Management of Choledocholithiasis in a Community Hospital: Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Approximately 10% of intraoperative cholangiograms identify choledocholithiasis (CDL), stones in the common bile duct. Choledocholithiasis management options include endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy, laparoscopic cholecystectomy (LC) followed by ERCP (LC + ERCP), cholecystectomy with open common bile duct exploration, or laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC + LCBDE). The goal of these interventions is to clear the obstruction from CDL. METHODS: Patients from a single-center community hospital undergoing LC with intraoperative cholangiogram (LC + IOC) progressing to LC + LCBDE from July 2020 to August 2022 were evaluated for hospital length of stay (LOS), operative times, and complications. These were compared to the prior standard practice of pre/post-operative ERCP. RESULTS: The results were evaluated using ANOVA, Student-Newman-Keuls, and chi square analysis. In comparison of LC + CBDE to ERCP + cholecystectomy, LOS was reduced (1.8 vs 4.6 days P < .0001). No difference in LOS between LC + IOC and LC + CBDE (1.4 vs 1.8 days, P > .05) was found. No difference in complication rates was found. Mean operative time differed between LC + IOC and LC + CBDE (63 vs 113 minutes, P < .0001). Fifty-five attempts of LC + CBDE were performed with only 10 requiring post-operative ERCP. DISCUSSION: Since implementation of LC + CBDE, there has been reduced LOS without increasing complication rates. Operative times are increased with LC + CBDE but offset by reduced LOS, additional anesthesia events, and procedures. Our institution will continue to pursue LC + CBDE when indicated with efforts to improve resource allocation.

The effect of operative time on early postoperative complications in total shoulder arthroplasty: An analysis of the ACS-NSQIP database.

BACKGROUND: Total shoulder arthroplasty has been demonstrated to be an effective treatment for arthritis of the glenohumeral joint. Prior studies have identified longer operative times as a risk factor for complications after numerous types of procedures. We hypothesized that increased operative time, in 20-min intervals, would be associated with complications following total shoulder arthroplasty. METHODS: Patients undergoing total shoulder arthroplasty from 2006 to 2015 were identified from the ACS-NSQIP database. Patient demographic information, perioperative parameters, and 30-day outcomes were retrieved. Pearson's Chi-square test and multivariate Poisson regression with robust error variance were used to analyze the relationship of operative time and outcomes. RESULTS: A total of 10,082 patients were included. Multivariate analysis revealed that for each increase in 20 min of operative time, there were significantly increased rates of any complication (relative risk (RR) 1.24, 95% confidence interval (CI) 1.19-1.26), anemia requiring transfusion (RR 1.33, 95%CI 1.26-1.4), peripheral nerve injury (RR 1.88, 95%CI 1.53-2.31), and urinary tract infection (RR 1.24, 95%CI 1.09-1.41). DISCUSSION: This study indicates that increasing operative time confers increased risk for postoperative complications following total shoulder arthroplasty. We anticipate the results of this manuscript will be used for provider education, policy decision-making, and potentially to derive algorithms that can improve safety and efficiency in total shoulder arthroplasty. LEVEL OF EVIDENCE: III.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Revision Hip and Knee Arthroplasty as Reported by American Board of Orthopaedic Surgery Part II Candidates.

BACKGROUND: The optimum venous thromboembolism (VTE) prophylaxis strategy to minimize risk of VTE and bleeding complications following revision total hip and knee arthroplasty (rTHA/rTKA) is controversial. The purpose of this study is to describe current VTE prophylaxis patterns following revision arthroplasty procedures to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopaedic Surgery Part II (oral) examination case list database was analyzed. Current Procedural Terminology codes for rTHA/rTKA were queried and geographic region, VTE prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were defined if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies were used. RESULTS: In total, 6387 revision arthroplasties were included. The national rate of less aggressive VTE prophylaxis strategies was 35.3% and more aggressive in 64.7%. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (89.8% vs 81.9%, P < .001). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (1.2% vs 0.3%, P < .001), mild bleeding (1.7% vs 0.6%, P < .001), moderate thrombotic (2.6% vs 0.4%, P < .001), moderate bleeding (6.2% vs 4.0%, P < .001), severe bleeding events (4.4% vs 2.4%, P < .001), infections (6.4% vs 3.8%, P < .001), and death within 90 days (3.1% vs 1.3%, P < .001). There were no significant differences in rates of fatal pulmonary embolism (0.1% vs 0.04%, P = .474). Subgroup analysis of rTHA and rTKA patients showed similar results. CONCLUSION: The individual rationale for using a more aggressive VTE prophylaxis strategy was unknown; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III.

High acuity polytrauma centers in orthopaedic trauma: Decreasing patient mortality with effective resource utilization.

BACKGROUND: There is a select number of massive-volume, high-acuity trauma centers (HACs) in the United States. Expertise in polytrauma care has been associated with improved mortality in general surgery trauma, though has not been investigated in orthopaedic trauma. With complex polytrauma proficiency comes the inherent risk of intensive care, complications, and prolonged inpatient stays, without a commensurate increase in allocated resources. The purpose of this study was to compare mortality, complications, and length of stay in polytraumatized orthopaedic patients treated at HACs vs. low-acuity trauma centers (LACs). METHODS: The National Trauma Data Bank was queried for orthopaedic injuries with injury severity score (ISS)>15 and mortality, complications, hospital length of stay, ICU length of stay, ventilation duration, and demographics. Hospitals where at least 13% (median percentage of patients with ISS > 15 admitted to all hospitals) of total admissions had an ISS>15 were classified as HAC; all others were LACs. RESULTS: HACs admitted 86.8% of 28,314 patients with ISS>15. On univariate analysis, patients at HACs have 16% decreased odds of in-hospital mortality vs. LACs (p=0.005); the effect increased to 27% (p=0.002) on multivariate analysis. Patients at HACs have 63% greater odds of ICU admission (p<0.001), 48% higher odds of ventilatory support (p=<0.001), 38% increased odds of unplanned reoperation (p=0.007), and 37% increased odds of medical complications (p<0.001). On multivariate analysis, secondary outcome measures showed no significant difference between HACs and LACs. Patients at HACs had 2.8 days longer length-of-stay (p<0.001). CONCLUSION: Severely injured orthopaedic trauma patients have decreased mortality at HACs, despite having a higher average ISS and a higher prevalence of obesity and active smoking. While there is a higher incidence of ICU admission, mechanical ventilation, complications, and unplanned reoperation on univariate analysis, correction for ISS and patient factors enhances the effect of HACs on mortality, but removes the effect on secondary measures. Thus, HACs are life-saving institutions for polytraumatized orthopaedic patients, and the known resource demand of these hospitals is supported by their favorable outcome profile. LEVEL OF EVIDENCE: IV.

Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures.

BACKGROUND: Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture. METHODS: This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes. RESULTS: The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001). CONCLUSION: While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate. LEVEL OF EVIDENCE: Level III, comparative study.

Is Operative Debridement Greater Than 24 Hours Post-admission Associated With Increased Likelihood of Post-operative Infection?

BACKGROUND: The historical "six-hour rule" as a golden hour for timing to debridement has been refuted in modern literature. Current standards prompt a timely debridement; however, in the setting of polytrauma, patients are often resuscitated for periods >24 h, with delayed orthopedic intervention. Therefore, we sought to determine the association between prolonged time to operative debridement (>24 h) and infection. METHODS: We conducted a retrospective review of patients with open fractures that underwent irrigation and debridement at a single institution from 2008 to 2016. Demographic, injury, and operative variables were collected. Infection was defined as the need for intravenous antibiotics and/or repeat irrigation and debridement. Chi-squared test and univariate logistic regression were performed. P < 0.05 was the cutoff for significance. RESULTS: Of 642 patients examined, 56 (8.7%) developed an infection. Prolonged time to debridement was not associated with increased infection rates (P = 1.00). Gustilo-Anderson classification was associated with increased risk of infection (type I: 2.1%, type II: 7.6%, and type III: 14.6%; P < 0.001). In univariate analysis, infection was associated with after-hours surgery (between 7 PM and 7 AM (odds ratio [OR] = 2.02; P < 0.02), definitive fixation more than 24 h post-admission (OR = 3.08; P < 0.001), wound closure more than 24 h post-admission (OR = 4.36; P < 0.001), and more than two operations performed post-admission (OR = 8.73; P < 0.001). Multivariate analysis of these factors found number of operations (OR = 7.13; P < 0.001) and time to definitive wound closure (OR = 4.04; P < 0.001) to be independent predictors of developing an infection. CONCLUSIONS: Our data suggests that there is no association between infection and prolonged time to debridement.

The Effect of Malnutrition on Postoperative Complications Following Surgery for Distal Radius Fractures.

PURPOSE: Malnutrition is known to negatively affect outcomes after arthroplasty, hip fracture, and spine surgery. Although distal radius fracture surgery may be considered in a similar patient cohort, the effect of malnutrition in this scenario is unknown. We hypothesized that admission serum albumin level, as a marker for malnutrition, would correlate with the rate of postoperative complications following surgery for distal radius fracture. METHODS: We performed a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement database. Patients undergoing open reduction and internal fixation of a distal radius fracture were identified using Current Procedural Terminology codes. We excluded patients who were septic at presentation, were multiply injured, or had open fractures. We collected patient demographics, length of stay, 30-day complications, reoperation, and readmission rates. We performed multivariable linear regression analysis controlling for age, sex, body mass index, operative time, discharge destination, and modified Frailty Index score. RESULTS: We identified 1,989 patients (mean age, 56 years; range, 18-90 years) with available albumin levels, and 14.7% had hypoalbuminemia (albumin, < 3.5 g/dL). Multivariable regression revealed that malnourished patients had higher rates of postoperative complications (6.5% vs 1.3%; odds ratio [OR] 4.88; 95% confidence interval [95% CI], 2.47-9.66). Specifically, these patients had increased rates of Clavien-Dindo IV (life-threatening) complications (2.4% vs 0%), readmission (7.2% vs 2%; OR, 3.37; 95% CI, 1.88-6.03), and mortality (1.7% vs 0.1%; OR, 9.23; 95% CI, 1.55-54.87). Malnourished patients had significantly longer length of stay (3.55 vs 0.73 days). Albumin concentration was inversely associated with risk of death (OR, 0.12; 95% CI, 0.03-0.52). CONCLUSIONS: Malnutrition, indicated by albumin less than 3.5 g/dL, is a powerful predictor of uncommon, but important, postoperative complications, including mortality, following surgery for distal radius fracture. Evaluation of preoperative albumin level may, therefore, help surgeons provide individualized counseling and more accurately stratify the risk of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Unhelmeted Motorcycle Riders Have Increased Injury Burden: A Need to Revisit Universal Helmet Laws.

BACKGROUND: The aim of this study was to compare hospital outcomes for patients in a motorcycle collision with and without helmet use. The study was conducted as a retrospective analysis of the National Trauma Data Bank's 2013 data set, which included reported data from 100 hospitals across the United States. METHODS: Inclusion criterion for this study is a motorcycle crash involving a driver or passenger. The total number of patients in motorcycle crashes as reported by the National Trauma Data Bank in 2013 was 10,345. Helmet use, hospital stay, ICU and ventilation days, mortality, Glasgow Coma Score, Injury Severity Score, patient payer mix, and complication data were obtained. RESULTS: Patients were divided into two groups: those wearing a helmet (n = 6250) and those without (n = 4095). Patients not wearing a helmet had an increased risk of admission to the ICU (OR = 1.36, P < 0.001, CI 1.25-1.48), requiring ventilation support (OR = 1.55, P < 0.001, CI 1.39-1.72), presenting with a Glasgow Coma Score of eight or below (OR = 2.15, P < 0.001), and in-patient mortality (OR = 2.00, P < 0.001, CI 1.58-2.54). Unhelmeted patients were more likely to have government insurance or be uninsured than those patients wearing a helmet (P < 0.001). CONCLUSIONS: It is not well understood why many states are repealing or have repealed universal helmet laws. Lack of helmet use increases the severity of injury in traumatized patients leading to a substantial financial impact on health care costs. Our analysis suggests the need to revisit the issue regarding laws that require protective headwear while riding motorcycles because of the individual and societal impact. LEVEL OF EVIDENCE: III.

Modified frailty index is an effective risk-stratification tool for patients undergoing total shoulder arthroplasty.

BACKGROUND: Frailty, as quantified by the modified frailty index (mFI), has emerged as a promising method to identify patients at high risk of complications after surgery. Several studies have shown that frailty, as opposed to age, is more predictive of adverse surgical outcomes. We hypothesized that a 5-item mFI could be used to identify patients at elevated risk of complications after total shoulder arthroplasty (TSA). METHODS: We identified patients aged 50 years or older who underwent TSA in the American College of Surgeons National Surgical Quality Improvement Program database. Pearson χ2 analysis and linear regression were used to determine the association of the mFI score with 30-day postoperative complications, reoperation, readmission, length of stay (LOS), adverse hospital discharge, and mortality rate. RESULTS: The study included 9861 patients with a mean age of 70 years. As the mFI score increased from 0 to 2 or greater, the following rates increased: postoperative complications from 4.2% to 9.4%, readmission from 1.6% to 4.4%, adverse hospital discharge from 6.3% to 19.6%, and LOS from 1.88 days to 2.43 days (P < .001). Multivariate analysis showed that patients with an mFI score of 2 or greater were over twice as likely to sustain a postoperative complication (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.86-3.10), readmission (OR, 2.80; 95% CI, 1.88-4.17), reoperation (OR, 1.82; 95% CI, 1.02-3.25), and adverse hospital discharge (OR, 3.14; 95% CI, 2.51-3.92). These effects were all significantly higher compared with age. CONCLUSION: Frailty is associated with increased rates of 30-day postoperative complications, readmission, reoperation, adverse hospital discharge, and hospital LOS after TSA. Use of a simple frailty evaluation may help inform decision making and risk assessment when considering TSA.

Hypoalbuminemia Is an Independent Risk Factor for 30-Day Mortality, Postoperative Complications, Readmission, and Reoperation in the Operative Lower Extremity Orthopaedic Trauma Patient.

INTRODUCTION: Malnutrition, as indicated by hypoalbuminemia, is known to have detrimental effects on outcomes after arthroplasty, geriatric hip fractures, and multiple general surgeries. Hypoalbuminemia has been examined in the critically ill but has largely been ignored in the orthopaedic trauma literature. We hypothesized that admission albumin levels would correlate with postoperative course in the nongeriatric lower extremity trauma patient. METHODS: Patients with lower extremity (including pelvis and acetabulum) fracture who underwent operative intervention were collected from the ACS-NSQIP database. Patients younger than 65 years were included. Patient demographic data, complications, length of stay, reoperation rate, and readmission rate were collected, and patient modified frailty index scores were calculated. Poisson regression with robust error variance was then conducted, controlling for potential confounders. RESULTS: Five thousand six hundred seventy-three patients with albumin available were identified, and 29.6% had hypoalbuminemia. Hypoalbuminemic patients had higher rates of postoperative complications [9.3% vs. 2.6%; relative risk (RR) 1.63] including increased rates of: mortality (3.2% vs. 0.4%; RR 4.86, 95% confidence interval 2.66-8.87), sepsis (1.5% vs. 0.5%, RR 2.35), and reintubation (2.3% vs. 0.4%; RR 3.84). Reoperation (5.5% vs. 2.6%, RR 1.74) and readmission (11.4% vs. 4.1%; RR 2.53) rates were also higher in patients with low albumin. CONCLUSION: Hypoalbuminemia is a powerful predictor of acute postoperative course and mortality after surgical fixation in nongeriatric, lower extremity orthopaedic trauma patients. Admission albumin should be a routine part of the orthopaedic trauma workup. Further study into the utility of supplementation is warranted, as this may represent a modifiable risk factor. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates.

BACKGROUND: Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS: In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION: It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III. DISCLAIMER: All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients.

OBJECTIVE: To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients. DESIGN: Retrospective observational cohort study. SETTING: Urban, American College of Surgeons-Verified, Level-1, Trauma Center. PATIENTS/PARTICIPANTS: Three hundred seventy-seven consecutive patients with isolated hip fractures. INTERVENTION: N/A. MAIN OUTCOME MEASURES: On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications. RESULTS: Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = -0.12) and albumin (P < 0.001; r = -0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15-7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality. CONCLUSIONS: When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries.

BACKGROUND: As morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant. RESULTS: 56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26-19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05-51.77, p < 0.001). CONCLUSION AND RELEVANCE: The mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures.

PURPOSE: Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures. METHODS: We retrospectively reviewed the American College of Surgeons-National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed. RESULTS: We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS. CONCLUSIONS: A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Adenocarcinoma ex-goblet cell carcinoid (appendiceal-type crypt cell adenocarcinoma) is a morphologically distinct entity with highly aggressive behavior and frequent association with peritoneal/intra-abdominal dissemination: an analysis of 77 cases.

High-grade versions of appendiceal goblet cell carcinoids ('adenocarcinoma ex-goblet cell carcinoids') are poorly characterized. We herein document 77 examples. Tumors occurred predominantly in females (74%), mean age 55 years (29-84), most with disseminated abdominal (77% peritoneal, 58% gynecologic tract involvement) and stage IV (65%) disease. Many presented to gynecologic oncologists, and nine had a working diagnosis of ovarian carcinoma. Metastases to liver (n=3) and lung (n=1) were uncommon and none arose in adenomatous lesions. Tumors had various histologic patterns, in variable combinations, most of which were fairly specific, making them recognizable as appendiceal in origin, even at metastatic sites: I: Ordinary goblet cell carcinoid/crypt pattern (rounded, non-luminal acini with well-oriented goblet cells), in variable amounts in all cases. II: Poorly cohesive goblet cell pattern (diffusely infiltrative cords/single files of signet ring-like/goblet cells). III: Poorly cohesive non-mucinous cell (diffuse-infiltrative growth of non-mucinous cells). IV: Microglandular (rosette-like glandular) pattern without goblet cells. V: Mixed 'other' carcinoma foci (including ordinary intestinal/mucinous). VI: goblet cell carcinoid pattern with high-grade morphology (marked nuclear atypia). VII: Solid sheet-like pattern punctuated by goblet cells/microglandular units. Ordinary nested/trabecular ('carcinoid pattern') was very uncommon. In total, 33(52%) died of disease, with median overall survival 38 months and 5-year survival 32%. On multivariate analysis perineural invasion and younger age (<55) were independently associated with worse outcome while lymph-vascular invasion, stage, and nodal status trended toward, but failed to reach, statistical significance. Worse behavior in younger patients combined with female predilection and ovarian-affinity raise the possibility of hormone-assisted tumor progression. In conclusion, 'adenocarcinoma ex-goblet cell carcinoid' is an appendix-specific, high-grade malignant neoplasm with distinctive morphology that is recognizable at metastatic sites and recapitulates crypt cells (appendiceal crypt cell adenocarcinoma). Unlike intestinal-type adenocarcinoma, it occurs predominantly in women, is disguised as gynecologic malignancy, and spreads along peritoneal surfaces with only rare hematogenous metastasis. It appears to be significantly more aggressive than appendiceal mucinous neoplasms.

Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications.

BACKGROUND: Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications. METHODS: Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed. RESULTS: A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients. CONCLUSIONS: CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.