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.

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.

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.

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.

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.

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.

Venous Thromboembolic Disease in Revision vs Primary Total Knee Arthroplasty.

BACKGROUND: Venous thromboembolic disease (VTED) is a serious complication of primary and revision total knee arthroplasty (TKA). However, the incidence and risk of VTED for revision compared with primary TKA cases have not been well-described. METHODS: We identified 225,584 TKAs (208,954 primaries, 16,630 revisions) in the 2003-2012 Statewide Planning and Research Cooperative System database. Odds ratios (ORs) expressed the risk of VTED for revision vs primary TKA, and models were adjusted for age, gender, race, and Charlson comorbidity scores. Outcome analyses were further stratified into deep venous thromboses (DVTs) and pulmonary emboli (PEs). RESULTS: The incidence of VTED within 30 days was 2.24% for primary and 1.84% for revision. In multivariable-adjusted regression, the OR of VTED within 30 days for revision compared with primary was 0.81 (95% confidence interval = 0.72-0.91; P < .001). The incidence of VTED within 90 days was 2.42% for primary and 2.13% for revision (P = .022), with a multivariable-adjusted OR of 0.87 (95% confidence interval = 0.78-0.97; P = .010) for revision compared with primary. The association was stronger for PE (OR = 0.63; P < .001) than DVT (OR = 0.87; P = .035) at 30 days, and significant for PE (OR = 0.69; P < .001), but not DVT (OR = 0.94; P = .284) at 90 days. CONCLUSION: In a large statewide database, the risk of VTED was lower for revision TKA compared with primary TKA. The reasons for this observation are not known, but might be related to aggressive prophylactic management of patients undergoing revision procedures. Future studies should attempt to clarify differences in patient selection and management for primary vs revision procedures.

Does Atrial Septal Defect Increase the Risk of Stroke Following Total Hip and Knee Arthroplasty?

INTRODUCTION: Atrial septal defect (ASD) is a common asymptomatic congenital heart condition that predisposes patients to paradoxical emboli in the cerebral vasculature. In this study, we evaluated the prevalence of ASD and risk of stroke for patients with ASD undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). MATERIALS AND METHODS: We used the New York Statewide Planning and Research Cooperative System to identify 258,911 elective primary THA/TKA between 2005 and 2014, including 140 patients with ASD. Logistic regression models calculated odds ratios (OR) and 95% confidence intervals (CI) and controlled for demographic and medical risk factors for stroke. RESULTS: The prevalence of ASD was 54 per 100,000 patients undergoing THA/TKA. The rate of stroke within 30 days of surgery was 5.7% (95% CI: 2.5%, 11.0%) for patients with ASD, and 0.1% (95% CI: 0.1%, 0.1%) for all other patients. In regression models, the risk of stroke was 70 times greater (OR: 70.0, 95% CI: 32.9, 148.9) for patients with ASD compared to patients without this condition (p<0.001). CONCLUSIONS: Patients with ASD undergoing THA and TKA are predisposed to stroke in the postoperative period. Orthopaedic surgeons indicating patients for surgery and internists performing preoperative medical clearance should be aware of these risks and discuss them prior to surgery. The efficacy of pharmacological and surgical measures to reduce postoperative stroke within this patient population should be topics of future investigation.

Prosthetic Dislocation and Revision After Primary Total Hip Arthroplasty in Lumbar Fusion Patients: A Propensity Score Matched-Pair Analysis.

BACKGROUND: Lumbar-pelvic fusion reduces the variation in pelvic tilt in functional situations by reducing lumbar spine flexibility, which is thought to be important in maintaining stability of a total hip arthroplasty (THA). We compared dislocation and revision rates for patients with lumbar fusion and subsequent THA to a matched comparison cohort with hip and spine degenerative changes undergoing only THA. METHODS: We identified patients in New York State who underwent primary elective lumbar fusion for degenerative disc disease pathology and subsequent THA between January 2005 and December 2012. A propensity score match was performed to compare 934 patients with prior lumbar fusion to 934 patients with only THA according to age, gender, race, Deyo comorbidity score, year of surgery, and surgeon volume. Revision and dislocation rates were assessed at 3, 6, and 12 months post-THA. RESULTS: At 12 months, patients with prior lumbar fusion had significantly increased rates of THA dislocation (control: 0.4%; fusion: 3.0%; P < .001) and revision (control: 0.9%; fusion: 3.9%; P < .001). At 12 months, fusion patients were 7.19 times more likely to dislocate their THA (P < .001) and 4.64 times more likely to undergo revision (P < .001). CONCLUSION: Patients undergoing lumbar fusion and subsequent THA have significantly higher risks of dislocation and revision of their hip arthroplasty than a matched cohort of patients with similar hip and spine pathology but only undergoing THA. During preoperative consultation for patients with prior lumbar fusion, orthopedic surgeons must educate the patient and family about the increased risk of dislocation and revision.

Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?

INTRODUCTION: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081. CONCLUSIONS: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

Does Chronic Corticosteroid Use Increase Risks of Readmission, Thromboembolism, and Revision After THA?

BACKGROUND: Systemic corticosteroids are commonly used to treat autoimmune and inflammatory diseases, but they can be associated with various musculoskeletal problems and disorders. There currently is a limited amount of data describing the postoperative complications of THA associated specifically with chronic corticosteroid use. QUESTIONS/PURPOSES: For chronic corticosteroid users undergoing THA, we asked: (1) What is the risk of hospital readmission at 30 and 90 days after surgery? (2) What is the risk of venous thromboembolism at 30 and 90 days after surgery? (3) What is the risk of revision hip arthroplasty at 12 and 24 months after surgery? METHODS: We identified patients in the Statewide Planning and Research Cooperative System who underwent primary THA between January 2003 and December 2010. This database provides hospital discharge abstracts for all admissions in the state of New York each year. We used propensity scores to three-to-one match the 402 chronic corticosteroid users with a comparison cohort of 1206 patients according to age, sex, race, comorbidity score, year of surgery, and hip osteonecrosis. The risk of each outcome was compared between chronic corticosteroid users and the matched cohort. Because multiple comparisons were made, we considered p less than 0.008 as statistically significant. RESULTS: Readmission was more common for corticosteroid users at 30 days (odds ratio [OR], 1.45; 95% CI, 1.14-1.85; p = 0.003) and 90 days (OR, 1.37; 95% CI, 1.09-1.73; p = 0.007). Venous thromboembolism was not more frequent in corticosteroid users at 30 days (OR, 2.39; 95% CI, 1.08-5.26; p = 0.031) or 90 days (OR, 1.91; 95% CI, 1.03-3.53; p = 0.039). Revision arthroplasty was more common in corticosteroid users at 12 months (OR, 2.49; 95% CI, 1.35-4.59; p = 0.004), but not 24 months (OR, 2.04; 95% CI, 1.19-3.50; p = 0.010). CONCLUSIONS: After THA, chronic corticosteroid use is associated with an increased risk of readmission at 30 and 90 days and revision hip arthroplasty at 12 months in corticosteroid users. Patients and providers should discuss these risks before surgery. Insurers should consider incorporating chronic corticosteroid use as a comorbidity in bundled payments for THA, since this patient population is more likely to return to their provider for care during the postoperative period. LEVEL OF EVIDENCE: Level III, therapeutic study.

Down Syndrome Increases the Risk of Short-Term Complications After Total Hip Arthroplasty.

BACKGROUND: Down syndrome is the most common chromosomal abnormality and is associated with degenerative hip disease. Because of the recent increase in life expectancy for patients with this syndrome, orthopaedic surgeons are likely to see an increasing number of these patients who are candidates for total hip arthroplasty (THA). METHODS: Using Nationwide Inpatient Sample (NIS) data from 1998 to 2010, we compared the short-term adverse outcomes of THA among 241 patients with Down syndrome and a matched 723-patient cohort. Specifically, we assessed: (1) incidence of THA; (2) perioperative medical and surgical complications during the primary hospitalization; (3) length of stay; and (4) hospital charges. RESULTS: The annual mean number of patients with Down syndrome undergoing THA was 19. Compared to matched controls, Down syndrome patients had an increased risk of perioperative (OR, 4.33; P<.001), medical (OR, 4.59; P<.001) and surgical (OR, 3.51; P<.001) complications during the primary hospitalization. Down syndrome patients had significantly higher incidence rates of pneumonia (P=.001), urinary tract infection (P<.001), and wound hemorrhage (P=.027). The mean lengths of stay for Down syndrome patients were 26% longer (P<.001), but there were no differences in hospital charges (P=.599). CONCLUSION: During the initial evaluation and pre-operative consultation for a patient with Down syndrome who is a candidate for THA, orthopaedic surgeons should educate the patient, family and their clinical decision makers about the increased risk of medical complications (pneumonia and urinary tract infections), surgical complications (wound hemorrhage), and lengths of stay compared to the general population.

The Impact of Hepatitis C on Short-Term Outcomes of Total Joint Arthroplasty.

BACKGROUND: With recent advances in the treatment of infection with hepatitis C increasing lifespan and quality of life, the need for total joint arthroplasty in this patient population is expected to grow. Presently, there are limited and conflicting data on the perioperative outcomes of lower-extremity total joint arthroplasty among patients with hepatitis C. The purpose of our study was to assess the association between hepatitis C and perioperative outcomes of lower-extremity total joint arthroplasty. METHODS: The Nationwide Inpatient Sample database was used to identify patients who underwent a total hip or knee arthroplasty in the United States from 1998 to 2010. Controls were matched in a three-to-one ratio to patients with hepatitis-C infection according to surgical procedure, age, race, sex, Deyo comorbidity score, and year of surgical procedure. Outcomes included perioperative complications (any, medical, surgical) and mean length of stay. RESULTS: There were 1,700,400 total joint arthroplasties performed and recorded in the database during the study period, among which 8044 patients (0.47%) had a documented hepatitis-C infection. The frequency of hepatitis-C infection increased from 1.9 per 1000 total joint arthroplasties in 1998 to 5.9 per 1000 total joint arthroplasties in 2010 (slope = 0.47; r(2) = 0.93). Compared with matched controls, patients with hepatitis C had a 30% increased risk of any complication (95% confidence interval, 17% to 44%; p < 0.001), a 15% increased risk of a medical complication (95% confidence interval, 2% to 30%; p = 0.025), a 78% increased risk of a surgical complication (95% confidence interval, 49% to 112%; p < 0.001), and a mean length of stay that was 14% longer (95% confidence interval, 12% to 15%; p < 0.001). CONCLUSIONS: Infection with hepatitis C is an infrequent but increasingly common comorbidity among patients undergoing total joint arthroplasty. Given these findings, orthopaedic surgeons should be aware of the increased risks of total joint arthroplasty in patients with hepatitis C and should discuss these risks with potential surgical candidates during a shared decision-making process.

What are the Risk Factors for Hardware Removal After Tibia or Fibula Fracture?

Indications for open reduction and internal fixation (ORIF) of tibia and/or fibula fractures vary; however, some patients require removal of hardware (ROH) due to various complications. Currently, data evaluating the epidemiology of and risk factors for ROH of the tibia/fibula are limited. We examined the associations between tibia/fibula fractures and (1) characteristics of fractures requiring ORIF, (2) indications for ROH, (3) demographic risk factors for ROH; (4) length of stay, and (5) total hospital charges. The Nationwide Inpatient Sample (NIS) was used to identify patients admitted for tibia/fibula ORIF and ROH between 1998 and 2010 in the United States. We used ICD-9 codes to identify fracture locations, comorbidities, and indications for ROH. We identified 1,610,149 ORIF patients, and 56,864 of these patients (3.5%) underwent ROH. Logistic regression analyses and independent sample t-tests were used to assess risk factors and differences. Among fractures requiring ORIF, the most common were for closed fractures of both tibia and fibula. The most common indications for ROH were infection and osteomyelitis. Risk factors for ROH included men and Deyo comorbidity scores of 1 and 2 or more. Age and race were not risk factors for ROH. The length of stay and total charges were significantly higher for ROH compared to those with ORIF only. Hardware removal is a serious complication following ORIF for fractures of the tibia/fibula. The results of the current study suggest that gender, presence of comorbidities, and payer status were all significant factors in predicting hardware removal for the tibia/fibula following ORIF.

Does sickle cell disease increase risk of adverse outcomes following total hip and knee arthroplasty? A nationwide database study.

Sickle cell disease (SCD) is associated with impaired vascular function and progressive vaso-occlusive injury to bones. We used the Nationwide Inpatient Sample to identify all THA and TKA admissions between 1998 and 2010. After controlling for patient age, gender, insurance, race, and comorbidities, the risk of complication among admissions with SCD was 152% higher (P<0.001) for THA and 137% higher (P=0.001) for TKA. Patients with SCD had a length of stay that was 42% longer (P<0.001) for THA and 20% longer for TKA (P<0.001), and hospital charges that were 19% higher (P<0.001) for THA and 16% higher (P=0.001) for TKA. Orthopedic surgeons should counsel potential THA and TKA candidates with SCD of these risks prior to admission.

Anterior cruciate ligament graft choices.

CONTEXT: Reconstruction of the anterior cruciate ligament (ACL) is a common surgical procedure; however, there is no consensus to what the best graft option is to replace the injured ACL. The main options available consist of allografts and autografts, which include patellar tendon, hamstring tendon, and quadriceps tendon autografts. EVIDENCE ACQUISITION: The PubMed database was searched in August 2010 for English-language articles pertaining to ACL grafts. RESULTS: Postoperative outcome variables were analyzed to determine similarities and differences among the different graft options. These variables include stability, strength, function, return to sports, patient satisfaction, complications, and cost. CONCLUSIONS: Both allografts and the 3 main options for autografts can provide excellent results in ACL reconstruction and lead to a high percentage of satisfied patients. However, differences exist among the graft choices. Both the similarities and the differences are important to discuss with a patient who will be undergoing ACL reconstruction so that he or she has the best information available when making a choice of graft.