Association of Preoperative Patient Frailty and Operative Stress With Postoperative Mortality.

Importance: Patients with frailty have higher risk for postoperative mortality and complications; however, most research has focused on small groups of high-risk procedures. The associations among frailty, operative stress, and mortality are poorly understood. Objective: To assess the association between frailty and mortality at varying levels of operative stress as measured by the Operative Stress Score, a novel measure created for this study. Design, Setting, and Participants: This retrospective cohort study included veterans in the Veterans Administration Surgical Quality Improvement Program from April 1, 2010, through March 31, 2014, who underwent a noncardiac surgical procedure at Veterans Health Administration Hospitals and had information available on vital status (whether the patient was alive or deceased) at 1 year postoperatively. A Delphi consensus method was used to stratify surgical procedures into 5 categories of physiologic stress. Exposures: Frailty as measured by the Risk Analysis Index and operative stress as measured by the Operative Stress Score. Main Outcomes and Measures: Postoperative mortality at 30, 90, and 180 days. Results: Of 432 828 unique patients (401 453 males [92.8%]; mean (SD) age, 61.0 [12.9] years), 36 579 (8.5%) were frail and 9113 (2.1%) were very frail. The 30-day mortality rate among patients who were frail and underwent the lowest-stress surgical procedures (eg, cystoscopy) was 1.55% (95% CI, 1.20%-1.97%) and among patients with frailty who underwent the moderate-stress surgical procedures (eg, laparoscopic cholecystectomy) was 5.13% (95% CI, 4.79%-5.48%); these rates exceeded the 1% mortality rate often used to define high-risk surgery. Among patients who were very frail, 30-day mortality rates were higher after the lowest-stress surgical procedures (10.34%; 95% CI, 7.73%-13.48%) and after the moderate-stress surgical procedures (18.74%; 95% CI, 17.72%-19.80%). For patients who were frail and very frail, mortality continued to increase at 90 and 180 days, reaching 43.00% (95% CI, 41.69%-44.32%) for very frail patients at 180 days after moderate-stress surgical procedures. Conclusions and Relevance: We developed a novel operative stress score to quantify physiologic stress for surgical procedures. Patients who were frail and very frail had high rates of postoperative mortality across all levels of the Operative Stress Score. These findings suggest that frailty screening should be applied universally because low- and moderate-stress procedures may be high risk among patients who are frail.

The Unstable Spine: A Surgeon's Perspective.

Instability of the spine is a complex clinical entity that exists on a wide spectrum encompassing many aspects of spinal pathology including traumatic, neoplastic, infectious, and degenerative processes. The importance of determining stability is paramount in the decision-making process regarding the need for operative or nonoperative care. Defining clinical instability can be a challenging and requires careful attention to the pathology involved, findings of necessary imaging, and a thorough clinical exam. Several classification systems have been developed to aid in surgical decision making, but certain limitations exist. Various imaging modalities play a crucial role in the evaluation of suspected instability. Computed tomography is the initial imaging modality of choice in the traumatic setting. Magnetic resonance imaging is an important adjunct in the setting of suspected ligamentous injury and the modality of choice in suspected infectious and neoplastic processes. Upright radiographs can be particularly useful in the setting of acute or subacute instability to glean information about how the spine responds to gravity and weightbearing. The clinical exam is also of critical importance in the determination of stability. The presence of a neurologic deficit is highly suggestive of a potentially unstable spine and appropriate spinal precautions should be maintained until instability and injury has been ruled out. Certain clinical entities, such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis, are at high risk for instability particularly in the traumatic setting. In these situations, the spine should be considered unstable until proven otherwise. Ultimately, the determination of spinal stability, and subsequent need for surgical treatment, should be based on the individual case. Combining information from the clinical exam and imaging findings, including upright radiographs when appropriate, allows for the appropriated determination of spinal stability.

The association of incomplete glenoid component seating and periprosthetic glenoid radiolucencies after total shoulder arthroplasty.

BACKGROUND: Radiolucent lines surrounding prosthetic glenoid components are commonly seen after unconstrained total shoulder arthroplasty and can be a harbinger of subsequent glenoid component failure. Whether less than 100% glenoid seating is associated with the development of radiolucent lines around glenoid prostheses is unknown. This study investigated the association between incomplete glenoid component seating and periprosthetic glenoid radiolucencies. METHODS: Thirty-six unconstrained total shoulder arthroplasties were performed in 29 patients for primary glenohumeral osteoarthritis with a minimum 2-year follow-up. All were implanted with a partially cemented all-polyethylene glenoid prosthesis. Patients were evaluated with standardized plain films preoperatively and postoperatively and with thin-cut computed tomography (CT) scans at the latest follow-up. The Lazarus and Yian classifications were used to assess radiolucency and seating on radiographs and CT scans. Ratings were calculated for intraobserver and interobserver reliability and given κ, the Kendall coefficient, and interclass correlation coefficient values. RESULTS: At a mean of 43 months (range 24-26 months) after surgery, neither Lazarus plain film radiolucency scores (P = .78) nor Yian CT radiolucency scores (P = .68) were associated with Lazarus plain film seating scores. Neither Lazarus plain film radiolucency scores (P = .25) nor Yian CT radiolucency scores (P = .91) were associated with modified Lazarus CT scan seating scores. CT allowed for better intraobserver and interobserver reliability in all categories. CONCLUSION: Radiolucencies around a partially cemented glenoid component were not associated with the degree of component seating. Complete seating of the glenoid component is not necessary to achieve radiographic implant stability at a mean follow-up of 43 months.

Bacterial Spine Infections in Adults: Evaluation and Management.

Bacterial spinal infections in adults can have notable adverse consequences, including pain, neurologic deficit, spinal instability and/or deformity, or death. Numerous factors can predispose a person to spinal infection, many of which affect the immune status of the patient. These infections are typically caused by direct seeding of the spine, contiguous spread, or hematogenous spread. Infections are generally grouped based on anatomic location; they are broadly categorized as vertebral osteomyelitis, discitis, and epidural abscess. In some cases, the diagnosis may not be elucidated early without a reasonable index of suspicion. Diagnosis is based on history and physical examination, laboratory data, proper imaging, and culture. Most infections can be treated with an appropriate course of antibiotics and bracing if needed. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/culture, evolving spinal instability or deformity, and neurologic deficit or deterioration.