Fasciotomy and rate of amputation after tibial fracture in adults: a population-based cohort study.

Objectives: Limb amputation is a possible outcome of acute compartment syndrome. We undertook this study to investigate the occurrence of fasciotomy and amputation in patients with tibial fractures in the Ontario adult population, aiming to evaluate variables that may be associated with each of these outcomes. Design: Retrospective, population-based cohort study (April 1, 2003-March 31, 2016). Setting: Canadian province of Ontario. Participants: Patients with tibial fracture, aged 14 years and older. Interventions: Fasciotomy after tibial fracture. Main Outcomes and Measures: The primary outcomes were fasciotomy and amputation within 1 year of fasciotomy. Secondary outcomes included repeat surgery, new-onset renal failure, and mortality, all within 30 days of fasciotomy. Results: We identified 76,299 patients with tibial fracture; the mean (SD) age was 47 (21) years. Fasciotomy was performed in 1303 patients (1.7%); of these, 76% were male and 24% female. Patients who were younger, male, or experienced polytrauma were significantly more likely to undergo fasciotomy. Limb amputation occurred in 4.3% of patients undergoing fasciotomy, as compared with 0.5% in those without fasciotomy; older age, male sex, presence of polytrauma, and fasciotomy were associated with an increased risk of amputation (age odds ratio [OR] of 1.03 [95% CI, 1.02-1.03], P < 0.0001; sex OR of 2.04 [95% CI, 1.63-2.55], P < 0.0001; polytrauma OR of 9.37 [95% CI, 7.64-11.50], P < 0.0001; fasciotomy OR of 4.35 [95% CI, 3.21-5.90], P < 0.0001), as well as repeat surgery within 30 days (sex OR of 1.54 [95% CI, 1.14-2.07], P = 0.0053; polytrauma OR of 4.24 [95% CI, 3.33-5.38], P < 0.0001). Conclusions: Among tibial fracture patients, those who were male and who experienced polytrauma were at significantly higher risk of undergoing fasciotomy and subsequent amputation. Fasciotomy was also significantly associated with risk of amputation, a finding that is likely reflective of the severity of the initial injury.

Predictors of Undergoing Revision Within 5 Years of Total Knee Arthroplasty: A Population-Based Study.

BACKGROUND: The objective of this study was to identify the rate and risk factors for revision total knee arthroplasty (TKA) within the first 5 years postoperative. Our secondary objective was to identify the rate of additional surgical procedures and death. METHODS: We conducted a retrospective cohort study among patients in Ontario, Canada who underwent an elective, primary TKA between April 1, 2007, and March 31, 2014, for osteoarthritis. We excluded patients under 40 years and who had undergone a TKA within the previous 15 years. Our final study cohort included 94,193 patients. We reported the proportion of the study cohort who experienced revision surgery within 2 and 5 years of the primary TKA; secondary surgery within 5 years. We conducted Cochran-Armitage tests for trends to assess changes in the proportion of patients who experienced each of the study outcomes, and multivariable logistic regressions to evaluate predictors of a revision TKA. RESULTS: There were 3,112 (3.3%) patients who had a revision within 5 years, and 1,866 (2.0%) within 2 years of their primary TKA. 3,316 (3.5%) had a secondary surgery (0.6% patellar resurfacing; 1.6% manipulation; 1.3% synovectomy; 0.5% washout; 0.9% debridement). Lower age, men, lower income, higher comorbidity score, depression, previous arthroscopy, lower surgeon volume, and general anesthesia were all significant positive predictors of revision. CONCLUSIONS: In our study cohort, 2.0% of patients had a revision TKA within 2 years, and 3.3% within 5 years of their primary TKA. Preoperative identification of risk factors may reduce the future prevalence of revision TKAs.

Association Between Complications after Vascular Surgery and Prolonged Postoperative Opioid Use.

BACKGROUND: Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery. METHODS: This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or nonruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013 and 2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation approach to account for the clustering of patients within physicians and institutions. RESULTS: This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an odds ratio (OR) of 13.27 (95% CI: 10.63-16.57) for AAA, 11.24 (95% CI: 9.18-13.75) for EVAR, and 4.69 (95% CI: 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI: 1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI: 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI: 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94). CONCLUSIONS: Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open LER. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing LER. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.

In focus: perplexing increase of urinary stone disease in children, adolescent and young adult women and its economic impact.

Background: Urinary stone disease (USD) historically has affected older men, but studies suggest recent increases in women, leading to a near identical sex incidence ratio. USD incidence has doubled every 10 years, with disproportionate increases amongst children, adolescent, and young adult (AYA) women. USD stone composition in women is frequently apatite (calcium phosphate), which forms in a higher urine pH, low urinary citrate, and an abundance of urinary uric acid, while men produce more calcium oxalate stones. The reasons for this epidemiological trend are unknown. Methods: This perspective presents the extent of USD with data from a Canadian Province and a North American institution, explanations for these findings and offers potential solutions to decrease this trend. We describe the economic impact of USD. Findings: There was a significant increase of 46% in overall surgical interventions for USD in Ontario. The incidence rose from 47.0/100,000 in 2002 to 68.7/100,000 population in 2016. In a single United States institution, the overall USD annual unique patient count rose from 10,612 to 17,706 from 2015 to 2019, and the proportion of women with USD was much higher than expected. In the 10-17-year-old patients, 50.1% were girls; with 57.5% in the 18-34 age group and 53.6% in the 35-44 age group. The roles of obesity, diet, hormones, environmental factors, infections, and antibiotics, as well as the economic impact, are discussed. Interpretation: We confirm the significant increase in USD among women. We offer potential explanations for this sex disparity, including microbiological and pathophysiological aspects. We also outline innovative solutions - that may require steps beyond typical preventive and treatment recommendations.

A population-based retrospective cohort study of surgical trends and outcomes of pediatric urolithiasis in Ontario, Canada (2002-2019).

INTRODUCTION: The worldwide incidence of pediatric urinary stone disease (PUSD) is increasing. However, there is no commensurate data on whether this translates to an increasing need for surgical intervention for PUSD, given the role of conservative management. OBJECTIVE: We aimed to evaluate the trends and outcomes of clinically significant PUSD, using administrative databases to identify patients surgically treated for PUSD. STUDY DESIGN: This retrospective population-based cohort study assessed the incidence and trends of surgically treated PUSD and outcomes in Ontario, Canada in patients <18 years of age who underwent their first PUSD procedure between 2002 and 2019 utilizing administrative databases held at the Institute of Clinical Evaluative Sciences (ICES). We assessed the incidence of surgically treated PUSD, demographics, initial surgical treatment and imaging modality, and risk factors for repeat intervention within 5 years. Statistical analyses summarized demographics, surgical trends, and logistic regression was used to identify risk factors for repeat surgical intervention. RESULTS: We identified 1149 patients (mean age 11.3 years), with 59.6% older than 12 years. There was a decrease in the number of PUSD procedures performed per year that was close to statistical significance (p = 0.059) and a trend towards increased utilization of ureteroscopy (URS) compared with Shockwave Lithotripsy (SWL). In addition, there was a significant increase in the proportion of females surgically treated with PUSD (p = 0.001). In the 706 patients followed for 5 years, 17.7% underwent a repeat procedure within 6 months, while 20.4% underwent a repeat procedure from 6-months to 5 years. Renal stone location (OR 2.79, 95% confidence interval (CI) 1.62-4.80, p = 0.0002) and index SWL (OR 1.66, 95% CI 1.20-2.31, p = 0.0025) were risk factors for repeat surgical intervention within the first 6-months. There was an increasing utilization of ultrasound (US) compared to computerized tomography (CT) (p = 0.0008). DISCUSSION: Despite the literature reporting increasing PUSD incidence, we observed a non-significant decrease in the number of surgical PUSD procedures performed. Exclusion of those treated conservatively may explain our results. The increase in the proportion of females treated reflects the narrowing gender gap in stone disease. A trend towards increased URS utilization was observed and re-intervention rates were similar to previous studies. CONCLUSION: The overall rate of surgically treated PUSD did not show an increasing trend in Ontario, Canada from 2002 to 2019. URS was the most common surgical treatment modality, with a corresponding decline in SWL rates. PUSD was associated with a high surgical re-intervention rate within 6 months.

The Reduction of Male Lower Urinary Tract Symptoms Is Associated With a Decreased Risk of Death.

PURPOSE: Male lower urinary tract symptoms have been correlated with an increased risk of death; however, it is unclear if treatment will reduce this risk. Our objective was to determine whether a reduction in lower urinary tract symptoms is associated with a reduced risk of mortality. MATERIALS AND METHODS: We conducted a secondary analysis of the MTOPS (Medical Treatment of Prostate Symptoms) randomized trial of placebo, doxazosin, finasteride, or doxazosin and finasteride. Men in the United States between 1993 and 1998 who were >50 years of age with moderate to severe lower urinary tract symptoms were included. We used various Cox regression models to assess the relationship between AUA Symptom Score (modeled as a time-varying exposure) and death. RESULTS: A total of 3,046 men (median age 62, quartiles 57-68) were randomized and had a baseline AUA Symptom Score. For each 1-point improvement in the AUA Symptom Score, the hazard ratio for death was 0.96 (0.94-0.99, P = .01). Our sensitivity analyses found a similar significant reduction in the hazard ratio for death within men who had active treatment, but not among men who were randomized to the placebo arm; our results did not change when men were censored at the time of transurethral prostate resection, with adjustment for potential confounders, or with a shorter observation period after the last study visit. A comparable significant reduction in death was seen with 1-point improvements in the storage (HR 0.94, 95% CI 0.88-0.99, P = .04) and voiding (HR 0.95, 95% CI 0.91-0.99, P = .03) subscales individually. CONCLUSIONS: Improvement in male lower urinary tract symptoms was associated with a reduced risk of death. Further study is warranted to determine if the male treatment paradigm should shift toward symptom treatment independent of bother.

Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

Total Hip Arthroplasty in Patients Aged 40 to 60 Years Old: A Population-Based Study.

BACKGROUND: Contemporary total hip arthroplasty (THA) has resolved many implant longevity concerns in younger patients. Patients in their fourth and fifth decades of life are projected to be the fastest-growing demographic of THA patients. We aimed to assess this demographic to: 1) evaluate the rate of THA over time; 2) evaluate the cumulative incidence of revision; and 3) identify risk factors for revision. METHODS: A retrospective population-based study of patients between 40 and 60 years old undergoing primary THA was conducted using administrative data from a large clinical data repository. A total of 28,414 patients were included for analysis with a mean age of 53 years (range, 40-60 years) and median follow-up of 9 years (range, 0-17 years). Linear regressions were used to assess annual rates of THA in this cohort over time. Kaplan-Meier analysis was used to determine cumulative incidence of revision. Multivariate Cox proportional hazards models were used to determine association of variables with revision risk. RESULTS: The annual rate of THA in our population increased by 60.7% over the study period (P < .0001). Cumulative incidence of revision was 2.9% at 5 years and 4.8% at 10 years. Younger age, women, non-osteoarthritis diagnosis, medical complications, and annual surgeon volume ≤ 60 THA were associated with increased revision risk. CONCLUSION: Demand for THA continues to dramatically increase in this cohort. Risk of revision was low but multiple risk factors were identified. Future studies will help delineate the effect of these variables on revision risk and assess implant survivorship beyond 10 years.

Complications From Postmastectomy Radiation Therapy in Patients Undergoing Immediate Breast Reconstruction: A Population-Based Study.

Purpose: Previous studies have shown an increase in the number of women electing for immediate breast reconstruction at the time of mastectomy. Although often not known at the time, some of these women will require postoperative radiation therapy. The purpose of this study was to investigate if exposure to radiation therapy after mastectomy with immediate breast reconstruction is associated with an increased risk of further surgery to manage complications arising from radiation. Methods and Materials: This retrospective, population-based cohort study included all patients who underwent mastectomy with immediate reconstruction from 2007 to 2014 in the province of Ontario, Canada. Exposure to adjuvant radiation therapy was captured using data from Ontario Health. The study outcome was reoperation for breast reconstruction performed during the follow-up window. Cox proportional hazard models were used to assess the effect of radiation therapy exposure on risk of breast reconstruction reoperation. Results: We identified 2342 patients who underwent mastectomy with immediate reconstruction over an 8-year period in Ontario, of whom 378 (16.1%) underwent adjuvant radiation therapy. Patients who received radiation were significantly more likely to undergo reoperation during follow-up (hazard ratio, 1.76; 95% confidence interval, 1.49-2.08; P < .0001). Patients with implant-based reconstructions (n = 1629, 69.6%) were not more likely to undergo reoperation than those with flap-based procedures (n = 713, 30.4%) (hazard ratio, 1.01; 95% confidence interval, 0.85-1.21; P = .885). Conclusions: Adjuvant radiation therapy initiated after mastectomy with immediate breast reconstruction is associated with an increased risk of additional breast reconstruction surgery, regardless of the type of reconstruction used. Patients with breast cancer who choose to undergo immediate reconstruction after mastectomy should be advised that additional reconstruction procedures may be required.

The Impact of Anticholinergic Use for Overactive Bladder on Cognitive Changes in Adults with Normal Cognition, Mild Cognitive Impairment, or Dementia.

Background: Few studies have addressed whether anticholinergic (AC) medications for overactive bladder (OAB) cause cognitive decline in individuals with existing cognitive impairment, and whether the APOE ε4 gene increases this risk. Objective: To determine whether OAB AC use is associated with a clinically relevant change in cognitive measures among adults with normal and abnormal cognition. Design setting and participants: This was a retrospective cohort study using data from the National Alzheimer's Coordinating Center. Patients were enrolled at specialized centers in the USA between 2005 and 2019. Patients with existing OAB AC use, missing APOE ε4 status, and confounding neurologic diagnoses were excluded. New users of an OAB AC were matched 1:1 to patients not taking an OAB AC using propensity scores. Intervention: New use of oxybutynin, tolterodine, solifenacin, trospium, darifenacin, or fesoterodine. Outcome measurements and statistical analysis: The outcome was a change in cognitive function, measured as a ≥1-point increase on the Clinical Dementia Rating (CDR) instrument or a ≥3-point decrease on the Mini-Mental State Examination (MMSE). Conditional logistic regression with odds ratios (ORs) was conducted. We also tested for APOE ε4 effect modification. Results and limitations: Among 18 835 eligible patients, 782 matched pairs were identified. The most common OAB ACs were oxybutynin (38%) and tolterodine (23%). There was no significant increase in the risk of a clinically relevant cognitive decline among OAB AC users (CDR: OR 1.38, 95% confidence interval [CI] 0.93-2.05; p = 0.11, MMSE: OR 1.06, 95% CI 0.79-1.43; p = 0.70). There was no significant interaction between APOE ε4 status and OAB AC use for the CDR (p = 0.38) or MMSE (p = 0.95) outcomes. Users of oxybutynin or tolterodine had numerically higher odds of a change on the CDR test (OR 1.65, 95% CI 0.98-2.77) that was close to statistical significance (p = 0.06). Limitations include the inability to determine medication dose or duration, and residual confounding. Conclusions: OAB AC use was not associated with a significant change in cognitive function among individuals with normal and abnormal cognition. Further research is necessary to determine if oxybutynin and tolterodine are significantly more likely to cause cognitive decline. Patient summary: Use of a specific class of overactive bladder medication was not associated with negative changes in brain function among patients with either normal or abnormal function. A genetic risk factor for Alzheimer's disease did not predispose individuals to cognitive decline when taking these drugs. Two of the drugs (oxybutynin and tolterodine) may lead to a higher risk of cognitive decline in comparison to other drugs, and this needs further research.

Opioid use for a first-incident upper extremity fracture in 220,440 patients without recent prior use in Ontario, Canada: a retrospective cohort study.

To describe opioid use for a first upper extremity fracture in a cohort of patients who did not have recent opioid use. Design: Descriptive epidemiological study. Setting: Emergency Department, Hospital. Patients/Participants: We obtained health administrative data records of adults presenting with a first adult upper extremity fracture from 2013 to 2017 in Ontario, Canada. We excluded patients with previous fractures, opioid prescription in the past 6 months or hospitalization >5 days after the fracture. Intervention: Opioid prescription. Main Outcome Measurements: We identified the proportion of patients filling an opioid prescription within 7 days of fracture. We described this based on different upper extremity fractures (ICD-10), Demographics (age, sex, rurality), comorbidity (Charlson Comorbidity Index, Rheumatoid arthritis, Diabetes), season of injury, and social marginalization (Ontario Marginalization Index-a data algorithm that combines a wide range of demographic indicators into 4 distinct dimensions of marginalization). We considered statistical differences (P< .01) that reached a standardized mean difference of 10% as being clinically important (standardized mean difference [SMD] ≥ 0.1). Results: From 220,440 patients with a first upper extremity fracture (50% female, mean age 50), opioids were used by 34% of cases overall (32% in males, 36% in females, P< .001, SMD ≥ 0.1). Use varied by body region, with those with multiple or proximal fractures having the highest use: multiple shoulder 64%, multiple regions 62%, shoulder 62%, elbow 38%, wrist 31%, and hand 21%; and was higher in patients who had a nerve/tendon injury or hospitalization (P< .01, SMD ≥ 0.1). Social marginalization, comorbidity, and season of injury had clinically insignificant effects on opioid use. Conclusions: More than one-third of patients who are recent-non-users will fill an opioid prescription within 7 days of a first upper extremity fracture, with usage highly influenced by fracture characteristics.Level of Evidence: Level II.

Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study.

BACKGROUND: The addition of fusion surgery to the decompression for lumbar degenerative disorders remains controversial. The purpose of this study is to compare the rate and outcome of decompression and fusion versus decompression alone. METHODS: This population-based retrospective cohort study used several linked administrative databases to identify patients who underwent spinal decompression surgery in Ontario, Canada, from 2006 to 2015. Patients who had previous spine surgery, concurrent lumbar disc replacement, or a diagnosis other than degenerative disc disease were excluded. Adjusted logistic regression was used to assess our outcomes. RESULTS: We identified 33,912 patients, of whom 9748 (28.74%) underwent fusion. Overall, fusion rates increased from 27.66% to 31.33% over the study period (P = 0.025). Factors associated with fusion included: older age, female sex, American Society of Anesthesiologists score ≥3, previous total joint replacement, and surgery by an orthopedic surgeon. Fusion surgery was associated with increased odds of 30-day mortality (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.01-3.09; P = 0.046), 30-day (OR 1.94, 95% CI 1.53-2.46; P < 0.0001) and 90-day reoperation (OR 1.66, 95% CI 1.35-2.05; P < 0.0001), and 30-day readmission (OR 1.23, 95% CI 1.02-1.49; P = 0.027) when adjusting for confounding variables. The odds of suffering a complication after fusion and decompression surgery vs. decompression surgery alone were 4.3-fold greater (95% CI 3.78-5.09; P < 0.0001). CONCLUSIONS: As compared with decompression alone, spinal fusion for degenerative lumbar disorders is associated with increased odds of adverse outcomes. These findings highlight the need for spine surgeons to consider carefully their indications for fusion procedures in the setting of degenerative spinal disorders.

Hip arthroscopy utilization and reoperation rates in Ontario: a population-based analysis comparing different age cohorts.

BACKGROUND: Older age (> 40 yr) and osteoarthritis are negative prognostic variables for hip arthroscopy, but their impact has not been quantified from a population standpoint. The purpose of this study was to perform a population-based analysis of hip arthroscopy utilization and associated 2- and 5-year reoperation rates and complications in different age cohorts. METHODS: Administrative databases from Ontario, Canada, were retrospectively reviewed to identify patients aged 18-60 years who underwent hip arthroscopy between 2006 and 2016. Patients were stratified into 2 cohorts: 18-39 and 40-60 years of age. Patients were followed for 2 and 5 years to capture the occurrence of subsequent surgery (repeat arthroscopy or total hip arthroplasty) and postoperative complications. RESULTS: A total of 1906 patients underwent hip arthroscopy, 818 (42.9%) of whom were aged 40-60 years. In the entire cohort, revision surgery occurred in 6.5% and 15.1% of cases at 2 and 5 years, respectively. Revision surgery rates were significantly higher among patients aged 40-60 years at 2 (10.8% v. 3.2%, p < 0.001) and 5 years (22.7% v. 8.2%, p < 0.001) than among those aged 18-39 years. Revision rates were higher among patients aged 50-60 years than among those aged 40-49 years at 2 years (14.3% v. 9.1%, p = 0.027). Complication rates did not differ between cohorts. Regression analysis revealed higher 2- and 5-year odds of secondary surgery in patients aged 40-49 years (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.70-4.22; OR 2.82, 95% CI 1.87-4.25; p < 0.001), patients aged 50-60 years (OR 4.39, 95% CI 2.67-7.22; OR 3.44, 95% CI 2.11-5.62; p < 0.001) and those with osteoarthritis (OR 2.41, 95% CI 1.39-4.20; p = 0.002; OR 1.76, 95% CI 1.00-3.09; p = 0.049). CONCLUSION: Revision surgery rates following hip arthroscopy are significantly higher among older patients and those with concomitant osteoarthritis. Although the data have limitations, they provide useful information to guide surgical decision-making.

The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study.

BACKGROUND: Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS: We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS: We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION: A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.

From Formation to Closure: Aggregate Morbidity and Mortality Associated With Defunctioning Loop Ileostomies.

BACKGROUND: Defunctioning loop ileostomies are used commonly, but there are significant morbidities. OBJECTIVE: This study aimed to describe the morbidity and mortality associated with the formation and closure of defunctioning loop ileostomies. DESIGN: This descriptive study is based on electronic health records and claims data. SETTINGS: This study was conducted at academic and community hospitals in Ontario, Canada. PATIENTS: Adult patients who had a low anterior resection with concurrent defunctioning loop ileostomy from 2002 to 2014 were included. MAIN OUTCOME MEASURES: Outcomes of interest included 30-day major complications, acute kidney injury, transfusion, and deep space infection. The rate of ileostomy reversal and the percentage of permanent ostomies were also collected. RESULTS: The cohort consists of 4658 patients who underwent low anterior resection with concurrent defunctioning loop ileostomy. The 30-day, 90-day, and 1-year mortality rates of these patients were 1.2%, 2.2%, and 5.1%. The rate of reoperation was 5.5%, the rate of hospital readmission was 13.4%, the rate of major complications was 28.5%, the rate of deep organ/space infection requiring percutaneous intervention was 5.2%, and the rate of acute kidney injury requiring hospitalization was 10.4%. Eighty-six percent had their ileostomy reversed, leaving 13.2% with a permanent ostomy. After ileostomy reversal, 30-day and 90-day mortality rates were 0.6% and 0.9%. The rate of major complications was 10.3%, bowel obstruction 7%, ventral hernia 10.5%, deep space infection 1.7%, and repeat operation 2.3%. LIMITATIONS: This study is based on electronic health records and claims data and, thus, the accuracy of results depends on the accuracy of data administration' which can be variable across institutions. CONCLUSIONS: Morbidity and mortality of defunctioning loop ileostomies are significant. One in 8 patients will have a permanent ostomy. See Video Abstract at http://links.lww.com/DCR/B810 . DESDE LA FORMACIN HASTA EL CIERRE AGREGADA MORBILIDAD Y MORTALIDAD ASOCIADA CON LAS ILEOSTOMAS EN ASA DERIVATIVA: ANTECEDENTES:Las ileostomías en asa derivativa se utilizan con frecuencia, pero existen morbilidades importantes.OBJETIVO:Describir la morbilidad y mortalidad asociadas con la formación y cierre de ileostomías en asa derivativa.DISEÑO:Estudio descriptivo basado en historias clínicas electrónicas y datos de reclamaciones.ENTORNO CLINICO:Hospitales académicos y comunitarios en Ontario, Canadá.PACIENTES:Pacientes adultos sometidos a resección anterior baja con concurrente ileostomía en asa derivativa de 2002 a 2014.PRINCIPALES MEDIDAS DE VALORACION:Los resultados de interés incluyeron complicaciones mayores a los 30 días, lesión renal aguda, transfusión e infección del espacio profundo. También se recolectó la tasa de reversión de la ileostomía y el porcentaje de ostomías permanentes.RESULTADOS:La cohorte consistió de 4658 pacientes sometidos a resección anterior baja con concurrente ileostomía en asa derivativa. La mortalidad de estos pacientes, a treinta días, 90 días y un año, fue del 1,2%, 2,2% y 5,1%, respectivamente. La tasa de reintervención fue del 5,5%, el reingreso hospitalario fue del 13,4%, la complicación mayor fue del 28,5%, la infección profunda de órganos / espacios que requirieron intervención percutánea fue del 5,2%, y la lesión renal aguda que requirió hospitalización fue del 10,4%. Ochenta y seis por ciento tuvieron reversión de su ileostomía, dejando al 13.2% con una ostomía permanente. Después de la reversión de la ileostomía, la mortalidad a los 30 días y 90 días fue de 0,6% y 0,9%, respectivamente. La tasa de complicaciones mayores fue del 10,3%, obstrucción intestinal del 7%, hernia ventral del 10,5%, infección del espacio profundo del 1,7% y reintervención del 2,3%.LIMITACIONES:El estudio se basa en registros médicos electrónicos y datos de reclamos y, por lo tanto, la precisión de los resultados depende de la precisión en la administración de datos, que pueden variar entre instituciones.CONCLUSIONES:La morbilidad y la mortalidad de las ileostomías en asa derivativa son significativas. Uno de cada 8 pacientes tendrá una ostomía permanente. Consulte Video Resumen en http://links.lww.com/DCR/B810 . (Traducción-Dr. Fidel Ruiz Healy ).

A population-based, retrospective cohort study analyzing contemporary trends in the surgical management of urinary stone disease in adults.

INTRODUCTION: We aimed to review the trends and incidence of surgical intervention for adults with upper urinary tract stones in Ontario, Canada, and to hypothesize potential causes for the observed changes. METHODS: We carried out a retrospective, population-based cohort study using administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) to identify all adults (≥18 years) who underwent surgical treatment for urolithiasis, defined by records using a combination of both hospital and physician billing from 2002-2019. Descriptive statistics were used to summarize baseline patient demographics, and surgical trends were analyzed using the Cochrane-Armitage test for trend. RESULTS: From 2002-2019, 140 263 patients were treated surgically for urolithiasis. During this time period, the total number of surgically treated stone disease increased by 80.5%. By type of procedure, percutaneous nephrolithotomy (PCNL) increased by 187% and ureteroscopy (URS) increased by 158%, while the number of shockwave lithotripsy (SWL) declined by 31.4%. The adult population in Ontario in the years evaluated grew by 24.4%. The number of surgical procedures per 100 000 people over this time grew by 45.3%. For every 1% increase in the population, there was a 2.6% rise in stone-related surgical procedures. CONCLUSIONS: The number of stone-related surgical procedures performed rose significantly and cannot be accounted for by population growth alone. This rise was proportionally larger in the female population, further supporting a narrowing of the gender gap in urinary stone disease. The reasons for the increase are likely multifactorial and may imply an increasing incidence of surgically treated stone disease. The change in the proportion of URS and SWL performed may demonstrate a continued shift in surgical preference or may be reflective of resource limitations and availability. The increase in PCNL volumes may also suggest a greater complexity of cases. These findings should be considered for future resource planning and require further study.

Fracture profiles of a 4-year cohort of 266,324 first incident upper extremity fractures from population health data in Ontario.

BACKGROUND: Understanding the profiles of different upper extremity fractures, particularly those presenting as a 1st incident can inform prevention and management strategies. The purpose of this population-level study was to describe first incident fractures of the upper extremity in terms of fracture characteristics and demographics. METHODS: Cases with a first adult upper extremity (UE) fracture from the years 2013 to 2017 were extracted from administrative data in Ontario. Fracture locations (ICD-10 codes) and associated characteristics (open/closed, associated hospitalization within 1-day, associated nerve, or tendon injury) were described by fracture type, age category and sex. Standardized mean differences of at least 10% (clinical significance) and statistical significance (p < 0.01) in ANOVA were used to identify group differences (age/sex). RESULTS: We identified 266,324 first incident UE fractures occurring over 4 years. The most commonly affected regions were the hand (93 K), wrist/forearm(80 K), shoulder (48 K) or elbow (35 K). The highest number of specific fractures were: distal radius (DRF, 47.4 K), metacarpal (30.4 K), phalangeal (29.9 K), distal phalangeal (24.4 K), proximal humerus (PHF, 21.7 K), clavicle (15.1 K), radial head (13.9 K), and scaphoid fractures (13.2 K). The most prevalent multiple fractures included: multiple radius and ulna fractures (11.8 K), fractures occurring in multiple regions of the upper extremity (8.7 K), or multiple regions in the forearm (8.4 K). Tendon (0.6% overall; 8.2% in multiple finger fractures) or nerve injuries were rarely reported (0.3% overall, 1.5% in distal humerus). Fractures were reported as being open in 4.7% of cases, most commonly for distal phalanx (23%). A similar proportion of females (51.5%) and males were present in this fracture cohort, but there were highly variant age-sex profiles across fracture subtypes. Fractures most common in 18-40-year-old males included metacarpal and finger fractures. Fractures common in older females were: DRF, PHF and radial head, which exhibited a dramatic increase in the over-50 age group. CONCLUSIONS: UE fracture profiles vary widely by fracture type. Fracture specific prevention and management should consider fracture profiles that are highly variable according to age and sex.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age.

PURPOSE: Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use. METHODS: A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage. RESULTS: Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use. CONCLUSION: Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use. LEVEL OF EVIDENCE: Level III.

An Opioid Prescription for Men Undergoing Minor Urologic Surgery Is Associated with an Increased Risk of New Persistent Opioid Use.

BACKGROUND: The opioid abuse epidemic has highlighted the risks associated with these medications. OBJECTIVE: To determine whether filling a postoperative opioid prescription after low acuity urologic surgery is associated with new persistent opioid use. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent their first vasectomy, transurethral prostatectomy, urethrotomy, circumcision, spermatocelectomy, or hydrocelectomy between 2013 and 2016. We excluded men with prior opioid use, confounding concurrent procedures, prolonged hospitalization, or cancer. INTERVENTION: Whether the patient filled a prescription for an opioid within 5 d of their surgery. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was evidence of at least two opioid prescriptions filled 9-15 mo after urologic surgery. The secondary outcome was admission for opioid overdose. Primary analysis was adjusted logistic regression analysis. RESULTS AND LIMITATIONS: We identified 91 083 men, most of whom underwent vasectomy (78%). A total of 32 174 (35%) men filled a prescription for an opioid after their procedure. The most common opioid prescribed was codeine (70%), and urologists were the primary prescribers (81%). Men who filled a postprocedure opioid prescription did not differ, for most of the 57 medical comorbidities or markers of healthcare utilization that we measured, from those who did not fill an opioid prescription. There was long-term opioid use in 1447 (1.6%); men who had filled a postoperative opioid prescription had a significantly higher risk of long-term opioid use (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.6) and opioid overdose (OR 3.0, 95% CI 1.5-5.9). A limitation is that we could not determine the indication for long-term opioid prescriptions. CONCLUSIONS: Prescription of opioids after low acuity urology procedures is significantly associated with increased opioid use at 1yr after surgery; efforts should be made to reduce postoperative opioids, especially for urologic procedures that do not typically require opioids. PATIENT SUMMARY: Filling an opioid prescription after minor urologic surgeries is associated with an increased risk of persistent long-term use of opioid medications and a higher risk of serious long-term complications such as hospital visits for an opioid overdose.'

Trends in immediate breast reconstruction and radiation after mastectomy: A population study.

In the last decade, there has been an increase in women undergoing immediate breast reconstruction (IBR) at the time of mastectomy. Recent literature suggests a shift in practice: Surgeons are becoming more comfortable with IBR in the setting of possible postoperative adjuvant radiotherapy, despite the known complications. This study sought to investigate, at a population level, the patient and surgeon characteristics associated with the use of IBR and which of these factors were predictive of adjuvant radiotherapy. This retrospective population-based cohort study included all adult women who underwent mastectomy in the province of Ontario from 2007 to 2014. The Canadian Institute for Health Information (CIHI) administrative data base was used to generate patient demographic and clinical data. The Ontario Health Insurance Plan (OHIP) data base was used to elicit surgeon characteristics including clinical experience and volume of practice dedicated to breast surgery. Outcome variables included reconstruction concurrent with mastectomy, alloplastic vs autologous reconstruction, and use of radiation. A total of 25 861 patients underwent mastectomy and 2972 had IBR (11.5%). The rate of IBR after mastectomy increased over time from 7.2% in 2007 to 17.2% in 2014 (P < .001). There was also an increase in the proportion of patients with IBR who received radiation over the time period, from 19.4% in 2007 to 28.2% in 2014 (P = .003). In the first regression analysis, IBR was associated with younger patient age, residing in closer proximity to cancer clinics, absence of malignant breast disease (ie, prophylactic mastectomy), having a younger surgeon performing the mastectomy, and receiving care at a teaching hospital. A second analysis showed that patient variables predictive of radiation after IBR were a younger age and a more advanced cancer stage and no variables specific to surgeon or institution were predictive of radiation in patients with IBR. A significant increase in the rate of IBR as well as the use of radiation occurred over the 7-year study period. Multiple patient and surgeon factors were associated with IBR. Variables associated with radiation in IBR were harder to predict. Given the increase in the use of radiation in IBR, further research is needed to look at long-term outcomes in these patients at the population level.