Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent.

BACKGROUND: Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation. METHODS: Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles. RESULTS: For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116). CONCLUSIONS: Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation.

BACKGROUND: Von Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival. METHODS: Adult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events. RESULTS: Of 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006). CONCLUSIONS: Patients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

Geriatric Vertebral Compression Fracture: A Database Study Characterizing Use and Trends for Prescribed Thoracic/Lumbar Orthoses.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Geriatric vertebral compression fractures are the most common fracture associated with osteoporosis. Using a large national database, the current study aimed to examine and characterize bracing trends for geriatric thoracic/lumbar compression fracture management. METHODS: The current study utilized the PearlDiver database from 2015-2021. Patients who suffered thoracic/lumbar compression fractures (fifth thoracic to the fifth lumbar vertebra [T5-L5]) were identified. Exclusion criteria included patients less than 65 years old or an indication of infection or neoplasm. Patients who received a brace within 90-days after the initial diagnosis of thoracic/lumbar compression fracture were abstracted and characterized overall and by fracture level. Multivariable logistic regression was performed to assess for correlation with bracing trends. RESULTS: In total 290 388 patients met inclusion criteria and suffered a thoracic/lumbar compression fracture (greatest incidence at the thoracolumbar junction). Of these, bracing was only prescribed for 4263 (1.5%), with the greatest variance of 1.5% by level. Independent predictors of bracing were geographic region (relative to northeast, west WE odds ratio [OR] 1.31, Midwest OR 1.20), younger age (OR 1.27 per decade), female sex (OR 1.17), and ECI (OR 1.02 per 2-point increase) (P < .05 for each). CONCLUSION: Overall, the current study examined over a quarter of a million patients who suffered a T5-L5 compression fractures and found that only 1.5% of patients were braced. This low percentage, and that greatest predictor for bracing was non-clinical (geographic region), highlight the inconsistency of this practice and may be useful for developing treatment algorithms.

Total shoulder arthroplasty in patients with Factor V Leiden.

BACKGROUND: Anatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. METHODS: Adult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and five-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents utilized, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescriptions found. RESULTS: Of 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1,081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR=9.50, p<0.0001), pulmonary embolism (PE, OR = 10.10, p<0.0001), and pneumonia (OR=2.43, p=0.0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, p=0.0001), serious (OR=6.38, p<0.0001), and all (OR=3.51, p<0.0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin/heparin/DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR=4.25, p<0.0001 and OR=2.54, p=0.0065) than those on aspirin/no prescriptions found (OR=7.64 and OR=21.95, p<0.0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). DISCUSSION AND CONCLUSIONS: TSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with versus without FVL.

Femoral Head Core Decompressions: Characterization of Subsequent Conversion to Total Hip Arthroplasty and Related Complications.

BACKGROUND: Core decompression is a minimally invasive joint-preserving approach for early-stage osteonecrosis. The rate at which core decompression patients require total hip arthroplasty (THA) and rates of perioperative adverse outcomes have not been well-characterized. METHODS: Adult patients undergoing core decompression and/or THA with osteonecrosis of the femoral head were identified from the 2015 to 2021 Q3 PearlDiver M157 database. Those undergoing THA without or with antecedent core decompression were identified and matched 4:1 on age, sex, and Elixhauser Comorbidity Index. Postoperative 90-day adverse events were compared with multivariable analysis. Five-year rates of revision, dislocation, and periprosthetic fracture were compared by the Kaplan-Meier curve and log-rank tests. RESULTS: Core decompressions were identified for 3,025 patients of whom 387 (12.8%) went on to THA within 5 years (64% within the first year). The median time from initial core decompression to THA was 252 days. For THA, 26,209 adults were identified and 387 had prior core decompression. After matching, there were 1,320 without core decompression and 339 with core decompression. No statistically significant differences were observed in 90-day postoperative adverse events or 5-year rates of revision, dislocation, or periprosthetic fracture. CONCLUSION: Core decompression may be an option for patients with osteonecrosis and does not seem to affect THA outcomes if required later.

Patients With Cystic Fibrosis Undergoing Total Hip and Total Knee Arthroplasty Are at Increased Risk for Perioperative Complications.

INTRODUCTION: Patients with cystic fibrosis (CF) are living longer and may be considered for total hip arthroplasty (THA) or total knee arthroplasty (TKA). Perioperative outcomes and implant survival after these procedures performed for those with CF have not been previously described. METHODS: Using the M151 PearlDiver database, a large, national, administrative database, THA and TKA patients with and without CF were identified and matched 1:10 based on age, sex, and Elixhauser Comorbidity Index. Ninety-day perioperative outcomes and 2-year revision rates were assessed and compared with multivariable logistic regression. RESULTS: For THA, 185 patients with CF were matched with 1,846 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including sepsis (odd radio [OR] 4.15), pneumonia (OR 3.40), pleural effusion (OR 2.77), minor events (OR 1.73), any adverse event (OR 1.64), urinary tract infection (UTI) (OR 1.63), and severe events (OR 1.60) ( P < 0.05 for each). For TKA, 505 patients with CF were matched with 5,047 control subjects without CF. Patients with CF were at significantly increased odds of 90-day postoperative events including pneumonia (OR 4.95), respiratory failure (OR 4.31), cardiac event (OR 2.29), minor events (OR 2.16), pleural effusion (OR 2.35), severe events (OR 2.06), urinary tract infection (OR 2.06), any adverse event (OR 1.96), atelectasis (OR 1.94), and acute kidney injury (OR 1.61) ( P < 0.05 for each). For both THA and TKA, those with CF were not at greater odds of 2-year rates of revision. DISCUSSION: After THA and TKA, those with CF were found to be at increased odds of multiple defined postoperative events (predominantly infectious/pulmonary), but not 2-year revision rates. These findings help define areas in need of focused optimization and are reassuring regarding risks of surgery.

Patients With Down Syndrome and Total Hip and Total Knee Arthroplasty: Outcome Measures Show Increased Risk of Perioperative Complications.

BACKGROUND: Patients with Down syndrome (DS) are being considered for total joint arthroplasty. There is limited literature regarding outcomes of patients with DS after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Data were abstracted from the 2010 to 2021 Q1 PearlDiver M151 database. THA and TKA osteoarthritis adult patients with and without DS were identified. Patients were matched 1:10. Ninety-day postoperative events and 2-year revision rates were compared. RESULTS: For THA, 154 patients with DS were matched with 1,532 patients without DS. For TKA, 150 patients with DS were matched with 1,495 patients without DS. On multivariable logistic regression, THA and TKA patients with DS were at markedly greater odds of postoperative events including any adverse event, sepsis, minor adverse event, urinary tract infection (UTI), acute kidney injury (AKI), and pneumonia. For both THA and TKA, 2-year revision rates were not increased for those with DS. DISCUSSION: This study represents the largest cohorts for matched patients with DS undergoing THA or TKA through 90 days postoperatively. For both procedures, DS patients were found to have greater risk of several adverse events, but not 2-year revisions. These findings may help guide perioperative risk assessment, patient/family counseling, and care pathways.

Lumbar Laminotomy: Variables Affecting 90-day Overall Reimbursement.

INTRODUCTION: Lumbar laminotomy/diskectomy is a common procedure performed to address radiculopathy that persists despite conservative treatment. Understanding cost/reimbursement variability and its drivers has the potential to help optimize related healthcare delivery. The goal of this study was to assess variability and factors associated with reimbursement through 90 days after single-level lumbar laminotomy/diskectomy. METHODS: Lumbar laminotomies/diskectomies were isolated from the 2010 to 2021 PearlDiver M151 data set. Exclusion criteria included patients younger than 18 years; other concomitant spinal procedures; and indications of trauma, oncologic, or infectious diagnoses. Patient, surgical, and perioperative data were abstracted. These variables were examined using a multivariable linear regression model with Bonferroni correction to determine factors independently correlated with reimbursement. RESULTS: A total of 28,621 laminotomies/diskectomies were identified. The average ± standard deviation 90-day postoperative reimbursement was $9,453.83 ± 19,343.99 and, with a non-normal distribution, the median (inner quartile range) was $3,314 ($5,460). By multivariable linear regression, variables associated with greatest increase in 90-day postoperative reimbursement were associated with admission (with the index procedure [+$11,757.31] or readmission [+$31,248.80]), followed by insurance type (relative to Medicare, commercial +$4,183.79), postoperative adverse events (+$2,006.60), and postoperative emergency department visits (+$1,686.89) (P < 0.0001 for each). Lesser associations were with Elixhauser Comorbidity Index (+$286.67 for each point increase) and age (-$24.65 with each year increase) (P < 0.001 and P = 0.003, respectively). DISCUSSION: This study assessed a large cohort of lumbar laminotomies/diskectomies and found substantial variations in reimbursement/cost to the healthcare system. The largest increase in reimbursement was associated with admission (with the index procedure or readmission), followed by insurance type, postoperative adverse events, and postoperative emergency department visits. These results highlight the need to balance inpatient versus outpatient surgeries while limiting postoperative readmissions to minimize the costs associated with healthcare delivery.

Ninety day adverse events following single level posterior lumbar interbody fusion in patients with sickle cell disease.

BACKGROUND CONTEXT: Sickle cell disease (SCD) is an inherited disorder of red blood cells caused by mutation in the hemoglobin beta chain and is the most common inherited genetic disorder in the United States. Postoperative outcomes following single-level posterior lumbar interbody fusion (PLIF) in patients with SCD are not well characterized. PURPOSE: To examine 90-day postoperative outcomes among a matched cohort of patients with and without SCD who underwent single level PLIF utilizing a national administrative database. STUDY DESIGN/SETTING: Retrospective database study. PATIENT SAMPLE: Adult patients without and with SCD who underwent single level PLIF from 2010 to 2021 Q1 were identified and matched 10:1 based on age, sex and ECI. Exclusion criteria included: age <18 years old, recent history of infection, neoplasm, or trauma, as well as not being active in the database for 90 days following their procedure. OUTCOME MEASURES: Ninety-day postoperative adverse events and emergency department (ED) visits. METHODS: The matched cohorts were defined, and 90-day adverse event and ED visit rates were compared with univariable analyses and multivariable logistic regression, controlling for age, sex, and Elixhauser comorbidity index (ECI). RESULTS: Overall, 191,765 PLIF patients were identified, of which SCD was noted for 76 (0.04%). On multivariable analysis of the matched populations, patients with SCD were at increased odds ratio (OR) of the following (in decreasing OR order): transfusion (OR 17.69), pneumonia (OR 6.30), sepsis (OR 4.86), aggregated minor adverse events (OR 4.65), aggregated all adverse events (OR 3.87), ED visits (OR 3.53), and aggregated severe adverse events (OR 2.80) (p<.05 for all). CONCLUSIONS: The current study examined a relatively small, but largest to date, cohort of SCD patients undergoing PLIF. Patients with this condition were at greater odds of several perioperative adverse events, and these findings may be helpful for patient counselling and surgical planning.

Trends in and Factors Associated With Surgical Management for Closed Clavicle Fractures.

INTRODUCTION: Clavicle fractures are common and have historically been managed nonsurgically. Over time, there are increasing surgical considerations for such injuries. Nonetheless, trends over the past decade are not well characterized. METHODS: Adult patients presenting for first diagnosis of clavicle fractures were identified from the 2010 to 2020 PearlDiver M151 database. Patients were defined to have undergone surgical management if they received clavicular open reduction and internal fixation within 90 days after fracture diagnosis. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance coverage, fracture anatomic location, and polytraumatic diagnoses were extracted. Factors independently associated with surgical management versus nonsurgical management were assessed with multivariable analysis. RESULTS: Overall, 50,980 patients with clavicle fractures were identified of whom 6,193 (12.1%) were managed surgically. This proportion increased significantly over the study period (7.4% in 2015 to 13.9% in 2020, P < 0.001). Independent predictors of surgical management included fracture diagnosis in 2020 (versus 2015, odds ratio [OR] 2.36), anatomic location (relative to lateral end, shaft OR 1.84 and sternal OR 3.35), and Midwest region of service (OR 1.26, relative to South) (P < 0.001 for all). DISCUSSION: A small but increasing minority of patients with clavicle fractures are managed surgically. Clinical factors and nonclinical factors were associated with surgical management.

Emergency Department Visits Following Patellofemoral Arthroplasty.

BACKGROUND: Readmissions are a typical postoperative metric; however, postoperative emergency department (ED) utilization also negatively affects patient care. Few studies have explored this metric after patellofemoral arthroplasty (PFA); thus, we investigated the incidence, timing, predictive factors, and reasons for ED utilization within 90 days after PFA. METHODS: Using the 2010 to 2021 PearlDiver M151Ortho data set, a national billing claims database containing information of over 151 million US orthopaedic patients across all payer types, the study examined weekly ED visits up to 90 days after PFA and conducted univariate and multivariate analyses to identify predictive factors. RESULTS: Of 7765 PFA patients, 11.2% (922) had ED visits within 90 days, with 46.7% (431) occurring in the first 3 weeks. Independent predictors of ED utilization included younger age (OR 1.40 per decade decrease), higher Elixhauser Comorbidity Index (OR 1.44 per 2-point increase), surgery in the South or Midwest (OR 1.27 and 1.31), and Medicaid insurance (OR 1.74). Postoperative pain accounted for 50.6% of visits. CONCLUSIONS: 11.2% of PFA patients visited the ED within 90 days, primarily for postoperative pain. Younger, more comorbid, and Medicaid-insured patients were most likely to use the ED. This study suggests the need for targeted perioperative pain management to reduce ED utilization after PFA.

Low Back Pain: Utilization of Urgent Cares Relative to Emergency Departments.

STUDY DESIGN /SETTING: Retrospective study. OBJECTIVE: To understand what patients utilize emergency departments (EDs) versus urgent care centers for low back pain (LBP). SUMMARY OF BACKGROUND DATA: LBP is a common reason for ED visits. In the setting of trauma, or recent surgery, the resources of EDs may be needed. However, urgent care centers, may be appropriate for other cases. METHODS: Adult patients less than 65 years of age presenting to the ED or urgent care on the day of diagnosis of low back pain were identified from the 2019 PearlDiver M151 administrative database. Exclusion criteria included history of radiculopathy or sciatica, spinal surgery, spinal cord injury, other traumatic, neoplastic, or infectious diagnoses in the 90 days prior, or Medicare insurance. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance, and management strategies were extracted. Factors associated with urgent care relative to ED utilization were assessed using multivariable analysis. RESULTS: Of 356,284 LBP patients, ED visits were identified for 345,390 (96.9%) and urgent care visits for 10,894 (3.1%). Factors associated with urgent care use relative to the ED were: geographic region (relative to Midwest; Northeast odds ratio (OR) 5.49, South OR 1.54, West OR 1.32), insurance (relative to Medicaid; Commercial OR 4.06), lower ECI (OR 1.28 per 2-point decrease), and higher age (OR 1.10 per decade), female sex (OR 1.09), and use of advanced imaging (OR 0.08) within 1 week (P<0.001 for all). CONCLUSIONS: Most patients presenting for a first diagnosis of isolated LBP went to the ED relative to urgent care. The greatest drivers of urgent care versus ED utilization for low back pain were insurance type and geographic region. Utilization of advanced imaging was higher among ED patients, but rates of surgical intervention were similar between those seen in the ED and urgent care.

Feasibility of Emulating Clinical Trials Supporting US FDA Supplemental Indication Approvals of Drugs and Biologics.

This cross-sectional study evaluates the supporting clinical trials for supplemental new drug applications and supplemental biologics license applications from 2017 to 2019.

Imaging in spinal infections: Current status and future directions.

Imaging plays an important role in the diagnosis of spinal infections. Early diagnosis is paramount in the treatment of spinal infections and leads to improved outcomes. This article reviews the imaging and relevant clinical details of infections of the spine: pyogenic spondylodiscitis, tuberculous spondylodiscitis, septic facet arthritis, epidural abscess, and subdural abscess. Though radiographs can reveal subtle changes with infections, advanced imaging modalities have increased sensitivity to aid in early diagnosis. Magnetic resonance imaging (MRI) is emphasized given it is generally the most sensitive and specific advanced imaging modality. However, nuclear medicine imaging and computer tomography (CT) play a role diagnosis in cases where MRI is not available or contra-indicated. Additionally, CT is also important for image-guided biopsy to guide antimicrobial treatment.

Orthopaedic Injury Patterns Related to Ice Skating, Inline Skating, and Roller Skating: A 20-Year Epidemiologic Analysis.

Background: Ice skating, inline skating, and roller skating are popular sports in the United States (US). Although they are similar, injuries incurred may be distinct and may have evolved over time. Purpose: To characterize injuries related to ice skating, inline skating, and roller skating and track injury patterns over a 20-year period. Study Design: Descriptive epidemiology study. Methods: The current study utilized the National Electronic Injury Surveillance System, a database reporting consumer product-related injuries seen at emergency departments in the US. All ice skating, inline skating, and roller skating injuries between 2002 and 2021 were identified, and patient demographics, types of injury, and year of injury were compared between skating types. Results: A total of 1,656,746 skating-related injuries were estimated nationally: 24% (403,791) for ice skating, 24% (400,172) for inline skating, and 52% (852,783) for roller skating. While the incidence of ice-skating- and roller-skating-related injuries decreased by 34.4% (from 22,490 in 2002-2004 to 14,758 in 2019-2021) and 29.6% (from 42,452 in 2002-2004 to 31,980 in 2019-2021), respectively, injuries related to inline skating decreased comparatively more, by 75.8% over the study period (from 48,097 in 2002-2004 to 11,662 in 2019-2021). Injuries occurred predominantly to the head/face/neck for ice skating (n = 139,501; 34.5% of injuries), whereas injuries occurred predominantly in the shoulder/arm/elbow/wrist for inline skating (n = 212,088, 53.0% of injuries) and roller skating (n = 425,216, 49.9% of injuries). Fracture was the most common injury type for all 3 skating types (n = 614,853, 37.1% of injuries), and the majority of fractures occurred in the upper extremity (shoulder/arm/elbow/wrist) for all 3 skating types (n = 59,624, 60.0% [ice skating]; n = 69,197, 41.2% [inline skating], and n = 237,099, 68.2% [roller skating]). Lower extremity (leg/knee/ankle) fractures were more common among ice skating (n = 28,019, 28.2%) and roller skating (n = 82,094, 23.6%) injuries compared with inline skating (n = 21,391, 12.7%). Conclusion: In the current study, we found that fractures were the most common type of injury regardless of skating type but that the location of the injury/fracture varied by skating type.

Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population.

BACKGROUND: As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS: The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS: Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS: While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE: Level III-Retrospective review of national database.

Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use.

BACKGROUND: Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established. METHODS: Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI. RESULTS: A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers. CONCLUSION: Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not. LEVEL OF EVIDENCE: Level III, Retrospective database study.

3D printed pedicle screw guides reduce the rate of intraoperative screw revision in adolescent idiopathic scoliosis surgery.

BACKGROUND CONTEXT: Pedicle screw fixation has become common in the treatment of adolescent idiopathic scoliosis (AIS). Malpositioned pedicle screws have significant complications and identifying surgical techniques to optimize screw placement accuracy is imperative. PURPOSE: To compare the rate of intraoperative revision, replacement, or removal of pedicle screws placed utilizing 3D printed guides compared with pedicle screws placed utilizing a freehand technique. STUDY DESIGN/SETTING: Retrospective cohort study/single academic center. PATIENT SAMPLE: Thirty-two patients aged 10 to 18 with AIS. OUTCOME MEASURES: Revision rate of pedicle screws and operative time between groups. METHODS: A retrospective study was performed on patients 10 to 18 years of age who underwent posterior spinal instrumented fusion for AIS from February 2021 to July 2022. The study received an IRB exemption. Patient demographics, intraoperative measures, and outcome variables were recorded. Intraoperatively, all patients underwent a 3-dimensional fluoroscopic "check scan," which included axial, sagittal, and coronal images, to assess for screw accuracy. A secondary outcome of operative time was compared between groups. The p-values <.05 were considered significant. RESULTS: A total of 32 patients were included in this study. There were 17 cases in the 3D guided and 15 cases in fluoroscopy-guided freehand cohort. There was a total of 254 pedicle screws using 3D guides and 402 screws using freehand technique. Between cohorts, there were no significant differences in a number of levels fused (p=.54) or length of surgery (p=.36). The total revision rate of 3D guided screw placement was 5.5% and that of the freehand technique was 8.5%. The freehand screw placement group had significantly higher revision rates per vertebral level compared with 3D guided (p=.0096). Notably, 3D printed guides had fewer screws that were removed/revised for being too anterior (7.1%) compared with freehand (23.5%). Surgical time was not significantly different between the 3D guided and freehand cohort (p=.35). CONCLUSIONS: 3D printed guides reduce intraoperative revision rate compared with freehand techniques. Total operative time is comparable to freehand technique.

Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement.

BACKGROUND: Total knee arthroplasty (TKA) is commonly considered to address symptomatically limiting knee osteoarthritis. With increasing utilization, understanding the variability and related drivers may help the healthcare system optimize delivery to the large numbers of patient to whom it is offered. METHODS: A total of 1,066,327 TKA patients who underwent primary TKA were isolated from a 2010 to 2021 PearlDiver national dataset. Exclusion criteria included patients less than 18 years old and traumatic, infectious, or oncologic indications. Overall, 90-day reimbursements and variables associated with the patient, surgical procedure, region, and perioperative period were abstracted. Multivariable linear regressions were performed to determine independent drivers of reimbursement. RESULTS: The 90-day postoperative reimbursements had an average (standard deviation) of $11,212.99 ($15,000.62), a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. Variables independently associated with the greatest increase in overall 90-day reimbursement were related to admission (in-patient index-procedure [+$5,695.26] or hospital readmission [+$18,495.03]). Further drivers were region (Midwest +$8,826.21, West +$4,578.55, South +$3,709.40; relative to Northeast), insurance (commercial +$4,492.34, Medicaid +$1,187.65; relative to Medicare), postoperative emergency department visits (+$3,574.57), postoperative adverse events (+$1,309.35), (P < .0001 for each). CONCLUSION: The current study assessed over a million TKA patients and found large variations in reimbursement/cost. The largest increases in reimbursement were associated with admission (readmission or index procedure). This was followed by region, insurance, and other postoperative events. These results underscore the necessity to balance performing out-patient surgeries in appropriate patients versus the risk of readmissions and defined other areas for cost containment strategies.

US Food and Drug Administration Review Time of Supplemental New Indication Approvals of Drugs and Biologics, 2017 to 2019.

This cross-sectional study examines US Food and Drug Administration regulatory review time of supplemental new indication approvals of drugs and biologics between 2017 and 2019.