Prediction of 5-year survival in soft tissue leiomyosarcoma using a machine learning model algorithm.

BACKGROUND AND OBJECTIVES: Leiomyosarcoma (LMS) is associated with one of the poorest overall survivals among soft tissue sarcomas. We sought to develop and externally validate a model for 5-year survival prediction in patients with appendicular or truncal LMS using machine learning algorithms. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used for development and internal validation of the models; external validation was assessed using our institutional database. Five machine learning algorithms were developed and then tested on our institutional database. Area under the receiver operating characteristic curve (AUC) and Brier score were used to assess model performance. RESULTS: A total of 2209 patients from the SEER database and 81 patients from our tertiary institution were included. All models had excellent calibration with AUC 0.84-0.85 and Brier score 0.15-0.16. After assessing the performance indicators according to the TRIPOD model, we found that the Elastic-Net Penalized Logistic Regression outperformed other models. The AUCs of the institutional data were 0.83 (imputed) and 0.85 (complete-case analysis) with a Brier score of 0.16. CONCLUSION: Our study successfully developed five machine learning algorithms to assess 5-year survival in patients with LMS. The Elastic-Net Penalized Logistic Regression retained performance upon external validation with an AUC of 0.85 and Brier score of 0.15.

Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty.

BACKGROUND: There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty. METHODS: A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts. RESULTS: There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort. CONCLUSION: SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Increased Dislocation Rates After Total Hip Arthroplasty in Patients With Prior Isolated Sacroiliac Joint Arthrodesis.

BACKGROUND: While stiffness of the lumbosacral spine is a known predictor of instability following total hip arthroplasty (THA), little is known about the medical- and surgical-related outcomes following THA in patients who have prior isolated sacroiliac (SI) joint arthrodesis. METHODS: 197 patients who had a history of isolated SI joint arthrodesis who subsequently underwent elective primary THA for a diagnosis of osteoarthritis (THA-SI) from 2015 to 2021 were identified in a national administrative database. Using propensity score matching and logistic regression analyses, this cohort was compared to two groups of patients: patients who did not have any history of lumbar or SI arthrodesis and patients undergoing primary THA who had a history of lumbar arthrodesis without extension into the SI joint (THA-LF). RESULTS: The THA-SI group had a significantly higher incidence of dislocation (odds ratio 2.06, 95% confidence interval 1.04-4.04, P = .037) with no increased incidence of medical complications or other surgical complications when compared to patients without a history of SI or lumbar arthrodesis. There were no significant differences in any complications in THA-SI patients when compared to THA-LF patients. CONCLUSION: Patients who had prior isolated SI joint arthrodesis undergoing primary THA demonstrated a two-fold increased incidence of dislocation when compared to those who did not have prior SI arthrodesis, although the risk of complications in this population was similar to that observed in patients who had prior isolated lumbar spine arthrodesis.

Artificial Intelligence in Adult Spinal Deformity.

Artificial Intelligence is gaining traction in medicine for its ease of use and advancements in technology. This study evaluates the current literature on the use of artificial intelligence in adult spinal deformity.

The Utilization of Postoperative Inpatient Ultrasound for Lower Extremity Deep Venous Thrombosis Following Total Hip Arthroplasty has Decreased Dramatically Over the Past Decade With No Obvious Negative Impact on Patient Care.

BACKGROUND: Surgeons are increasingly performing total hip arthroplasty (THA) in the outpatient setting. Lower lengths of stay (LOS) could result in fewer lower extremity ultrasounds for deep vein thromboses (DVT). The objective of this study was to evaluate the incidence of lower extremity ultrasounds ordered and positive DVT results in the immediate postoperative period. METHODS: All patients undergoing elective primary THA at an academic tertiary care center from January 2010 to February 2020 were included. Primary outcome of interest was incidence of postoperative DVT ultrasounds while inpatient and within 2 weeks following THA. Statistical analysis, including descriptive statistics and significance testing, was performed. RESULTS: A total of 3,665 patients were included, of which, 2.0% (N = 72) of patients received a lower extremity ultrasound while inpatient, with only 2 being positive (2.8%), for an overall positivity rate of 0.05% of the entire cohort. The incidence of postoperative inpatient ultrasounds decreased from 7.0% in 2010 to 0.3% in 2020 (P < .001) whereas, the incidence of ultrasounds at 2 weeks and 2-week positivity rate remained stable. LOS was identified as a risk factor for postoperative inpatient ultrasound (P < .001). CONCLUSIONS: Postoperative ultrasounds to evaluate for DVT are associated with a low yield and appear to be a consequence of reduced LOS in the hospital. Given the stable diagnosis rate of DVT at 2 weeks, our data suggests that the increasing trend toward outpatient arthroplasty will not result in missed opportunities to diagnose postoperative DVTs or lead to adverse outcomes and may provide benefit to patients by eliminating unnecessary testing. LEVEL III EVIDENCE: Retrospective cohort study.

Treatment Decision Regret in Patients Who Develop Periprosthetic Joint Infection and Require Two-Stage Revision Surgery.

BACKGROUND: The decision to proceed with total joint arthroplasty (TJA) can be complex and requires an assessment of potential risks of surgery. Patients who experience the potentially devastating complication of periprosthetic joint infection (PJI) may have a poor outcome and wish they had never elected to have surgery. No study has examined decision regret related to the choice to pursue TJA in patients who develop PJI. METHODS: All patients who were treated for PJI with a two-stage revision at a tertiary academic medical center between 2010 and 2020 were surveyed. Ninety-six patients agreed to answer 12 questions concerning their understanding of their preoperative risk of infection and their level of regret with the decision to pursue index TJA. Patient regret was calculated using the Decision Regret Scale. RESULTS: Seventy-two percent of patients reported that their joint replacement and concomitant infection had a severe ongoing impact on their quality of life, although only 28% of respondents regretted their choice to undergo index TJA, and 65% would undergo TJA again. A higher Musculoskeletal Infection Society outcome stage (typically due to failed treatment) and lower understanding of joint infection were associated with a higher level of regret on the Decision Regret Scale (P < .001). CONCLUSION: Self-reported decisional regret was present in only 1 in 4 patients who underwent arthroplasty despite experiencing a devastating complication, and almost two-thirds of patients with PJI reported they would undergo primary TJA again. Patients who were more informed about infection before TJA experienced less regret when they subsequently developed PJI. LEVEL OF EVIDENCE: III.

Development of machine learning model algorithm for prediction of 5-year soft tissue myxoid liposarcoma survival.

BACKGROUND: Predicting survival in myxoid liposarcoma (MLS) patients is very challenging given its propensity to metastasize and the controversial role of adjuvant therapy. The purpose of this study was to develop a machine-learning algorithm for the prediction of survival at five years for patients with MLS and externally validate it using our institutional cohort. METHODS: Two databases, the surveillance, epidemiology, and end results program (SEER) database and an institutional database, were used in this study. Five machine learning models were created based on the SEER database and performance was rated using the TRIPOD criteria. The model that performed best on the SEER data was again tested on our institutional database. RESULTS: The net-elastic penalized logistic regression model was the best according to our performance indicators. This model had an area under the curve (AUC) of 0.85 when compared to the SEER testing data and an AUC of 0.76 when tested against institutional database. An application to use this calculator is available at https://sorg-apps.shinyapps.io/myxoid_liposarcoma/. CONCLUSION: MLS is a soft-tissue sarcoma with adjunct treatment options that are, in part, decided by prognostic survival. We developed the first machine-learning predictive algorithm specifically for MLS using the SEER registry that retained performance during external validation with institutional data.

Obesity and Postoperative Complications Following Ankle Arthrodesis: A Propensity Score Matched Analysis.

Obese patients undergoing orthopedic procedure have been reported to have higher rates of postoperative complications, but the published associations have numerous confounders. This study aims to evaluate the independent effect of obesity on postoperative complications and hospital utilization following ankle arthrodesis. A database review of a Medicare database was performed on patients less than 85 years old who underwent ankle arthrodesis between 2005 and 2014. Patient cohorts were defined using International Classification of Diseases-9 coding for body mass index (BMI)-obese (30-40 kg/m2), and morbidly obese (>40 kg/m2). Normal BMI patients were defined as those without the respect codes for obesity (30-40 kg/m2), morbidly obese (>40 kg/m2), or underweight (<19 kg/m2). All groups were propensity score matched by demographics and comorbidities. Outcomes of interest included 90-day major and minor medical complications, and hospital burden. Morbid obesity was associated with an increased risk of acute kidney injury (4.4% vs 2.4%, OR 1.94, 95% CI 1.37-2.74, p < .001), urinary tract infection (5.2% vs 3.2%, OR 1.66, 95% CI 1.21-2.25, p = .001), readmission (13.6% vs 10.8%, OR 1.33, 95% CI 1.10-1.61, p = .003), and overall minor complications (16.0% vs 11.8%, OR 1.44, 95% CI 1.19-1.74, p < .001) compared to normal BMI patients, and an increased risk for acute kidney injury (4.4% vs 1.9%, OR 2.25, 95% CI 1.32-3.97, p = .003) compared to obese patients. Obesity was not associated with increased medical complications (p > .05). While morbid obesity was associated with an increase in the postoperative complications, obesity was not associated with any increase in postoperative complications following ankle arthrodesis.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). METHODS: A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. RESULTS: Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). CONCLUSION: Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Treatment of Hepatitis C Virus Prior to Posterior Lumbar Fusion: No Difference in Medical Outcomes or Reoperation.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To analyze and confirm the rates of postoperative complications of patients with hepatitis C virus (HCV) undergoing primary posterior lumbar fusion (PLF) and assess whether treatment of HCV before surgery reduces complications. BACKGROUND CONTEXT: HCV causes chronic disease, leading to increased risk of cirrhosis and chronic illness. Currently, there is a lack of research regarding whether the patient's HCV is a modifiable risk factor for postoperative complications after spinal procedures. METHODS: The Mariner database was utilized to find patients from 2010 to 2018 undergoing PLF with active follow-up for a year. Cases involving same-day revision procedures and patients with a history of spine, infection, trauma, human immunodeficiency virus, hepatitis B, or neoplasm were excluded. Patients with a history of HCV diagnosis were identified and further stratified whether they had prior treatment using the national drug codes for antiviral, interferons, or ribavirin. Patients with HCV were matched with those without respect to age, sex, and comorbidity of burden. Outcome measured included 90-day medical complications, infection, readmission, and 1-year reoperation. RESULTS: There were 2,129 patients with HCV and 10,544 patients in the matched control group who underwent primary PLF. Out of the 2,129 patients, 469 (22.0.%) were treated with HCV medications before surgery. Patients with prior history of HCV had a significantly increased risk of wound complications (4.4% vs. 3.2%, odds ratio 1.56, 95% confidence interval 1.24-1.96, P =0.009), and infection (7.7% vs. 5.7%, odds ratio 1.26, 95% confidence interval 1.07-1.53, P =0.009) within 90 days of surgery. Patients treated before surgery did not have a difference in major ( P =0.205) or minor medical complications ( P =0.681) after surgery. CONCLUSIONS: Patients with prior history of HCV are at increased risk for many complications after surgery; however, this risk factor does not seem to be modifiable as the treatment group did not experience any improvement in postoperative outcomes. LEVEL OF EVIDENCE: Level III.

Venous Thromboembolic Events are Exceedingly Rare in Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Review of health care record database and determination of population statistics. OBJECTIVE: The purpose of this study was to quantify the incidence of clinically significant venous thromboembolic (VTE) events in patients undergoing spinal fusion surgery for adolescent idiopathic scoliosis (AIS) and to identify risk factors for VTE. SUMMARY OF BACKGROUND DATA: VTE is a serious complication that can cause disability and even death following surgery. Incidence of VTE following AIS surgery has not been well studied; the use of a national database allows the assessment of rare, yet important complications. MATERIALS AND METHODS: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2020. Patient records were cross-referenced for documented VTEs within 30 and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors for correlation with VTE events. RESULTS: Thirty-eight of 11,775 (0.323%) patients undergoing surgery for AIS developed a VTE complication within 90 postoperative days. Hypercoagulability [odds ratio (OR)=13.50, P <0.0001], spinal fusion involving 13+ vertebral levels (OR=2.61, P <0.0001), obesity (OR=1.30, P <0.005), and older (15-18 y) compared with younger adolescence (10-14 y) (OR=2.12, P <0.0001) were associated with VTE. Seven of 38 (18.4%) patients with a diagnosed thrombophilia experienced VTE. CONCLUSIONS: The incidence of clinically significant VTEs in pediatric patients following spinal fusion surgery for AIS is low with an incidence of 0.323%. Postoperative chemoprophylaxis in the general pediatric population is not indicated. Patients with obesity, those undergoing spinal fusion of 13 or more vertebrae, and adolescents 15-18 years old were found to have higher but still small risk of VTE following surgery. Further prospective studies are needed to validate the risk profile of patients with hypercoagulability and establish clinical guidelines for use of postoperative chemoprophylaxis in this cohort. LEVEL OF EVIDENCE: Level III.

Orthopedic Surgery Fellowship Directors: Trends in Demographics, Education, Employment, and Institutional Familiarity.

Background: Fellowship directors are assumed to be distinguished in orthopedics, but the traits and training that have enabled them to achieve their leadership positions have not been assessed. Purpose: We sought to identify common demographics, research output, and educational trends of fellowship directors in orthopedics, with an emphasis on racial, ethnic, and gender diversity. Methods: We conducted a literature review to identify published studies on fellowship directors in orthopedic surgery and found 4 cross-sectional studies of fellowship directors in spine, arthroplasty, pediatrics, and sports medicine subspecialties. Another 4 accredited orthopedic subspecialties and their fellowship directors were identified using the American College of Graduate Medical Education Public Accreditation Data System for 2020-2021 and national fellowship directories. Data endpoints included race/ethnicity, age, sex, residency and fellowship training institutions, year of fellowship completion, year of hire at current institution, year of fellowship directors appointment, and h-index. The demographics and educational backgrounds for listed fellowship directors were collected from curricula vitae (CVs). Results: Of the 537 fellowship directors identified among 8 orthopedic subspecialties, the average age was 52.9 ± 2.2 years, 5.6% (N = 30) were women, 79.1% (N = 406) were white, 12.5% (N = 64) were Asian American, 3.7% (N = 19) were African American, 2.9% (N = 15) were Middle Eastern, and 1.7% (N = 9) were Hispanic/Latino. Oncology 20% (N = 4) had the highest percentage of female fellowship directors; 37.6% (N = 202) of fellowship directors were at the same institution they trained at for residency or fellowship. Their average h-index was 18.6 ± 3.7. Conclusion: This study of fellowship directors in orthopedics found that they have a high research output and a high level of institutional familiarity. We identified a need for greater diversity in these leadership positions in both gender and race/ethnicity.

Predictors of Symptomatic Venous Thromboembolism in Patients with Soft Tissue Sarcoma in the Lower Extremity.

Orthopedic surgery and soft-tissue sarcoma (STS) both independently increase the risk of developing symptomatic venous thromboembolic events (SVTE), but there are no established risk factors or guidelines for how to prophylactically treat patients with STS undergoing surgery. The objectives of this study were to (1) identify the prevalence of SVTE in patients undergoing STS surgery, (2) identify risk factors for SVTE, and (3) determine the risk of wound complications associated with VTE prophylaxis. This retrospective study was conducted in a tertiary level, academic hospital. A total of 642 patients were treated for soft-tissue sarcoma in the lower extremity with follow up for at least 90 days for the development of SVTE such as deep venous thrombosis and pulmonary embolism. Multivariate logistic regression was used to identify predictors for these events by controlling for patient characteristics, surgical characteristics, and treatment variables, with significance held at p < 0.05. Twenty eight patients (4.36%) were diagnosed with SVTE. Multivariate analysis found six significant predictors ordered based on standardized coefficients: pre-operative (PTT) partial thromboplastin time (p < 0.001), post-operative PTT (p = 0.010), post-op chemotherapy (p = 0.013), metastasis at diagnosis (p = 0.025), additional surgery for metastasis or local recurrence (p = 0.004), and tumor size larger than 10 cm (p < 0.001). The risk of wound complications (p = 0.04) and infection (p = 0.017) increased significantly in patients who received chemical prophylaxis. Our study identifies risk factors for patients at increased risk of developing VTE. Further prospective research is necessary to identify which protocols would be beneficial in preventing SVTE in high-risk patients with a low profile of wound complications.

Improvement of postural stability and gait velocity after cervical decompression surgery in patients with cervical spondylotic myelopathy.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to significant neurological deficits, including gait instability. Biomechanical alterations of gait and its various components are poorly understood. The goal of the current study was to determine how spatiotemporal gait parameters, as well as postural and dynamic stability, change after surgery in CSM patients. METHODS: A total of 47 subjects were included, with 23 test subjects and 24 controls. Baseline measurements were made for both cohorts. In the CSM cohort, repeat measurements were made at 3 and 6 months postoperatively. To record spatiotemporal and dynamic stability parameters, subjects performed walking trials over force plates on a 15-m runway. To assess postural stability, standing balance trials were conducted on a floor-mounted force plate. Three-dimensional motion analysis cameras and gait modeling software were used to quantify and visually represent results. Statistical analysis was completed using repeated-measures ANOVA and paired t-tests. Significance was set at p < 0.05. RESULTS: CSM patients had significantly increased gait velocity at the 6-month follow-up (mean 0.948 ± 0.248 m/sec/leg length) versus baseline (mean 0.852 ± 0.257 m/sec/leg length) (p = 0.039). The tilted ellipse area was significantly decreased at the 6-month follow-up compared with baseline (mean 979.8 ± 856.7 mm2 vs 598.0 ± 391.1 mm2, p = 0.018). Angular momentum excursion was not significantly different between baseline and the 3- and 6-month follow-ups. CONCLUSIONS: CSM patients displayed significant improvement in gait velocity and postural stability parameters after decompressive surgery. Dynamic stability parameters did not change significantly during the study period.

Postoperative Outcomes Following Posterior Lumbar Fusion in Patients With Multiple Sclerosis.

SUMMARY OF BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory disease that can cause physical and neurological dysfunction. Patients with MS are living longer and undergoing more orthopedic procedures, but the risk of patients with MS undergoing posterior lumbar fusion (PLF) has not been studied in literature before. OBJECTIVE: This study aims to (1) analyze the rates of postoperative complications of MS patients undergoing primary PLF and (2) analyze the economic burden associated with these surgeries in the MS population compared with patients without MS. METHODS: A retrospective review of the Medicare database was conducted on all patients who underwent PLF and/or posterior lumbar interbody fusion between the years of 2006 and 2013. Cases involving same-day anterior or revision procedures and patients with a history of spine, infection, and trauma, or neoplasm were excluded from the study. Demographics, comorbidities, 90-day postoperative complications, cost, and length of stay were calculated. All outcomes of interest were analyzed using multivariate logistic regression, adjusting for age, sex, and comorbidity burden. Significance was defined as P-value <0.05. RESULTS: There were 2363 patients with MS and 23,569 matched controlled patients. We found a significant increase in the risk of sepsis [odds ratio (OR)=1.85, P=0.034], urinary tract infection (OR=1.89, P<0.001), deep vein thrombosis (OR=1.4, P=0.044), 90-day emergency room visit (OR=1.14, P=0.027), and 90-day readmissions (OR=1.20, P=0.011) compared with patients without a history of MS. Patients with MS also incurred $4379 extra in total hospital charge, a $1679 increase in the cost of hospitalization, and an increase in length of stay (4.05 vs. 3.61, P<0.001). CONCLUSIONS: A diagnosis of MS is associated with a significant increase in postoperative complications and higher costs after hospitalization. It is imperative for physicians to understand the risk factors of patients undergoing PLF and/or posterior lumbar interbody fusion with MS to better counsel them about postoperative complications before surgery. LEVEL OF EVIDENCE: Level III.

National Evaluation of Social Determinants of Health in Orthopedic Fracture Care: Decreased Social Determinants of Health Is Associated With Increased Adverse Complications After Surgery.

OBJECTIVES: To assess the individual impact of social determinants of health disparities (SDHD) on surgical outcomes following orthopaedic trauma surgery. DESIGN: Retrospective Cohort Study. SETTING: Mariner Claims Database. PATIENTS: Inclusion criteria were patients 18-85 years of age, undergoing surgery for hip fractures or ankle fractures from 2010 to 2018. INTERVENTION: Patients were divided based on SDHD using International Classification of Diseases 9 and International Classification of Diseases 10 codes. Those with SDHD were propensity-score matched with those who did not have any disparities with respect to age, gender, Charlson comorbidity index, tobacco use, and obesity (body mass index >30 kg/m2). OUTCOMES: Ninety-day major medical complications, infection, readmission, and revisions within 1 year. RESULTS: Patients with educational deficiencies had increased rates of readmission and major complications compared with those without disparities following hip and ankle fracture management. Moreover, economic disparities were associated with an increased risk of readmission and revision following hip fracture surgery and infection and readmission following ankle fracture surgery. DISCUSSION/CONCLUSIONS: This study emphasizes the large impact of SDHD on patients' outcomes following surgery and the importance of proper follow-up interventions to optimize patient care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Penicillin Allergy in Spine Surgery: Increased Rates of Sepsis, Emergency Room Visits, and Readmission.

OBJECTIVE: To determine if a penicillin allergy is an independent risk factor for poor outcomes after anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF). METHODS: A retrospective database review was performed using the PearlDiver data set. The study population included all patients younger than 85 years who underwent elective PLF or ACDF with diagnosis of penicillin allergy using International Classification of Diseases codes. Study patients were compared with controls for 90-day complications and 1-year reoperation rates. A multivariate logistic regression was used to determine the independent effect of penicillin allergy on the postoperative outcomes. RESULTS: PLF cohort multivariate analysis showed that patients with a penicillin allergy had a significantly increased risk of sepsis (2.6% vs. 2.0%; P = 0.020), urinary tract infection (10.8% vs. 8.4%; P < 0.001), emergency room visits (27.3% vs. 20.2%; P < 0.001), and readmissions (9.6% vs. 6.4%; P < 0.001) within 90 days index of surgery. Similarly, the ACDF cohort multivariate analysis showed that a penicillin allergy was associated with an increased risk of sepsis (1.8% vs. 1.1%; P < 0.001), emergency room visits (27.2% vs. 20.7%; P < 0.001), and readmissions (6.8% vs. 5.6%; P = 0.003) within 90 days index of surgery. CONCLUSIONS: The present study found that a reported penicillin allergy is associated with an increase in sepsis, urinary tract infection, emergency room visit, and readmission postoperatively within 90 days after PLF and ACDF. The findings can help physicians provide patients with more comprehensive preoperative counseling in the setting of patient-reported penicillin allergy.

Propensity Scored Analysis of Outpatient Anterior Lumbar Interbody Fusion: No Increased Complications.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim were to (1) evaluate differences in postoperative outcomes and cost associated with outpatient anterior lumbar interbody fusion (ALIF) compared with inpatient ALIF, and to (2) identify independent factors contributing to complications after outpatient ALIF. SUMMARY OF BACKGROUND: While lumbar fusion is traditionally performed inpatient, outpatient spinal surgery is becoming more commonplace as surgical techniques improve. METHODS: The study population included all patients below 85 years of age who underwent elective ALIF (CPT-22558). Patients were then divided into those who underwent single-level fusion and multilevel fusion using the corresponding additional level fusion codes (CPT-22585). These resulting populations were then split into outpatient and inpatient cohorts by using a service location modifier. To account for selection bias, propensity score matching was performed; the inpatient cohorts were matched with respect to the outpatient cohorts based on age, sex, and Charlson Comorbidity Index. Statistical significance was set at P<0.05 and the Bonferroni correction was used for each multiple comparison (P<0.004). RESULTS: Patients undergoing outpatient procedure had decreased rates of medical complications following both single-level and multilevel ALIF. In addition, age above 60, female sex, Charlson Comorbidity Index>3, chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, hypertension, and tobacco use were all identified as independent risk factors for increased complications. Finally, the cost of outpatient ALIF was $12,013 while the cost of inpatient ALIF was $27,271 (P<0.001). CONCLUSION: The findings add to the growing body of literature advocating for the utilization of ALIF in the outpatient setting for a properly selected group of patients. LEVEL OF EVIDENCE: Level IV.

How old is too old?: Matched analysis of geriatric patients undergoing anterior lumbar interbody fusion.

STUDY DESIGN: Retrospective Review INTRODUCTION/OBJECTIVE: The aim of this study is to utilize a national database to identify how age affects patient outcomes following anterior lumbar interbody fusion (ALIF). There are no established age guidelines for the geriatric population within the spine specialty, which makes patient selection challenging. Furthermore, there are conflicting studies for the risks of performing spine surgeries in the elderly. METHODS: A retrospective review of the Mariner Claims Database was conducted on patients who underwent a single level ALIF (CPT 22558) between 2010 and 2018. Patients were separated into three groups by age: 50-64, 65-74, and 75-84 and matched with respect to gender, smoking, and comorbidity burden. Multivariable logistic regression was used to determine the independent effect of outpatient surgery on the postoperative outcomes after adjusting for demographic factors and pertinent comorbidities. Statistical significance was set at p < 0.05. RESULTS: The study identified 8459 matched patients (3350 50-64; 3350 65-74; and 1759 75-84). Compared with patients aged 50-64, patients aged 65-74 and 75-84 had significantly increased risks of pneumonia (65-74: OR 1.53, 95% CI 1.06-2.24, p = 0.025; 75-84: OR 1.62, 95% CI 1.07-2.42, p = 0.022), sepsis (65-74: OR 2.20, 95% CI 1.36-3.76, p = 0.002; 75-84: OR 2.42, 95% CI 1.43-4.13, p = 0.001), and major complications (65-74: OR 1.35, 95% CI 1.05-1.74, p = 0.021; 75-84: OR 1.48, 95% CI 1.11-1.95, p = 0.006) (Table 2). There were no significant differences between patients aged 65-74 and 75-84 for risks of postoperative pneumonia, sepsis, and major complications (p > 0.05). There were no differences between any groups in terms of long-term outcomes such as pseudoarthrosis, implant related complications, or reoperation (p > 0.05) (Table 3). DISCUSSION/CONCLUSION: The study showed that those older than 65 had a significant increase in risk of pneumonia, sepsis, and major complications following ALIF. In the two cohorts above the age of 65 (65-74 and 75-84) there was no significant differences in postoperative outcomes. LEVEL OF EVIDENCE: 3.

Prognostic Factors Impacting Surgical Outcomes in Patients With Cervical Spondylotic Myelopathy.

The purpose of surgical decompression in patients who have CSM is to stop the progression of symptoms and hopefully improve function. It is critical to understand prognostic factors that affect the outcome. Factors intrinsic to the patient that can adversely affect outcomes include diabetes, older age, tobacco use, the presence of mental health disease, and obesity. MRI imaging findings of T2 hyperintensity and clinical duration and severity of symptoms is also associated with poorer outcomes. Patients should be counseled regarding the efficacy of decompressive procedures for CSM and given realistic expectations based on their unique biophysical profiles.