Learning curve for endoscopic posterior cervical foraminotomy.

PURPOSE: While anterior cervical discectomy and fusion as well as cervical disk arthroplasty are gold standard treatments for the surgical treatment of cervical radiculopathy, posterior endoscopic cervical foraminotomy (PECF) as a substitute procedure is gaining popularity. To date, studies investigating the number of surgeries needed to achieve proficiency in this procedure are lacking. The purpose of the study is to examine the learning curve for PECF. METHODS: The learning curve in operative time for two fellowship-trained spine surgeons at independent institutions was retrospectively assessed for 90 uniportal PECF procedures (PBD: n = 26, CPH: n = 64) performed from 2015 to 2022. Operative time was assessed across consecutive cases using a nonparametric monotone regression, and a plateau in operative time was used as a proxy to define the learning curve. Secondary outcomes assessing achievement of endoscopic prowess before and after the initial learning curve included number of fluoroscopy images, visual analog scale (VAS) for neck and arm, Neck Disability Index (NDI), and the need for reoperation. RESULTS: There was no significant difference in operative time between surgeons (p = 0.420). The start of a plateau for Surgeon 1 occurred at 9 cases and 111.6 min. The start of a plateau for Surgeon 2 occurred at 29 cases and 114.7 min. A second plateau for Surgeon 2 occurred at 49 cases and 91.8 min. Fluoroscopy use did not significantly change before and after surmounting the learning curve. The majority of patients achieved minimally clinically important differences in VAS and NDI after PECF, but postoperative VAS and NDI did not significantly differ before and after achieving the learning curve. There were no significant differences in revisions or postoperative cervical injections before and after reaching a steady state in the learning curve. CONCLUSION: PECF is an advanced endoscopic technique with an initial improvement in operative time that occurred after as few as 8 cases to as many as 28 cases in this series. A second learning curve may occur with additional cases. Patient-reported outcomes improve following surgery, and these outcomes are independent of the surgeon's position on the learning curve. Fluoroscopy use does not change significantly along the learning curve. PECF is a safe and effective technique that current and future spine surgeons should consider as part of their armamentarium.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity between Posterior Cervical Decompression and Fusion Performed in Inpatient and Outpatient Settings.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To compare 30-day readmission, reoperation, and morbidity for patients undergoing posterior cervical decompression and fusion (PCDF) in inpatient vs. outpatient settings. OVERVIEW OF LITERATURE: PCDF has recently been increasingly performed in outpatient settings, often utilizing minimally invasive techniques. However, literature evaluating short-term outcomes for PCDF is scarce. Moreover, no currently large-scale database studies have compared short-term outcomes between PCDF performed in the inpatient and outpatient settings. METHODS: Patients who underwent PCDF from 2005 to 2018 were identified using the National Surgical Quality Improvement Program database. Regression analysis was utilized to compare primary outcomes between surgical settings and evaluate for predictors thereof. RESULTS: We identified 8,912 patients. Unadjusted analysis revealed that outpatients had lower readmission (4.7% vs. 8.8%, p =0.020), reoperation (1.7% vs. 3.8%, p =0.038), and morbidity (4.5% vs. 11.2%, p <0.001) rates. After adjusting for baseline differences, readmission, reoperation, and morbidity no longer statistically differed between surgical settings. Outpatients had lower operative time (126 minutes vs. 179 minutes) and levels fused (1.8 vs. 2.2) (p <0.001). Multivariate analysis revealed that age (p =0.008; odds ratio [OR], 1.012), weight loss (p =0.045; OR, 2.444), and increased creatinine (p <0.001; OR, 2.233) independently predicted readmission. The American Society of Anesthesiologists (ASA) classification of ≥3 predicted reoperation (p =0.028; OR, 1.406). Rehabilitation discharge (p <0.001; OR, 1.412), ASA-class of ≥3 (p =0.008; OR, 1.296), decreased hematocrit (p <0.001; OR, 1.700), and operative time (p <0.001; OR, 1.005) predicted morbidity. CONCLUSIONS: The 30-day outcomes were statistically similar between surgical settings, indicating that PCDF can be safely performed as an outpatient procedure. Surrogates for poor health predicted negative outcomes. These results are particularly important as we continue to shift spinal surgery to outpatient centers. This importance has been highlighted by the need to unburden inpatient sites, particularly during public health emergencies, such as the coronavirus disease 2019 pandemic.

Impact of Navigation on 30-Day Outcomes for Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective database study. OBJECTIVE: Navigation has been increasingly used to treat degenerative disease, with positive radiographic and clinical outcomes and fewer adverse events and reoperations, despite increased operative time. However, short-term analysis on treating adult spinal deformity (ASD) surgery with navigation is limited, particularly using large nationally represented cohorts. This is the first large-scale database study to compare 30-day readmission, reoperation, morbidity, and value-per-operative time for navigated and conventional ASD surgery. METHODS: Adults were identified in the National Surgical Quality Improvement Program (NSQIP) database. Multivariate regression was used to compare outcomes between navigated and conventional surgery and to control for predictors and baseline differences. RESULTS: 3190 ASD patients were included. Navigated and conventional patients were similar. Navigated cases had greater operative time (405 vs 320 min) and mean RVUs per case (81.3 vs 69.7), and had more supplementary pelvic fixations (26.1 vs 13.4%) and osteotomies (50.3 vs 27.7%) (P <.001).In univariate analysis, navigation had greater reoperation (9.9 vs 5.2%, P = .011), morbidity (57.8 vs 46.8%, P = .007), and transfusion (52.2 vs 41.8%, P = .010) rates. Readmission was similar (11.9 vs 8.4%). In multivariate analysis, navigation predicted reoperation (OR = 1.792, P = .048), but no longer predicted morbidity or transfusion. Most reoperations were infectious and hardware-related. CONCLUSIONS: Despite controlling for patient-related and procedural factors, navigation independently predicted a 79% increased odds of reoperation but did not predict morbidity or transfusion. Readmission was similar between groups. This is explained, in part, by greater operative time and transfusion, which are risk factors for infection. Reoperation most frequently occurred for wound- and hardware-related reasons, suggesting navigation carries an increased risk of infectious-related events beyond increased operative time.

What is a better value for your time? Anterior cervical discectomy and fusion versus cervical disc arthroplasty.

Introduction: Compared to anterior cervical discectomy and fusion (ACDF), the motion preservation of cervical disc arthroplasty (CDA) provides an attractive alternative with similar short-term results. However, there is a paucity of the economics of performing CDA over ACDF. Study Design: This was retrospective study. Objective: The objective of this study is to evaluate relative-value-units (RVUs), operative time, and RVUs-per-minute between single-level ACDF and CDA. Secondary outcomes included 30-day readmission, reoperation, and morbidity. Methods: Adults who underwent ACDF or CDA in 2011-2019 National Surgical Quality Improvement Program database datasets. Multivariate quantile regression was utilized. Results: There were 26,595 patients (2024 CDA). ACDF patients were older, more likely to be female, discharged to inpatient rehabilitation, and have a history of obesity, smoking, diabetes, steroid use, and the American Society of Anesthesiologists-class ≥3. ACDF had greater median RVUs-per-case (41.2 vs. 24.1) and RVUs-per-minute (0.36 vs. 0.27), despite greater operative-time (109 min vs. 92 min) (P < 0.001). ACDF predicted a 16.9 unit increase in median RVUs per case (P < 0.001, confidence interval [CI]95: 16.3-17.5), an 8.81 min increase in median operative time per case (P < 0.001, CI95: 5.69-11.9), and 0.119 unit increase in median RVUs-per-minute (P < 0.001, CI95: 0.108-0.130). ACDF was associated with greater unadjusted rates of readmission (3.2% vs. 1.4%) morbidity (2.3% vs. 1.1%) (P < 0.001), but similar rates of reoperation (1.3% vs. 0.8%, P = 0.080). After adjusting for significant patient-related and procedural factors, readmission (odds ratio [OR] = 0.695, P = 0.130, CI95: 0.434-1.113) and morbidity (OR = 1.102, P = 0.688, CI95: 0.685-1.773) was similar between ACDF and CDA. Conclusions: Median RVUs-per-minute increased by 0.119 points for ACDF over CDA, or $257.7/h for each additional-hour of surgery. Adjusted 30-day outcomes were similar between procedures. Reimbursement for CDA does not appear to be in line with ACDF and may be a barrier to widespread usage.

Liposomal bupivacaine does not decrease postoperative opioid use or length of hospital stay in patients undergoing anterior cervical discectomy and fusion.

Background: Despite its widespread use, definitive data demonstrating the efficacy of liposomal bupivacaine (LB) is limited especially in patients undergoing anterior cervical discectomy and fusion (ACDF). Therefore, this investigation examined whether ACDF patients who received intra-operative LB (LB cohort) exhibited decreased post-operative opioid use and lengths of hospital stay (LOS) compared to ACDF patients who did not receive intra-operative LB (controls). Methods: Eighty-two patients who underwent primary ACDF by a single surgeon from 2016 to 2019 were identified from an institutional database. Fifty-nine patients received intra-operative LB while twenty-three did not. Patient characteristics, medical comorbidities, complications, post-operative opioid consumption, and LOS data were collected. Results: The LB cohort did not require fewer opioids on post-operative day (POD) 0, POD1, POD2, or throughout the hospital course after normalizing by LOS (total per LOS). The number of cervical vertebrae involved in surgery, but not LB use, predicted opioid consumption on POD0, POD1, and total per LOS. For every vertebral level involved, 242 additional morphine milligram equivalents (MME) were consumed on POD0, 266 additional MME were utilized on POD1, and 130 additional MME were consumed in total per LOS. Conclusions: ACDF patients who received intra-operative LB did not require fewer post-operative opioids or exhibit a decreased LOS compared to controls. Patients whose procedures involved a greater number of cervical vertebrae were associated with greater opioid consumption on POD0, POD1, and total per LOS. ACDF patients, especially those who had a high number of vertebrae involved, may require alternative analgesia to LB.

Discharge to Rehabilitation Predicts Increased Morbidity in Patients Undergoing Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare 30-day readmission and postdischarge morbidity for posterior cervical decompression and fusion (PCDF) in patients who were discharged to home versus rehabilitation. SUMMARY OF BACKGROUND DATA: An increasing number of patients are being discharged to postacute inpatient care facilities following spine surgery. However, little research has been performed to evaluate the effect of this trend on short-term outcomes. MATERIALS AND METHODS: Patients who underwent PCDF from 2011 to 2018 were identified using the National Surgical Quality Improvements Program (NSQIP)-database. Regression was utilized to compare primary outcomes between home and rehabilitation groups and to control for predictors of outcomes. RESULTS: We identified 8912 patients. Unadjusted analysis revealed that rehabilitation-discharge patients had greater readmission (10.4% vs. 8.0%, P=0.002) and postdischarge morbidity (7.1% vs. 4.0%, P<0.001) rates. After controlling for patient-related factors, rehabilitation-discharge independently predicted postdischarge morbidity (P<0.001, odds ratio=2.232). Readmission no longer differed between groups (P=0.071, odds ratio=1.311). Rates of discharge to rehabilitation increased from 23.5% in 2011 to 25.3% in 2018, while postdischarge morbidity rates remained stagnant.Patients discharged to rehabilitation were older (66.9 vs. 59.4 y); more likely to be African American (21.4% vs. 13.8%) and have diabetes (27.1% vs. 17.5%), steroid use (6.4% vs. 4.7%, P=0.002), and American Society of Anaesthesiologists (ASA)-class ≥3 (80.2% vs. 57.7%); less likely to be male (53.9% vs. 57.4%, P=0.004) and smokers (20.3% vs. 26.6%); and had greater operative time (198 vs. 170 min) and length of hospital stay (5.9 vs. 3.3 d) (P<0.001). CONCLUSIONS: Despite controlling for significant factors, discharge to rehabilitation independently predicted a 2.2 times increased odds of postdischarge morbidity. Rates of discharge to rehabilitation increased overtime without an appreciable decrease in postdischarge morbidity, suggesting that greater resources are being utilized in the postacute care period without an obvious justification. Therefore, home-discharge should be prioritized after hospitalization for PCDF when feasible. These findings are notable in light of reform efforts aimed at reducing costs while improving quality of care.

The Incidence of Subsequent Cervical Spine Surgery after Cervical Disc Arthroplasty, a Minimum Two-year Follow-up.

To identify the risk factors and incidence of subsequent cervical spine surgery in patients undergoing primary cervical disc arthroplasty (CDA). We analyzed the 2005-2015 NYS SPARCS database. Patients were longitudinally followed to determine the incidence of re-operation. Univariate and Multivariate analyses were used to identify demographic risk factors. Eight-hundred and thirty-five CDA patients had a cervical spine re-operation rate of 7.5%; 4.4% re-operation rate at two-year follow-up. The most common cervical re-operation was a primary anterior cervical discectomy and fusion (ACDF) (76.2%). Patients who underwent re-operation were more likely to be younger (p = 0.034) and female (p = 0.007). Logistic regression analysis found only female sex to have increased odds of re-operation (odds ration = 2.10, 95% confidence interval 1.21-3.63). There was a 4.4% rate of subsequent cervical spine surgery following CDA at 2 years and a 7.5% rate of subsequent cervical spine surgery. The most common cervical spine procedure following CDA was ACDF. Female sex was the only patient demographic factor to significantly influence the odds of cervical spine re-operation. (Journal of Surgical Orthopaedic Advances 31(1):007-011, 2022).

Robotic Spine Surgery: Past, Present, and Future.

STUDY DESIGN: Systematic review. OBJECTIVE: The aim of this review is to present an overview of robotic spine surgery (RSS) including its history, applications, limitations, and future directions. SUMMARY OF BACKGROUND DATA: The first RSS platform received United States Food and Drug Administration approval in 2004. Since then, robotic-assisted placement of thoracolumbar pedicle screws has been extensively studied. More recently, expanded applications of RSS have been introduced and evaluated. METHODS: A systematic search of the Cochrane, OVID-MEDLINE, and PubMed databases was performed for articles relevant to robotic spine surgery. Institutional review board approval was not needed. RESULTS: The placement of thoracolumbar pedicle screws using RSS is safe and accurate and results in reduced radiation exposure for the surgeon and surgical team. Barriers to utilization exist including learning curve and large capital costs. Additional applications involving minimally invasive techniques, cervical pedicle screws, and deformity correction have emerged. CONCLUSION: Interest in RSS continues to grow as the applications advance in parallel with image guidance systems and minimally invasive techniques. IRB APPROVAL: N/A.

Impact of Discharge to Rehabilitation on Postdischarge Morbidity Following Multilevel Posterior Lumbar Fusion.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to compare 30-day postdischarge morbidity for 3-or-more level (multilevel) posterior lumbar fusion in patients who were discharged to home versus rehabilitation. SUMMARY OF BACKGROUND DATA: Spine surgery has been increasingly performed in the elderly population, with many of these patients being discharged to rehabilitation and skilled nursing facilities. However, research evaluating the safety of nonhome discharge following spine surgery is limited. MATERIALS AND METHODS: Patients who underwent multilevel posterior lumbar fusion from 2005 to 2018 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Regression was utilized to compare primary outcomes between discharge disposition and to evaluate for predictors thereof. RESULTS: We identified 5276 patients. Unadjusted analysis revealed that patients who were discharged to rehabilitation had greater postdischarge morbidity (5.6% vs. 2.6%). After adjusting for baseline differences, discharge to rehabilitation no longer predicted postdischarge morbidity [odds ratio (OR)=1.409, confidence interval: 0.918-2.161, P=0.117]. Multivariate analysis also revealed that age (P=0.026, OR=1.023), disseminated cancer (P=0.037, OR=6.699), and readmission (P<0.001, OR=28.889) independently predicted postdischarge morbidity. CONCLUSIONS: Thirty days morbidity was statistically similar between patients who were discharged to home and rehabilitation. With appropriate patient selection, discharge to rehabilitation can potentially minimize 30-day postdischarge morbidity for more medically frail patients undergoing multilevel posterior lumbar fusion. These results are particularly important given an aging population, with a great portion of elderly patients who may benefit from postacute care facility discharge following spine surgery.

Risk factors for reoperation after lumbar total disc replacement at short-, mid-, and long-term follow-up.

BACKGROUND CONTEXT: The reoperation rate following TDR (Total Disc replacement) has been established at short- and mid-term time points through the Food and Drug Administration Investigational Device Exemption (FDA IDE) trials. However, these trials include highly selected centers and surgeons with strict governance of indications. The utilization of TDR throughout the community needs further analysis. PURPOSE: To identify the risk factors for lumbar spine reoperation in patients undergoing lumbar total disc replacement (TDR) at short-, mid-, and long-term follow-up. STUDY DESIGN/SETTING: This study is a multi-center retrospective cohort study utilizing the New York Statewide Planning and Research Cooperative System database. PATIENT SAMPLE: We identified 1,368 patients who underwent an elective primary lumbar TDR in New York State between January 1, 2005 and September 30, 2013. OUTCOME MEASURES: The primary functional outcome of interest was lumbar reoperation, specifically the evaluation of independent risk factors for lumbar reoperation at a minimum of 2 years, with sub-analyses performed at 5 and ten years. METHODS: International Classification of Diseases, Ninth revision codes were utilized to identify patients undergoing a primary lumbar TDR. We excluded patients with primary/revision lumbar fusion procedures and revision disc replacement procedures. Hospital academic status was determined by the Accreditation Council for Graduate Medical Education. Unique encrypted patient identifiers allowed for longitudinal follow-up for reoperation. Logistic regression models compared reoperation and no-reoperation cohorts, and were performed on sub-analyses for significant univariate predictors of reoperation. RESULTS: Between January 2005 and September 2013, 1368 patients underwent a primary lumbar TDR. Reoperation occurred in 8.8% by 2 years, 15.8% by 5 years, and 19.5% by ten years. Diabetics were more likely to have reoperations (7.5% vs 3.8%, p=.013). Teaching hospitals experienced a decreased reoperation rate compared to nonteaching hospitals at 2-year (5.0% vs 10.5%, p=.002), 5-year (10.7% vs 17.9%, p=.002) and 10-year (11.7% vs 21.9%, p=.045) follow-up. Lumbar fusion was the most common reoperation (14.2%). CONCLUSION: We identified an 8.8% reoperation rate after inpatient lumbar TDR at 2-years, 15.8% at 5-years, and 19.5% at 10-years. When stratifying by teaching status, reoperation rates at teaching centers align with those reported in FDA IDE studies. Diabetes was the only patient factor influencing reoperation rate. There is a growing consensus that lumbar TDR is a durable and appropriate surgical option for lumbar degenerative disc disease. Proper indications are crucial to obtaining good outcomes with lumbar TDR.

Comparative Analysis of 30-Day Readmission, Reoperation, and Morbidity Between Lumbar Disc Arthroplasty Performed in the Inpatient and Outpatient Settings Utilizing the ACS-NSQIP Dataset.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Spine surgery has been increasingly performed in the outpatient setting, providing greater control over cost, efficiency, and resource utilization. However, research evaluating the safety of this trend is limited. The objective of this study is to compare 30-day readmission, reoperation, and morbidity for patients undergoing lumbar disc arthroplasty (LDA) in the inpatient versus outpatient settings. METHODS: Patients who underwent LDA from 2005 to 2018 were identified using the ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database. Regression was utilized to compare readmission, reoperation, and morbidity between surgical settings, and to evaluate for predictors thereof. RESULTS: We identified 751 patients. There were no significant differences between inpatient and outpatient LDA in rates of readmission, reoperation, or morbidity on univariate or multivariate analyses. There were also no significant differences in rates of specific complications. Inpatient operative time (138 ± 75 minutes) was significantly (P < .001) longer than outpatient operative time (106 ± 43 minutes). In multivariate analysis, diabetes (P < .001, OR = 7.365), baseline dyspnea (P = .039, OR = 6.447), and increased platelet count (P = .048, OR = 1.007) predicted readmission. Diabetes (P = .016, OR = 6.533) and baseline dyspnea (P = .046, OR = 13.814) predicted reoperation. Baseline dyspnea (P = .021, OR = 8.188) and ASA (American Society of Anesthesiologists) class ≥3 (P = .014, OR = 3.515) predicted morbidity. Decreased hematocrit (P = .008) and increased operative time (P = .003) were associated with morbidity in univariate analysis, but not in multivariate analysis. CONCLUSIONS: Readmission, reoperation, and morbidity were statistically similar between surgical setting, indicating that LDA can be safely performed in the outpatient setting. Higher ASA class and specific comorbidities predicted poorer 30-day outcomes. These findings can guide choice of surgical setting given specific patient factors.

Is academic department teaching status associated with adverse outcomes after lumbar laminectomy and discectomy for degenerative spine diseases?

BACKGROUND CONTEXT: Lumbar laminectomy and discectomy surgeries are among the most common procedures performed in the United States, and often take place at academic teaching hospitals, involving the care of resident physicians. While academic institutions are critical for the maturation of the next generation of attending surgeons, concerns have been raised regarding the quality of resident-involved care. There is conflicting evidence regarding the effects of resident participation in teaching hospitals on spine surgery patient outcomes. As the volume of lumbar laminectomy and discectomy increases, it is imperative to determine how academic status impacts clinical and economic outcomes. PURPOSE: The purpose of this study is to determine if lumbar laminectomy and discectomy surgeries for degenerative spine diseases performed at academic teaching centers is associated with more adverse clinical outcomes and increased cost compared to those performed at nonacademic centers. STUDY DESIGN/SETTING: This study is a multi-center retrospective cohort study using a New York Statewide database. PATIENT SAMPLE: We identified 36,866 patients who met the criteria through the New York Statewide Planning and Research Cooperative System who underwent an elective lumbar laminectomy and/or discectomy in New York State between January 1, 2009 and September 30, 2014. OUTCOME MEASURES: The primary functional outcomes of interest included: length of stay, cost of the index admission; 30-day and 90-day readmission; 30-day, 90-day, and 1-year return to the operating room. METHODS: International Classification of Diseases, Ninth revision codes were utilized to define patients undergoing a laminectomy and/or discectomy who also had a diagnosis code for a lumbar spine degenerative condition. We excluded patients with a procedural code for lumbar fusion, as well as those with a diagnosis of scoliosis, neoplasm, inflammatory disorder, infection or trauma. Hospital academic status was determined by the Accreditation Council for Graduate Medical Education. Unique encrypted patient identifiers allowed for longitudinal follow-up for readmission and re-operation analyses. We extracted charges billed for each admission and calculated costs through cost-to-charge ratios. Logistic regression models compared teaching and nonteaching hospitals after adjusting for patient demographics and comorbidities. RESULTS: Compared to patients at nonteaching hospitals, patients at teaching hospitals were more likely to be younger, male, non-Caucasian, be privately insured and have fewer comorbidities (p<.001). Patients undergoing surgery at teaching hospitals had 10% shorter lengths of stay (2.7 vs. 3.0 days, p<.001), but 21.5% higher costs of admission ($13,693 vs. $11,601 p<.001). Academic institutions had a decreased risk of return to the operating room for revision procedures or irrigation and debridement at 30 days (OR:0.70, 95% confidence interval [CI]: 0.60-0.82, p<.001), 90 days (OR:0.75, 95%CI: 0.66-0.86, p<.001), and 1 year (OR:0.84, 95%CI: 0.77-0.91, p<.001) post index procedure. There was no difference in 30- and 90-day all-cause readmission, or discharge disposition between the two groups. CONCLUSIONS: Elective lumbar laminectomy and discectomy for degenerative lumbar conditions at teaching hospitals is associated with higher costs, but decreased length of stay and no difference in readmission rates at 30- and 90-days postoperatively compared to nonteaching hospitals. Teaching hospitals had a decreased risk of return to the operating room at 30 days, 90 days and 1 year postoperatively. Our findings might serve as an impetus for other states or regions to compare outcomes at teaching and nonteaching sites.

Changing trends in the management of proximal humerus fractures in New York State.

PURPOSE: Reverse shoulder arthroplasty (RSA) as an alternative to hemiarthroplasty (HA) as treatment for proximal humerus fractures has prompted a re-evaluation of utilization trends. METHODS: Operative treatment for proximal humeral fractures were analyzed using a New York State database. RESULTS: After introduction as an ICD-9 code, RSA increased to 39.3% (m = +5.2%/year, r = 0.984). When stratifying by age ≥65, HA decreased to 7.7% (m = -2.8%/year, r = 0.962) while RSA increased to 50.6% (m = +6.4%/year, r = 0.985). CONCLUSION: RSA overtook HA as the arthroplasty procedure of choice for proximal humerus fractures. In patients ≥65, RSA passed ORIF as the most prevalent procedure in 2017. LEVEL OF EVIDENCE: III, Descriptive Epidemiology Study, Large Database Analysis.

Surgeon volume affects short- and long-term surgical outcomes in idiopathic scoliosis.

STUDY DESIGN: Retrospective review of New York Statewide Planning and Research Cooperative System (SPARCS) Inpatient Database. OBJECTIVE: To identify the differences in short- and long-term complications, following long-segment pediatric spinal fusion in idiopathic scoliosis surgery, between surgeons with low versus high annual surgical volume. Spinal deformity surgery is complex and requires significant training and repetition to master. Surgeon and hospital volume have been shown to correlate with outcomes following cervical and lumbar spine surgery. However, there is limited literature regarding the impact of surgeon volume on long-term outcomes following pediatric idiopathic spinal deformity correction. METHODS: This is a retrospective review of the SPARCS inpatient database from 2004 to 2013 of pediatric patients who underwent idiopathic scoliosis surgery. Surgeons were stratified into high (> 15 cases/year)- and low (≤ 15 cases/year)-volume cohorts by aggregating all cases completed over the study period until 50% of the total cases were captured above and below an average case per-year threshold. This threshold occurred at 15 cases/year. Short-term and long-term readmission and medical/surgical complications were collected. Multivariate logistic regression models assessed the risk of short- and long-term complications between cohorts. RESULTS: 3910 pediatric patients underwent a primary arthrodesis from a total of 223 surgeons. More high-volume surgeons operated at academic teaching hospitals (p < 0.001), used a combined AP surgical approach (p < 0.001), and fewer utilized rhBMP (p < 0.001). High-volume surgeons had shorter lengths of stay (p < 0.001). Low-volume surgeons had increased odds of inpatient surgical complications (OR 1.55, 95% CI 1.00-2.45). Low-volume surgeons had increased odds of revision at 5 and 10 years (5 years. OR 1.56, 95% CI 1.05-2.31; 10 years. OR 1.59, 95% CI 1.09-2.31). Low-volume surgeons had increased odds of implant malfunction at 10 years (OR 1.81, 95% CI 1.15-2.86). CONCLUSIONS: High-volume surgeons had decreased odds of short- and long-term complications compared to low volume when performing primary spinal arthrodesis in idiopathic scoliosis. Low-volume surgeons experienced significantly greater odds of inpatient surgical complications, as well as increased risk of revision during long-term follow-up with a significantly increased risk of implant malfunction at 10 years post-operatively. LEVEL OF EVIDENCE: Level III.

Spine Injuries in Child Abuse.

BACKGROUND: Although rare, spinal injuries associated with abuse can have potentially devastating implications in the pediatric population. We analyzed the association of pediatric spine injury in abused children and determined the anatomic level of the spine affected, while also focusing on patient demographics, length of stay, and total hospital charges compared with spine patients without a diagnosis of abuse. METHODS: A retrospective review of the Kids' Inpatient Database was conducted from 2000 to 2012 to identify pediatric patients (below 18 y) who sustained vertebral column fractures or spinal cord injuries. Patients with a documented diagnosis of abuse were identified using ICD-9-CM diagnosis codes. Our statistical models consisted of multivariate linear regressions that were adjusted for age, race, and sex. RESULTS: There were 22,192 pediatric patients with a diagnosis of spinal cord or vertebral column injury during the study period, 116 (0.5%) of whom also had a documented diagnosis of abuse. The most common type of abuse was physical (75.9%). Compared with nonabused patients, abused patients were more likely to be below 2 years of age (OR=133.4; 95% CI, 89.5-198.8), female (OR=1.67; 95% CI, 1.16-2.41), and nonwhite (black: OR=3.86; 95% CI, 2.31-6.45; Hispanic: OR=2.86; 95% CI, 1.68-4.86; other: OR=2.33; 95% CI, 1.11-4.86). Abused patients also presented with an increased risk of thoracic (OR=2.57; 95% CI, 1.67-3.97) and lumbar (OR=1.67; 95% CI, 1.03-2.72) vertebral column fractures and had a multivariate-adjusted mean length of stay that was 62.2% longer (P<0.001) and mean total charges that were 52.9% higher (P<0.001) compared with nonabused patients. Furthermore, 19.7% of all pediatric spine patients under 2 years of age admitted during the study period belonged to the abused cohort. CONCLUSIONS: Spine injuries are rare but can be found in the pediatric population. With an additional documented diagnosis of abuse, these injuries affect younger patients in the thoracolumbar region of the spine, and lead to longer lengths of stay and higher hospital costs when compared with nonabused patients. Because of these findings, physicians should maintain a higher level of suspicion of abuse in patients with spine injuries, especially patients under 2 years of age. LEVEL OF EVIDENCE: Level III evidence-a case-control study.

What are the trends and demographics in sports-related pediatric spinal cord injuries?

OBJECTIVES: Pediatric spinal cord injury (PSCI) is a devastating injury that can cause significant long-term consequences. The purpose of this study is to calculate and report the prevalence of PSCI, identify risk factors for sports-related PSCI, and evaluate associated factors. METHODS: The data sets of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) from 2000-2012 were analyzed using ICD-9-CM external cause of injury codes to identify the mechanism of injury contributing to PSCI hospitalization. We then extracted demographic data on each admission including age, gender, race, and year of admission. We further stratified the data by sports-related cases of injury. Multivariate logistic regression analyses were used to identify independent risk factors. RESULTS: Of our study population, 0.8% had a documented diagnosis of spinal cord injury (SCI). The most common documented external cause of injury code was motor vehicle accidents, representing roughly half of all cases in patients 0-9 years-old (p = 0.001). PSCI due to sports as an external cause of injury was more prevalent in patients 10-17 years old, and was especially prevalent in the 10-13 year-old age category in which sports-related PSCI reached a high of 25.6%. Risk factors for traumatic PSCI after a sports-related external cause included being of older age, male, and white. CONCLUSIONS: The prevalence of SCI increased with age. Given the popularity of youth sports in the United States, parents and sports officials should be aware of the increased risk of sports-related PSCI among patients 10-17 years old. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Atrial Septal Defect Increases the Risk for Stroke After Total Hip Arthroplasty.

BACKGROUND: Atrial septal defect (ASD) and patent foramen ovale (PFO) are 2 of the most common congenital heart diseases in adults and pose important risks of perioperative acute ischemic stroke (AIS) from paradoxical emboli. We evaluated the following: (1) the prevalence of ASD/PFO in the total hip arthroplasty (THA) population; (2) the rate of perioperative AIS during index admissions; and (3) the risk for perioperative AIS after THA for patients with ASD/PFO vs matched controls. METHODS: We identified 393,652 patients in the Nationwide Inpatient Sample who underwent THA between January 1, 2007, and December 31, 2013. The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify patients with ASD/PFO and perioperative AIS. Propensity scores matched 252 patients with ASD/PFO to 756 controls (3:1 ratio) without ASD/PFO according to age, gender, race, Deyo comorbidity score, year of surgery, and stroke risk factors. Logistic regression models assessed risk for perioperative AIS. RESULTS: The prevalence of ASD/PFO was 64 per 100,000 THA patients. The rate of perioperative AIS was 99 per 100,000 THA in the general THA population. The rate of perioperative AIS was 7.14% for ASD/PFO patients compared with 0.26% in matched controls (P < .001). Risk for perioperative AIS was 29 times greater for patients with ASD/PFO compared with matched controls (odds ratio, 29.00; 95% confidence interval, 6.68-125.89; P < .001). CONCLUSION: Patients with ASD/PFO undergoing THA are at a significantly higher risk of perioperative AIS. Orthopedic surgeons should discuss this risk with patients before surgery. The efficacy of mechanical and pharmacologic thromboprophylactic measures to reduce perioperative AIS among ASD/PFO patients warrants further investigation.

Is Day of Surgery Associated With Adverse Clinical and Economic Outcomes Following Primary Total Knee Arthroplasty?

BACKGROUND: As orthopedics transition to value-based purchasing, hospitals and providers are incentivized to identify inefficiencies of care delivery. In our experience, weekends are characterized by decreased staffing of ancillary services to coordinate patient discharges, which can lead to prolonged hospital stays for many of our primary total knee arthroplasty (TKA) admissions. METHODS: We identified 115,053 patients who underwent primary TKA on a weekday between 2009 and 2013 in New York State. We used mixed effects regression models to compare length of stay (LOS), 90-day readmission, and cost according to the day of TKA. RESULTS: Mean LOS was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). There was no significant difference in 90-day readmission risk according to day of surgery. Mean cost was significantly higher for surgeries performed on Wednesday (P < .001), Thursday (P < .001), and Friday (P < .001). When LOS was held constant across every day of the week, the mean cost of TKA decreased by $247 for Wednesday, $627 for Thursday, and $394 for Friday. CONCLUSION: Primary TKA performed later in the week is associated with an increased LOS and increased costs of admission, but a similar risk of 90-day readmission. Preferential scheduling of primary TKA cases early in the week, as well as the development of standardized clinical care pathways with appropriate weekend staffing of social work and rehabilitation services, could help to decrease the daily variation in LOS and increase the value of TKA episodes.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BACKGROUND: Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. METHODS: We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients undergoing surgery at teaching hospitals had longer lengths of stay (ß = 3.2%; P < .001) and higher costs of admission (ß = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). CONCLUSION: Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Have Periprosthetic Hip Infection Rates Plateaued?

BACKGROUND: Periprosthetic joint infection (PJI) is a serious complication of total hip arthroplasty (THA). Although the number of revision cases is increasing, the prevalence of PJI as an indication for revision surgery, and the variability of this indication among surgeons and hospitals, is unclear. METHODS: The New York Statewide Planning and Research Cooperative System was used to identify 33,582 patients undergoing revision THA between 2000 and 2013. PJI was identified using International Classification of Diseases, Ninth Revision diagnosis codes. Volume was defined using mean number of revision THAs performed annually by each hospital and surgeon. RESULTS: PJI was the indication for 13.0% of all revision THAs. The percentage of revision THAs for PJI increased between years 2000 and 2007 (odds ratio [OR] = 1.05, P < .001), but decreased between years 2008 and 2013 (OR = 0.96, P = .001). Compared to medium-volume hospitals, the PJI burden at high-volume hospitals decreased during years 2000-2007 (OR = 0.58, P < .001) and 2008-2013 (OR = 0.57, P < .001). Compared to medium-volume surgeons, the PJI burden for high-volume surgeons increased during years 2000-2007 (OR = 1.39, P < .001), but did not differ during years 2008-2013 (P = .618). CONCLUSION: The burden of PJI as an indication for revision THA may be plateauing. High-volume institutions have seen decreases in the percentage of revisions performed for PJI over the complete study duration. Specific surgeon may be associated with the plateauing in PJI rates as high-volume surgeons in 2008-2013 were no longer found to be at increased risk of PJI as an indication for revision THA.