Injury patterns and risk factors for orthopaedic trauma from snowboarding and skiing: a national perspective.

PURPOSE: Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports. METHODS: The National Trauma Data Bank was queried for patients presenting to emergency departments due to injuries sustained from skiing and snowboarding during 2011 and 2012. Patient demographics, comorbidities, and injury patterns were tabulated and compared between skiing and snowboarding. Risk factors for increased injury severity score and lack of helmet use were identified using multivariate logistic regression. RESULTS: Of the 6055 patients identified, 55.2 % were skiers. Sixty-one percent had fractures. Lower extremity fractures were the most common injury and occurred more often in skiers (p < 0.001). Upper extremity fractures were more common in snowboarders, particularly distal radius fractures (p < 0.001). On multivariate analysis, increased injury severity was independently associated with age 18-29, 60-69, 70+, male sex, a positive blood test for alcohol, a positive blood test for an illegal substance, and wearing a helmet. Lack of helmet use was associated with age 18-29, 30-39, smoking, a positive drug test for an illegal substance, and snowboarding. CONCLUSIONS: Young adults, the elderly, and those using substances were shown to be at greater risk of increased injury severity and lack of helmet use. The results of this study can be used clinically to guide the initial assessment of these individuals following injury, as well as for targeting preventive measures and education. LEVEL OF EVIDENCE: Prognostic Level III.

Definitional Differences of 'Outpatient' Versus 'Inpatient' THA and TKA Can Affect Study Outcomes.

BACKGROUND: There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are "observed" for one or more nights. Current regulations in the United States allow these "observed" patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, "outpatient" means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data. QUESTIONS/PURPOSES: The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of "inpatient" and "outpatient" (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions. METHODS: Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed "outpatient" by the hospital. The actual hospital LOS of "outpatients" was characterized. "Outpatients" were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors. RESULTS: Of 72,651 patients undergoing THA, 529 were identified as "outpatients" but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as "outpatients" but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found "inpatient" THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with "outpatient" THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort. CONCLUSIONS: Future THA, TKA, or other investigations on this topic should consistently quantify the term "outpatient" because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications. LEVEL OF EVIDENCE: Level III, therapeutic study.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data.

BACKGROUND: National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies. QUESTIONS/PURPOSES: (1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events? METHODS: Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with > 10% rate of missing data were removed from the regression; among variables with ≤ 10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database. RESULTS: Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists. CONCLUSIONS: Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled. CLINICAL RELEVANCE: Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Is Outpatient Total Hip Arthroplasty Safe?

BACKGROUND: Safety data for outpatient total hip arthroplasty (THA) remains scarce. METHODS: The present study retrospectively reviews prospectively collected data from the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program Database. Patients who underwent THA were categorized by day of hospital discharge to be outpatient (length of stay [LOS] 0 days) or inpatient (LOS 1-5 days). Those with extended LOS beyond 5 days were excluded. To account for baseline nonrandom assignment between the study groups, propensity score matching was used. The propensity matched populations were then compared with multivariate Poisson regression to compare the relative risks of adverse events during the initial 30 postoperative days including readmission. RESULTS: A total of 63,844 THA patients were identified. Of these, 420 (0.66%) were performed as outpatients and 63,424 (99.34%) had LOS 1-5 days. Outpatients tended to be younger, male, and to have fewer comorbidities. After propensity score matching, outpatients had no difference in any of 18 adverse events evaluated other than blood transfusion, which was less for outpatients than those with a LOS of 1-5 days (3.69% vs 9.06%, P < .001). CONCLUSION: After adjusting for potential confounders using propensity score matching and multivariate logistic regression, patients undergoing outpatient THA were not at greater risk of 30 days adverse events or readmission than those that were performed as inpatient procedures. Based on the general health outcome measures assessed, this data supports the notion that outpatient THA can appropriately be considered in appropriately selected patients.

Which Pediatric Orthopaedic Procedures Have the Greatest Risk of Adverse Outcomes?

BACKGROUND: Quality improvement in orthopaedic surgery has received increasing attention; however, there is insufficient information available about the perioperative safety of many common pediatric orthopaedic procedures. This study aimed to characterize the incidence of adverse events in a national pediatric patient sample to understand the risk profiles of common pediatric orthopaedic procedures, and to identify patients and operations that are associated with increased rates of adverse outcomes. METHODS: A retrospective cohort study was conducted using the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Pediatric patients who underwent 29 different orthopaedic procedures were identified in the 2012 NSQIP Pediatric database. The occurrence of any adverse event, infection, return to the operating room, and readmission within 30 days, were reported for each procedure. Multivariate regression was then used to identify the association of patient and operative characteristics with the occurrence of each adverse outcome. RESULTS: A total of 8975 pediatric patients were identified. Supracondylar humerus fracture fixation was the most common procedure performed in this sample (2274 patients or 25.57% of all procedures), followed by posterior spinal fusion (1894 patients or 21.10% of all procedures). Adverse events occurred in 352 patients (3.92% of all patients). Four deaths were noted (0.04% of all patients), which only occurred in patients with nonidiopathic scoliosis undergoing spinal fusion. Infections occurred in 143 patients (1.59%), and 197 patients (2.19%) were readmitted within 30 days. Multiple patient characteristics and procedures were found to be associated with each adverse outcome studied. CONCLUSIONS: Spinal fusion, multiaxial external fixation, and fasciotomy were procedures associated with increased rates of adverse outcomes within 30 days. Patients with obesity, ASA class ≥3, and impaired cognitive status also had increased rates of adverse outcomes. The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlight areas for quality improvement. LEVEL OF EVIDENCE: Level III-Prognostic.

Variation in Resource Utilization for Patients With Hip and Pelvic Fractures Despite Equal Medicare Reimbursement.

BACKGROUND: Medicare currently reimburses hospitals for inpatient admissions with "bundled" payments based on patient Diagnosis-related Groups (DRGs) regardless of true hospital costs. At present, DRG 536 (fractures of the hip and pelvis) includes a broad spectrum of patients with orthopaedic trauma, likely with varying inpatient resource utilization. With the growing incidence of fractures in the elderly, inadequate reimbursements from Medicare for certain patients with DRG 536 may lead to growing financial strain on healthcare institutions caring for these patients with higher costs. QUESTIONS/PURPOSES: The purposes of the study were to determine whether (1) inpatient length of stay; (2) intensive care unit stay; and (3) ventilator time differ among subpopulations with Medicare DRG 536. METHODS: A total of 56,683 patients, 65 years or older, with fractures of the hip or pelvis were identified in the 2011 and 2012 National Trauma Data Bank. This clinical registry contains data on trauma cases from more than 900 participating trauma centers, allowing analysis of resource utilization in centers across the United States. Patients were grouped in the following subgroups: hip fractures (n = 35,119), nonoperative pelvic fractures (n = 15,506), acetabulum fractures, operative and nonoperative, (n = 7670), and operative pelvic fractures (n = 682). Total inpatient length of stay, intensive care unit (ICU) stay, and ventilator time were compared across groups using multivariate analysis that controlled for hospital factors. RESULTS: After controlling for patient and hospital factors, difference in inpatient length of stay was -0.2 days for patients with nonoperative pelvis fractures compared with inpatient length of stay for patients with hip fractures (95% CI, -0.4 to -0.1 days; p = 0.001); 1.7 days for patient with acetabulum fractures (95% CI, 1.4-1.9 days; p < 0.001); and 7.7 days for patients with operative pelvic fractures (95% CI, 7.0-8.4 days; p < 0.001). The difference in ICU length of stay for patients with nonoperative pelvis fractures was 0.8 days compared with ICU length of stay for patients with hip fractures (95% CI, 0.7-0.9 days; p < 0.001); 1.9 days for patients with acetabulum fractures (95% CI, 1.8-2.1 days; p < 0.001); and 6.3 days for patients with operative pelvic fractures (95% CI, 5.9-6.7 days; p < 0.001). The difference in mechanical ventilation time for patients with nonoperative fractures was 0.5 days compared with ventilation time for patients with hip fractures (95% CI, 0.4-0.6 days; p < 0.001); 1.1 days for patients with acetabulum fractures (95% CI, 1.0-1.2 days; p < 0.001); and 3.9 days for patients with operative fractures (95% CI, 2.5-3.2 days; p < 0.001). CONCLUSIONS: In our current multitiered trauma system, certain centers will see higher proportions of patients with acetabulum and operative pelvic fractures. Because hospitals are reimbursed equally for these subgroups of Medicare DRG 536, centers that care for a greater proportion of patients with more-complex pelvic trauma will experience lower financial margins per trauma patient, limiting their potential for growth and investment compared with competing institutions that may not routinely see patients with high-energy trauma. Because of this, we believe reevaluation of this Medicare Prospective Payment System DRG is warranted. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Orthopaedic Surgeons Receive the Most Industry Payments to Physicians but Large Disparities are Seen in Sunshine Act Data.

BACKGROUND: Industry payments made to physicians by drug and device manufacturers or group purchasing organizations are now reported to the Centers for Medicare and Medicaid Services (CMS) as a part of the Physician Payments Sunshine Act. Initial reports from the program show that orthopaedic surgeons lead all physician specialties in total and average industry payments. However, before further discussion of these payments and their implications can take place, it remains to be seen whether these figures are a true reflection of the field of orthopaedic surgery in general, rather than the result of a few outlier physicians in the field. In addition, the nature and sources of these funds should be determined to better inform the national dialogue surrounding these payments. QUESTIONS/PURPOSES: We asked: (1) How do industry payments to orthopaedic surgeons compare with payments to physicians and surgeons in other fields, in terms of median payments and the Gini index of disparity? (2) How much do payments to the highest-receiving orthopaedic surgeons contribute to total payments? (3) What kind of industry payments are orthopaedic surgeons receiving? (4) How much do the highest-paying manufacturers contribute to total payments to orthopaedic surgeons? MATERIALS AND METHODS: We reviewed the most recent version of the CMS Sunshine Act Open Payments database released on December 19, 2014, containing data on payments made between August 1, 2013 and December 31, 2013. Data on total payments to individual physicians, physician specialty, the types of payments made, and the manufacturers making payments were reviewed. The Gini index of statistical dispersion was calculated for payments made to orthopaedic surgeons and compared with payments made to physicians and surgeons in all other medical specialties. A Gini index of 0 indicates complete equality of payments to everyone in the population, whereas an index of 1 indicates complete inequality, or all income going to one individual. RESULTS: A total of 15,376 orthopaedic surgeons receiving payments during the 5-month period were identified, accounting for USD 109,846,482. The median payment to orthopaedic surgeons receiving payments was USD 121 (interquartile range, USD 34-619). The top 10% of orthopaedic surgeons receiving payments (1538 surgeons) received at least USD 4160 and accounted for 95% of total payments. Royalties and patent licenses accounted for 69% of all industry payments to orthopaedic surgeons. CONCLUSIONS: Even as a relatively small specialty, orthopaedic surgeons received substantial payments from industry (more than USD 110 million) during the 5-month study period. Whether there is a true return of value from these payments remains to be seen; however, future ethical and policy discussions regarding industry payments to orthopaedic surgeons should take into account the large disparities in payments that are present and also the nature of the payments being made. It is possible that patients and policymakers may view industry payments to orthopaedic surgeons more positively in light of these new findings. LEVEL OF EVIDENCE: Level III, Economic and Decision Analysis.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

Novel Vacuum-Assisted Method for Harvesting Autologous Cancellous Bone Graft and Bone Marrow From the Proximal Tibial Metaphysis.

BACKGROUND: Autogenous cancellous bone graft and bone marrow aspirate are commonly used in lower extremity fusion procedures to enhance fusion potential, and frequently in revision situations where bone loss and osteolysis may be a feature. The tibial metaphysis is a common donor site for bone graft, with the procedure typically performed using a curette or trephine to harvest the cancellous bone. Some limitations of this technique include suboptimal harvest of the marrow portion in particular, incomplete graft harvest, and loss of graft material during the harvest process. We describe a novel vacuum-assisted bone harvesting device to acquire cancellous bone and marrow from the proximal tibia. METHODS: This is a retrospective study of a single surgeon's consecutive patients who underwent foot and ankle arthrodesis procedures using proximal tibia autograft obtained using a vacuum-assisted bone harvesting device. Descriptive statistics were used to summarize patient and operative characteristics and outcomes. We identified 9 patients with a mean age of 51 years, 4 of whom were female. RESULTS: On average, the skin incision was slightly more than 2 cm, and 27 mL of solid graft and 16 mL of liquid phase aspirate were collected. At 6 weeks after the procedure, there was minimal to no pain at the donor site, and we did not observe any fractures or other complications. CONCLUSIONS: We report the use of a novel vacuum-assisted curette device to harvest bone graft from the proximal tibial metaphysis for use in foot and ankle fusions. This device has been reliable and efficient in clinical practice. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Clusters of Injuries From Motorcycle Collisions: Exploratory Factor Analysis of a Single Institution Trauma Registry.

Objective With the goal of guiding acute management of associated injuries motorcycle trauma patients, this study aims to identify patterns of associated injuries after motorcycle collisions using exploratory factor analysis. Methods We conducted a retrospective review at a Level 1 trauma center of all patients who presented after motorcycle collisions resulting in trauma system activations between July 2, 2002 and December 31, 2013. We performed exploratory factor analysis on this dataset to identify sets of injuries that cluster together. Results We identified 1,050 patients who presented for trauma after a motorcycle collision. These patients had 3,101 injuries, including 1,694 fractures. Using exploratory factor analysis, we developed a model with four latent factors that explained approximately half of the variance in injuries. These factors were defined by: head and cervical spine injuries; extremity injuries; abdomen, pelvis and upper extremity injuries; and shoulder girdle and thorax injuries. We also found a novel injury pattern relationship between forearm shaft/wrist and lower extremity injuries. Conclusions Motorcycle trauma results in distinct clusters of associated injuries likely due to common motorcycle collision patterns, most notably a novel relationship between forearm shaft/wrist and lower extremity injuries that merits further exploration, and could play a role during secondary survey.

Orthopaedic Foot and Ankle Surgeon Industry Compensation Reported by the Open Payments Database.

Background. The current study aims to characterize and explore trends in Open Payments Database (OPD) payments reported to orthopaedic foot and ankle (F&A) surgeons. OPD payments are classified as General, Ownership, or Research. Methods. General, Ownership, and Research payments to orthopaedic F&A surgeons were characterized by total payment sum and number of transactions. The total payment was compared by category. Payments per surgeon were also assessed. Median payments for all orthopaedic F&A surgeons and the top 5% compensated were calculated and compared across the years. Medians were compared through Mann-Whitney U tests. Results. Over the period, industry paid over $39 million through 29,442 transactions to 802 orthopaedic F&A surgeons. The majority of this payment was General (64%), followed by Ownership (34%) and Research (2%). The median annual payments per orthopaedic F&A surgeon were compared to the 2014 median ($616): 2015 ($505; P = .191), 2016 ($868; P = .088), and 2017 ($336; P = .084). Over these years, the annual number of compensated orthopaedic F&A surgeons increased from 490 to 556. Averaged over 4 years, 91% of the total orthopaedic F&A payment was made to the top 5% of orthopaedic F&A surgeons. The median payment for this group increased from $177 000 (2014) to $192 000 (2017; P = .012). Conclusion. Though median payments to the top 5% of orthopaedic F&A surgeons increased, there was no overall change in median payment over four years for all compensated orthopaedic F&A surgeons. These findings shed insight into the orthopaedic F&A surgeon-industry relationship.Levels of Evidence: III, Retrospective Study.

Timing of Adverse Events Following Geriatric Hip Fracture Surgery: A Study of 19,873 Patients in the American College of Surgeons National Surgical Quality Improvement Program.

This study uses a prospective surgical registry to characterize the timing of 10 postoperative adverse events following geriatric hip fracture surgery. There were 19,873 patients identified who were ≥70 years undergoing surgery for hip fracture as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). The median postoperative day of diagnosis (and interquartile range) for myocardial infarction was 3 (1-5), cardiac arrest requiring cardiopulmonary resuscitation 3 (0-8), stroke 3 (1-10), pneumonia 4 (2-10), pulmonary embolism 4 (2-11), urinary tract infection 7 (2-13), deep vein thrombosis 9 (4-16), sepsis 9 (4-18), mortality 11 (6-19), and surgical site infection 16 (11-22). For the earliest diagnosed adverse events, the rate of adverse events had diminished by postoperative day 30. For the later diagnosed adverse events, the rate of adverse events remained high at postoperative day 30. Findings help to enable more targeted clinical surveillance, inform patient counseling, and determine the duration of follow-up required to study specific adverse events effectively. Orthopedic surgeons should have the lowest threshold for testing for each adverse event during the time period of greatest risk.

Thromboembolic Events After Traumatic Vertebral Fractures: An Analysis of 190,192 Patients.

STUDY DESIGN: Retrospective cohort study OBJECTIVE.: To determine the rate of venous thromboembolism event (VTE) and risk factors for their occurrence in patients with vertebral fractures. SUMMARY OF BACKGROUND DATA: Deep vein thrombosis or pulmonary embolism (VTE) events are a significant source of potentially preventable morbidity and mortality in trauma patients. In patients with traumatic vertebral fractures, a common high-energy injury sometimes resulting in spinal cord injury, there is debate about what factors may be associated with such VTEs. METHODS: All patients with vertebral fractures in the American College of Surgeons National Trauma Data Bank Research Data Set (NTDB RDS) from years 2011 and 2012 were identified. Multivariate logistic regression was used to determine factors associated with the occurrence of VTE while considering patient factors, injury characteristics, and hospital course. RESULTS: A total of 190,192 vertebral fractures patients were identified. The overall rate of VTE was 2.5%. In multivariate analysis, longer inpatient length of stay was most associated with increased VTEs with an odds ratio (OR) of up to 96.60 (95% CI: 77.67 - 129.13) for length of stay longer than 28 days (compared to 0 - 3 days). Additional risk factors in order of decreasing odds ratios were older age (OR of up to 1.65 [95% CI: 1.45 - 1.87] for patients age 70 - 79 years [compared to age 18 - 29 years]), complete spinal cord injuries (OR: 1.49 [95% CI: 1.31 - 1.68]), cancer (OR: 1.37 [95% CI: 1.25 - 1.50]), and obesity (OR: 1.32 [95% CI: 1.18 - 1.48]). Multiple associated non-spinal injuries were also associated with increased rates of VTE. CONCLUSION: While the overall rate of VTE is relatively low after vertebral fractures, longer LOS and other defined factors to lesser extents were predisposing factors. By determining patients at greatest risk, protocols to prevent such adverse outcomes can be developed and optimized. LEVEL OF EVIDENCE: 3.

Incidence of and Risk Factors for Knee Collateral Ligament Injuries With Proximal Tibia Fractures: A Study of 32,441 Patients.

Proximal tibia fractures are associated with concurrent collateral ligament injuries. Failure to recognize these injuries may lead to chronic knee instability. The purpose of this study was to identify risk factors for concurrent collateral ligament injuries with proximal tibia fractures and their association with inpatient outcomes. A total of 32,441 patients with proximal tibia fractures were identified in the 2011-2012 National Trauma Data Bank. A total of 1445 (4.5%) had collateral ligament injuries, 794 (2.4%) had injuries to both collateral ligaments, 456 (1.4%) had a medial collateral ligament injury only, and 195 (0.6%) had a lateral collateral ligament injury only. On multivariate analysis, risk factors found to be associated with collateral ligament injuries included distal femur fracture (odds ratio, 2.1), pedestrian struck by motor vehicle (odds ratio, 2.0), obesity (odds ratio, 1.6), young age (odds ratio, 1.9 for 18 to 29 years vs 40 to 49 years), motorcycle accident (odds ratio, 1.5), and Injury Severity Score of 20 or higher (odds ratio, 1.4). In addition, patients with simultaneous injuries to both collateral ligaments had higher odds of inpatient adverse events (odds ratio, 1.51) and longer hospital stay (mean, 2.27 days longer). The risk factors reported by this study can be used to identify patients with proximal tibia fractures who may warrant more careful and thorough evaluation and imaging of their knee collateral ligaments. [Orthopedics. 2018; 41(2):e268-e276.].

Incidence of and Risk Factors for Inpatient Stroke After Hip Fractures in the Elderly.

Although uncommon, stroke can be a catastrophic inpatient complication for patients with hip fractures. The current study determines the incidence of inpatient stroke after hip fractures in elderly patients, identifies risk factors associated with such strokes, and determines the association of stroke with short-term inpatient outcomes. A retrospective review of all patients aged 65 years or older with isolated hip fractures in the 2011 and 2012 National Trauma Data Bank was conducted. A total of 37,584 patients met inclusion criteria. Of these patients, 162 (0.4%) experienced a stroke during their hospitalization for the hip fracture. In multivariate analysis, a history of prior stroke (odds ratio [OR], 13.24), coronary artery disease (OR, 2.05), systolic blood pressure 180 mm Hg or higher (OR, 1.66), and bleeding disorders (OR, 1.65) were associated with inpatient stroke. Inpatient stroke was associated with increased mortality (OR, 7.17) and inpatient serious adverse events (OR, 6.52). These findings highlight the need for vigilant care of high-risk patients, such as those with a history of prior stoke, and for an understanding that patients who experience an inpatient stroke after a hip fracture are at significantly increased risk of mortality and inpatient serious adverse events. [Orthopedics. 2018; 41(1):e27-e32.].

Discriminative ability of commonly used indices to predict adverse outcomes after poster lumbar fusion: a comparison of demographics, ASA, the modified Charlson Comorbidity Index, and the modified Frailty Index.

BACKGROUND CONTEXT: As research tools, the American Society of Anesthesiologists (ASA) physical status classification system, the modified Charlson Comorbidity Index (mCCI), and the modified Frailty Index (mFI) have been associated with complications following spine procedures. However, with respect to clinical use for various adverse outcomes, no known study has compared the predictive performance of these indices specifically following posterior lumbar fusion (PLF). PURPOSE: This study aimed to compare the discriminative ability of ASA, mCCI, and mFI, as well as demographic factors including age, body mass index, and gender for perioperative adverse outcomes following PLF. STUDY DESIGN/SETTING: A retrospective review of prospectively collected data was performed. PATIENT SAMPLE: Patients undergoing elective PLF with or without interbody fusion were extracted from the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). OUTCOME MEASURES: Perioperative adverse outcome variables assessed included the occurrence of minor adverse events, severe adverse events, infectious adverse events, any adverse event, extended length of hospital stay, and discharge to higher-level care. METHODS: Patient comorbidity indices and characteristics were delineated and assessed for discriminative ability in predicting perioperative adverse outcomes using an area under the curve analysis from the receiver operating characteristics curves. RESULTS: In total, 16,495 patients were identified who met the inclusion criteria. The most predictive comorbidity index was ASA and demographic factor was age. Of these two factors, age had the larger discriminative ability for three out of the six adverse outcomes and ASA was the most predictive for one out of six adverse outcomes. A combination of the most predictive demographic factor and comorbidity index resulted in improvements in discriminative ability over the individual components for five of the six outcome variables. CONCLUSION: For PLF, easily obtained patient ASA and age have overall similar or better discriminative abilities for perioperative adverse outcomes than numerically tabulated indices that have multiple inputs and are harder to implement in clinical practice.

Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery.

Studies of adverse events (AEs) after orthopedic surgery commonly use composite AE outcomes. An example of such an outcome is any AE. These types of outcomes treat AEs with different clinical significance (eg, death, urinary tract infection) similarly. We conducted a study to address this shortcoming in research methodology by creating a single severity-weighted outcome that can be used to characterize the overall severity of a given patient's postoperative course. All orthopedic faculty members at 2 academic institutions were invited to complete a severity-weighting exercise in which AEs were assigned a percentage severity of death. Mean (standard error) severity weight for urinary tract infection was 0.23% (0.08%); blood transfusion, 0.28% (0.09%); pneumonia, 0.55% (0.15%); hospital readmission, 0.59% (0.23%); wound dehiscence, 0.64% (0.17%); deep vein thrombosis, 0.64% (0.19%); superficial surgical-site infection, 0.68% (0.23%); return to operating room, 0.91% (0.29%); progressive renal insufficiency, 0.93% (0.27%); graft/prosthesis/flap failure, 1.20% (0.34%); unplanned intubation, 1.38% (0.53%); deep surgical-site infection, 1.45% (0.38%); failure to wean from ventilator, 1.45% (0.48%); organ/space surgical-site infection, 1.76% (0.46%); sepsis without shock, 1.77% (0.42%); peripheral nerve injury, 1.83% (0.47%); pulmonary embolism, 2.99% (0.76%); acute renal failure, 3.95% (0.85%); myocardial infarction, 4.16% (0.98%); septic shock, 7.17% (1.36%); stroke, 8.73% (1.74%); cardiac arrest requiring cardiopulmonary resuscitation, 9.97% (2.46%); and coma, 15.14% (3.04%). Future studies may benefit from using this new severity-weighted outcome score.

After Posterior Fusions for Adult Spinal Deformity, Operative Time is More Predictive of Perioperative Morbidity, Rather Than Surgical Invasiveness: A Need for Speed?

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study was to determine the independent effects of operative time and surgical invasiveness on perioperative outcomes after posterior spinal fusions for adult spinal deformity. SUMMARY OF BACKGROUND DATA: Morbidity is high after posterior fusions for adult spinal deformity. Although previous reports have demonstrated an association between perioperative outcomes and the extent of correction and fusion (number of posterior levels fused, pelvic fixation, combined anterior-posterior fusion), no study has looked at the independent effects of the surgical invasiveness after controlling for operative time. METHODS: All adult patients, undergoing posterior spinal fusion for spinal deformity, were identified in the 2010 to 2014 National Surgical Quality Improvement Program (NSQIP) database. Multivariate analysis was used to determine the independent effects of longer operative timing and the surgical invasiveness (number of levels fused, anterior or transforaminal interbody fusions, osteotomies, and pelvic fixation) on 30-day complications. RESULTS: A total of 1540 patients undergoing posterior spinal fusion for adult spinal deformity were identified. The overall rate of complications was 15.3%. In multivariate analysis, greater operative timing was associated with increased inpatient complications [odds ratio (95% confidence interval, 95% CI) from 2.23 (1.25-3.98) for 7-8 hours to 4.46 (2.61-7.64) for 9+ hours; P < 0.001]. Although the number of levels fused, anterior/interbody fusions, osteotomies, and pelvic fixation were associated with complications on bivariate analysis, these factors were not associated with increased complications in multivariate analysis when controlling for other factors such as operative time. CONCLUSION: For adult deformity surgery, longer operative time appears to be a better predictor of the overall rate perioperative complications than surgical invasiveness in multivariate analysis. Rather than avoidance of a more extensive and invasive surgical procedure, which may be indicated to improve alignment and stability, these data suggest the importance of safely and efficiently minimizing overall operative time. LEVEL OF EVIDENCE: 4.

Poor visualization limits diagnosis of proximal junctional kyphosis in adolescent idiopathic scoliosis.

BACKGROUND CONTEXT: Multiple methods are used to measure proximal junctional angle (PJA) and diagnose proximal junctional kyphosis (PJK) after fusion for adolescent idiopathic scoliosis (AIS); however, there is no gold standard. Previous studies using the three most common measurement methods, upper-instrumented vertebra (UIV)+1, UIV+2, and UIV to T2, have minimized the difficulty in obtaining these measurements, and often exclude patients for which measurements cannot be recorded. PURPOSE: The purpose of this study is to assess the technical feasibility of measuring PJA and PJK in a series of AIS patients who have undergone posterior instrumented fusion and to assess the variability in results depending on the measurement technique used. STUDY DESIGN/SETTING: A retrospective cohort study was carried out. PATIENT SAMPLE: There were 460 radiographs from 98 patients with AIS who underwent posterior spinal fusion at a single institution from 2006 through 2012. OUTCOME MEASURES: The outcomes for this study were the ability to obtain a PJA measurement for each method, the ability to diagnose PJK, and the inter- and intra-rater reliability of these measurements. METHODS: Proximal junctional angle was determined by measuring the sagittal Cobb angle on preoperative and postoperative lateral upright films using the three most common methods (UIV+1, UIV+2, and UIV to T2). The ability to obtain a PJA measurement, the ability to assess PJK, and the total number of patients with a PJK diagnosis were tabulated for each method based on established definitions. Intra- and inter-rater reliability of each measurement method was assessed using intra-class correlation coefficients (ICCs). RESULTS: A total of 460 radiographs from 98 patients were evaluated. The average number of radiographs per patient was 5.3±1.7 (mean±standard deviation), with an average follow-up of 2.1 years (780±562 days). A PJA measurement was only readable on 13%-18% of preoperative filmsand 31%-49% of postoperative films (range based on measurement technique). Only 12%-31% of films were able to be assessed for PJK based on established definitions. The rate of PJK diagnosis ranged from 1% to 29%. Of these diagnoses, 21%-100% disappeared on at least one subsequent film for the given patient. ICC ranges for intra-rater and inter-rater reliability were 0.730-0.799 and 0.794-0.836, respectively. CONCLUSIONS: This study suggests significant limitations of the three most common methods of measuring and diagnosing PJK. The results of studies using these methods can be significantly affected based on the exclusion of patients for whom measurements cannot be made and choice of measurement technique.

Predicting Postoperative Morbidity and Readmission for Revision Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The primary aim of this study was to determine the incidence and risk factors for 30-day adverse events after revision posterior lumbar fusion. The secondary aim was to determine the incidence and risk factors for 30-day readmission after revision posterior lumbar fusion. SUMMARY OF BACKGROUND DATA: The need for revision of a lumbar fusion is an unfortunate occurrence, and there is little known about specific risk factors for morbidity and readmission after this procedure. The purpose of this study is to use a large, national sample to identify patient and operative factors that may contribute to the development of these adverse outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing revision posterior lumbar fusion from 2005 to 2013. Patient characteristics were tested for association with any adverse event (AAE), severe adverse events (SAEs), minor adverse events (MAEs), and readmission within 30 days postoperatively using multivariate analysis. RESULTS: Of the 1287 patients identified, 8.2% had an AAE, 5.6% had an SAE, and 3.2% had an MAE. AAE was independently associated with American Society of Anesthesiologists (ASA) classification ≥3 and operative time ≥310 minutes (P<0.05 for each). SAEs were associated with only ASA classification ≥3 (P=0.047). MAEs were associated with insulin-dependent diabetes, operative time ≥310 minutes, and 3 or more levels of fusion (P<0.05 for all).Sixty-five patients (5.6%) were readmitted. On multivariate analysis, body mass index (BMI) 25-30, BMI 30-35, BMI≥35, ASA classification ≥3, insulin-dependent diabetes, a 2-level fusion, and 3 or more levels of fusion were associated with readmission (P<0.05 for all). CONCLUSIONS: In general, longer, more extensive procedures on sicker patients were associated with increased risk of postoperative complications and readmission.