Time to surgery and complications in hip fracture patients on novel oral anticoagulants: a systematic review.

BACKGROUND: Early surgery has been consistently demonstrated to reduce complications and mortality in hip fracture patients. There remains no general consensus, however, regarding the optimal time to surgery for hip fracture patients who are on novel oral anticoagulants (NOAC) on admission and its effect on clinical outcomes after surgery. The objective of this review was to assess the effect of preoperative NOAC therapy on time to surgery and postoperative complications in hip fracture patients. METHODS: We performed a systematic review of the literature using the PubMed, Embase, and Cochrane Library electronic databases. Relevant articles were identified and included if they: (i) included patients on NOAC therapy on admission who did not undergo reversal; (ii) included a control group of patients not on any anticoagulation; (iii) included time from admission to surgery; and (iv) included one of the following outcomes: blood transfusion, venous thromboembolism (VTE), stroke, readmission, and mortality. RESULTS: Nine studies were included with a total of 4,419 patients. There were 414 NOAC patients and 4,005 non-anticoagulated patients. Six of the nine studies found a significant increase in time to surgery for patients on NOAC therapy. Three of the seven studies that reported rates of blood transfusion found a significantly higher incidence of transfusion in patients on NOACs. None of the studies found a significant difference in VTE and stroke. One of the two studies that reported readmissions showed a higher risk of readmission for patients on NOACs. Eight of the nine included studies found no significant difference in postoperative mortality rates between the NOAC and control groups, with the remaining study finding a higher mortality rate only in patients on NOAC therapy who underwent fixation and not those who underwent arthroplasty. CONCLUSIONS: These mixed findings suggest that delay to surgery may not be warranted in the urgent surgical setting of patients on NOAC therapy who sustain hip fractures.

Orthogonal plating of distal femur fractures: A biomechanical comparison with plate-nail and parallel plating constructs.

Purpose: This study compared the biomechanical properties of orthogonal plating with plate-nail and parallel plating constructs for supracondylar distal femur fractures. Methods: A supracondylar distal femur fracture was simulated using 15 synthetic osteoporotic femurs. Constructs included: (1) plate-nail (lateral locked distal femoral plate + retrograde intramedullary nail); (2) parallel plating (lateral locked distal femoral plate + medial 4.0 mm compression plate); and (3) orthogonal plating (lateral locked distal femoral plate + posterior one-third tubular plate). Specimens underwent nondestructive loading, fatigue loading, and loading to failure. Gapping at the fracture was measured using a three-dimensional motion capture system. Baseline torsional and axial stiffness, stiffness and strain after fatigue loading, and load to failure were determined. A case example of orthogonal plating is also presented. Results: There was no difference in baseline torsional (p = 0.51) and axial stiffness (p = 0.53). Stiffness after fatigue loading was highest with parallel plating, with no difference between the plate-nail and orthogonal plating constructs (p = 0.84). Strain after fatigue loading was lowest in the parallel plating group (0.54 ± 0.19%), followed by the plate-nail (2.89 ± 0.83%) and orthogonal plating groups (3.04 ± 0.51%). Conclusion: Orthogonal plating demonstrated comparable baseline stiffness to plate-nail and parallel plating constructs, and similar biomechanical performance in fatigue loading to plate-nail constructs. All specimens had ≤3% strain after fatigue loading, suggesting sufficient stability for fracture healing. The benefits of enhanced stability from dual-implant fixation may be achieved through orthogonal plating while avoiding an additional medial surgical approach, and therefore warrants further investigation as a novel alternative for distal femur fracture fixation.

Conceptualizing Biological Aging and Frailty in Orthopaedics: A Framework for Clinical Practice.

➤: Biological aging can best be conceptualized clinically as a combination of 3 components: frailty, comorbidity, and disability. ➤: Despite advancements in the understanding of senescence, chronological age remains the best estimate of biological age. However, a useful exercise for practitioners is to look beyond chronological age in clinical and surgical decision-making. ➤: A chronologically aging person does not age biologically at the same rate. ➤: The best way to understand frailty is to consider it as a physical phenotype. ➤: Physical optimization should parallel medical optimization before elective surgery. ➤: The poorer the host (both in terms of bone quality and propensity for healing), the more robust the implant construct must be to minimize reliance on host biology.

Anterior hip dislocation complicated by thrombus in the common femoral vein: A case report.

CASE: A 90-year-old male sustained a low energy anterior hip dislocation without fracture after a ground-level fall. Magnetic resonance imaging (MRI) detected femoral vessel compression and thrombosis. The patient underwent placement of an inferior vena cava (IVC) filter prior to successful closed reduction in the operating room. CONCLUSION: Anterior hip dislocations are rare events that require urgent intervention to reduce the risk of complications. One underreported complication is femoral vessel thrombosis from direct compression against the femoral head. Dedicated imaging should be considered to rule out a thrombus. An IVC filter can be placed prior to reduction attempts to avoid potential thrombotic emboli.

Timing of proximal femoral shortening in the early postoperative period after cephalomedullary nailing of hip fractures.

OBJECTIVES: Examine the timing of proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. METHODS: A retrospective cohort study of 21 patients ≥50 years old with pertrochanteric hip fractures treated with a short cephalomedullary nail (CMN) was performed. Abductor lever arm shortening, femoral height shortening, and PFS were measured. RESULTS: Mean PFS at 10-21 days postoperatively was 5.54 mm, compared to 11.31 mm at final follow-up. The percentage of total PFS that occurred within 10-21 days postoperatively was 53.9%. CONCLUSION: Approximately half of total PFS occurs within 1.5-3 weeks and is notable on radiographs by the first postoperative visit.

Early outcomes after hip fracture surgery in COVID-19 patients in New York City.

INTRODUCTION: The COVID-19 pandemic has spread globally and placed healthcare systems under substantial strain. Hip fracture patients represent a high-risk population for severe COVID-19 symptoms, as they are generally older with multiple medical comorbidities. There has been limited information available on the presenting characteristics and outcomes of COVID-positive patients with hip fractures who undergo surgical treatment. METHODS: This was a retrospective study of 10 patients ≥60 years of age with a hip fracture and COVID-19 who underwent surgical treatment in New York City during the COVID-19 outbreak from March 1, 2020 to May 22, 2020. Clinical characteristics and early postoperative outcomes were reported. RESULTS: Eight out of the 10 COVID-positive hip fracture patients in our series were asymptomatic on admission with no clinical signs or symptoms of COVID-19 infection. Only 2 patients presented with hypoxia. All 10 patients underwent surgery within 2 days of admission. Five out of the 10 patients - including the patients who presented with hypoxia - subsequently required supplemental oxygen postoperatively. Two patients had persistently elevated oxygen demands requiring prolonged administration of supplemental oxygen therapy beyond postoperative day 3. None of the patients were put on mechanical ventilation. One patient had a presumed venous thromboembolism postoperatively and subsequently died on postoperative day 19, likely due to respiratory failure. There were no other deaths in the early postoperative period. The average length of inpatient stay was 7.8 days. CONCLUSIONS: Our findings suggest that hip fracture patients who present with asymptomatic or mild COVID-19 infection may have temporarily increased oxygen demands postoperatively, but they can safely undergo early surgical intervention after appropriate medical optimization.

The effect of nail diameter on proximal femoral shortening after internal fixation of pertrochanteric hip fractures with short cephalomedullary nails.

OBJECTIVE: Investigate the effect of distal nail diameter on proximal femoral shortening (PFS) after cephalomedullary nailing of hip fractures. METHODS: A retrospective cohort study of 80 patients aged 50 years and older with pertrochanteric hip fractures treated with a 10 or 11 mm short cephalomedullary nail (CMN) was performed. We measured abductor lever arm shortening, femoral height shortening, and PFS. RESULTS: There was no difference in abductor lever arm shortening (p = 0.09), femoral height shortening (p = 0.86), and PFS (p = 0.34) between the 10 and 11 mm groups. CONCLUSIONS: Our results suggest that distal nail diameter does not affect PFS. LEVEL OF EVIDENCE: III.

Early mortality after hip fracture surgery in COVID-19 patients: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to assess the risk of early mortality in hip fracture patients with COVID-19 infection who undergo surgical intervention. DATA SOURCES: MEDLINE (PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. STUDY SELECTION: Studies were included in the systematic review if they reported postoperative mortality in patients with COVID-19 infection who underwent operative intervention for hip fracture. From this selection of studies, only investigations that reported postoperative mortality in a COVID-positive and a non-COVID group were included in the meta-analysis. DATA EXTRACTION: Data regarding patient demographics, age, and sex were recorded. Additional data that was extracted included study location, data collection period, length of follow-up, COVID testing methodology, COVID testing results, and number of patients who underwent operative versus nonoperative management. The primary outcome of interest was postoperative mortality. DATA SYNTHESIS: Random effects meta-analyses were performed to assess the pooled relative risk of postoperative mortality according to COVID status. Odds ratios and 95% confidence intervals (CI) were calculated. CONCLUSIONS: The overall pooled mortality rate in the early postoperative period for hip fracture patients with concomitant COVID-19 infection was 32.6%. The relative risk for postoperative mortality in COVID-positive patients compared to non-COVID patients was 5.66 (95% CI 4.01-7.98; p < 0.001). The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for early postoperative mortality in the already susceptible hip fracture population. Further investigations will be needed to assess longer-term morbidity and mortality in this patient population. LEVEL OF EVIDENCE: Therapeutic Level IV.

Postoperative Complications Associated With Metabolic Syndrome Following Adult Spinal Deformity Surgery.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The objective of this study was to examine the effect of metabolic syndrome on 30-day postoperative complications following corrective surgery for the adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Metabolic syndrome has been shown to increase the risk of cardiovascular morbidity and mortality. Few studies have examined the effect of metabolic syndrome on patients with ASD undergoing surgery. MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent spinal fusion for ASD. Patients were divided into 2 groups based on the presence or absence of metabolic syndrome, which was defined as a combination of hypertension, diabetes mellitus, and obesity. Baseline patient characteristics and operative variables were compared between the 2 groups. We also compared the incidence of 30-day postoperative complications between the 2 groups. A multivariable regression analysis was then performed to identify 30-day postoperative complications that were independently associated with metabolic syndrome. RESULTS: A total of 6696 patients were included with 8.3% (n=553) having metabolic syndrome. Patients with metabolic syndrome were more likely to have renal comorbidity (P=0.042), bleeding disorder (P=0.011), American Society of Anesthesiology classification ≥3 (P<0.001), and undergo a long fusion (P=0.009). Patients with metabolic syndrome had higher rates of 30-day mortality (P=0.042), superficial surgical site infection (P=0.006), sepsis (P=0.003), cardiac complications (P<0.001), pulmonary complications (P=0.003), pulmonary embolism (P=0.050), prolonged hospitalization (P=0.010), nonhome discharge (P=0.007), and reoperation (P=0.003). Metabolic syndrome was an independent risk factor for cardiac complications [odds ratio (OR)=4.2; 95% confidence interval (CI): 1.7-10.2; P=0.001], superficial surgical site infection (OR=2.8; 95% CI: 1.4-5.7; P=0.004), sepsis (OR=2.2, 95% CI: 1.2-3.9; P=0.009), reoperation (OR=1.7; 95% CI: 1.2-2.5; P=0.006), pulmonary complications (OR=1.7; 95% CI: 1.1-2.5; P=0.017), and prolonged hospitalization (OR=1.4; 95% CI: 1.0-1.9; P=0.039). CONCLUSIONS: Recognition and awareness of the relationship between metabolic syndrome and postoperative complications following ASD surgery is important for preoperative optimization and perioperative care.

Risk Factors for 90-day Readmissions With Fluid and Electrolyte Disorders Following Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study of the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. OBJECTIVE: To identify risk factors for 30- and 90-day readmission due to fluid and electrolyte disorders following posterior lumbar fusion. SUMMARY OF BACKGROUND DATA: Thirty- and 90-day readmission rates are important quality and outcome measures for hospitals and physicians. These measures have been tied to financial penalties for abnormally high rates of readmission. Furthermore, complex and high cost surgeries have been increasingly reimbursed in the form of bundled disease resource group payments, where any treatment within 90-day postdischarge is covered within the original bundled payment scheme. METHODS: A total of 65,121 patients in the Healthcare Cost and Utilization Project Nationwide Readmissions Database met our inclusion criteria, of which 1128 patients (1.7%) were readmitted within 30 days, and 1669 patients (2.6%) were readmitted within 90 days due to fluid and electrolyte abnormalities. A bivariate analysis was performed to compare baseline characteristics between patients readmitted with fluid and electrolyte disorders and the remainder of the cohort. A multivariate regression analysis was then performed to identify independent risk factors for readmission due to fluid and electrolyte disorders at 30 and 90 days. RESULTS: The strongest independent predictors of 30-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and drug use disorder. The five strongest predictors of 90-day readmissions were age ≥80 years, age 65 to 79 years, age 55 to 64 years, liver disease, and fluid and electrolyte disorders. CONCLUSION: Patients with baseline liver disease, previously diagnosed fluid and electrolyte disorders, age older than 55 years, or drug use disorders are at higher risk for readmissions with fluid and electrolyte disorders following posterior lumbar fusion. Close monitoring of fluid and electrolyte balance in the perioperative period is essential to decrease complications and reduce unplanned readmissions. LEVEL OF EVIDENCE: 3.

Can C7 Slope Be Used as a Substitute for T1 Slope? A Radiographic Analysis.

STUDY DESIGN: Retrospective radiographic study. OBJECTIVES: T1 slope is an important parameter of sagittal spinal balance. However, the T1 superior endplate can be difficult to visualize on radiographs due to overlying anatomical structures. C7 slope has been proposed as a potential substitute for T1 slope when the T1 superior endplate is not well visualized. The objective of this study was 2-fold: (1) to assess the correlation between C7 and T1 slopes on upright cervical spine radiographs and (2) to evaluate the interrater reliability of C7 slope. METHODS: Cervical spine radiographs taken between December 2017 and June 2018 at a single institution were reviewed. Two observers measured upper C7 slope, lower C7 slope, and T1 slope. The correlations between upper and lower C7 slope and T1 slope were evaluated, and linear regression analyses were performed. Interrater reliability of C7 slope was also assessed. RESULTS: In this cohort of 152 patients, there was a strong correlation between upper C7 slope and T1 slope (r = 0.91, P < .001), as well as between lower C7 slope and T1 slope (r = 0.90, P < .001). T1 slope could be estimated from the linear regression equation, T1 slope = 0.87 × C7 slope + 7, with an overall model fit of R 2 = 0.8. There was strong interrater reliability for upper (intraclass correlation coefficient [ICC] = 0.95, P < .001) and lower C7 slope (ICC = 0.96, P < .001). CONCLUSIONS: Both the upper and lower C7 slope are strongly correlated with T1 slope and can be used as a substitute to estimate T1 slope when the superior endplate of T1 is not well visualized.

Utilization, effectiveness, and safety of tranexamic acid use in hip fracture surgery: A population-based study.

OBJECTIVE: To assess the effect of tranexamic acid (TXA) use in hip fracture surgery. METHODS: A retrospective cohort study was performed using the Premier Healthcare database. A propensity score matching approach was applied to assess associations between TXA use and blood transfusion, perioperative complications, length of stay (LOS), and hospitalization cost. RESULTS: In 153,169 patients, TXA use was associated with a 17% decrease in odds of blood transfusion, no increase in the risk of perioperative complications, 16% shorter LOS, and minimal effects on hospitalization cost. CONCLUSION: Our results are in support of a wider use of TXA in hip fracture surgery. LEVEL OF EVIDENCE: Level III.

Emerging Techniques in Diagnostic Imaging for Idiopathic Scoliosis in Children and Adolescents: A Review of the Literature.

Traditionally, full spine standing radiographs have been the reference standard for diagnostic imaging in adolescent idiopathic scoliosis (AIS). However, recent advances in diagnostic imaging have the potential to reduce radiation exposure and preserve the image quality and utility. Recent advances in diagnostic imaging for AIS include the EOS imaging system, the DIERS formetric scanner, and ultrasonography. Moderate to strong evidence is available to support the interobserver reliability and validity of each of these modalities, even compared with the reference standard imaging techniques. As such, these emerging techniques might prove beneficial in diagnosing and monitoring AIS and its progression, without high levels of continued radiation exposure. To understand the historical perspective and current state of advanced imaging techniques for AIS, a search of PubMed electronic database was conducted to identify studies that had examined these new techniques in the diagnosis of idiopathic scoliosis in children and adolescents.

Predicting In-Hospital Complications After Anterior Cervical Discectomy and Fusion: A Comparison of the Elixhauser and Charlson Comorbidity Indices.

OBJECTIVE: The objective of this study was to determine the ability of the Elixhauser Comorbidity Index (ECI) and Charlson Comorbidity Index (CCI) to predict postoperative complications after anterior cervical discectomy and fusion (ACDF). METHODS: This was a retrospective study of ACDF hospitalizations in the National Inpatient Sample from 2013 to 2014. The ECI and CCI were calculated, and patients who experienced postoperative complications were identified. The ability of these indexes to predict complications was compared using the c statistic (area under the receiver operating characteristic curve [AUC]). In addition, the CCI and ECI were compared with a base model that included age, sex, race, and primary payer. RESULTS: A total of 261,780 patients were included. Patients who experienced a complication were more often male (P < 0.0001) and older (P < 0.0001). They also had a higher comorbidity burden as assessed by both the ECI (P < 0.0001) and the CCI (P < 0.0001). The ECI was superior in predicting airway complications (AUC, 0.81 vs. 0.75; P < 0.0001), hemorrhagic anemia (AUC, 0.67 vs. 0.63; P = 0.0015), pulmonary embolism (AUC, 0.91 vs. 0.77; P < 0.0001), wound dehiscence (AUC, 0.80 vs. 0.55; P = 0.0080), sepsis (AUC, 0.87 vs. 0.82; P = 0.0001), and septic shock (AUC, 0.94 vs. 0.83; P < 0.0001). The CCI was not found to be superior to the ECI for predicting any complications. Both were excellent for predicting mortality (ECI AUC, 0.87; CCI AUC, 0.90). CONCLUSIONS: The ECI was superior to the CCI in predicting 6 of 15 complications in this study. Both are excellent tools for predicting mortality after ACDF.

Automated Measurement of Lumbar Lordosis on Radiographs Using Machine Learning and Computer Vision.

STUDY DESIGN: Cross sectional database study. OBJECTIVE: To develop a fully automated artificial intelligence and computer vision pipeline for assisted evaluation of lumbar lordosis. METHODS: Lateral lumbar radiographs were used to develop a segmentation neural network (n = 629). After synthetic augmentation, 70% of these radiographs were used for network training, while the remaining 30% were used for hyperparameter optimization. A computer vision algorithm was deployed on the segmented radiographs to calculate lumbar lordosis angles. A test set of radiographs was used to evaluate the validity of the entire pipeline (n = 151). RESULTS: The U-Net segmentation achieved a test dataset dice score of 0.821, an area under the receiver operating curve of 0.914, and an accuracy of 0.862. The computer vision algorithm identified the L1 and S1 vertebrae on 84.1% of the test set with an average speed of 0.14 seconds/radiograph. From the 151 test set radiographs, 50 were randomly chosen for surgeon measurement. When compared with those measurements, our algorithm achieved a mean absolute error of 8.055° and a median absolute error of 6.965° (not statistically significant, P > .05). CONCLUSION: This study is the first to use artificial intelligence and computer vision in a combined pipeline to rapidly measure a sagittal spinopelvic parameter without prior manual surgeon input. The pipeline measures angles with no statistically significant differences from manual measurements by surgeons. This pipeline offers clinical utility in an assistive capacity, and future work should focus on improving segmentation network performance.

Predictors of 30-Day Postoperative Pulmonary Complications After Open Reduction and Internal Fixation of Vertebral Fractures.

OBJECTIVE: The purpose of this study was to identify predictors of 30-day postoperative pulmonary complications after open reduction and internal fixation (ORIF) of vertebral fractures. METHODS: We performed a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014. Adult patients who underwent ORIF of vertebral fractures were included and divided into 2 groups based on the occurrence of 30-day postoperative pulmonary complications. Baseline patient and operative characteristics were compared between the 2 groups. Multivariate regression (MVR) analysis was performed to identify independent risk factors for pulmonary complications. RESULTS: A total of 900 patients were included in our cohort. The overall 30-day pulmonary complication rate was 5.67%. Patients who had a pulmonary complication after vertebral ORIF were more often men and more often had diabetes, functional dependence, American Society of Anesthesiologists score classification of 3 or higher, pulmonary comorbidity, renal comorbidity, and preoperative anemia. The pulmonary complication group also had a higher incidence of 30-day mortality, prolonged hospitalization, pneumonia, cardiac complications, urinary tract infection, blood transfusion, and sepsis. The MVR analysis found that pulmonary comorbidity (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.5-11.5; P < 0.001), diabetes (OR, 2.1; 95% CI, 1.0-4.2; P = 0.037), partial or dependent functional status (OR, 4.7; 95% CI, 2.2-10.2; P < 0.001), and cervical spine involvement (OR, 3.6; 95% CI, 1.7-8.0; P = 0.001) were independent predictors of pulmonary complications. CONCLUSIONS: Early identification of risk factors for postoperative pulmonary complications is important in the evaluation of patients with vertebral fractures for surgical decision-making, preoperative optimization, and subsequent postoperative care to improve patient outcomes and minimize morbidity.

Idiopathic Scoliosis in Children and Adolescents: Emerging Techniques in Surgical Treatment.

BACKGROUND: Idiopathic scoliosis is the most common spinal disorder in the pediatric population. The goals of treatment for pediatric idiopathic scoliosis are to correct deformity, prevent curve progression, restore trunk symmetry and balance, and minimize pain and morbidity. Surgical treatment has advanced significantly, from the advent of segmental pedicle screw instrumentation several decades ago to the recent development of robotic-assisted surgery and growth-modulating fusionless surgery. The objective of the present study was to review the reported data on emerging techniques in the surgical treatment of idiopathic scoliosis in children and adolescents. METHODS: The PubMed and Google Scholar electronic databases were used to identify studies that had examined new emerging techniques in the surgical treatment of idiopathic scoliosis in children and adolescents. RESULTS: Major developments in the surgical techniques for pediatric idiopathic scoliosis have included robotic-assisted pedicle screw placement, vertebral body stapling, vertebral body tethering, magnetically controlled growing rods, ApiFix (not currently approved for use in the United States by the Food and Drug Administration), and sublaminar polyester bands. Such growth-modulating fusionless surgical techniques have received increasing attention in recent years, especially for the younger pediatric scoliosis population with significant growth potential remaining. CONCLUSIONS: Various emerging techniques in the surgical treatment of idiopathic scoliosis in children and adolescents have demonstrated promising results in the reported data thus far. However, longer term prospective studies with larger cohorts are necessary to better evaluate their safety and efficacy.

Predictors of Discharge Disposition Following Laminectomy for Intradural Extramedullary Spinal Tumors.

OBJECTIVE: To identify independent risk factors for non-home discharge in patients undergoing laminectomy for intradural extramedullary spinal tumors. METHODS: We performed a retrospective cohort analysis of data from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014. Adult patients who underwent laminectomy for the excision of intradural extramedullary spinal tumors were included and divided into 2 groups based on home or non-home discharge disposition. We compared baseline patient characteristics, comorbidities, and operative factors between the 2 groups, and then performed multivariate regression analyses to identify independent risk factors for non-home discharge. RESULTS: A total of 1232 patients were included, of whom 248 (20.1%) were discharged to a non-home facility. Univariate analysis demonstrated that patients discharged to a non-home facility were more frequently aged ≥65 years and American Society of Anesthesiologists classification ≥3 with obesity, diabetes, dyspnea, functional dependence, cardiac comorbidity, renal comorbidity, and anemia. Operative factors correlated with non-home discharge were operative time of ≥4 hours and tumor location in the cervical or thoracic spine. Multivariate regression analysis identified age ≥65 years (odds ratio [OR] 2.73; confidence interval [CI] 1.80-4.13; P < 0.001), American Society of Anesthesiologists classification ≥3 (OR 2.36; CI 1.53-3.65; P < 0.001), dependent functional status (OR 4.30; CI 1.95-9.48; P < 0.001), hospital-acquired conditions (OR 2.32; CI 1.15-4.68; P = 0.019), and prolonged length of stay (OR 4.05; CI 2.72-6.03; P < 0.001) as predictors of non-home discharge. CONCLUSIONS: Early identification of patients at risk for non-home discharge is important in order to implement comprehensive discharge planning protocols that reduce inpatient length of stay, as well as associated complications and costs.

Anterior Column Realignment in Adult Spinal Deformity: A Case Report and Review of the Literature.

OBJECTIVE: Anterior column realignment (ACR) is a new emerging minimally invasive surgical technique for adult spinal deformity (ASD) that has the potential to provide similar corrective ability to traditional posterior approaches. This article reviews the current literature on the clinical efficacy and safety of ACR and illustrates an additional use of this technique in a case of sagittal imbalance after posterior spinal fusion with segmental instrumentation. METHODS: We performed a literature search of all published ACR reports using PubMed, including only clinical studies describing the ACR technique and reporting radiographic and/or clinical outcomes. RESULTS: Thirteen studies were included. Improvement in lumbar lordosis after ACR ranged from 12.7° to 39°, and increases in focal segmental lordosis at each ACR level ranged from 1° to 34°. Good clinical and functional outcomes have consistently been reported after ACR. The complication rate has been comparable to or lower than traditional posterior-based techniques. We also illustrate the use of ACR in a patient with sagittal imbalance after a prior posterior instrumented spinal fusion. ACR in combination with a posterior osteotomy allowed for the induction of lordosis by cantilevering of rods and compression of pedicle screws. CONCLUSIONS: Radiographic and clinical outcomes after ACR have been promising so far. In addition to primary ASD surgery, ACR can also be effectively used in cases with prior posterior instrumented spinal fusion to correct sagittal imbalance.

Risk Factors Associated with 30-Day Mortality After Open Reduction and Internal Fixation of Vertebral Fractures.

OBJECTIVE: Few studies have examined the outcomes of open reduction and internal fixation of vertebral fractures. The purpose of this study was to determine patient-related and surgery-related risk factors associated with 30-day postoperative mortality after open reduction and internal fixation (ORIF) of cervical, thoracic, and lumbar vertebral fractures. METHODS: This was a retrospective cohort study of data from the 2010-2014 ACS-NSQIP database. Adult patients who underwent ORIF of vertebral fractures in the cervical, thoracic, or lumbar spine were included. Patients were divided into 2 groups on the basis of the occurrence of 30-day postoperative mortality. A univariate analysis was performed to compare baseline patient characteristics, comorbidities, operative variables, and 30-day postoperative complications between the mortality and nonmortality groups. A subsequent multivariate regression analysis adjusting for patient and operative factors was then performed to identify independent risk factors for 30-day mortality. RESULTS: A total of 900 patients who underwent vertebral ORIF were included. The overall 30-day postoperative mortality rate was 1.56%. The mortality group had a higher incidence of pneumonia, pulmonary complications, cardiac complications, blood transfusion, sepsis, and prolonged hospitalization. Multivariate regression analysis identified pulmonary comorbidity and diabetes as independent predictors of 30-day mortality following ORIF of vertebral fractures. CONCLUSIONS: Pulmonary comorbidity and diabetes were found to be independent risk factors for 30-day mortality after ORIF of vertebral fractures. Recognizing these risk factors is important in preoperative risk stratification, perioperative care, and patient counseling.