A Geometrical Explanation for Change in Pelvic Tilt (or Lack of Change) Following Long Spinal Fusions.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: Examine the relationship between compensatory pelvic retroversion, positive sagittal imbalance (measured by C2 tilt), and the C2 pelvic angle (C2PA) in patients prior to long spinal fusions; and to determine the association between changes in C2PA and pelvic tilt (PT) following long spinal fusions. BACKGROUND: Adult spinal deformity surgical goals often include a PT target, yet patients frequently demonstrate persistent compensatory pelvic retroversion following surgery. MATERIALS AND METHODS: Adults>18y undergoing long spinal fusions (>4 levels) with standing preoperative and postoperative radiographs were included. To examine drivers of preoperative sagittal balance, regression models were fit to estimate the association between preoperative C2PA and pelvic incidence, with preoperative PT and C2 tilt. To predict postoperative change in PT, multivariable regression was used to estimate change in PT, adjusting for change in C2PA and preoperative C2 tilt. RESULTS: Among 80 patients identified, median age was 61 (IQR, 45 to 72) and 46 (58%) were female. Median number of levels fused was 10 (IQR, 8 to 13) and 55 (69%) were instrumented to the sacrum/pelvis. Preoperative C2PA had a significant nonlinear association with preoperative PT (r2=0.81, P<0.001), and preoperative C2 tilt (r2=0.41, P=0.002). Postoperative change in PT was strongly associated with change in C2PA (ß=0.81; P<0.001) and preoperative C2 tilt (ß=0.55; P<0.001). CONCLUSIONS: Following long spinal fusions, change in PT (or lack thereof) can be reliably predicted based on change in C2PA and preoperative C2 tilt. In patients with normal preoperative C2 tilt, the change in C2PA is nearly equivalent to the change in PT, but in patients with more positive C2 tilt (sagittal imbalance), a greater change in C2PA will be required to achieve equivalent change in PT. LEVEL OF EVIDENCE: III.

Preoperative Dehydration Predicts Adverse Events Following Anterior Cervical Discectomy and Fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a common procedure for neck arthritis, typically alleviating pain and improving function. Preoperative dehydration has been correlated with postoperative infection, acute renal failure, deep vein thrombosis, and increased hospital length of stay. However, some studies have suggested that preoperative dehydration has a minimal relationship with postoperative outcomes, specifically in arthroplasty and lumbar surgery candidates. METHODS: Patients who underwent ACDF from 2015 to 2020 as part of the American College of Surgeons National Surgical Quality Improvement Program database were identified. We excluded patients who presented with acute trauma. Dehydration was determined using the accepted definition of preoperative blood urea nitrogen to creatinine ratio greater than 20. Lengths of stay and 30-day postoperative adverse events were compared between dehydrated and nondehydrated cohorts, adjusting for baseline features using standard multivariate regression. RESULTS: We identified 14,932 patients, and 4206 (28.1%) of whom were preoperatively dehydrated. Dehydrated patients had significantly higher odds of wound, hematological, and pulmonary complications; Clavien-Dindo grade IV, delayed length of stay (>5 days); and a lower likelihood of being discharged home (P < 0.005), even after controlling for demographic features (eg, sex, age, body mass index, race, and ethnicity). Furthermore, linear regression suggested an overall half-day increased length of hospital stay for dehydrated patients (95% CI [0.36, 0.60], P < 0.001). CONCLUSION: Preoperative dehydration is common among ACDF surgery patients and appears to correlate with an increased risk of postoperative complications and prolonged length of hospital stay. Evaluation of a patient's hydration status from standard preoperative laboratory metrics can be employed for risk stratification, patient counseling, and timing of ACDF surgeries.

Vascular Injury After Scoliosis Correction in Ehlers-Danlos Syndrome: Proceed With Caution.

Ehlers-Danlos syndrome (EDS) is a rare inherited connective tissue disorder characterized by collagen synthesis disruption, resulting in joint hyperlaxity, skin and vascular fragility, and bleeding diathesis. Patients with EDS are susceptible to spinal deformities, with scoliosis accounting for up to 23.4% of musculoskeletal abnormalities. Conservative management is often trialed initially; however, severe scoliosis can lead to significant sagittal imbalance and cardiopulmonary compromise. Surgical intervention for scoliosis correction in patients with EDS presents unique challenges because of tissue fragility and an increased risk of vascular and wound complications. This case report discusses a 20-year-old man with type II EDS and scoliosis, who experienced retroperitoneal compartment syndrome, significant left lower extremity weakness, and loss of sensation after scoliosis correction surgery. The report also provides an overview of the existing literature on scoliosis surgery outcomes in patients with EDS, highlighting the need for heightened vigilance and cautious surgical approaches.

The Effect of Obesity on Distal Radius Fractures: An Analysis from the NSQIP Database.

The rate and severity of obesity has risen over the past 40 years, and class III (formerly morbid) obesity presents additional sequelae. The effect of obesity on the incidence and recovery of hand and wrist fractures remains unclear. We sought to quantify the relationship between class III obesity and postoperative distal radius fracture (DRF) complications. Methods: We performed a retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database for surgical DRF patients more than 50 years old from 2015 to 2020. We then stratified patients into class III obese (BMI > 40) and compared the rates of postoperative complications to a control group with BMI less than 40. Results: We included 10,022 patients (570 class III obese vs. 9,452 not class III obese). Patients with class III obesity had significantly increased odds of experiencing any complication (OR 1.906, p<0.001), adverse discharge (OR 2.618, p<0.001), delayed hospital stay of longer than three days (OR 1.91, p<0.001), and longer than seven days (OR 2.943, p<0.001) than controls. They also had increased odds of unplanned reoperation (OR 2.138, p = 0.026) and readmission (OR 2.814, p < 0.001) than non-class III obese patients. Class III obese patients had a significantly longer average operation time (79.5 min vs. 72.2 min, p < 0.001). They also spent more time in the hospital postoperatively (0.86 days vs. 0.57 days, p = 0.001). Conclusion: Class III obese patients undergoing DRF repair are more likely to experience postoperative complications than non-class III obese patients.

Medial Elbow Pain Syndrome: Current Treatment Strategies.

Medial elbow pain is a common presentation that can be a challenge to appropriately treat for the orthopedic surgeon. Causes include medial epicondylitis, ulnar neuritis, ulnar collateral ligament injury, flexor pronator strain, or snapping medial triceps. A good outcome is typically achieved with adequate treatment of tendon degeneration at the common flexor tendon origin. Mainstay treatment is nonoperative modalities such as stretching, rest, activity modification, therapy, and injections. If nonoperative management fails, intermediate interventions such as extracorporeal shockwave therapy, platelet-rich plasma injections, prolotherapy, and ultrasound-guided percutaneous tenotomy can be attempted. Surgical treatments are dictated based on the severity of the pathology, involvement of soft tissues, and concomitant pathology. Medial elbow complaints can be multifactorial and require a broad differential diagnosis. [Orthopedics. 2023;46(2):e81-e88.].

The articular surface technique for lumbar pedicle screw placement: a 3D feasibility study.

Background: Traditional pedicle screws (TPSs) and cortical based trajectory pedicle screws each apply stability with fusions of the lumbar spine and have shown good success. However, the technical considerations of each technique imply complications of loosening and failure that either technique is uniquely prone to having. The current study proposes a new pedicle screw technique through the articular surface of the vertebral superior facet. It is hypothesized that this path will allow utilization of a larger screw that rivals that of the TPS technique, while also maintaining the high-density bone encountered in the cortical based trajectory technique. Methods: Retrospective review of 50 consecutive trauma patients that underwent lumbar computed tomography (CT) scans at a Level 1 Trauma Center in the age range 18-45. These scans were uploaded to Brainlab software for ideal starting point and trajectory mapping of pedicle screws coursing through each superior facet and pedicle of vertebral levels L1-S1 without cortical breach. Satisfactory pedicle screw variables consisted of a medial angle <10 degrees, screw length at least 30 mm, screw width at least 5.0 mm, and starting point measurements such as distance to the inferior articular surface and distance to the lateral articular surface. Results: A total of 600 virtual pedicle screws were placed, in which 525 were satisfactory and measured with the above variables. The pedicle widths were shown to significantly widen with lower-level vertebra in the lumbar spine. Approximately 72% of unsuccessful pedicle screws were placed in levels L1 and L2 allowing wider pedicle screws to be placed more further down the vertebral column. Conclusions: The articular surface technique (AST) for pedicle screw placement is a viable alternative in lumbar spinal fusions that offers decreased soft tissue dissection. However, the technique is likely better suited for lower lumbar fusions in L3 to S1.

The 8-item Modified Frailty Index Is an Effective Risk Assessment Tool in Anterior Cervical Decompression and Fusion.

STUDY DESIGN: Case-control study; Level of evidence, 3. OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is one of the most common procedures for cervical diseases often with reliable outcomes. However, morbidity rates can be as high as 19.3% so appropriate patient selection and risk stratification is imperative. Our modified frailty index (MFI) predicts postoperative complications after other orthopaedic procedures. We hypothesized that this index would predict complications in a large cohort of ACDF patients. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, including patients who underwent ACDF from 2015-2020. An 8-item MFI score was calculated for each patient. We recorded 30-days postoperative complications, readmission, and reoperation rates, adjusting for baseline features using standard multivariate regression. This project was approved of by the University of Texas Health Science Center Institutional Review Board and an IRB exception was granted. RESULTS: We identified 17 662 ACDF cases. Patients with MFI of 5 or greater had a 37.53 times increased odds of incurring postoperative complications compared to patients with MFI of 0 (P < .001) even when age, sex, race, and ethnicity were controlled for. Specifically, life-threatening Clavien-Dindo IV complications, as well as wound, cardiac, renal, and pulmonary complications were significantly increased in patients with an MFI of 5 or greater. Also, as MFI increased from 1-2 to 3-4 to 5 or greater, the odds of readmission increased from 1.36 to 2.31 to 5.42 times (P < .001) and odds of reoperation from 1.19 (P = .185) to 2.3 to 6.54 times (P < .001). Frailty was still associated with increased complications, readmission, and reoperation after controlling for demographic data, including age, as well as operative time and length of stay. CONCLUSION: Frailty is highly predictive of postoperative complications, readmission, and reoperation following ACDF. Employing a simple frailty evaluation can guide surgical decision-making and patient counseling for cervical disease.

Socioeconomic Status Affects Pre- and Postoperative Two-point Discrimination in Patients with Carpal Tunnel Syndrome.

Carpal tunnel release is a life-changing procedure within hand surgery. Multiple factors may have an impact on the outcome following surgery. Methods: In this retrospective cohort study, we reviewed all patients who underwent carpal tunnel release in our institutional database from 2018 to 2020. We included patients with a minimum of 6-week follow-up. Patient demographics were identified, including insurance status and comorbidities. Patients were categorized as "improved" or "not improved" based on two-point test differences. Results were analyzed using the Fisher exact test. We ran a logistic regression model to analyze the relationship between income status (operationalized by having Medicaid/Carelink) and preoperative scores, and inferential statistics were computed with appropriate t tests. Results: Of the 125 patients who met the inclusion criteria, 47 (37.6%) had Medicaid or Carelink, and 79 (62.4%) had commercial insurance. Medicaid/ Carelink patients presented with worse two-point discrimination on initial presentation (P < 0.001). Compared to commercial insurance, Medicaid/Carelink patients were less likely to show improvement in postoperative two-point discrimination (P < 0.001). Male patients were also less likely to show improvement. Race, ethnicity, medical comorbidities, and age were not shown to have a significant effect on improvement in two-point discrimination. Conclusions: Although medical comorbidities did not have a significant effect on postoperative two-point, patients with low-income status (Medicaid/Carelink) may have a less predictable outcome. These socioeconomic considerations are critical in appropriately risk stratifying surgical candidates, and counseling patients in whom tactile acuity may be less predictable.

Survival rates in atlanto-occipital dissociation: a look at the past 20 years.

BACKGROUND CONTEXT: Atlanto-occipital dissociation (AOD) has historically been considered a fatal injury. Recent small case series, however, have suggested that AOD injuries have become increasingly survivable. There has not been an adequately powered study that confirms this. PURPOSE: The aim of this study is to assess whether the survival rate for patients with AOD increased over time. STUDY DESIGN/SETTING: Retrospective case series. PATIENT SAMPLE: Patients with traumatic AOD identified from our Level 1 Trauma Center database. OUTCOME MEASURES: Mortality following traumatic AOD. METHODS: Patients with traumatic AOD from 1996 to 2019 were retrospectively identified from our Level 1 Trauma Center database using International Classification of Diseases 9 and 10 codes. Patients were stratified into two cohorts- those diagnosed before August 1, 2015 and after. RESULTS: A total of 52 patients met our inclusion criteria and were analyzed. Mean age was 34.41 (11.71), with 34 (65.4) females, and 26 (50) Hispanics. Mean BMI was 28.13 (7.30), mean injury severity score was 40.79 (21.72), and mean Glasgow coma scale was 5.91 (4.72). Overall, 33 patients died (63.5%). The mortality rate before 2015 was 81.80%, this number dropped down to 50% for those who were treated post 2015 (p=.01). CONCLUSIONS: This study demonstrates that patients treated recently for AOD at a level 1 trauma center were more likely to survive than patients treated in the past at the same center. Possible reasons for the improved survival rate seen in this study include: increased awareness of AOD, improved diagnostic protocols with more uniform computed tomography based imaging, and advances in the care of these patients.

The internal joint stabilizer for chronic elbow dislocation: a surgical technique.

The main goal of treatment for chronically unreduced elbow dislocations is to restore a stable, concentric joint and regain a satisfactory arc of motion. Due to the conflicting goals of restoring elbow stability and regaining a good arc of motion, the treatment of chronic elbow dislocation remains a challenge for even the experienced orthopedic surgeon. The standard treatment of these dislocations consists of open reduction, V-Y muscleplasty of the triceps, and temporary arthrodesis or cast immobilization. However, prolonged postoperative immobilization may result in elbow stiffness, which significantly limits the functional outcome. We present our surgical technique with a focus on restoring stable reduction such that early motion can be instituted and complications of prolonged immobilization can be avoided. From position to wound closure, surgical steps are presented in detail, with pearls for practice and a discussion on chronic elbow dislocation. The internal joint stabilizer is a safe and effective implant that complements the management of chronic elbow dislocations. This reproducible surgical technique allows for stability and early mobility while having the added benefit of circumventing complications associated with prolonged immobilization and hinged external fixation. Understanding the surgical indications, as well as the nuances of the surgical technique utilizing the internal joint stabilizer, is critical in order to improve patient outcomes and avoid complications.

Periosteal Chondroma of the Pelvis: An Uncommon Tumor in an Unusual Location.

Periosteal chondromas (PCs) are rare tumors composed of hyaline cartilage that are typically present in long bones and tubular bones of the hand. These lesions are easily mistaken for other, more common tumors. This study reports a case of PC located in the posterior pelvis of a 24-year-old female. The patient initially presented with a four-month history of pelvic pain with a presumptive diagnosis of endometriosis. However, when an MRI was performed, a 6.0 cm x 5.6 cm x 4.5 cm mass was found along the right posterior ilium extending to the ipsilateral sacroiliac joint. The patient underwent intralesional excision and curettage of the mass. Histologic analysis of the excised lesion revealed a proliferation of chondrocytes and abundant hyaline cartilage without chondroblasts, further suggesting the diagnosis of PC. The current study highlights the unusual location of this rare tumor and alerts the physician of the clinical presentation and differential diagnosis.

The Clinical Manifestations of Femoral-Facial Syndrome in an Orthopaedic Patient.

Femoral-facial syndrome (FFS) is an exceedingly rare congenital disorder of unknown etiology related to maternal diabetes during pregnancy. It is characterized by variations of bilateral femoral hypoplasia and facial anomalies. We discuss an interesting case of a 3-year-old girl with FFS with an extensive surgical history who presented to a pediatric orthopaedic clinic with ankle pains and absent femurs. As this disease process is not frequently encountered, it is imperative for the practicing clinician to be aware of the various presentations. In this study, we discuss the different orthopaedic presentations in the literature and discuss various management recommendations.

An Analysis of Traumatic Ankle Fracture Patients: Does Income Status Influence Access to Acute Orthopaedic Surgical Care?

PURPOSE: To evaluate if income status affects the timing of presentation to orthopaedic care, surgical treatment, or continuity of care following a closed ankle fracture. METHODS: Th is retrospective study identified 434 patients with closed ankle fractures treated with operative fixation from 2014 to 2016. Median income data were extracted using the patients' ZIP codes and data from the U.S. Census Bureau. RESULTS: Lower-income patients presented to the hospital and received surgical treatment significantly later than others. They were also more often uninsured and nonadherent with postoperative weightbearing precautions. Additionally, these patients less frequently sought care on the day of their injury, and they had both shorter inpatient stays and duration of overall follow-up in comparison with others. CONCLUSION: Socioeconomic status is a vital consideration for improving patient access to acute orthopaedic surgical care. Lower-income patients are more susceptible to multiple time-sensitive delays in their care, and these patients frequently encounter difficulties maintaining appropriate follow-up carex.

Skin closure with surgical staples in ankle fractures: a safe and reliable method.

PURPOSE: The purpose of this study is to examine the rates of surgical site complications of staple closure versus suture closure following open reduction and internal fixation of closed unstable ankle fractures. METHODS: Between 2014 and 2016, a total of 545 patients with closed ankle fractures were treated at our level-1 trauma centre by means of open reduction and internal fixation. A total of 360 patients matched the inclusion criteria and were included in the final analysis of this study. This included 119 patients undergoing wound closure using sutures and 241 patients using surgical staples. The demographics, clinical data, and injury characteristics were recorded. The primary outcome measure was the adverse event of any type of surgical site complication. RESULTS: The overall rate of patients with a surgical site complication was 15.6%. There was a trend towards a higher risk of surgical site complication in patients undergoing wound closure with sutures as compared with staples (20.2% versus 13.3%); however, this difference was not statistically significant (P = 0.0897). The rate of superficial surgical site infection also trended higher in patients undergoing wound closure with sutures versus staples without demonstrating statistical significance (10.1% versus 5%, P = 0.0678). The rate of deep surgical site infection was similar in both groups. CONCLUSION: The use of metal staples remains controversial in the setting of orthopedic surgery, particularly involving the foot and ankle. The current study supports that metal staples are a safe and reliable option in the closure of traumatic ankle fractures.

The Unique Bipolar Clavicle Dislocation: A Novel Reconstruction Technique and Case Report.

A bipolar clavicle separation is defined as a simultaneous dislocation of the ipsilateral sternoclavicular joint (SCJ) and acromioclavicular joint (ACJ). This rare injury pattern is usually the result of a high-energy mechanism, such as a motor vehicle collision or fall from height. While there are several treatment options such as screw fixation, sutures, or plate fixations, there is no single standard approach for this infrequent injury. We describe a unique case of bipolar clavicle dislocation, specifically an anteriorly displaced SCJ and posteriorly displaced ACJ, treated with a novel surgical technique-a TightRope technique (Arthex®) and semitendinosus allograft.

Management of Pediatric Tibial Nonunion following Osteotomy: A Case Series and Review of the Literature.

Pediatric tibial nonunion following corrective osteotomy is a rare complication that is not well understood. While adult nonunions have been linked to endocrine and metabolic aberrations, this has not been established in a pediatric population. Pediatric tibial nonunion has been shown to respond to debridement with revision fixation using dynamic compression plating, supplementary bone graft, and fibular osteotomy to allow compression. Necessity of referral for metabolic and endocrinology workup remains unclear in the pediatric population, though inflammatory markers should be obtained in each case to rule out infection. We present three consecutive cases of pediatric tibial nonunion following osteotomy over a five-year period and discuss the management.

Orthopaedics and neurosurgery: Is there a difference in surgical outcomes following anterior cervical spinal fusion?

OBJECTIVE: The superiority of neurosurgical over orthopaedic spinal procedures is a point of contention. While there is the perception that neurosurgeons are more specifically trained to deal with spinal pathology, no study has directly compared outcomes of spinal surgeries performed by both groups. METHODS: We sought to evaluate the differences in length of surgery, hospital stay, complications, mortality, and readmission for anterior cervical decompression and fusion (ACDF) performed by neurosurgeons versus orthopaedic surgeons. RESULTS: 17,967 ACDF procedures were analyzed. Neurosurgeons performed 74.3% of the fusions with a trend towards longer operative times and significantly more patients that were discharged to extended care facilities. There was no significant difference in the length of stay, overall complications, mortality, readmission, or reoperation when comparing the two specialties. CONCLUSION: Despite a significantly higher volume of ACDF performed by neurosurgeons, outcomes are comparable following orthopaedic and neurosurgical procedures.

Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality.

Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009-2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137-143, 2019).

Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology.

BACKGROUND: There is a paucity of literature describing distal femoral osteotomies (DFO) in regards to complications and outcomes with previously studied cohorts containing primarily older, arthritic subjects. There has been no study to date focusing on younger, pre-arthritic patients. METHODS: All service members indicated for distal femoral osteotomy for coronal plane malalignment were isolated from military treatment centers between 2007 and 2013. Demographic and surgical variables were extracted, and perioperative complications, clinical course, and return to military function were extracted using clinical notes and radiographs. RESULTS: A total of 22 knees in 19 patients were identified at an average 3.2 year follow-up, with the exclusion of 16 individuals. Statistical analysis revealed worse outcomes associated with smoking, over correction, breach of the medial cortex, and prior surgeries. Overall 58% of patients left the military as the result of knee dysfunction despite an average improvement in visual analog scores (VAS) from 4.0 to 1.9 (p = 0.004). CONCLUSIONS: While offloading the lateral compartment improves symptoms at short to midterm follow-up preventing progression to arthroplasty, young active duty military members have suboptimal return to duty rates.

Alive or dead: Validity of the Social Security Administration Death Master File after 2011.

OBJECTIVE: To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records. DATA SOURCES: Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse. STUDY DESIGN: Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated. DATA COLLECTION METHODS: Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking. PRINCIPAL FINDINGS: 97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS. CONCLUSIONS: The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality.