, p=0.0007). Within the sub-cohort of patients with bacteremia, failure of attempted one stage I&D was noted for 80%. CONCLUSION: Less than one percent of a large cohort of patients undergoing spine surgery were found to develop SSIs. Of those undergoing attempted one stage I&D, most patient, surgical, and infection variables did not influence outcome of the intervention. However, those with bacteremia were at 38.3 times greater odds of failing attempted one-stage I&D. These results suggest considering delayed closure approaches in these cases.

Bucket-Handle Meniscus Tear Management With Meniscectomy Versus Repair Correlates With Patient, Socioeconomic, and Hospital Factors.

INTRODUCTION: Bucket-handle meniscus tears are common knee injuries that are often treated surgically with meniscectomy or meniscal repair. Although clinical factors may influence the choice of one treatment approach over the other, the influence of patient, socioeconomic, and hospital factors remains poorly characterized. This study aimed to estimate the relative nationwide utilization of these two procedures and delineate a variety of factors that are associated with the selection of one treatment approach over the other. METHODS: Meniscal repair and meniscectomy procedures conducted for isolated bucket-handle meniscus tears in 2016 and 2017 were identified in the Nationwide Ambulatory Surgery Sample database. Cases were weighted using nationally representative discharge weights. Univariate analyses and a multivariable logistic regression model were used to compare patient, socioeconomic, and hospital factors associated with meniscal repair versus meniscectomy. RESULTS: In total, 12,239 cases were identified, which represented 17,236 cases after weighting. Of these, meniscal repair was conducted for 4,138 (24.0%). Based on the logistic regression model, meniscal repair was less likely for older and sicker patients. By contrast, several factors were associated with markedly higher odds of undergoing meniscal repair compared with meniscectomy. These included urban teaching hospitals; geographic location in the midwest, south, and west; and higher median household income. DISCUSSION: Using a large nationally representative cohort, the current data revealed that only 24.0% of surgically treated bucket-handle meniscus tears were treated using repair. Identification of patient, socioeconomic, and hospital factors differentially associated with meniscal repair suggest that other factors may systematically influence surgical decision-making for this patient population. Surgeons should be conscious of these potential healthcare disparities when determining the optimal treatment for their patients. LEVEL OF EVIDENCE: Level III.

Is There Utility to Requiring Spine MRI Pre-authorizations? Pre-authorizations: A Single Institution's Perspective.

STUDY DESIGN: A retrospective cohort study of a patient undergoing treatment at a single institution's Spine Center. OBJECTIVE: The current study assessed the rates and eventual disposition of pre-authorizations required before spine MRIs are ordered from an academic spine center. SUMMARY OF BACKGROUND DATA: Spine magnetic resonance imaging (MRI) often requires preauthorization by insurance carriers. While there are potential advantages to ensuring consistent indicators for imaging modalities, previous studies have found that such processes can add administrative burdens and barriers to care. METHODS: Patients from a single academic institution's spine center who were covered by commercial insurance and had a spine MRI ordered between January 2013 and December 2019 were identified. The requirement for preauthorization and eventual disposition of each of these studies was tracked. Multivariate logistic regression was used to determine if commercial insurance carriers or anatomic region MRIs were associated with requiring a preauthorization. The eventual disposition of studies associated with this process was tracked. RESULTS: In total, 2480 MRI requests were identified, of which preauthorization was needed for 2122 (85.56%). Relative to cervical spine scans, preauthorization had greater odds of being required for thoracic (OR=2.71, P =0.003) and lumbar (OR=2.46, P <0.001) scans. Relative to a reference insurer, 4 of the 5 commercial carriers had statistically significant increased odds of requiring preauthorization (OR=1.54-10.17 P <0.050 for each).Of the imaging studies requiring preauthorization, peer to peer review was required for 204 (9.61%), and 1,747 (82.33% of all requiring preauthorization) were approved. Of 375 (17.67%) initially cancelled or denied by the preauthorization process, 290 (77.33% of those initially cancelled or denied) were completed within 3 months. In total, only 85 were not eventually approved and completed. CONCLUSION: Of 2480 distinct MRI orders, commercial insurers required preauthorization for 85.56%. Nonetheless, 96.57% of all scans went on to be completed within 3 months, raising questions about the costs, benefits, and overall value of this administrative process.

Revision Total Hip and Knee Arthroplasty are Associated With Lower Hospital Consumer Assessment of Healthcare Providers and Systems Patient Satisfaction Scores Compared With Primary Arthroplasty.

INTRODUCTION: As rates of primary total joint arthroplasty continue to rise, so do rates of revision. Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) are more frequently done at larger centers, are associated with higher morbidity, and may have different patient satisfaction outcomes. This study compares the survey results of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) between patients who underwent primary versus revision THA or TKA. METHODS: All adult patients who underwent inpatient, elective, primary, and revision THA or TKA at a single institution were selected for retrospective analysis. Patient demographics, comorbidities, functional status, surgical variables, 30-day outcomes, and HCAHPS scores were assessed. Univariate and multivariate analyses were done to determine correlations between the aforementioned variables and top-box HCAHPS survey scores for primary versus revision THA and TKA. RESULTS: Of 2,707 patients who met the inclusion criteria and had returned the HCAHPS survey, primary THA was documented in 1,075 patients (39.71%), revision THA in 75 (2.77%), primary TKA in 1,497 (55.30%), and revision TKA in 60 (2.22%). Revision THA patients were more functionally dependent, and TKA patients had higher American Society of Anesthesiologists score than their primary comparators. Revisions had longer hospital length of stay for both procedures. For THA, revision THA patients demonstrated lower total top-box rates compared withprimary THA patients (71.64% versus 75.67% top-box, P < 0.001) and lower scores on the care from doctors subsection (76.26% versus 85.34%, P < 0.001) of the HCAHPS survey. Similarly, for TKA, revision TKA patients demonstrated lower total top-box rates (76.13% versus 79.22%, P < 0.013) and lower scores on the care from doctors subsection (66.28% versus 83.65%, P < 0.001) of the HCAHPS survey. DISCUSSION: For both THA and TKA, revision procedures were associated with lower total HCAHPS scores and rated care from doctors. This suggests that HCAHPS scores may be biased by factors outside the surgeon's control, such as the complexity associated with revision procedures. LEVEL OF EVIDENCE: Level III.

Correlation of Patient Reported Satisfaction With Adverse Events Following Elective Posterior Lumbar Fusion Surgery: A Single Institution Analysis.

Background: With increasing emphasis on patient satisfaction metrics, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, hospital reputations and reimbursements are being affected by their results. The purpose of the current study is to determine if post-operative self-reported patient satisfaction differed among patients who experienced any adverse event (AAE) following elective posterior lumbar fusion (PLF) surgery compared to those who did not. Methods: Patients who underwent elective PLF surgery performed at a single institution between February 2013 and May 2020 and returned an HCAHPS survey following discharge were included in the retrospective cohort analysis. Demographic, comorbidity, and HCAHPS survey data were compared between patients who did and did not experience any adverse event (AAE) in the 30-days postoperatively. Results: Of 5,117 PLF patients, the HCAHPS survey was returned by 1,071 patients, of which 30-day AAE was experienced by 40 (3.73%). Of those that experienced AAE, the survey response rate was significantly lower (13.94% versus 21.35%, p=0.003). Those responding reported lower scores pertaining to if medication side-effects were adequately explained (22.22% versus 52.56%, p=0.002) and if post-discharge care was adequately explained (79.17% versus 93.76%, p=0.005), as well as overall top-box responses (67.62% versus 75.93% survey average, p<0.001). Conclusions: Patients experiencing AAE after elective PLF surgery are less likely to respond to surveys about their hospital experience. For those who did respond, they report less satisfaction with multiple aspects of their hospital care measured by the HCAHPS survey. Understanding how postoperative adverse events impact patients' perception of healthcare quality provides insight into what patients value and has implications for optimizing their care.

In-hospital complications after cervical fusion in cases with versus without cerebral palsy.

Background: Patients with cerebral palsy (CP) are at increased risk for cervical spine pathology. Cervical fusion surgery may be considered in this population, but perioperative outcomes relative to patients without CP remains poorly understood. The purpose of this study was to compare in-hospital complications after cervical fusion in patients with versus without cerebral palsy (CP) using a retrospective cohort design. Methods: Cervical fusion cases with and without CP were identified in the National Inpatient Sample (NIS) database. In-hospital adverse events were tabulated and grouped into any (AAE), serious (SAE), and minor adverse events (MAE). Length of hospital stay (LOS) and mortality were assessed. Multiple logistic regression models with and without 1:1 propensity matching were used to compare outcomes between cases with and without CP, controlling for demographic and preoperative variables. Results: After weighting, 1,518,012 cases were included in the study population, of which 4,554 (0.30%) had CP. Those with CP were younger, more often male, suffered more comorbidities, more frequently operated on from a posterior or combined approach, and were more frequently addressed at more than one level. By multiple logistic regression after matching, CP cases had higher odds of AAE (OR 1.72; 95% CI 1.05-2.81; p=0.030) and MAE (OR 2.07; 95% CI 1.20-3.57; p=0.009), but no differences in odds of SAE or in-hospital mortality. Conclusions: As there is increasing awareness of potentially cervical pathology in the CP population, the current study suggests that surgical intervention for this population can be appropriately considered without severe in-hospital morbidity or mortality.

Admission NarxCare Narcotic Scores Are Associated With Increased Odds of Readmission and Prolonged Length of Hospital Stay After Primary Elective Total Knee Arthroplasty.

INTRODUCTION: The association of preoperative narcotic use with postoperative outcomes after primary elective total knee arthroplasty (TKA) has remained poorly characterized. The NarxCare platform analyzes patients' state Prescription Drug Monitoring Program records to assign numerical scores that approximate a patient's overall opioid usage. The present study investigated the utility of admission NarxCare narcotic scores in predicting the odds of adverse events (AEs) after primary elective TKA. METHODS: Elective primary TKA patients performed at a single institution between October 2017 and May 2020 were evaluated. NarxCare narcotic scores at the time of admission, patient characteristics, 30-day AEs, readmissions, revision surgeries, and mortality were abstracted. Elective TKA patients were binned based on admission NarxCare narcotic scores. The odds of experiencing adverse outcomes were compared. RESULTS: In total, 1136 patients met the criteria for inclusion in the study (Narx Score 0: n = 293 [25.8%], 1 to 99: n = 253 [22.3%], 100 to 299: n = 368 [32.4%], 300 to 499: n = 161 [14.2%], and 500+: n = 61 [5.37%]). By logistic regression, patients with higher admission narcotic scores tended to have a dose-dependent increase in the odds of prolonged length of hospital stay, readmission within 30 days, and aggregated AEs. DISCUSSION: Admission narcotic scores may be used to predict readmission and to stratify TKA patients by risk of AEs.

Patient Demographic and Socioeconomic Factors Associated With Physical Therapy Utilization After Uncomplicated Meniscectomy.

INTRODUCTION: The extent to which physical therapy (PT) is used after meniscectomy is unknown. The objective of this study was to estimate the extent to which PT is implemented after meniscectomy and to identify factors associated with its utilization. METHODS: The Mariner PearlDiver database was queried to identify patients who underwent uncomplicated meniscectomy. The number of PT visits for each patient was tabulated. Logistic regressions were used to compare demographic factors associated with no use of PT and use of nine or more PT visits. RESULTS: In total, 92,291 patients met inclusion criteria. Of these patients, 72.21% did not use PT and 27.8% used 1 or more PT visits. Of the patients who used PT, 19.76% had 1 to 8 PT visits and 8.03% had 9 or more PT visits. Older age and noncommercial insurance types were associated with no PT use. Male sex, Medicaid, and Medicare were associated with markedly lower odds of increased PT utilization. CONCLUSION: PT is used in the minority of the time after meniscectomy. Among patients who do use PT, however, notable variation exists in the amount of PT visits used. Patient age, sex, insurance status, and geographic variables were independently associated with PT utilization.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion.

Background: Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use. Methods: Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression. Results: Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001). Conclusions: More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Emergency Department Visits Within 90 Days of Anterior Cruciate Ligament Reconstruction.

Background: Emergency department (ED) visits after orthopaedic surgery such as anterior cruciate ligament reconstruction (ACLR) affect patients and health care systems and should be better understood. Purpose: To determine the incidence, predictors, and reasons for ED visits within 90 days after ACLR. Study Design: Descriptive epidemiologic study. Methods: Patients who had undergone ACLR between 2010 and 2020 were identified in a national database, and 90-day ED visits, readmissions, risk factors, and primary diagnoses for visits were determined. One-year postoperative data were used to establish baseline weekly ED visits for the cohort. Patient age, sex, Elixhauser comorbidity index, region of the country (Northeast, Midwest, West, South), and insurance coverage (Medicare, Medicaid, and commercial) were extracted, and these variables were compared using univariate analysis and multivariate logistic regression. Results: Out of 81,179 patients, ED visits were identified for 6764 (8.3%), and readmissions were identified for 592 (0.7%). Overall, 5300 patients had 1 ED visit, 1020 patients had 2 visits, 275 patients had 3 visits, and 169 patients had ≥4 or more visits; visits occurred within 2 weeks of surgery 38% of the time. Notably, weekly visits returned to baseline at week 3. Independent predictors of ED utilization from multivariate analysis were insurance type (relative to commercial insurance: Medicaid [odds ratio [OR], 2.41; 95% CI, 2.23-2.60] and Medicare [OR, 1.38; 95% CI, 1.19-1.60]), higher Elixhauser comorbidity index (per 2-point increase: OR, 2.24; 95% CI, 2.18-2.29), younger age (per 10-year decrease: OR, 1.23; 95% CI, 1.21-1.24), female sex (OR, 1.05; 95% CI, 1.02-1.08), and region of the country (relative to the West: Midwest [OR, 1.33; 95% CI, 1.26-1.39], Northeast [OR, 1.24; 95% CI, 1.18-1.30], and South [OR, 1.17; 95% CI, 1.12-1.23]). In the first 2 weeks, 67.5% of ED visits were for issues involving the surgical site, most commonly surgical-site pain (29% of all visits). In the total 90-day period, 39.4% of visits involved the surgical site. Conclusion: Within 90 days of ACLR, >8% of patients visited the ED, while 0.7% were readmitted. ED visits increased in the first 2 postoperative weeks and returned to baseline rates around week 3. Within the first 2 weeks, two-thirds of visits involved the surgical site. Younger patients, patients with greater comorbidity burden, those in certain regions of the country, and those with Medicaid had greater odds of ED utilization.

Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion.

Background: Osteoporosis is ubiquitous in elderly populations, such as those undergoing ACDF. Short- and longer-term outcomes might be affected in the setting of osteoporosis related to graft subsidence, bony union, and stresses on adjacent segments. Better understanding the potential correlation of osteoporosis and outcomes after ACDF might affect patient counseling and surgical planning. The current study compares 90-day adverse events and 5-year reoperations following single-level anterior cervical discectomy and fusion (ACDF) between patients with and without osteoporosis. Methods: Single-level ACDF procedures were identified in a national administrative database. Exclusion criteria included age under 18 years, less than 90 days of follow-up in the database, multi-level procedures, posterior concomitant procedures, and surgeries performed for trauma, neoplasm, or infection. After matching based on patient characteristics, 90-day perioperative adverse events were compared with multivariate analyses and five-year reoperations were compared with log-rank analysis. Reasons for reoperations were also evaluated. Results: Relative to age, sex, and comorbidity-matched patients without osteoporosis, those with osteoporosis had a small but statistically greater incidence of experiencing any 90-day adverse event (10.9% vs 9.4%, p < 0.001) and 5-year reoperations (19.1% vs 17.0%, p < 0.001). Of those requiring reoperation, those in the osteoporosis group had a greater proportion for nonunion (7.5% vs 5.6% p = 0.003). Conclusions: Following single-level ACDF, patients with osteoporosis experience slightly greater 90-day adverse events and 5-year reoperations. These results suggest the importance of recognizing osteoporosis in the ACDF population and accounting for this with surgical planning and patient counselling.

Underweight patients are the highest risk body mass index group for perioperative adverse events following stand-alone anterior lumbar interbody fusion.

BACKGROUND CONTEXT: Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts. PURPOSE: The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases. OUTCOME MEASURES: Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality. METHODS: Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/m3), were calculated. Multivariate analysis was then performed controlling for patient factors. RESULTS: In total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI<18.5 kg/m3) and super morbidly obese (>50 kg/m3), however, multivariate risks for adverse events and postoperative infection were elevated for underweight patients beyond those found in any other BMI category. No effect was noted in these identical variables between normal, overweight, obese class 1, or even obese class 2 patients. Multivariate analysis also found overweight patients to show a slightly protective trend against mortality while the super morbidly obese had elevated odds. CONCLUSIONS: Underweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.

Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery.

Venous thromboembolism (VTE) is an uncommon but highly morbid and potentially preventable complication in children. This study aimed to characterize the incidence of, and risk factors for, VTE in children undergoing orthopedic surgery. A retrospective analysis was performed using the 2012 to 2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Patient demographics, comorbidities, operative variables, and perioperative outcomes were compared between patients who did and did not develop a VTE. In total, 81,490 pediatric patients who underwent orthopedic surgery were identified. Of those, the mean±SD age was 9.7±4.8 years, and 50.1% were male. Sixty patients (0.07%) developed a postoperative VTE. On multivariate regression, demographic and surgical variables associated with a VTE were ages 16 to 18 years (P=.002; compared with ages 11 to 15 years), American Society of Anesthesiologists (ASA) classes III and V (P=.003; compared with ASA classes I and II), preoperative blood transfusion (P<.001), arthrotomy (P<.001), and femur fracture (P<.001). Postoperative adverse events occurring prior to a VTE were also assessed. Controlling for patient factors, independent risk factors for VTE included any adverse event (P<.001), major adverse events (P<.001), minor adverse events (P<.001), reoperation (P<.001), and readmission (P<.001). This study identified an incidence of VTE of 0.07% in a population of more than 80,000 children undergoing orthopedic surgery. The identification of risk factors for VTE in this patient population raises the issue of VTE prophylaxis for select high-risk subpopulations. [Orthopedics. 2022;45(1):31-37.].