Early Medical Complications and Delayed Discharge after Spinopelvic Fusion: A Comparative Analysis of 887 NSQIP Cases from 2006 to 2016.

INTRODUCTION: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively. METHODS: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected. RESULTS: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group (p < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days p < 0.001; SNF: SPF 21.3% vs LF 10.4% p < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups (p = 0.531). The odds ratio for transfusion in the SPF group was 2.9 (p < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, p < 0.012, Discharge disposition OR: 1.8, p < 0.001). CONCLUSIONS: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients.

The critical shoulder angle (CSA) in glenohumeral osteoarthritis: Does observer experience affect measurement reliability on plain radiographs?

BACKGROUND: The critical shoulder angle (CSA) has been associated with full-thickness rotator cuff tears both in the presence and absence of glenohumeral arthritis. It is unclear whether the CSA can be reliably measured from plain radiographs of concentric glenohumeral osteoarthritis amongst examiners at differing levels of training. METHODS: We retrospectively reviewed the radiographs of consecutive patients who underwent shoulder arthroplasty for glenohumeral osteoarthritis. The CSA was measured on a standardized AP scapular view at baseline and then 4 weeks later by fellowship-trained orthopaedic surgeons, a shoulder fellow and a senior orthopaedic resident. Grade of arthritis was categorized using the Samilson and Prieto method. The inter- and intra-observer reliability was then determined for all examiners, as well as for increasing severity of radiographic arthritis. The relationship between the CSA and grade of arthritis was assessed. RESULTS: There were 166 included patients comprised of 104 females (63%) and 62 males (37%) with a mean age of 65.9 ± 10.4 years. The inter- and intra-observer reliability for measuring the CSA amongst all examiners was found to be excellent, with an intra-class coefficient (ICC) of >0.9 (p < 0.0001). The ICC remained excellent even amongst radiographs with more advanced arthritis. Furthermore, there was a weak, inverse relationship between the grade of arthritis and the CSA (r = -0.377, p < 0.005). CONCLUSION: The CSA can reliably be measured by examiners at varying levels of orthopaedic training, even with more advanced radiographic glenohumeral osteoarthritis. Level of evidence: Level III (Prognostic).

Patient Preferences for Plain Radiographs in the Setting of Atraumatic Shoulder Pain: Which Factors Influence Their Decision?

INTRODUCTION: Plain radiographs of the shoulder are routinely obtained for patients presenting with atraumatic shoulder pain, although the diagnostic utility of this imaging modality is unclear. Despite this, patients often prefer to obtain radiographs and may associate them with a more satisfactory visit. METHODS: New patients presenting with atraumatic shoulder pain were provided with information regarding the potential advantages and disadvantages of plain radiographs as part of their visit. Patients then decided whether to receive radiographs and baseline patient demographics were collected. A detailed physical examination and history was performed by a fellowship-trained provider, and a preliminary diagnosis and tentative treatment plan was formulated. The radiographs were then reviewed to determine whether the diagnosis and treatment plan was altered by addition of the radiographs. Patients who opted for radiographs then reported whether they felt the radiographs aided in diagnosis and treatment and whether the addition of the radiograph influenced their visit satisfaction. RESULTS: A total of 220 patients met the inclusion criteria. Overall, 121 patients (55%) requested a radiograph. The mean age was 57.1 ± 16.1 years (range, 18 to 91 years). Lack of bachelor's degree (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2 to 6.2; P = 0.01), lack of previous contralateral shoulder pain (OR, 4.0; 95% CI, 2.0 to 8.2; P = 0.0001), and lack of a previous shoulder radiograph (OR, 8.4; 95% CI, 4.1 to 16.9; P < 0.0001) or MRI within the last 6 months (OR, 6.2; 95% CI, 1.4 to 26.8; P = 0.01) were independently associated with patient preference to obtain radiographs for atraumatic shoulder pain. Of the 121 patients who requested radiographs, 117 (96.7%) felt that radiographs improved their satisfaction. DISCUSSION: Patients who obtained radiographs overwhelmingly reported its importance in improving visit satisfaction and diagnostic accuracy. Given the increasing emphasis on shared decision making, further study of patient factors influencing the decision to obtain routine radiographs will lead to more efficient practice management and potentially improved patient satisfaction. LEVEL OF EVIDENCE: Level II (Diagnostic).

Comparing the Predictive Power of Preoperative Risk Assessment Tools to Best Predict Major Adverse Cardiac Events in Kidney Transplant Patients.

BACKGROUND: Patients undergoing kidney transplantation have increased risk of adverse cardiovascular events due to histories of hypertension, end-stage renal disease, and dialysis. As such, they are especially in need of accurate preoperative risk assessment. METHODS: We compared three different risk assessment models for their ability to predict major adverse cardiac events at 30 days and 1 year after transplant. These were the PORT model, the RCRI model, and the Gupta model. We used a method based on generalized U-statistics to determine statistically significant improvements in the area under the receiver operator curve (AUC), based on a common major adverse cardiac event (MACE) definition. For the top-performing model, we added new covariates into multivariable logistic regression in an attempt to create further improvement in the AUC. RESULTS: The AUCs for MACE at 30 days and 1 year were 0.645 and 0.650 (PORT), 0.633 and 0.661 (RCRI), and finally 0.489 and 0.557 (Gupta), respectively. The PORT model performed significantly better than the Gupta model at 1 year (p=0.039). When the sensitivity was set to 95%, PORT had a significantly higher specificity of 0.227 compared to RCRI's 0.071 (p=0.009) and Gupta's 0.08 (p=0.017). Our additional covariates increased the receiver operator curve from 0.664 to 0.703, but this did not reach statistical significance (p=0.278). CONCLUSIONS: Of the three calculators, PORT performed best when the sensitivity was set at a clinically relevant level. This is likely due to the unique variables the PORT model uses, which are specific to transplant patients.

Reducing Lateral Femoral Cutaneous Nerve Palsy in Obese Patients in the Beach Chair Position: Effect of a Standardized Positioning and Padding Protocol.

INTRODUCTION: To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position. METHODS: We retrospectively reviewed the medical records of 400 consecutive patients with a body mass index (BMI) of ≥30 kg/m who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Before June 2013, all patients were placed in standard beach chair positioning with no extra padding. After June 2013, patients had foam padding placed over their thighs underneath a wide safety strap and underneath the abdominal pannus. Flexion at the waist was minimized, and reverse Trendelenburg was used to position the shoulder appropriately. Patient demographic and surgical data, including age, sex, weight, BMI, presence of diabetes, procedure duration, American Society of Anesthesiologists (ASA) grade, and anesthesia type (general, regional, regional/general) were recorded. Symptoms of LFCN palsy were specifically elicited postoperatively in a prospective fashion and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh. RESULTS: The median age was 58.0 years, and the study consisted of 142 male (36%) and 258 female (64%) subjects. Five cases (3.6%) of LFCN palsy occurred with conventional beach chair positioning, and a single case (0.4%) occurred with the standardized positioning and padding technique (P = 0.02). Median age, sex, presence of diabetes, median BMI, surgery type, and surgical time were not significantly different between the patients who did and did not develop LFCN palsy. All cases resolved completely within 6 months. DISCUSSION: The occurrence of LFCN palsy following shoulder surgery in the beach chair position remains uncommon, even among obese patients. Use of a standardized positioning and padding protocol for obese patients in the beach chair position reduced the prevalence of LFCN palsy. LEVEL OF EVIDENCE: Level III (prognostic).

Prevalence and Risk Factors for Lateral Femoral Cutaneous Nerve Palsy in the Beach Chair Position.

PURPOSE: To report on the prevalence of lateral femoral cutaneous nerve (LFCN) palsy in patients who had undergone shoulder surgery in the beach chair position and to identify patient and surgical risk factors for its development. METHODS: We retrospectively reviewed the medical records of 397 consecutive patients who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Patient demographic and surgical data including age, gender, weight, body mass index (BMI), diabetes, procedure duration, and anesthesia type (general, regional, regional/general) were recorded. LFCN palsy symptoms were recorded prospectively at the initial postoperative visit and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh. RESULTS: The median patient age was 59.0 years and consisted of 158 males (40%) and 239 (60%) females. Five cases of LFCN palsy were identified for a prevalence of 1.3%. These patients had a higher median weight (108.9 kg vs 80.7 kg, P = .005) and BMI (39.6 vs 29.4, P = .005) than the patients who did not develop LFCN palsy. Median age, gender, diabetes, and surgical time were not significantly different between the groups. All cases resolved completely within 6 months. CONCLUSIONS: LFCN palsy after shoulder surgery in the beach chair position in our study has a prevalence of 1.3%, making it an uncommon complication. Patients with elevated BMI should be counseled about its possible occurrence after shoulder surgery in the beach chair position. LEVEL OF EVIDENCE: Level IV, prognostic.