Unicompartmental Knee Arthroplasty Provides Significantly Greater Improvement in Function than Total Knee Arthroplasty Despite Equivalent Satisfaction for Isolated Medial Compartment Osteoarthritis.

BACKGROUND: While some advocate for unicompartmental knee arthroplasty (UKA) for isolated medial compartment osteoarthritis (OA), others favor total knee arthroplasty (TKA). The purpose of this study was to compare the functional outcomes of UKA and TKA performed for patients with unicompartmental arthritis (OA). METHODS: A study was performed on 133 patients that met strict criteria for UKA, but who underwent either medial UKA or TKA for isolated medial compartment OA based upon physician equipoise. The primary outcome-New Knee Society Score (KSS)-was assessed preoperatively and at 2 years postoperatively. A propensity score weighted regression was used to balance the groups on several key covariates, including age, gender, body mass index, and baseline KSS. RESULTS: After propensity weighting, there were no significant differences between UKA and TKA in overall baseline KSS or KSS after 2 years postoperatively. While TKA patients had demonstrated a significantly greater improvement in the symptoms KSS subscale, UKA patients had a significantly greater improvement in the function subscale. Expectations were significantly more likely to be met after UKA, but there were no differences in patient satisfaction. CONCLUSION: UKA and TKA are both highly successful options for treating patients with medial compartment OA, although functionality increased more, and expectations were more likely to be met, after UKA in this study. Given equivalent patient satisfaction after both TKA and UKA, surgeons should consider factors such as clinical experience, individual preference, cost of care, surgical risk, and recovery needs, when making treatment decisions regarding this clinical entity.

Routine Postoperative Laboratory Tests Are Unnecessary After Partial Knee Arthroplasty.

BACKGROUND: While partial knee arthroplasty (PKA) is increasingly performed on an outpatient basis, many surgeons still admit patients overnight and obtain laboratory studies on the first postoperative day. The purpose of this study was to investigate the utility and cost effectiveness of routine postoperative laboratory studies after PKA. METHODS: This is a retrospective review of 322 consecutive unilateral or bilateral simultaneous PKAs (unicompartmental, patellofemoral, and modular bicompartmental knee arthroplasty) performed by a single surgeon. There were 408 complete blood counts and basic metabolic panels ordered. RESULTS: Despite a large number of laboratory studies ordered and abnormalities detected, there was a 1.6% rate of laboratory-associated interventions (for either hypokalemia or hyperglycemia in 5 patients) and no red blood cell transfusions. Hospital charges associated with laboratory studies totaled $85,413. There were no 90-day postoperative hospital readmissions or emergency department evaluations related to abnormal postoperative laboratory values. CONCLUSION: With an increasing emphasis placed on cost containment, the low rate of laboratory-associated interventions after PKA suggests that routinely obtaining laboratory studies are neither necessary nor cost effective.

Does Anterior Cervical Spine Surgery Increase the Likelihood of Developing Obstructive Sleep Apnea? A Pearldiver Study.

OBJECTIVES: Literature is sparse on the development of obstructive sleep apnea (OSA) after anterior cervical spine surgery and includes few case reports. Our objective is to evaluate the role of anterior cervical spine surgery as a risk factor for developing OSA. METHODS: A retrospective cohort study was performed utilizing the M157 subset of the PearlDiver national database. Two matched cohorts of patients were identified based on anterior cervical spine surgery using CPT codes. ICD-9 and 10 was used to identify patients who developed OSA within one year time frame in both the cohorts. Relative risk of OSA was calculated for the study and risk factors for developing OSA in the cohort of anterior cervical surgery were evaluated using logistic regression. RESULTS: The 2 cohorts contained 277,475 patients each. The 1-year incidence rate of OSA in those who undergo anterior cervical spine surgery is 3.5% and is 3.1% in the control group. The relative risk of OSA in the surgery group is 1.13 times compared to the control. Multilevel cervical spine surgery and surgery performed for spondylosis had a higher risk of developing OSA. CONCLUSIONS: Anterior cervical spine surgery is associated with an increased risk of developing OSA within one year of surgery. Timely diagnosis and management of OSA in patients who underwent anterior cervical spine surgery can help prevent morbidity and improve quality of life (QOL).

Geographical and Specialty-specific Variation in the Utilization of Laminoplasty for Cervical Myelopathy.

STUDY DESIGN: Level IV retrospective cohort study. OBJECTIVES: Despite the positive outcomes associated with laminoplasty, there is significant surgeon variability in the use of laminoplasty for cervical myelopathy in the United States. In this study, we explored how geographic and specialty-specific differences may influence the utilization of laminoplasty to treat cervical myelopathy. BACKGROUND: We queried the Mariner 157 database (PearlDiver, Inc.), a national administrative claims database containing diagnostic, procedural, and demographic records from over 157 million patients from 2010 to 2021. PATIENTS AND METHODS: Using the International Classification of Diseases 10th Revision/International Classification of Diseases Ninth Revision and Current Procedural Terminology codes, we identified all patients with a diagnosis of cervical myelopathy who had undergone multilevel posterior cervical decompression and fusion (PCDF) or laminoplasty. We further analyzed patients' demographics, comorbidities, geographical location, and specialty of the surgeon (neurosurgery or orthopedic spine surgery). RESULTS: There were 34,432 patients with a diagnosis of cervical myelopathy, of which 4,033 (11.7%) underwent laminoplasty and 30,399 (88.3%) underwent multilevel PCDF. Northeast, South, and West regions had lower percentages of laminoplasty utilization compared with the Midwest in terms of total case mix between laminoplasty and PCDF. In addition, 2,300 (57.0%) of the laminoplasty cases were performed by orthopedic spine surgeons compared with 1,733 (43.0%) by neurosurgeons. Temporal trends in laminoplasty utilization were stable for orthopedic surgeons, whereas laminoplasty utilization decreased over time between 2010 and 2021 for neurosurgeons (P < 0.001). CONCLUSIONS: Utilization of laminoplasty in the United States is not well defined. Our results suggest a geographical and training-specific variation in the utilization of laminoplasty. Surgeons with orthopedic training were more likely to perform laminoplasty compared with surgeons with a neurosurgery training background. In addition, we found greater utilization of laminoplasty in the Midwest compared with other regions.

Mindfulness Applications: Can They Serve as a Stress, Anxiety, and Burnout Reduction Tool in Orthopaedic Surgery Training? A Randomized Control Trial.

Stress and burnout are prevalent within the orthopaedic surgery community. Mindfulness techniques have been shown to improve wellness, yet traditional courses are generally time-intensive with low surgeon utilization. We sought to determine whether the introduction of a simple mindfulness-based phone application would help decrease stress, anxiety, and burnout in orthopaedic surgery residents. Methods: Twenty-four residents participated in this prospective, randomized controlled trial. After simple 1:1 randomization, the treatment group received access to a mindfulness-based phone application for 2 months while the control group did not receive access. All participants completed the Perceived Stress Scale, Generalized Anxiety Disorder-7, and Maslach Burnout Inventory with emotional exhaustion (EE), depersonalization (DP), and personal accomplishment subscores to measure stress, anxiety, and burnout at baseline and after 2 months. Paired t tests were used to compare baseline scores and conclusion scores for both groups. Results: There was no difference in baseline burnout scores between groups, but the treatment group had higher stress and anxiety scores at baseline. On average, the treatment group spent approximately 8 minutes per day, 2 days per week using the mindfulness application. After 2 months, the treatment group had significantly decreased stress (mean = -7.42, p = 0.002), anxiety (mean = -6.16, p = 0.01), EE (mean = -10.83 ± 10.72, p = 0.005), and DP (mean = -5.17 ± 5.51, p = 0.01). The control group did not have any significant differences in stress, anxiety, or burnout subscores. Conclusions: Use of a mindfulness-based phone app for 2 months led to significant reductions in stress, anxiety, and burnout scores in orthopaedic surgery residents. Our results support the use of a mindfulness-based app to help decrease orthopaedic resident stress, anxiety, and burnout. Benefits were seen with only modest use, suggesting that intensive mindfulness training programs may not be necessary to effect a change in well-being. The higher baseline stress and anxiety in the treatment group may suggest that mindfulness techniques are particularly effective in those who perceive residency to be more stressful. Level of Evidence: I.

Should patients with lumbar stenosis and grade I spondylolisthesis be treated differently based on spinopelvic alignment? A retrospective, two-year, propensity matched, comparison of patient-reported outcome measures and clinical outcomes from multiple sites within a single health system.

BACKGROUND: Degenerative lumbar spondylolisthesis is one of the most common pathologies addressed by surgeons. Recently, data demonstrated improved outcomes with fusion in conjunction with laminectomy compared to laminectomy alone. However, given not all degenerative spondylolistheses are clinically comparable, the best treatment option may depend on multiple parameters. Specifically, the impact of spinopelvic alignment on patient reported and clinical outcomes following fusion versus decompression for grade I spondylolisthesis has yet to be explored. PURPOSE: This study assessed two-year clinical outcomes and one-year patient reported outcomes following laminectomy with concomitant fusion versus laminectomy alone for management of grade I degenerative spondylolisthesis and stenosis. The present study is the first to examine the effect of spinopelvic alignment on patient-reported and clinical outcomes following decompression alone versus decompression with fusion. STUDY DESIGN/SETTING: Retrospective sub-group analysis of observational, prospectively collected cohort study. PATIENT SAMPLE: 679 patients treated with laminectomy with fusion or laminectomy alone for grade I degenerative spondylolisthesis and comorbid spinal stenosis performed by orthopaedic and neurosurgeons at three medical centers affiliated with a single, tertiary care center. OUTCOME MEASURES: The primary outcome was the change in Patient-Reported Outcome Measurement Information System (PROMIS), Global Physical Health (GPH), and Global Mental Health (GMH) scores at baseline and post-operatively at 4-6 and 10-12 months postoperatively. Secondary outcomes included operative parameters (estimated blood loss and operative time), and two-year clinical outcomes including reoperations, duration of postoperative physical therapy, and discharge disposition. METHODS: Radiographs/MRIs assessed stenosis, spondylolisthesis, pelvic incidence, lumbar lordosis, sacral slope, and pelvic tilt; from this data, two cohorts were created based on pelvic incidence minus lumbar lordosis (PILL), denoted as "high" and "low" mismatch. Patients underwent either decompression or decompression with fusion; propensity score matching (PSM) and coarsened exact matching (CEM) were used to create matched cohorts of "cases" (fusion) and "controls" (decompression). Binary comparisons used McNemar test; continuous outcomes used Wilcoxon rank-sum test. Between-group comparisons of changes in PROMIS GPH and GMH scores were analyzed using mixed-effects models; analyses were conducted separately for patients with high and low pelvic incidence-lumbar lordosis (PILL) mismatch. RESULTS: 49.9% of patients (339) underwent lumbar decompression with fusion, while 50.1% (340) received decompression. In the high PLL mismatch cohort at 10-12 months postoperatively, fusion-treated patients reported improved PROs, including GMH (26.61 vs. 20.75, p<0.0001) and GPH (23.61 vs. 18.13, p<0.0001). They also required fewer months of outpatient physical therapy (1.61 vs. 3.65, p<0.0001) and had lower 2-year reoperation rates (12.63% vs. 17.89%, p=0.0442) compared to decompression-only patients. In contrast, in the low PLL mismatch cohort, fusion-treated patients demonstrated worse endpoint PROs (GMH: 18.67 vs. 21.52, p<0.0001; GPH: 16.08 vs. 20.74, p<0.0001). They were also more likely to require skilled nursing/rehabilitation centers (6.86% vs. 0.98%, p=0.0412) and extended outpatient physical therapy (2.47 vs. 1.34 months, p<0.0001) and had higher 2-year reoperation rates (25.49% vs. 14.71%,p=0.0152). CONCLUSIONS: Lumbar laminectomy with fusion was superior to laminectomy in health-related quality of life and reoperation rate at two years postoperatively only for patients with sagittal malalignment, represented by high PILL mismatch. In contrast, the addition of fusion for patients with low-grade spondylolisthesis, spinal stenosis, and spinopelvic harmony (low PILL mismatch) resulted in worse quality of life outcomes and reoperation rates.

Comparison of Single-Level Posterior Cervical Foraminotomy to Anterior Cervical Discectomy and Fusion for Radiculopathy.

BACKGROUND: Posterior cervical foraminotomy (PCF) and anterior cervical discectomy and fusion (ACDF) are 2 commonly used surgical approaches to address cervical radiculopathy. Demonstrating superiority in clinical outcomes and durability of one of the approaches could change clinical practice on a large scale. This is the largest reported single-institutional retrospective cohort of single-level PCFs compared with single-level ACDFs for cervical radiculopathy. METHODS: Patients undergoing either ACDF or PCF between 2014 and 2021 were identified using Current Procedural Terminology codes. Medical records were reviewed for demographics, surgical characteristics, and reoperations. Statistical analysis included t tests for continuous characteristics and c2 testing for categorical characteristics. RESULTS: In total, 236 single-level ACDFs and 138 single-level PCFs were included. There was no significant difference in age (51.0 vs 51.3 years), body mass index (BMI; 28.6 vs 28.1), or Charlson Comorbidity Index (1.89 vs 1.68) between patients who underwent ACDF and those who underwent PCF. There was no difference in the rate of reoperation (5.1% vs 5.1%), time to reoperation (247 vs 319 days), or reoperation for recurrent symptoms (1.7% vs 2.9%) for ACDF vs PCF. Hospital length of stay (LOS) was longer for ACDF compared with PCF (1.65 vs 1.35 days, P = 0.041), and the overall readmission rate after ACDF was 20.8% vs 10.9% after PCF (P = 0.014). CONCLUSIONS: Overall reoperation rates or reoperation for recurrent symptoms between ACDF and PCF were not significantly different, demonstrating that either procedure effectively addresses the indication for surgery. There was a significantly longer LOS after ACDF than PCF, and readmission rates at 90 days and 1 year were higher after ACDF.

Operating room traffic is a major concern during total joint arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) is a challenging complication associated with total joint arthroplasty(TJA). Traffic in the operating room (OR) increases bacterial counts in the OR, andmay lead to increased rates of infection. QUESTION/PURPOSES: Our purposes were to (1) define the incidence of door opening during primary and revision TJA,providing a comparison between the two types of procedures,and (2) identify the causes of door opening in order to develop a strategy to reduce traffic in the operating room. METHODS: An observer collected data during 80 primary and 36 revision TJAs. Surgeries were performed under vertical, laminar flow. Operating room personnel were unaware of the observer, thus removing bias from traffic. The observer documented the number, reason, and personnel involved in the event of a door opening from time of tray opening to closure of the surgical site. RESULTS: The average operating time for primary and revision procedures was 92 and 161 minutes, respectively. Average door openings were 60 in primary cases and 135 in revisions, yielding per minute rates of 0.65 and 0.84, respectively. The circulating nurse and surgical implant representatives constituted the majority of OR traffic. CONCLUSIONS: Traffic in the OR is a major concern during TJA. Revision cases demonstrated a particularly high rate of traffic. Implementation of strategies, such as storage of instruments and components in the operating room and education of OR personnel, is required to reduce door openings in the OR.

A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty.

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. The surgeon has the highest rate of glove perforation. Outer-glove perforations should prompt careful inspection of the inner glove.

Periprosthetic joint infection: are patients with multiple prosthetic joints at risk?

Patients who present with a periprosthetic joint infection in a single joint may have multiple prosthetic joints. The risk of these patients developing a subsequent infection in another prosthetic joint is unknown. Our purposes were (1) to identify the risk of developing a subsequent infection in another prosthetic joint and (2) to describe the time span and organism profile to the second prosthetic infection. We retrospectively identified 55 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. Of the 55 patients, 11 (20%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 4 (36%) of 11 patients. The time to developing a second infection averaged 2.0 years (range, 0-6.9 years).

Racial Differences in Patients Undergoing Anterior Cervical Discectomy and Fusion: A Multi-Site Study.

STUDY DESIGN: This was a retrospective chart review. OBJECTIVE: The objective of this study was to examine disparities within patients undergoing anterior cervical discectomy and fusion (ACDF) at a multi-site tertiary referral center with specific focus on factors related to length of stay (LOS). SUMMARY OF BACKGROUND DATA: There are previously described racial disparities in spinal surgery outcomes and quality metrics. METHODS: A total of 278 consecutive patients undergoing ACDF by 8 different surgeons over a 5-year period were identified retrospectively. Demographic data, including age at time of surgery, sex, smoking status, and self-identified race [White or African American (AA)], as well as surgical data and postoperative course were recorded. Preoperative health status was recorded, and comorbidities were scored by the Charlson Comorbidity Index. Univariable and multivariable linear regression models were employed to quantify the degree to which a patient's LOS was related to their self-identified race, demographics, and perioperative clinical data. RESULTS: Of the 278 patients who received an ACDF, 71.6% (199) self-identified as White and 28.4% (79) identified as AA. AA patients were more likely to have an ACDF due to myelopathy, while White patients were more likely to have an ACDF due to radiculopathy (P=0.001). AA patients had longer LOS by an average of half a day (P=0.001) and experienced a larger percentage of extended stays (P=0.002). AA patients experienced longer overall operation times on average (P=0.001) across all different levels of fusion. AA race was not an independent driver of LOS (ß=0.186; P=0.246). CONCLUSIONS: As hypothesized, and consistent with previous literature on racial surgical disparities, AA race was associated with increased LOS, increased operative times, and increased indication of myelopathy in this study. Additional research is necessary to evaluate the underlying social determinants of health and other factors that may contribute to this study's results. LEVEL OF EVIDENCE: Level III.

Association of Thoracic MRI Findings With Specialty and Training.

STUDY DESIGN: Retrospective. OBJECTIVE: To compare the rate of positive pathology on thoracic MRI ordered by surgical spine specialists to those ordered by nonsurgical spine specialists. METHODS: Outpatient thoracic MRIs from January-March 2019 were evaluated from a single academic health care system. Studies without a known ordering provider, imaging report, or patients with known presence of malignancy, multiple sclerosis, recent trauma, or surgery were excluded (n = 320). Imaging studies were categorized by type of provider placing the order (resident, attending, or advanced practice practitioner) and department. MRIs were deemed positive if they showed relevant pathology that correlated with indication for exam as determined by a radiologist. One-sided chi-squared analysis was performed to determine statistical significance. RESULTS: Overall, our data demonstrated 17.2% of studies with positive pathology. Compared to nonspecialty clinicians, subspecialists showed 35/184 (19.0%) positivity rate versus the non-specialist with 20/136 (14.7%) positivity rate (P = .156). Posthoc analysis demonstrated that surgical specialists who order thoracic MRIs yield significantly higher positivity rates at 19/79 (24.0%) compared to nonsurgical specialists at 36/241 (14.9%) (P < .05). Overall, neurosurgery demonstrated the highest rate of positive thoracic MRIs at 14/40 (35.0%). Comparison between the rate of positivity between physicians and advanced practitioners was insignificant (P > .05). CONCLUSIONS: Clinical diagnosis of symptomatic thoracic spine degenerative disease requires an expert physical exam combined with careful attention to radiology findings. Although the percent of relevant pathology on thoracic MRI is low, our data suggests evaluation by a surgical specialist should precede ordering a thoracic spine MRI.

Primary total hip arthroplasty with an uncemented femoral component five- to nine-year results.

This study reports the outcome of total hip arthroplasty with use of an uncemented, tapered stem with a 5- to 9-year follow-up. The first 200 consecutive patients (214 hips) undergoing total hip arthroplasty with the Accolade TMZF stem (Stryker Orthopaedics, Mahwah, NJ) were enrolled prospectively. Follow-up for these patients averaged 7.6 years and encompassed review of clinical records as well as review of serial anteroposterior and lateral radiographs. There were 5 revision surgeries for aseptic loosening, 2 cases of infection, instability, and polyethylene wear. Our failure rate, defined as hips needing revision, was 2.6%, and the failure rate due to aseptic loosening of the femoral component was 0.6%. These results demonstrate the high success rate of this implant providing support for its continued use.

Predicting Reciprocal Thoracic Change, Proximal Junctional Kyphosis, and Revision Surgery in Adult Spinal Deformity.

BACKGROUND: Compensatory mechanisms in patients with adult spinal deformity (ASD) that lead to poor quality of life include positive sagittal balance and pelvic retroversion. The objective of this retrospective review was to identify demographic and radiographic parameters of sagittal alignment that are correlated with thoracic kyphosis (TK), PJK, and reoperation in patients undergoing surgical correction for ASD. METHODS: A single-center database of 155 patients with ASD undergoing surgery from 2008 to 2015 was reviewed. Patients >18 years old who underwent multilevel thoracolumbar fusion or fusion of thoracic vertebrae to the pelvis were included. Demographics and radiographic measurements of sagittal alignment were collected preoperatively, 6 weeks postoperatively, and 1 year postoperatively. Statistical analysis was performed to compare groups that did or did not develop change in thoracic kyphosis or PJK at early or late follow-up. Additionally, patients requiring reoperation were evaluated. RESULTS: Increased thoracic kyphosis was associated with older age, hypolordosis, and comorbid PJK. Early PJK was associated with older age, hypolordosis, and increased T1 pelvic angle. Reoperation was associated with older age, higher positive sagittal balance, hypolordosis, and pelvic retroversion; PJK and thoracic kyphosis did not increase risk for reoperation. CONCLUSIONS: Thoracic reciprocal change following surgical correction of ASD is highly associated with PJK, although neither increased risk of reoperation. PJK may be predicted by older age, hypolordosis, and increased T1 pelvic angle. Reoperation in patients with ASD is more likely in older patients with positive sagittal balance, a compensatory flat lower back, and compensatory pelvic retroversion.

Preoperative Risk Stratification: Who Needs Medical Consultation?

STUDY DESIGN: Spine update. OBJECTIVE: The purpose of this study is to provide a review of preoperative clearance and optimization, before elective spine surgery. SUMMARY OF BACKGROUND DATA: Patient optimization preceding elective surgery is critical to ensure the best possible outcome. METHODS: Historical and current literature pertaining to patient clearance and optimization, before elective surgery, was reviewed. These data were then synthesized and assessed to provide a balanced view on current trends in regards to preoperative management and optimization. RESULTS: The American Academy of Cardiology defines spine surgery as "intermediate" risk, and thus patients are permitted to forgo formal cardiac evaluation if they have no active cardiac condition and demonstrate adequate functional capacity; however, those with active or chronic medical conditions require further investigation before elective operations. CONCLUSION: Overall, preoperative screening and optimization of comorbidities are vital to ensure positive outcomes in elective spine surgery, and the aforementioned criteria must be considered on an individual basis. Further research into specific preoperative optimization guidelines would help to ensure successful outcomes for those undergoing spine surgery. LEVEL OF EVIDENCE: N/A.

The Outcomes of Patients With Neck Pain Following ACDF: A Comparison of Patients With Radiculopathy, Myelopathy, or Mixed Symptomatology.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025). CONCLUSION: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements. LEVEL OF EVIDENCE: 3.

The Impact of Multiple Comorbid Mental Health Disorders on Health-related Quality of Life Following ACDF.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The goal was to determine whether comorbid depression and/or anxiety influence outcomes after anterior cervical discectomy and fusion (ACDF) for patients with degenerative cervical pathology. BACKGROUND DATA: The role preoperative mental health has on patient reported outcomes after ACDF surgery is not well understood. METHODS: Patients undergoing elective ACDF for degenerative cervical pathology were identified. Patients were grouped based on their preoperative mental health comorbidities, including patients with no history, depression, anxiety, and those with both depression and anxiety. All preoperative medical treatment for depression and/or anxiety was identified. Outcomes including Physical Component Score (PCS-12), Mental Component Score (MCS-12), Neck Disability Index (NDI), Visual Analogue Scale neck pain score (VAS Neck ), and Visual Analogue Scale arm pain score (VAS Arm) were compared between groups from baseline to postoperative measurements using multiple linear regression analysis-controlling for factors such as age, sex, and body mass index, etc. A P-value <0.05 was considered statistically significant. RESULTS: A total of 264 patients were included in the analysis, with an average age of 53 years and mean follow-up of 19.8 months (19.0-20.6). All patients with a diagnosis of depression or anxiety also reported medical treatment for the disease. The group with no depression or anxiety had significantly less baseline disability than the group with 2 mental health diagnoses, in MCS-12 (P=0.009), NDI (P<0.004), VAS Neck (P=0.003), and VAS Arm (P=0.001) scores. Linear regression analysis demonstrated that increasing occurrence of mental health disorders was not a significant predictor of change over time for any of the outcome measures included in the analysis. CONCLUSIONS: Despite more severe preoperative symptoms, patients with a preoperative mental health disorder(s) demonstrated significant improvement in postoperative outcomes after ACDF. No differences were identified in postoperative outcomes between each of the groups. LEVEL OF EVIDENCE: Level III.

Proton Pump Inhibitor Use Affects Pseudarthrosis Rates and Influences Patient-Reported Outcomes.

STUDY DESIGN: Retrospective cohort review. OBJECTIVES: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. METHODS: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. RESULTS: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P = .022). CONCLUSIONS: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Sarcopenia does not affect clinical outcomes following lumbar fusion.

Sarcopenia, defined as decreased skeletal muscle mass or function, has recently been found to have increased perioperative morbidity and mortality. The relationship between sarcopenia and clinical outcomes in patients undergoing lumbar fusion has not been examined. This study investigates whether sarcopenia affects fusion rates and outcomes following single-level lumbar decompression and fusion. A retrospective analysis was undertaken of 97 consecutive patients who underwent a single level lumbar fusion for degenerative spondylolisthesis. Demographics, perioperative data, and patient reported clinical outcomes were collected. Measurements of paraspinal muscle CSA were made using a standardized protocol at the level of the L3-4 disc space on a preoperative lumbar MRI. Univariate analysis was used to compare cohorts with regards to demographics, comorbidities, and clinical outcomes. Of 97 patients, 16 patients (15.8%) were in the sarcopenic cohort utilizing a threshold of 986.1 mm2/m2. Reoperation rates were not significantly different between the two groups (0% vs 3.6%, p = .451). The sarcopenia cohort had lower BMI (28.1 vs 31.8, p = .017) and less male patients (6.3% vs 55.6%, p < .001). Mean follow-up was 18.3 months. There was no significant difference in postoperative Oswestry Disability Index (ODI) (24.7 vs 23.2, p = .794) Short Form 12 Physical (38.0 vs. 40.4, p = .445) Mental scores (55.5 vs. 53.6, p = .503), or visual analog scale (VAS) back pain scores (3.4 vs. 3.3, p = .818). No significant difference was found with regards to outcomes when comparing sarcopenic to non-sarcopenic patients undergoing lumbar fusion. Sarcopenia does not impact the clinical success of lumbar fusion for degenerative spondylolisthesis.

Medicaid Reimbursement for Common Orthopedic Procedures Is Not Consistent.

Two major forms of physician reimbursement include Medicare (MCR; federally funded) and Medicaid (MCD; state funded). The only oversight provided to individual states for setting MCD reimbursement is that it must provide a standard payment that does not negatively affect patient care. The goals of this study were to determine the variability of MCD reimbursement for patients who require orthopedic procedures and to assess how this compares with regional MCR reimbursement. Medicaid reimbursement rates from each state were obtained for total knee arthroplasty, total hip arthroplasty, anterior cruciate ligament repair, rotator cuff repair, anterior cervical decompression and fusion, posterior lumbar decompression, carpal tunnel release, distal radius open reduction and internal fixation, proximal femur open reduction and internal fixation, and ankle open reduction and internal fixation. Discrepancy in reimbursement for these procedures and overall differences in MCD vs MCR reimbursement were determined. Average MCD reimbursement was 81.9% of MCR reimbursement. There was significant variation between states (37.7% to 147% of MCR reimbursement for all 10 procedures). Twenty and 40 states provided less than 75% and 100% of MCR reimbursements, respectively. Medicaid valued knee arthroplasty (91.4% of MCR reimbursement) over other common procedures. Conversely, carpal tunnel release (74.1% of MCR reimbursement; P=.004) had the lowest reimbursements. The most interstate variation was noted for anterior cruciate ligament reimbursement, ranging from 20.6% to 229% of local MCR reimbursement. Disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to understand the impact of these significant differences. It is likely that these discrepancies lead to suboptimal access to necessary orthopedic care. [Orthopedics. 2019; 42(2):e193-e196.].