Adult spinal deformity.

Adult spinal deformity affects the thoracic or thoracolumbar spine throughout the ageing process. Although adolescent spinal deformities taken into adulthood are not uncommon, the most usual causes of spinal deformity in adults are iatrogenic flatback and degenerative scoliosis. Given its prevalence in the expanding portion of the global population aged older than 65 years, the disorder is of growing interest in health care. Physical examination, with a focus on gait and posture, along with radiographical assessment are primarily used and integrated with risk stratification indices to establish optimal treatment planning. Although non-operative treatment is regarded as the first-line response, surgical outcomes are considerably favourable. Global disparities exist in both the assessment and treatment of adults with spinal deformity across countries of varying incomes, which represents an area requiring further investigation. This Seminar presents evidence and knowledge that represent the evolution of data related to spinal deformity in adults over the past several decades.

The Dubousset Functional Test is a Novel Assessment of Physical Function and Balance.

BACKGROUND: Currently, the functional status of patients undergoing spine surgery is assessed with quality-of-life questionnaires, and a more objective and quantifiable assessment method is lacking. Dr. Jean Dubousset conceptually proposed a four-component functional test, but to our knowledge, reference values derived from asymptomatic individuals have not yet been reported, and these are needed to assess the test's clinical utility in patients with spinal deformities. QUESTIONS/PURPOSES: (1) What are the reference values for the Dubousset Functional Test (DFT) in asymptomatic people? (2) Is there a correlation between demographic variables such as age and BMI and performance of the DFT among asymptomatic people? METHODS: This single-institution prospective study was performed from January 1, 2018 to May 31, 2018. Asymptomatic volunteers were recruited from our college of medicine and hospital staff to participate in the DFT. Included participants did not report any musculoskeletal problems or trauma within 5 years. Additionally, they did not report any history of lower limb fracture, THA, TKA, or patellofemoral arthroplasty. Patients were also excluded if they reported any active medical comorbidities. Demographic data collected included age, sex, BMI, and self-reported race. Sixty-five asymptomatic volunteers were included in this study. Their mean age was 42 ± 15 years; 27 of the 65 participants (42%) were women. Their mean BMI was 26 ± 5 kg/m. The racial distribution of the participants was 34% white (22 of 65 participants), 25% black (16 of 65 participants), 15% Asian (10 of 65 participants), 9% subcontinental Indian (six of 65 participants), 6% Latino (four of 65 participants), and 10% other (seven of 65 participants). In a controlled setting, participants completed the DFT after verbal instruction and demonstration of each test, and all participants were video recorded. The four test components included the Up and Walking Test (unassisted sit-to-stand from a chair, walk forward/backward 5 meters [no turn], then unassisted stand-to-sit), Steps Test (ascend three steps, turn, descend three steps), Down and Sitting Test (stand-to-ground, followed by ground-to-stand, with assistance as needed), and Dual-Tasking Test (walk 5 meters forwards and back while counting down from 50 by 2). Tests were timed, and data were collected from video recordings to ensure consistency. Reference values for the DFT were determined via a descriptive analysis, and we calculated the mean, SD, 95% CI, median, and range of time taken to complete each test component, with univariate comparisons between men and women for each component. Linear correlations between age and BMI and test components were studied, and the frequency of verbal and physical pausing and adverse events was noted. RESULTS: The Up and Walking Test was completed in a mean of 15 seconds (95% CI, 14-16), the Steps Test was completed in 6.3 seconds (95% CI, 6.0-6.6), the Down and Sitting Test was completed in 6.0 seconds (95% CI, 5.4-6.6), and the Dual-Tasking Test was performed in 13 seconds (95% CI, 12-14). The length of time it took to complete the Down and Sitting (r = 0.529; p = 0.001), Up and Walking (r = 0.429; p = 0.001), and Steps (r = 0.356; p = 0.014) components increased with as the volunteer's age increased. No correlation was found between age and the time taken to complete the Dual-Tasking Test (r = 0.134; p = 0.289). Similarly, the length of time it took to complete the Down and Sitting (r = 0.372; p = 0.005), Up and Walking (r = 0.289; p = 0.032), and Steps (r = 0.366; p = 0.013) components increased with increasing BMI; no correlation was found between the Dual-Tasking Test's time and BMI (r = 0.078; p = 0.539). CONCLUSIONS: We found that the DFT could be completed by asymptomatic volunteers in approximately 1 minute, although it took longer for older patients and patients with higher BMI. CLINICAL RELEVANCE: We believe, but did not show, that the DFT might be useful in assessing patients with spinal deformities. The normal values we calculated should be compared in future studies with those of patients before and after undergoing spine surgery to determine whether this test has practical clinical utility. The DFT provides objective metrics to assess function and balance that are easy to obtain, and the test requires no special equipment.

Spine Injuries in Child Abuse.

BACKGROUND: Although rare, spinal injuries associated with abuse can have potentially devastating implications in the pediatric population. We analyzed the association of pediatric spine injury in abused children and determined the anatomic level of the spine affected, while also focusing on patient demographics, length of stay, and total hospital charges compared with spine patients without a diagnosis of abuse. METHODS: A retrospective review of the Kids' Inpatient Database was conducted from 2000 to 2012 to identify pediatric patients (below 18 y) who sustained vertebral column fractures or spinal cord injuries. Patients with a documented diagnosis of abuse were identified using ICD-9-CM diagnosis codes. Our statistical models consisted of multivariate linear regressions that were adjusted for age, race, and sex. RESULTS: There were 22,192 pediatric patients with a diagnosis of spinal cord or vertebral column injury during the study period, 116 (0.5%) of whom also had a documented diagnosis of abuse. The most common type of abuse was physical (75.9%). Compared with nonabused patients, abused patients were more likely to be below 2 years of age (OR=133.4; 95% CI, 89.5-198.8), female (OR=1.67; 95% CI, 1.16-2.41), and nonwhite (black: OR=3.86; 95% CI, 2.31-6.45; Hispanic: OR=2.86; 95% CI, 1.68-4.86; other: OR=2.33; 95% CI, 1.11-4.86). Abused patients also presented with an increased risk of thoracic (OR=2.57; 95% CI, 1.67-3.97) and lumbar (OR=1.67; 95% CI, 1.03-2.72) vertebral column fractures and had a multivariate-adjusted mean length of stay that was 62.2% longer (P<0.001) and mean total charges that were 52.9% higher (P<0.001) compared with nonabused patients. Furthermore, 19.7% of all pediatric spine patients under 2 years of age admitted during the study period belonged to the abused cohort. CONCLUSIONS: Spine injuries are rare but can be found in the pediatric population. With an additional documented diagnosis of abuse, these injuries affect younger patients in the thoracolumbar region of the spine, and lead to longer lengths of stay and higher hospital costs when compared with nonabused patients. Because of these findings, physicians should maintain a higher level of suspicion of abuse in patients with spine injuries, especially patients under 2 years of age. LEVEL OF EVIDENCE: Level III evidence-a case-control study.

Comparison of a Posterior versus Anterior Approach for Lumbar Interbody Fusion Surgery Based on Relative Value Units.

INTRODUCTION: The current value-driven healthcare system encourages physicians to continuously optimize the value of the services they provide. Relative value units (RVUs) serve as the basis of a reimbursement model linking the concept that as the effort and value of services provided to patient's increases, physician reimbursement should increase proportionately. Spine surgery is particularly affected by these factors as there are multiple ways to achieve similar outcomes, some of which require more time, effort, and risk. Specifically, as the trend of spinal interbody fusion has increased over the past decade, the optimal approach to use-posterior versus anterior lumbar interbody fusion (PLIF vs. ALIF)-has been a source of controversy. Due to potential discrepancies in effort, one factor to consider is the correlation between RVUs and the time needed to perform a procedure. Therefore, the purpose of this study was to compare: 1) mean RVUs; 2) mean operative time; and 3) mean RVUs per unit of time between PLIF and ALIF with the utilization of a national surgical database. We also performed an individual surgeon cost benefit analysis for performing PLIF versus ALIF. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify 6,834 patients who underwent PLIF (CPT code: 22630) and 6,985 patients who underwent ALIF (CPT code: 22558) between 2008 and 2015. The mean operative times (in minutes), mean RVUs, and RVUs per minute were calculated and compared using the Student's t-tests. In addition, the reimbursement amount (in dollars) per minute, case, day, and year for an individual surgeon performing PLIF versus ALIF were also calculated and compared. A p-value of less than 0.05 was used as the threshold for statistical significance. RESULTS: Compared to ALIF cases, PLIF cases had longer mean operative times (203 vs. 212 minutes, p<0.001). However, PLIF cases were assigned lower mean RVUs than ALIF cases (22.08 vs. 23.52, p<0.001). Furthermore, PLIF had a lower mean RVU/minutes than ALIF cases (0.126 vs. 0.154, p<0.001). The reimbursement amounts calculated for PLIF versus ALIF were: $4.52 versus $5.53 per minute, $958.66 versus $1,121.95 per case, and $2,875.98 versus $3,365.86 per day. The annual cost difference was $78,380.92. CONCLUSION: The data from this study indicates a potentially greater annual compensation of nearly $80,000 for performing ALIF as opposed to PLIF due to a higher "hourly rate" for ALIF as is noted by the significantly greater RVU per minute (0.154 vs. 0.126 RVU/minutes). These results can be used by spine surgeons to design more appropriate compensation effective practices while still providing quality care.

Complications in Patients Undergoing Spinal Fusion After THA.

INTRODUCTION: Patients with lumbar spine and hip disorders may, during the course of their treatment, undergo spinal fusion and THA. There is disagreement among prior studies regarding whether patients who undergo THA and spinal fusion are at increased risk of THA dislocation and other hip-related complications. QUESTIONS / PURPOSES: Is short or long spinal fusion associated with an increased rate of postoperative complications in patients who underwent a prior THA? PATIENTS AND METHODS: A retrospective study of New York State's Department of Health database (SPARCS) was performed. SPARCS has a unique identification code for each patient, allowing investigators to track the patient across multiple admissions. The SPARCS dataset spans visit data of patients of all ages and races across urban and rural locations. The SPARCs dataset encompasses all facilities covered under New York State Article 28 and uses measures to further representative reporting of data concerning all races. Owing to the nature of the SPARCS dataset, we are unable to comment on data leakage, as there is no way to discern between a patient who does not subsequently seek care and a patient who seeks care outside New York State. ICD-9-Clinical Modification codes identified adult patients who underwent elective THA from 2009 to 2011. Patients who had subsequent spinal fusion (short: 2-3 levels, or long: ≥ 4 levels) with a diagnosis of adult idiopathic scoliosis or degenerative disc disease were identified. Forty-nine thousand nine hundred twenty patients met the inclusion criteria of the study. In our inclusion and exclusion criteria, there was no variation with respect to the distribution of sex and race across the three groups of interest. Patients who underwent a spinal procedure (short versus long fusion) had comparable age. However, patients who did not undergo a spinal procedure were older than patients who had short fusion (65 ± 12.4 years versus 63 ± 10.7 years; p < 0.001). Multivariate binary logistic regression models that controlled for age, sex, and Deyo/Charlson scores were used to investigate the association between spinal fusion and THA revisions, postoperative dislocation, contralateral THAs, and total surgical complications to the end of 2013. A total of 49,920 patients who had THAs were included in one of three groups (no subsequent spinal fusion: n = 49,209; short fusion: n = 478; long fusion: n = 233). RESULTS: Regression models revealed that short and long spinal fusions were associated with increased odds for hip dislocation, with associated odds ratios (ORs) of 2.2 (95% CI, 1.4-3.6; p = 0.002), and 4.4 (95% CI, 2.7-7.3; p < 0.001), respectively. Patients who underwent THA and spinal surgery also had an increased odds for THA revision, with ORs of 2.0 (95% CI, 1.4-2.8; p < 0.001) and 3.2 (95% CI, 2.1-4.8; p < 0.001) for short and long fusion, respectively. However, spinal fusions were not associated with contralateral THAs. Further, short and long spinal fusions were associated with increased surgical complication rates (OR = 2.8, 95% CI, 2.1-3.8, p < 0.001; OR = 5.3, 95% CI, 3.8-7.4, p < 0.001, respectively). CONCLUSION: We showed that spinal fusion in adults is associated with an increased frequency of complications and revisions in patients who have had a prior THA. Specifically, patients who had a long spinal fusion after THA had 340% higher odds of experiencing a hip dislocation and 220% higher odds of having to undergo a revision THA. Further research is necessary to determine whether this relationship is associated with the surgical order, or whether more patient-specific surgical goals of revision THA should be developed for patients with a spinal deformity. LEVEL OF EVIDENCE: Level III, therapeutic study.

Adult cervical deformity: radiographic and osteotomy classifications.

Cervical spine deformity represents a broad spectrum of pathologies that are both complex in etiology and debilitating towards quality of life for patients. Despite advances in the understanding of drivers and outcomes of cervical spine deformity, only one classification system and one system of nomenclature for osteotomy techniques currently exist. Moreover, there is a lack of standardization regarding the indications for each technique. This article reviews the adult cervical deformity (ACD) and current classification and nomenclature for osteotomy techniques, highlighting the need for further work to develop a unified approach for each case and improve communication amongst the spine community with respect to ACD.

Does Total Ankle Arthroplasty Belong in the Comprehensive Care for Joint Replacement?

The Comprehensive Care for Joint Replacement (CJR) model seeks to lower costs and improve quality for primary lower extremity joint replacements. This includes total ankle arthroplasty (TAA), which is performed far less frequently than total hip (THA) and knee (TKA) arthroplasty. We used the SPARCS database to identify 537 TAA and 239,053 elective primary THA or TKA procedures from 2009 to 2014, excluding hip fractures. Compared with THA and TKA, TAA had a shorter mean length of stay (2.2 versus 3.2 days), greater mean cost ($20,817 versus $17,613), lower rate of disposition to nursing and rehabilitation facilities (17% versus 52%), and lower rate of 90-day readmission (4.9% versus 5.8%). In multivariable-adjusted regression models of TAA versus THA and TKA, length of stay was 30% shorter (p < .001), costs were 14% greater (p < .001), and risk of disposition to nursing and rehabilitation facilities was 86% lower (p < .001), with no significant difference in 90-day readmission (p = .957). Patients undergoing TAA had different patterns of short-term resource usage compared with patients undergoing THA and TKA, most notably higher short-term costs. The economic viability of TAA is threatened by alternative payment models that reimburse hospitals for TAA at the same rate as THA and TKA.

ORIF versus arthroplasty for open proximal humerus fractures: Nationwide Inpatient Sample data between 1998 and 2013.

BACKGROUND: Limited data exists in analyzing open reduction and internal fixation (ORIF) and arthroplasty in the management of open proximal humerus fractures. We analyzed differences in hospital course between these procedures, patient demographics, complication rate, length of stay, hospital charges, and mortality rate. MATERIALS AND METHODS: This is a retrospective review of the Nationwide Inpatient Sample database. ICD-9 codes identified patients hospitalized for open proximal humerus fractures from 1998 to 2013 who underwent ORIF or shoulder arthroplasty (hemi-, total, or reverse). Demographics and in-hospital complications were compared. Logistic regression controlling for age, gender, and Deyo index tested the impact of ORIF vs ARTH on any complications. RESULTS: Seven hundred thirty patients were included (ORIF, n = 662 vs ARTH, n = 68). ORIF patients were younger (p < 0.001), more likely to be males (p < 0.001), and had a lower Deyo score (p = 0.012). Both groups had comparable complication rates (21.4% vs 18.0%, p = 0.535), lengths of stay (7.86 days vs 7.44 days, p = 0.833), hospital charges ($76,998 vs $64,133, p = 0.360), and mortality rates (0.2% vs 0%, p = 0.761). Type of surgery was not a predictor of any complications (OR = 0.67 [95% CI 0.33-1.35], p = 0.266), extended length of stay (OR = 1.01 [95% CI 0.58-1.78], p = 0.967), or high hospital charges (OR = 1.39 [95% CI 0.68-2.86], p = 0.366). CONCLUSION: We revealed no differences in hospital course between ORIF and arthroplasty for management of open proximal humerus fractures. Although differences in demographics existed, no differences in complication rates, length of stay, hospital charges and mortality rates were noted. Future studies can evaluate the long-term outcomes of these procedures. LEVEL OF EVIDENCE: Level III.

Prosthetic Dislocation and Revision After Primary Total Hip Arthroplasty in Lumbar Fusion Patients: A Propensity Score Matched-Pair Analysis.

BACKGROUND: Lumbar-pelvic fusion reduces the variation in pelvic tilt in functional situations by reducing lumbar spine flexibility, which is thought to be important in maintaining stability of a total hip arthroplasty (THA). We compared dislocation and revision rates for patients with lumbar fusion and subsequent THA to a matched comparison cohort with hip and spine degenerative changes undergoing only THA. METHODS: We identified patients in New York State who underwent primary elective lumbar fusion for degenerative disc disease pathology and subsequent THA between January 2005 and December 2012. A propensity score match was performed to compare 934 patients with prior lumbar fusion to 934 patients with only THA according to age, gender, race, Deyo comorbidity score, year of surgery, and surgeon volume. Revision and dislocation rates were assessed at 3, 6, and 12 months post-THA. RESULTS: At 12 months, patients with prior lumbar fusion had significantly increased rates of THA dislocation (control: 0.4%; fusion: 3.0%; P < .001) and revision (control: 0.9%; fusion: 3.9%; P < .001). At 12 months, fusion patients were 7.19 times more likely to dislocate their THA (P < .001) and 4.64 times more likely to undergo revision (P < .001). CONCLUSION: Patients undergoing lumbar fusion and subsequent THA have significantly higher risks of dislocation and revision of their hip arthroplasty than a matched cohort of patients with similar hip and spine pathology but only undergoing THA. During preoperative consultation for patients with prior lumbar fusion, orthopedic surgeons must educate the patient and family about the increased risk of dislocation and revision.

Venous Thromboembolic Disease in Revision vs Primary Total Knee Arthroplasty.

BACKGROUND: Venous thromboembolic disease (VTED) is a serious complication of primary and revision total knee arthroplasty (TKA). However, the incidence and risk of VTED for revision compared with primary TKA cases have not been well-described. METHODS: We identified 225,584 TKAs (208,954 primaries, 16,630 revisions) in the 2003-2012 Statewide Planning and Research Cooperative System database. Odds ratios (ORs) expressed the risk of VTED for revision vs primary TKA, and models were adjusted for age, gender, race, and Charlson comorbidity scores. Outcome analyses were further stratified into deep venous thromboses (DVTs) and pulmonary emboli (PEs). RESULTS: The incidence of VTED within 30 days was 2.24% for primary and 1.84% for revision. In multivariable-adjusted regression, the OR of VTED within 30 days for revision compared with primary was 0.81 (95% confidence interval = 0.72-0.91; P < .001). The incidence of VTED within 90 days was 2.42% for primary and 2.13% for revision (P = .022), with a multivariable-adjusted OR of 0.87 (95% confidence interval = 0.78-0.97; P = .010) for revision compared with primary. The association was stronger for PE (OR = 0.63; P < .001) than DVT (OR = 0.87; P = .035) at 30 days, and significant for PE (OR = 0.69; P < .001), but not DVT (OR = 0.94; P = .284) at 90 days. CONCLUSION: In a large statewide database, the risk of VTED was lower for revision TKA compared with primary TKA. The reasons for this observation are not known, but might be related to aggressive prophylactic management of patients undergoing revision procedures. Future studies should attempt to clarify differences in patient selection and management for primary vs revision procedures.

Have Periprosthetic Hip Infection Rates Plateaued?

BACKGROUND: Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Although the number of revision cases is increasing, the prevalence of PJI as an indication for revision surgery, and the variability of this indication among surgeons and hospitals, is unclear. METHODS: The New York Statewide Planning and Research Cooperative System was used to identify 33,582 patients undergoing revision THA between 2000 and 2013. PJI was identified using International Classification of Diseases, Ninth Revision diagnosis codes. Volume was defined using mean number of revision THAs performed annually by each hospital and surgeon. RESULTS: PJI was the indication for 13.0% of all revision THAs. The percentage of revision THAs for PJI increased between years 2000 and 2007 (odds ratio [OR] = 1.05, P < .001), but decreased between years 2008 and 2013 (OR = 0.96, P = .001). Compared to medium-volume hospitals, the PJI burden at high-volume hospitals decreased during years 2000-2007 (OR = 0.58, P < .001) and 2008-2013 (OR = 0.57, P < .001). Compared to medium-volume surgeons, the PJI burden for high-volume surgeons increased during years 2000-2007 (OR = 1.39, P < .001), but did not differ during years 2008-2013 (P = .618). CONCLUSION: The burden of PJI as an indication for revision THA may be plateauing. High-volume institutions have seen decreases in the percentage of revisions performed for PJI over the complete study duration. Specific surgeon may be associated with the plateauing in PJI rates as high-volume surgeons in 2008-2013 were no longer found to be at increased risk of PJI as an indication for revision THA.

Is Day of Surgery Associated With Adverse Clinical and Economic Outcomes Following Primary Total Knee Arthroplasty?

BACKGROUND: As orthopedics transition to value-based purchasing, hospitals and providers are incentivized to identify inefficiencies of care delivery. In our experience, weekends are characterized by decreased staffing of ancillary services to coordinate patient discharges, which can lead to prolonged hospital stays for many of our primary total knee arthroplasty (TKA) admissions. METHODS: We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State. We used mixed effects regression models to compare length of stay (LOS), 90-day readmission, and cost according to the day of TKA. RESULTS: Mean LOS was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). There was no significant difference in 90-day readmission risk according to day of surgery. Mean cost was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). When LOS was held constant across every day of the week, the mean cost of TKA decreased by $247 for Wednesday, $627 for Thursday, and $394 for Friday. CONCLUSION: Primary TKA performed later in the week is associated with an increased LOS and increased costs of admission, but a similar risk of 90-day readmission. Preferential scheduling of primary TKA cases early in the week, as well as the development of standardized clinical care pathways with appropriate weekend staffing of social work and rehabilitation services, could help to decrease the daily variation in LOS and increase the value of TKA episodes.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BACKGROUND: Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. METHODS: We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients undergoing surgery at teaching hospitals had longer lengths of stay (ß = 3.2%; P < .001) and higher costs of admission (ß = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). CONCLUSION: Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Demographics of Tennis-Related Injuries that Presented to Emergency Departments in the United States.

INTRODUCTION: Tennis injuries are not uncommon, and efforts have been made to reduce the risk of these injuries. There are a number of different factors that have been shown to influence injury rates of tennis players, in particular patient-related risks. Therefore, the purpose of this study was to investigate the epidemiology of tennis-related injuries. Specifically, we evaluated: 1) demographics; 2) incidence and trends of injuries; and 3) incidence and trends of body parts that were injured. MATERIALS AND METHODS: This study utilized the National Electronic Injury Surveillance System (NEISS) database to collect all tennis-related sprains/strains that occurred between January 1, 2010 and December 31, 2016. Patients were stratified into four groups based on their age: 13 years and younger, 14 to 29 years, 30 to 54 years, and 55 years and older. Race was reported as white, black, Hispanic, Asian, Native Hawaiian, American Indian, Multiracial, and not stated. The various types of tennis-related injuries that occurred, and the different body parts that were affected were identified. RESULTS: There were a total of 150,747 tennis-related injuries that occurred during the study period. Thirty-nine percent of all injuries occurred in patients aged 55 years and older, 25% in patients between the ages of 14 and 29 years, 24% occurred between the ages of 30 and 54 years, and 12% occurred in patients aged 13 years and younger. In terms of gender, 56% were men and 44% were women. In terms of race, injuries most commonly occurred in patients who were white (48%). The most common overall injury pattern was sprains/strains, which represented 32% of all reported injuries, followed by fractures (15%) and contusions (11%). The most commonly injured body parts were the ankle (13%), wrist (9.4%), upper-trunk (8.5%), knee (7.8%), and lower-trunk (6.7%). Over the study period, there was a significant decrease in ankle injuries (R2=0.691, p=0.021) and a significant increase in upper-trunk injuries (R2=0.695, p=0.020). CONCLUSION: The present study provided important insight regarding tennis-related injuries in terms of demographics, injury types, and injury patterns. This information is paramount for the future treatment of all tennis-related injuries and for the implementation of prevention strategies for those injuries which are most prevalent.

Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?

INTRODUCTION: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081. CONCLUSIONS: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

Have the Yearly Trends of Total Hip Arthroplasty in Ankylosing Spondylitis Patients Decreased?

INTRODUCTION: Ankylosing spondylitis (AS) is characterized by spinal inflammation and structural damage, primarily to the axial skeleton and sacroiliac joints. Between 25% and 70% of patients may experience progressive peripheral joint involvement, which, despite advancement in pharmacologic therapy, may necessitate surgical intervention. Total hip arthroplasty (THA) yields improved pain and functional outcomes for AS patients with hip involvement. It is unclear whether the annual rates of patients undergoing THA have changed due to newer pharmacologic management. Therefore, the purpose of this study was to evaluate the annual trends of AS patients who underwent THA. Specifically, we evaluated: 1) the annual trends of THAs due to AS in the United States population, and 2) the annual trends in the proportion of THAs due to AS in the United States. MATERIALS AND METHODS: This study used the Nationwide Inpatient Sample to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, an additional query was performed to identify THA patients who had a diagnosis of AS, defined by the International Classification of Disease 9th revision diagnosis code 720. The incidence of THAs with a diagnosis of AS in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of AS in patients who underwent THA. RESULTS: Review of the database identified 5,562 patients with AS who underwent THA. The overall annual prevalence of THA in the AS population significantly decreased during the 12-year study period from 2.24 per 1,000 THAs in 2002 to 1.73 per 1,000 THAs in 2013 (R2=0.445; p=0.018). CONCLUSION: Annual THA trends in AS patients have significantly declined from 2002 to 2013. This decline may be attributed to improvements in medical management that delay the time from disease onset to requirement of a THA. Since THA is an option with advanced disease, the observed declining trends may indicate the efficacy of current medical management.

Does Chronic Corticosteroid Use Increase Risks of Readmission, Thromboembolism, and Revision After THA?

BACKGROUND: Systemic corticosteroids are commonly used to treat autoimmune and inflammatory diseases, but they can be associated with various musculoskeletal problems and disorders. There currently is a limited amount of data describing the postoperative complications of THA associated specifically with chronic corticosteroid use. QUESTIONS/PURPOSES: For chronic corticosteroid users undergoing THA, we asked: (1) What is the risk of hospital readmission at 30 and 90 days after surgery? (2) What is the risk of venous thromboembolism at 30 and 90 days after surgery? (3) What is the risk of revision hip arthroplasty at 12 and 24 months after surgery? METHODS: We identified patients in the Statewide Planning and Research Cooperative System who underwent primary THA between January 2003 and December 2010. This database provides hospital discharge abstracts for all admissions in the state of New York each year. We used propensity scores to three-to-one match the 402 chronic corticosteroid users with a comparison cohort of 1206 patients according to age, sex, race, comorbidity score, year of surgery, and hip osteonecrosis. The risk of each outcome was compared between chronic corticosteroid users and the matched cohort. Because multiple comparisons were made, we considered p less than 0.008 as statistically significant. RESULTS: Readmission was more common for corticosteroid users at 30 days (odds ratio [OR], 1.45; 95% CI, 1.14-1.85; p = 0.003) and 90 days (OR, 1.37; 95% CI, 1.09-1.73; p = 0.007). Venous thromboembolism was not more frequent in corticosteroid users at 30 days (OR, 2.39; 95% CI, 1.08-5.26; p = 0.031) or 90 days (OR, 1.91; 95% CI, 1.03-3.53; p = 0.039). Revision arthroplasty was more common in corticosteroid users at 12 months (OR, 2.49; 95% CI, 1.35-4.59; p = 0.004), but not 24 months (OR, 2.04; 95% CI, 1.19-3.50; p = 0.010). CONCLUSIONS: After THA, chronic corticosteroid use is associated with an increased risk of readmission at 30 and 90 days and revision hip arthroplasty at 12 months in corticosteroid users. Patients and providers should discuss these risks before surgery. Insurers should consider incorporating chronic corticosteroid use as a comorbidity in bundled payments for THA, since this patient population is more likely to return to their provider for care during the postoperative period. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does Hemophilia Increase the Risk of Postoperative Blood Transfusion After Lower Extremity Total Joint Arthroplasty?

BACKGROUND: Hemophilia can lead to the development of arthropathies secondary to recurrent hemarthroses. However, given these patients' bleeding tendencies, postoperative complications associated with blood loss are a considerable concern. METHODS: We identified men in the Nationwide Inpatient Sample who underwent total hip or knee arthroplasty between January 1998 and December 2010. We used propensity scores to match 332 hemophiliacs (267 hemophilia A, 65 hemophilia B) to a comparison cohort of 996 patients in a 1:3 ratio, according to the site of arthroplasty, year of admission, age, race, and Charlson and Deyo score. RESULTS: The incidence of any postoperative transfusion was 15.06% for hemophiliacs, compared with 9.84% for the matched comparison cohort (P = .012). For hemophiliacs, the odds ratio was 1.60 (95% confidence interval [CI] = 1.11-2.31; P = .013) for any transfusion, 1.90 (95% CI = 1.24-2.92; P = .003) for allogenic transfusion, and 1.05 (95% CI = 0.56-1.95; P = .888) for autogenic transfusion. CONCLUSION: Hemophilia is associated with an increased risk of blood transfusion after lower extremity total joint arthroplasty. Patients and providers should discuss these risks before surgery, and insurers should consider incorporating this comorbidity into bundled payments for total hip and knee arthroplasty.

In-Hospital Mortality Following Open and Closed Long Bone Fracture: A Comparative Study.

BACKGROUND: Open fracture is a serious orthopaedic injury that can lead to significant patient morbidity and mortality. There is limited data on the mortality risk for open compared to closed long bone fracture. METHODS: The Nationwide Inpatient Sample was used to identify all patients who were admitted with a long bone fracture in the United States between 1998 and 2010. Cox proportional hazards regression modeling was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of mortality. RESULTS: After adjusting for age, gender, race, insurance, and comorbidities, the HR of mortality was 2.89 (95% CI, 2.56-3.28; p<0.001) for open compared to closed fracture. Stratified by anatomical site, the HR of mortality for open compared to fracture was 3.43 for femur (95% CI, 2.78-4.23; p<0.001), 2.81 for tibia or fibula (95% CI, 2.17-3.64; p<0.001), 2.54 for humerus (95% CI, 1.81-3.56; p<0.001), and 1.56 for radius or ulna (95% CI, 1.10-2.23; p=0.014). CONCLUSIONS: This data suggests that open fracture carries a worse prognosis compared to closed fracture at the same anatomical site.

Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

STUDY DESIGN: Retrospective Single-Center Study. OBJECTIVE: To assess the influence of frailty on optimal outcome following ASD corrective surgery. SUMMARY OF BACKGROUND DATA: Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on best possible outcome. METHODS: ASD patients with frailty measures, baseline and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on 2-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation. RESULTS: 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF-group had the highest rate of deterioration (16.7%, P=0.025) at the second postoperative year but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P=0.886). Improvement of SF patients was greatest at 6 months (ΔODI of -22.6±18.0, P<0.001) but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at 6 months, P<0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 years, F: 6.7±0.511 years, SF: 5.8±0.757 years; P=0.113). CONCLUSIONS: Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery. LEVEL OF EVIDENCE: III.