How Common-and How Serious- Is Clostridium difficile Colitis After Geriatric Hip Fracture? Findings from the NSQIP Dataset.

BACKGROUND: Patients with geriatric hip fractures may be at increased risk for postoperative Clostridium difficile colitis, which can cause severe morbidity and can influence hospital quality metrics. However, to our knowledge, no large database study has calculated the incidence of, factors associated with, and effect of C. difficile colitis on geriatric patients undergoing hip fracture surgery. QUESTIONS/PURPOSES: To use a large national database with in-hospital and postdischarge data (National Surgical Quality Improvement Program [NSQIP®]) to (1) determine the incidence and timing of C. difficile colitis in geriatric patients who underwent surgery for hip fracture, (2) identify preoperative and postoperative factors associated with the development of C. difficile colitis in these patients, and (3) test for an association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality. PATIENTS AND METHODS: This is a retrospective study. Patients who were 65 years or older who underwent hip fracture surgery were identified in the 2015 NSQIP database. The primary outcome was a diagnosis of C. difficile colitis during the 30-day postoperative period. Preoperative and procedural factors were tested for association with the development of C. difficile colitis through a backward stepwise multivariate model. Perioperative antibiotic type and duration were not included in the model, as this information was not recorded in the NSQIP. The association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality were tested through multivariate regressions, which adjusted for preoperative and procedural characteristics such as age, comorbidities, and surgical procedure. A total of 6928 patients who were 65 years or older and underwent hip fracture surgery were identified. RESULTS: The incidence of postoperative C. difficile colitis was 1.05% (95% CI, 0.81%-1.29%; 73 of 6928 patients). Of patients who had C. difficile colitis develop, 64% (47 of 73 patients) were diagnosed postdischarge and 79% (58 of 73 patients) did not have a preceding infectious diagnosis. Preoperative factors identifiable before surgery that were associated with the development of C. difficile colitis included admission from any type of chronic care facility (versus admitted from home; relative risk [RR] = 1.98; 95% CI, 1.11-3.55; p = 0.027), current smoker within 1 year (RR = 1.95; 95% CI, 1.03-3.69; p = 0.041), and preoperative anemia (RR = 1.76; 95% CI, 1.07-2.92; p = 0.027). Patients who had pneumonia (RR = 2.58; 95% CI, 1.20-5.53; p = 0.015), sepsis (RR = 4.20; 95% CI, 1.27-13.82; p = 0.018), or "any infection" (RR = 2.26; 95% CI, 1.26-4.03; p = 0.006) develop after hip fracture were more likely to have C. difficile colitis develop. Development of C. difficile colitis was associated with greater postoperative length of stay (22 versus 5 days; p < 0.001), 30-day readmission (RR = 3.41; 95% CI, 2.17-5.36; p < 0.001), and 30-day mortality (15% [11 of 73 patients] versus 6% [439 of 6855 patients]; RR = 2.16; 95% CI, 1.22-3.80; p = 0.008). CONCLUSIONS: C. difficile colitis is a serious infection after hip fracture surgery in geriatric patients that is associated with 15% mortality. Patients at high risk, such as those admitted from any type of chronic care facility, those who had preoperative anemia, and current smokers within 1 year, should be targeted with preventative measures. From previous studies, these measures include enforcing strict hand hygiene with soap and water (not alcohol sanitizers) if a provider is caring for patients at high risk and those who are C. difficile-positive. Further, other studies have shown that certain antibiotics, such as fluoroquinolones and cephalosporins, can predispose patients to C. difficile colitis. These medications perhaps should be avoided when prescribing prophylactic antibiotics or managing infections in patients at high risk. Future prospective studies should aim to determine the best prophylactic antibiotic regimens, probiotic formula, and discharge timing that minimize postoperative C. difficile colitis in patients with hip fractures. LEVEL OF EVIDENCE: Level III, therapeutic study.

Injuries Associated with Subdural Hematoma: A Study of the National Trauma Data Bank.

Of 92030 patients with subdural hematoma (SDH) in the National Trauma Data Bank (NTDB), 55729 had fall mechanisms of injury (61%), while 36301 had other traumatic mechanisms (nonfall, 39%). For nonfall mechanisms, the three associated injuries with the highest incidence were: skull fractures (43.3%), rib/sternum injuries (25.0%), and thoracic organ injuries (24.0%). For fall mechanisms, the three associated injuries with the highest incidence were: skull fractures (19.0%), spinal injuries (7.1%), and upper extremity fractures (6.8%). Mortality was associated with age and most studied associated injuries (odds ratios ofup to 2.04). 'This study conveys an important clinical point: even though traditional teaching highlights the risk of noncontiguous spine fractures in patients with a known spine fracture, the risk of a noncontiguous spine fracture is higher when dealing with a patient with SDH. This is underscored by the fact that mortality is higher for SDH patients with other associated injuries.

Case of a Missed Giant Cell Tumor of Bone: An Opportunity to Observe its Natural History Disease.

Giant cell tumor of bone (GCT) is a benign neoplasm that most commonly presents with pain and is rarely diagnosed as an incidental finding. We present the report of a young woman whose pre-operative MRI was only noted to have a tear of the anterior cruciate ligament (ACL). Subsequently, the patient underwent anACL reconstruction. A second MRI, performed four years later, demonstrated an enlarged mass in the same location. A retrospective evaluation of the initial MRI revealed an eccentric metaphyseal lesion. Histology obtained from the lesion demonstrated a giant cell tumor of bone. We present the case of an asymptomatic GCT discovered retrospectively as an incidental finding and reevaluated four years later. 'Ihis case serves as a reminder of the importance for the critical review of routine preoperative imaging and also offers a unique perspective on the natural history of giant cell tumor of bone.

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data.

BACKGROUND: Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments. QUESTIONS/PURPOSES: We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons? MATERIALS AND METHODS: We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual. RESULTS: A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34-619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons. CONCLUSIONS: Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings. LEVEL OF EVIDENCE: Level III, Economic and Decision Analysis.

Porous Tantalum Buttress Augments for Severe Acetabular Posterior Column Deficiency.

In revision total hip arthroplasty (THA), consensus is lacking regarding the optimal method for reconstruction of the most severe acetabular defects. Porous tantalum (TM) buttress augments were designed for the most severe postero-superior defects. The purpose of this study was to report the results of a consecutive series of acetabular reconstructions utilizing TM buttress augments. Eight complex acetabular reconstructions utilizing a TM buttress augment were performed at two centers. All were Paprosky 3A or Paprosky 3B bone loss classification, with severe superior and posterior column deficiency where wedge augments were insufficient for mechanical support. The acetabular cup sizes ranged from 64-78, and a buttress shim was used in 7 of 8 cases. Clinical and radiographic follow-up averaged 16.5 months (range, 10-28) and no cases were lost to follow-up. There were no cases of clinical or radiographic loosening, and no case had required reoperation or revision. All patients except one were ambulating with either no assist device or a single cane at final follow-up. There was one complication of an iliac wing fracture noted incidentally on postoperative x-rays in the lone patient in whom a buttress shim was not used. At short-term follow-up, TM acetabular buttress augments appear to effectively substitute for the use of structural allografts or cages, which would otherwise be used in this challenging setting. The potential for biologic fixation is promising for the durability of these reconstructions; however, longer-term follow-up is required for full evaluation.

Factors Associated with the Transfer of Pediatric Patients with Supracondylar Humerus Fractures to a Level I Pediatric Trauma Center.

OBJECTIVE: To compare the characteristics of pediatric patients with supracondylar humerus fractures transferred to a level I pediatric trauma center to those who presented directly to our institution. METHODS: Retrospective chart review of patients with a supracondylar humerus fracture during a 42-month period (2008-2011) at a major level I pediatric trauma center were reviewed. Of 195 patients, 37 were transferred from outside hospitals. RESULTS: After multivariable analysis, it was determined that transferred patients were significantly more likely to present on the weekends (p = 0.003) and require operative treatment (p < 0.001) as compared to nontransferred patients. CONCLUSIONS: Injuries requiring operative treatment and presentation on a weekend were independent predictors of the transfer of pediatric patients with supracondylar humerus fractures.

Modern perceptions and expectations regarding total knee arthroplasty.

It is established that patients and surgeons share different perceptions regarding total knee replacement (TKA). This study's objective was to determine patient perceptions regarding TKA as well as the influence of the various information sources in shaping these perceptions. All patients presenting with knee pain for evaluation of TKA were offered a questionnaire. Multivariate statistical analysis correlated response and demographic variables. Approximately 81% of patients felt the main reason for TKA was to alleviate pain, whereas only 19% felt return to sports-related activities was the main reason. Approximately 37% of patients felt TKAs should last for 20 years or more, which was strongly correlated with TV, newspaper, or Internet exposure (p ≤ 0.01). Approximately 38% of respondents had heard of partial knee replacement, whereas relatively few had received information regarding patient-specific, gender-specific, mobile-bearing, or high-flexion TKA designs. Men were likelier than women to get their information from friends, family, or another patient (p = 0.04). Although most respondents perceived pain relief as the primary goal, patients getting information from the media are likelier to expect TKA to last longer than 20 years. This suggests direct-to-patient marketing with such claims as 30-year durability may influence patient perceptions regarding TKA.

The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy.

Study Design: The study design is a retrospective cohort study. Objective: To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM). Summary of Background Data: Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements. Materials and Methods: A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA. Results: There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm (P = 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points, P < 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points, P = 0.017). Both younger age (P = 0.017, ß-coefficient = -0.05) and higher preoperative mJOA (P < 0.001, ß-coefficient = 0.37) predicted higher postoperative mJOA. Conclusions: Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.

Safe Spine Surgery During the COVID-19 Pandemic.

Safe spine surgery is possible during the COVID-19 pandemic. Certain urgent procedures must still be performed during this challenging time to prevent permanent long-term disability or death for patients. Precautions must be taken in the operating room to optimize safety, including the use of personal protective equipment and appropriate room setup and anesthesia and equipment optimization. Evidence-based guidelines to create a safe operative paradigm for use in future viral outbreaks are paramount.

Variations in Patient Satisfaction Scores Between HCAHPS and a Novel Orthopedic Practice-Specific Survey.

Performance on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey can affect up to 33% of a physician's reimbursement from the Centers for Medicare & Medicaid Services. At this pseudo-private orthopedic practice, the authors characterized how physicians often achieve drastically different scores between HCAHPS and an Internal Patient Satisfaction Questionnaire (IPSQ). Eighteen physicians were ranked separately according to percentage of top-box scores on HCAHPS and IPSQ. There was an inverse relationship between physician rank for the 2 surveys according to Spearman correlation coefficient (ρ = -0.36, P = .15). Qualitative subanalysis indicated that although "physician interaction" was the most common reason for negative comments on HCAHPS, "ancillary staff" and "workflow" concerns were common on IPSQ. The outpatient setting remains a critical component in achieving high-quality orthopedic care. Consequently, HCAHPS alone may not be a sufficient indicator of patient satisfaction for orthopedic and other subspecialty practices.

A Novel Scoring System to Predict Length of Stay After Anterior Cervical Discectomy and Fusion.

INTRODUCTION: The movement toward reducing healthcare expenditures has led to an increased volume of outpatient anterior cervical diskectomy and fusions (ACDFs). Appropriateness for outpatient surgery can be gauged based on the duration of recovery each patient will likely need. METHODS: Patients undergoing 1- or 2-level ACDFs were retrospectively identified at a single Level I spine surgery referral institution. Length of stay (LOS) was categorized binarily as either less than two midnights or two or more midnights. The data were split into training (80%) and test (20%) sets. Two multivariate regressions and three machine learning models were developed to predict a probability of LOS ≥ 2 based on preoperative patient characteristics. Using each model, coefficients were computed for each risk factor based on the training data set and used to create a calculatable ACDF Predictive Scoring System (APSS). Performance of each APSS was then evaluated on a subsample of the data set withheld from training. Decision curve analysis was done to evaluate benefit across probability thresholds for the best performing model. RESULTS: In the final analysis, 1,516 patients had a LOS <2 and 643 had a LOS ≥2. Patient characteristics used for predictive modeling were American Society of Anesthesiologists score, age, body mass index, sex, procedure type, history of chronic pulmonary disease, depression, diabetes, hypertension, and hypothyroidism. The best performing APSS was modeled after a lasso regression. When applied to the withheld test data set, the APSS-lasso had an area under the curve from the receiver operating characteristic curve of 0.68, with a specificity of 0.78 and a sensitivity of 0.49. The calculated APSS scores ranged between 0 and 45 and corresponded to a probability of LOS ≥2 between 4% and 97%. CONCLUSION: Using classic statistics and machine learning, this scoring system provides a platform for stratifying patients undergoing ACDF into an inpatient or outpatient surgical setting.

The Accurate Free-hand Placement of S2 Alar Iliac (S2AI) Screw.

Achieving an osseous fusion across the lumbosacral spine is still challenging in spine surgery. For the long multisegmental fusion surgery, it is crucial to build a robust and substantial foundation, which sometimes necessitates the distal spinal fixation to the pelvis. The pelvic fixation technique involves advancing the screw through the alar, thereby providing more purchase across the sacroiliac joint and into the ilium. The S2 alar iliac screws can obtain immediate stability and proper biomechanical strength of constructs. Here we demonstrated our experience of how to place the S2 alar iliac screw accurately as well as some pitfalls and pearls of this technique.

The C2 "Parsicle" Screw: Introduction of a Novel Posterior Surgical Technique For Upper Cervical Fixation.

The instrumentation of C2 is technically challenging given the anatomic complexity of the upper cervical spine. Although the placement of C2 pedicle screws may be safer than transarticular screw placement, the inconsistent location of the transverse foramen and vertebral artery precludes placement of such screws in up to 26% of patients. In cases where vertebral artery anatomy prevents the safe placement of a pedicle screw, a pars screw is an excellent alternative. However, pars screws must stop short of the vertebral foramen, limiting the typical length of these screws to only 14-18 mm. The associated purchase and rigidity are compromised compared with the pedicle screw. A modified C2 fixation technique was developed by our group which we have named the C2 "parsicle" screw reflecting the hybrid nature of the screw incorporating aspects of pars and pedicle screw fixation.

Role of Imaging, Tissue Sampling, and Biomarkers for Diagnosis of SSI in Spine Surgery.

In July 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 15 focused on the use of imaging, tissue sampling, and biomarkers in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Consensus on Implants in Infections After Spine Surgery.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 9 focused on implants questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Update on Spinal Cord Injury Management.

The management of acute spinal cord injury requires a multidisciplinary approach to maximize patient outcomes and potential. Treatment of this injury involves both surgical and medical intervention. Medical intervention in acute spinal cord injury is aimed at decreasing the neurotoxic environment that occurs as part of the secondary injury. New neuroregenerative therapies are being developed.

Consensus on the Role of Antibiotic Use in SSI Following Spinal Surgery.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Consensus on Risk Factors and Prevention in SSI in Spine Surgery.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 11 focused on risk factors and prevention questions in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Consensus on Wound Care of SSI in Spine Surgery.

In July of 2018, the Second International Consensus Meeting on Musculoskeletal Infection convened in Philadelphia, PA to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 7 focused on wound care, for which this article provides the recommendations, voting results, and rationales.

General Principles in the Consensus of SSI Management After Spine Surgery.

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 8 questions focused on general principles in spine surgery, for which this article provides the recommendations, voting results, and rationales.