Predicting Postoperative Course After Total Shoulder Arthroplasty Using a Medical-Social Evaluation Model.

INTRODUCTION: The ability to predict successful outcomes is important for patient satisfaction and optimal results after shoulder arthroplasty. We hypothesize that a medical-social scoring tool will predict resource requirements in doing total shoulder arthroplasty (TSA). METHODS: A retrospective analysis of 453 patients undergoing TSA was undertaken. Preoperatively, medical and social surveys were completed by each patient. Demographics, comorbidity scores, hospital course, postdischarge disposition, and readmissions were collected. RESULTS: The average length of stay was 1.6 days (0 to 7). There was an association with utilization of home care or inpatient rehabilitation and both the medical (7.3 versus 3.9; P = 0.0002) and social (7.1 versus 3.4; P < 0.0001) components of the survey. There was a weak correlation between hospital length of stay and the social component of the survey (R = 0.29; P < 0.001), but not the medical component (R = 0.04; P = 0.38). No variable was predictive of readmission. Social score of eight was found to be predictive of postoperative requirement of home care or rehabilitation. CONCLUSION: This study found that Medical and Social Survey Scores can stratify patients who are at risk of requiring more advanced postdischarge care and/or a longer hospital stay. With this, we can match patients to the most appropriate level of postoperative care.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Routine Patellar Resurfacing During Total Knee Arthroplasty Is Not Cost-Effective in Patients Without Patellar Arthritis.

BACKGROUND: Currently, the decision to resurface the patella is often made irrespective of the presence of patellar arthritis. The purpose of this study is to utilize the existing literature to assess cost-utility of routinely vs selectively resurfacing the patella. METHODS: Prospective randomized studies of patella resurfacing vs non-resurfacing in total knee arthroplasty (TKA) were identified through literature review. Data from these studies represented probabilities of varied outcomes following TKA dependent upon patella resurfacing. Using previously validated utility scores from the McKnee modified Health Utilities Index, endpoint utility values were provided for each potential outcome. RESULTS: Literature review yielded a total of 14 studies with 3,562 patients receiving 3,823 TKAs, of which 1,873 (49.0%) patellae were resurfaced. Persistent postoperative anterior knee pain occurred in 20.9% vs 13.2% (P < .001) and patella reoperation was performed in 3.7% vs 1.6% (P < .001) of unresurfaced and resurfaced patella, respectively. In studies excluding those with arthritic patellae, the incidence of anterior knee pain was equivalent between groups and reoperation decreased to 1.2% vs 0% (P = .06). Patella resurfacing provided marginally improved quality-adjusted life-years (QALY) for both selective and indiscriminate patella resurfacing. When including all studies, the incremental cost per QALY was $3,032. However, when analyzing only those studies with nonarthritic patellae, the incremental cost per QALY to resurface the patella increased to $183,584. CONCLUSION: Patellar resurfacing remains a controversial issue in TKA. Utilizing data from new prospective randomized studies, this analysis finds that routinely resurfacing arthritis-free patellae in TKA are not cost-effective.

Helical Blade Versus Screw Fixation in the Treatment of Hip Fractures With Cephalomedullary Devices: Incidence of Failure and Atypical "Medial Cutout".

OBJECTIVE: To evaluate the rates and mechanisms of failure for cephalomedullary nail fixation using helical blade versus screw fixation and to identify the predictors of failure. DESIGN: Retrospective study. SETTING: Community teaching hospital. PATIENTS/PARTICIPANTS: A total of 126 patients were treated with cephalomedullary fixation for low-energy hip fractures. INTERVENTION: All procedures used the Trochanteric Fixation Nail (Synthes) with either a helical blade [71 (56.3%)] or screw [55 (43.7%)]. MAIN OUTCOME MEASUREMENTS: Failures, defined by nonunion, hardware cutout, and need for revision surgery were independently reviewed by a fellowship-trained orthopaedic trauma surgeon for an assessment of reduction quality and hardware placement. RESULTS: Seven failures of fixation (5.6%) occurred, all of which used a helical blade. Five failures resulted from medial migration of the helical blade through the femoral head, whereas 2 resulted from typical superolateral cutout and varus collapse. There was no difference in the average tip apex distance between the cases using blade versus screw fixation or between failures and the remainder of the cohort. Basicervical fractures had a significantly higher rate of failure than other fracture patterns. CONCLUSIONS: This study showed a higher failure rate with use of the blade and supports the use of screw fixation in these fractures. In addition, we confirm an atypical mode of failure, lateral migration of the femoral head with protrusion of the helical blade, which contributes significantly to the overall failure rate of this implant and occurs despite appropriate fracture reduction and hardware placement. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preinjury Patient Characteristics and Postinjury Neurological Status Are Associated With Mortality Following Spinal Cord Injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates the association between spinal cord injuries (SCI) and post-injury mortality. SUMMARY OF BACKGROUND DATA: SCIs) are severe conditions treated in the acute trauma setting. Owing to neurological deficits, unstable spinal columns, and associated injuries, these patients often have complex inpatient hospitalizations with significant morbidity and mortality. It is assumed that a high rate of postinjury mortality would follow such severe injuries; however, the effect of SCI and its treatment on predictors of longevity remain largely unknown. METHODS: Patients seen at a regional referral center for SCI were reviewed from a prospectively maintained database. Four hundred and twenty-six patients with SCI and varying degrees of injury between 2004 and 2009 were collected. Injury characteristics, including injury severity score, level of SCI, and type of SCI were retrieved. To determine independent predictors of 5-year mortality, a logistic regression using patient and injury characteristics at the time of presentation was performed. RESULTS: Average age was 47.4 years (range: 14-95), and 74.5% (318/426) were male. Half of the cohort sustained low-energy mechanisms of injury (220/426; 52.4%). The 30-day, 90-day, 1-year, 2-year, and 5-year mortality rates in the SCI cohort were 6.6% (28/426), 9.2% (39/426), 12.0% (51/426), 15.0% (64/426), and 17.8%, respectively (76/426). Logistic regression demonstrated that increasing age (B = 1.06, P < 0.001), increasing ICU length-of-stay (B = 1.06; P = 0.002), decreased motor score at presentation (B = 0.98; P = 0.004), and lack of surgical intervention (B = 0.38; P < 0.001) were independent predictors of mortality at 5 years. CONCLUSION: There is substantial mortality associated with SCI. A significant proportion of the mortalities occurred acutely after injury. Mortality was associated with neurological deficit and severity of injury, as well as with preinjury patient characteristics. To combat this high rate of death, efforts are needed to address the concomitant disease processes associated with neurological deficits. LEVEL OF EVIDENCE: 3.

The Effect of Postoperative Spinal Infections on Patient Mortality.

STUDY DESIGN: A retrospective, matched cohort study. OBJECTIVES: This study aims to investigate the association between surgical site infection (SSI) and mortality and ascertain any factors that predict mortality in those diagnosed with SSI. SUMMARY OF BACKGROUND DATA: Despite significant efforts toward mitigation, SSI, including deep infection, remains a common complication following spine surgery, Considerable morbidity may be associated with infection, including hospital readmission, revision surgery, and delayed rehabilitation. However, it is not known whether this increase in morbidity is associated with increased mortality. METHODS: Patients from a single center requiring reoperation for SSI following elective spine surgery between 2005 and 2013 were identified in a retrospective fashion. These patients were then matched one-to-three with patients undergoing elective spine surgery without SSI. Patients were matched for age, gender, body mass index (BMI), Charlson comorbidity index, year of surgery, spine region, and approach. The Social Security Death Index was utilized to identify deceased patients and their time of death. Univariate statistics were then utilized to compare mortality rates between the two groups. In addition, the SSI cohort was evaluated for predictors of mortality following SSI. RESULTS: One-hundred ninety-five patients developed SSI at a mean of 27.4 (range: 1-467) days from the index surgery. Ninety-day, 1-year, 2-year, and 5-year mortality rates were 1.54% versus 1.03% (P = 0.70), 4.62% versus 1.2% (P = 0.006), 7.73% versus 2.25% (P = 0.001), and 15.45% versus 3.43% (P = 0.0002) for SSI versus control patients, respectively. Predictors of 2-year mortality in the SSI cohort were increased age (P = 0.02) and increased Charlson Comorbidity Index (P < 0.001). Region and approach of surgery, days to infection, and reason for elective surgery did not influence mortality. CONCLUSION: SSI results in significant morbidity in the postoperative period, with the risk of reoperation, prolonged hospitalization, and need for other invasive procedures. In addition, this study provides evidence that SSI is associated with an increased mortality following elective spine surgery. LEVEL OF EVIDENCE: 4.