The Cost-Effectiveness of Tibial Metaphyseal Cones in Revision Total Knee Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the cost-effectiveness of tibial cones in revision total knee arthroplasty. METHODS: A Markov model was used for cost-effectiveness analysis. The average cone price was obtained from Orthopedic Network News. The average cone aseptic loosening rate was determined by literature review. Hospitalization costs and baseline re-revision rates were calculated using the PearlDiver Database. RESULTS: The maximum cost-effective cone price varied from $3514 at age 40 to $648 at age 90, compared to the current average selling price of $4201. Cones became cost-effective with baseline aseptic loosening rates of 0.89% annually at age 40 to 4.38% annually at age 90, compared to the current average baseline loosening rate of 0.76% annually. CONCLUSION: For the average patient, tibial cones are not cost-effective, but may become so at lower prices, in younger patients, or in patients at substantially increased risk of aseptic loosening.

Are Patients Who Undergo THA for Infection at Higher Risk for 30-day Complications?

BACKGROUND: Value-based payment models, such as bundled payments, continue to become more widely adopted for total joint arthroplasty. However, concerns exist regarding the lack of risk adjustment in these payment and quality reporting models for THA. Providers who care for patients with more complicated problems may be financially incentivized to screen out such patients if reimbursement models fail to account for increased time and resources needed to care for these more complex patients. QUESTIONS/PURPOSES: (1) Are patients who undergo revision THA for infectious causes at greater adjusted risk of 30-day short-term major complications, return to the operating room, readmission, and mortality compared with patients undergoing aseptic revision? (2) What are other independent factors associated with the risk of 30-day major complications, readmission, and mortality in this patient population? METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database for all patients undergoing revision THA from 2012 to 2015. The NSQIP database allows for the analysis of 30-day surgical outcomes, including postoperative complications, return to the operating room, readmission, and mortality of patients from approximately 400 participating institutions. The NSQIP was selected over other larger databases, such as the National Impatient Sample (NIS), because the NSQIP includes readmission data and 30-day complications rates that were relevant to our study. Patients undergoing aseptic revision THA and those undergoing revision THA with a diagnosis of periprosthetic joint infection were identified. We identified 8973 patients who underwent revision THA and excluded six patients due to a diagnosis of malignancy leaving 8967 patients; 726 (8%) of these were due to infection. Demographic variables, medical comorbidities, and 30-day major complications, hospital readmissions, reoperations, and mortality were compared among patients undergoing aseptic and infected revision THA. A major complication was defined as myocardial infarction, postoperative mortality, sepsis, septic shock, and stroke. A multivariate logistic regression analysis was then performed to identify factors independently associated with the primary outcome of 30-day hospital readmission, and secondary endpoints of 30-day major complications, return to operating room, and mortality. RESULTS: Controlling for medical comorbidities and demographic factors, the patients who underwent THA for infection were more likely to experience a major complication (odds ratio [OR], 4.637; 95% confidence interval [CI], 2.850-7.544; p < 0.001) within 30 days of surgery and more likely to return to the operating room (OR = 1.548; 95% CI, 1.062-2.255; p = 0.023). However, there were no greater odds of 30-day readmission (OR, 1.354; 95% CI, 0.975-1.880; p = 0.070) or 30-day mortality (OR, 0.661; 95% CI, 0.218-2.003; p = 0.465). Preoperative malnutrition was associated with an increased risk of return to the operating room (OR, 1.561; 95% CI, 1.152-2.115; p = 0.004), 30-day readmission (OR, 1.695; 95% CI, 1.314-2.186; p < 0.001), and 30-day mortality (OR, 7.240; 95% CI, 2.936-17.851; p < 0.001). CONCLUSIONS: Patients undergoing revision THA for infection undergo reoperation and experience major complications more frequently in a 30-day episode of care than patients undergoing aseptic revision THA. Without risk adjustment to existing alternative payment and quality reporting models, providers may experience a disincentive to care for patients with infected THAs, who may face difficulties with access to care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Risk Adjustment Is Necessary in Value-based Outcomes Models for Infected TKA.

BACKGROUND: The Medicare Access and CHIP Reauthorization Act of 2015 provides the framework to link reimbursement for providers based on outcome metrics. Concerns exist that the lack of risk adjustment for patients undergoing revision TKA for an infection may cause problems with access to care. QUESTIONS/PURPOSES: (1) After controlling for confounding variables, do patients undergoing revision TKA for infection have higher 30-day readmission, reoperation, and mortality rates than those undergoing revision TKA for aseptic causes? (2) Compared with patients undergoing revision TKA who are believed not to have infections, are patients undergoing revision for infected TKAs at increased risk for complications? METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients undergoing revision TKA from 2012 to 2015 identified by Current Procedural Terminology (CPT) codes 27486, 27487, and 27488. Of the 10,848 patients identified, four were excluded with a diagnosis of malignancy (International Classification of Diseases, 9th Revision code 170.7, 170.9, 171.8, or 198.5). This validated, national database records short-term outcome data for inpatient procedures and does not rely on administrative coding data. Demographic variables, comorbidities, and outcomes were compared between patients believed to have infected TKAs and those undergoing revision for aseptic causes. A multivariate logistic regression analysis was performed to identify independent factors associated with complications, readmissions, reoperations, and mortality. RESULTS: After controlling for demographic factors and medical comorbidities, TKA revision for infection was independently associated with complications (odds ratio [OR], 3.736; 95% confidence interval [CI], 3.198-4.365; p < 0.001), 30-day readmission (OR, 1.455; 95% CI, 1.207-1.755; p < 0.001), 30-day reoperation (OR, 1.614; 95% CI, 1.278-2.037; p < 0.001), and 30-day mortality (OR, 3.337; 95% CI, 1.213-9.180; p = 0.020). Patients with infected TKA had higher rates of postoperative infection (OR, 3.818; 95% CI, 3.082-4.728; p < 0.001), renal failure (OR, 36.709; 95% CI, 8.255-163.231; p < 0.001), sepsis (OR, 7.582; 95% CI, 5.529-10.397; p < 0.001), and septic shock (OR, 3.031; 95% CI, 1.376-6.675; p = 0.006). CONCLUSIONS: Policymakers should be aware of the higher rate of mortality, readmissions, reoperations, and complications in patients with infected TKA. Without appropriate risk adjustment or excluding these patients all together from alternative payment and quality reporting models, fewer providers will be incentivized to care for patients with infected TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Complications and Mortality Following Total Hip Arthroplasty in the Octogenarians: An Analysis of a National Database.

BACKGROUND: As advances in medicine have increased life expectancy, more octogenarians are undergoing total hip arthroplasty (THA) than ever before. Concerns exist, however, about the safety of performing this elective procedure in this age group. The purpose of this study is to determine the 30-day complications associated with THA patients over 80 years of age and to identify high-risk patients. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between patients under vs over 80 years of age. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes. RESULTS: Of the total 66,839 patients who underwent THA, 7198 (11%) patients were 80 years of age or older. Octogenarians had a higher overall complication rate (29% vs 15%, P < .001) and a higher mortality rate (0.9% vs 0.1%, P < .001). When controlling for other comorbidities, age over 80 years is an independent risk factor for mortality (odds ratio 2.02, 95% confidence interval 1.25-3.26, P = .004) and complications (odds ratio 1.41, 95% confidence interval 1.30-1.525, P < .001) following THA. Malnutrition and chronic kidney disease are also independent risk factors for readmission, complications, and mortality (all P < .05). CONCLUSION: THA in patients older than 80 years old are at an increased risk of complications and mortality. Octogenarian patients should be counseled on their risk profile, particularly those with malnutrition and chronic kidney disease.

Bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis.

INTRODUCTION: Since its introduction BMP has been utilized in populations with higher rates of malunion, such as adult spinal deformity (ASD) patients. Contradictory conclusions exist in spinal literature regarding the safety and efficacy of the use of BMP in this setting. Previous studies, however, did not distinguish deformity cases from spondylolisthesis or stenosis. The purpose of this study is to evaluate the safety and efficacy of BMP use in spinal fusion surgery for ASD. METHODS: 166 papers were screened after database search. 40 full texts were assessed for eligibility. Five studies were included for meta-analysis. Three were comparative studies between a BMP and non-BMP group, and the other was used to supplement dose-effect analysis. RESULTS: The current meta-analysis found increased odds of developing radiculitis or neurological complications (OR = 2.18, 95% CI, p = 0.02, i 2 = 0), but no other significant relationship between complications commonly attributed to BMP use (tumorigenesis, infections, seroma formation, or osteolysis) and BMP use. BMP patients had decreased rates of pseudarthrosis (OR = 0.23, 95% CI, p = 0.002, i 2 = 0). There was an average dose of 8.75 mg/level in the 417 patients studied, lower than the advised dosage of 12 mg/level. CONCLUSIONS: The current literature shows BMP to be a safe and effective grafting technique in the treatment of ASD. Spine surgeons may currently be using sub-optimal doses of BMP. The benefit of increasing the rate of fusion must be weighed against the increased risk of radiculitis and neurologic complications in this patient population.

Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.

BACKGROUND: As outpatient total hip (THA) and knee arthroplasties (TKA) increase in popularity, concerns exist about the safety of discharging patients home the same day. The purpose of this study is to determine the complications associated with outpatient total joint arthroplasty (TJA) and to identify high-risk patients who should be excluded from these protocols. METHODS: We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary TKA or THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between outpatient and traditional inpatient procedures. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes. RESULTS: Of the total 169,406 patients who underwent TJA, 1220 were outpatient (0.7%). The outpatient and inpatient groups had an overall complication rate of 8% and 16%, respectively. Patients aged more than 70 years, those with malnutrition, cardiac history, smoking history, or diabetes mellitus are at higher risk for readmission and complications after THA and TKA (all P < .05). Surprisingly, outpatient TJA alone did not increase the risk of readmission (OR 0.652, 95% CI 0.243-1.746, P = .395) or reoperation (OR 1.168, 95% CI 0.374-3.651, P = .789), and was a negative independent risk factor for complications (OR 0.459, 95% CI 0.371-0.567, P < .001). CONCLUSION: With the resources available in a hospital setting, outpatient TJA may be a safe option, but only in select, healthier patients. Care should be taken to extrapolate these results to an outpatient facility, where complications may be more difficult to manage.

Are Revision Hip Arthroplasty Patients at Higher Risk for Venous Thromboembolic Events Than Primary Hip Arthroplasty Patients?

BACKGROUND: The purpose of this study is to determine whether revision total hip arthroplasty (THA) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) when compared to primary THA. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program database for all primary and revision THA cases from 2011 to 2014. Demographic data, medical comorbidities, and venous thromboembolic rates within 30 days of surgery were compared between the primary and revision THA groups. RESULTS: Revision THA had a higher rate of DVT than the primary THA (0.6% vs 0.4%, P = .016), but there was no difference in the rate of PE (0.3% vs 0.2%, P = .116). When controlling for confounding variables, revision surgery alone was not a risk factor for DVT (odds ratio 0.833, 95% confidence interval 0.564-1.232) or PE (odds ratio 1.009, 95% confidence interval 0.630-1.616). Independent risk factors for DVT include age >70 years, malnutrition, infection, operating time >3 hours, general anesthesia, American Society of Anesthesiologists classification 4 or greater, and kidney disease (all P < .05). Probability of DVT ranged from 0.2% with zero risk factors to 10% with all risk factors. Independent risk factors for PE included age >70 years, African American ethnicity, and operating time >3 hours (all P < .05) with probabilities of PE postoperatively ranging from 0.2% to 1.1% with all risk factors. CONCLUSION: Revision surgery alone is not a risk factor for venous thromboembolism after hip arthroplasty. Surgeons should weigh the risks and benefits of more aggressive anticoagulation in certain high-risk patients.

Predictors of inpatient morbidity and mortality in adult spinal deformity surgery.

PURPOSE: This nationwide study identifies ASD surgical risk factors for morbidity/mortality. METHODS: NIS discharges from 2001 to 2010 aged 25+ with scoliosis diagnoses, 4+ levels fused, and procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included. Demographics, comorbidities and procedure-related complications were determined for each subgroup (degenerative, congenital, idiopathic, other). Multivariate analysis reported as [OR (95% CI)]. RESULTS: 11,982 discharges were identified. Morbidity, excluding device-related, and mortality rates were 50.81 and 0.28%, respectively. Certain comorbidities were associated with increased morbidity/mortality: congestive heart failure (CHF) [1.62 (1.42-1.84)] [5.67 (3.30-9.73)], coagulopathy [3.52 (3.22-3.85)] [2.32 (1.44-3.76)], electrolyte imbalance [2.65 (2.52-2.79)] [4.63 (3.15-6.81)], pulmonary circulation disorders [9.45 (7.45-11.99)] [8.94 (4.43-18.03)], renal failure [1.29 (1.13-1.47)] [5.51 (2.57-11.82)], and pathologic weight loss [2.38 (2.01-2.81)] [7.28 (4.36-12.14)]. Chronic pulmonary disease was associated with higher morbidity [1.08 (1.02-1.14)]; liver disease was linked to increased mortality [36.09 (16.16-80.59)]. 9+ level fusions had increased morbidity vs 4-8 level fusions [1.69 (1.61-1.78)] and refusions [1.08 (1.02-1.14)]. Idiopathic scoliosis was associated with decreased morbidity vs all other subgroups [0.85 (0.80-0.91)]. Age >65 was associated with increased morbidity and mortality vs 25-64 group [1.09 (1.05-1.14)] [3.49 (2.31-5.29)]. Females had increased morbidity [1.18 (1.13-1.23)] and decreased mortality [0.30 (0.21-0.44)]. Mean comorbidity index (0.55) and age (64.38) for degenerative cohort were higher vs all other subgroups (P < 0.0001). CONCLUSIONS: Longer fusions were associated with increased morbidity. Age >65 was associated with increased morbidity/mortality, while females were associated with increased morbidity but decreased mortality. Idiopathic scoliosis had decreased morbidity. Degenerative ASD cases had higher comorbidity indices, potentially due to older age. This study is clinically useful for patient education, surgical decision-making, and optimizing patient outcomes.

Cervical spine alignment following lumbar pedicle subtraction osteotomy for sagittal imbalance.

PURPOSE: The alignment of the cervical spine is of primary importance to maintain horizontal gaze and contributes to the functional outcome of patients. Cervical spine alignment after correction of major sagittal imbalance has rarely been reported in the literature. METHODS: Retrospective review of 31 consecutive patients with sagittal plane deformities operated by lumbar pedicle subtraction osteotomy. Pre-operative and 3 months post-operative full-length radiographies were analyzed for spinopelvic and cervical-specific parameters. RESULTS: There was a significant increase in lumbar lordosis (LL), thoracic kyphosis, and sacral slope. There was also a significant decrease in pelvic tilt, pelvic incidence minus LL, knee flexion and sagittal vertical axis. The cervical analysis revealed that there was no significant difference between pre- and post-operative global cervical lordosis (CL) angle and external auditory meatus (EAM) tilt. There was a significant decrease of C7 slope and distal CL, while a significant increase in occipito-C2 (OC2) angle was observed. CONCLUSION: LL restoration decreased the need of compensation at the pelvis and thoracic spine. The distal CL and C7 slope decreased because there was no need for compensation at this level after the surgery, but the proximal cervical spine takes a slightly flexed position to maintain horizontal sight. EAM tilt measures the head position toward C7, and is close to 0° even in severe cases. Changes of this parameter after surgery are insignificant, probably due to the balance between upper and lower cervical segments; when one of these segments shifts backward the other shifts forward and the result is a balanced head over C7.

Hypoalbuminemia Increases Mortality after Two-Stage Revision Total Joint Arthroplasty.

Objectives: This study aimed to evaluate the effect of hypoalbuminemia on failure rates and mortality after a two-stage revision for PJI. Methods: 199 Patients (130 knees and 69 hips) with a mean age of 64.7 ± 10.7 years who underwent a two-stage exchange were retrospectively reviewed at a mean of 51.2 ± 39.7 months. Failure of treatment was defined as any revision within the follow-up period, failure to undergo reimplantation, or death within one year of initiating treatment. Results: There were 71 failures (35.7%), including 38 septic failures (19.1%). We found no differences between successful revisions and failures regarding hypoalbuminemia (43% vs. 42% prior to stage 1, P=1 and 32% vs. 29% prior to stage 2, P=0.856). There were also no differences in hypoalbuminemia rates between septic failures and the rest of the cohort (42% vs. 43% prior to stage 1, P=1.0 and 34% vs. 30% prior to stage 2, P=0.674). Hypoalbuminemia prior to stage 2 was a significant predictor of mortality based on multivariate analysis (odds ratio 5.40, CI 1.19-24.54, P=0.029). Hypoalbuminemia was independently associated with a greater length of stay by 2.2 days after stage 1 (P=0.002) and by 1.0 days after the second stage reimplantation (P=0.004). Conclusion: Preoperative hypoalbuminemia is a significant predictor of mortality and increased length of stay following two-stage revision but is not a predictor of failure of PJI treatment. Further study is required to understand if hypoalbuminemia is a modifiable risk factor or a marker for poor outcomes.

Intraoperative Acoustics: Auditory Cues in Hip Reconstructive Surgery.

Background: Orthopaedic surgeons rely on visual and tactile cues to guide performance in the operating room (OR). However, there is very little data on how sound changes during orthopaedic procedures and how surgeons incorporate audio feedback to guide performance. This study attempts to define meaningful changes in sound during vital aspects of total hip arthroplasty (THA) within the spectrum of human hearing. Methods: 84 audio recordings were obtained during primary elective THA procedures during sawing of the femoral neck, reaming of the acetabulum, acetabular cup impaction, polyethylene liner impaction, femoral broaching, planning of the femoral calcar and press-fit of a porous-coated stem in 14 patients. We graphed changes in frequency intensity across the human spectrum of hearing and sampled frequencies showing differences over time for statistically meaningful changes. Results: Sawing of the femoral neck, polyethylene impaction, and stem insertion showed significant temporal increases in overall sound intensity. Calcar planing showed a significant decrease in sound intensity. Moreover, spectrographic analysis showed that, for each of the critical tasks in THA, there were characteristic frequencies that showed maximal changes in loudness. These changes were above the 1 dB change in intensity required for detection by the human ear. Conclusion: Our results clearly demonstrate reproducible sound changes during total hip arthroplasty that are detectable by the human ear. Surgeons can incorporate sound as a valuable source of feedback while performing total hip arthroplasty to guide optimal performance in the OR. These findings can be extrapolated to other orthopaedic procedures that produce characteristic changes in sound. Moreover, it emphasizes the importance of limiting ambient noise in the OR that might make sound changes hard to distinguish.

Low Socioeconomic Status Is Associated With Increased Complication Rates: Are Risk Adjustment Models Necessary in Cervical Spine Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The objective of this study was to determine whether lower socioeconomic status was associated with increased resource utilization following anterior discectomy and fusion (ACDF). METHODS: The National Inpatient Sample database was queried for patients who underwent a primary, 1- to 2-level ACDF between 2005 and 2014. Trauma, malignancy, infection, and revision surgery were excluded. The top and bottom income quartiles were compared. Demographics, medical comorbidities, length of stay, complications, and hospital cost were compared between patients of top and bottom income quartiles. RESULTS: A total of 69 844 cases were included. The bottom income quartile had a similar mean hospital stay (2.04 vs 1.77 days, P = .412), more complications (2.45% vs 1.77%, P < .001), and a higher mortality rate (0.18% vs 0.11%, P = .016). Multivariate analysis revealed bottom income quartile was an independent risk factor for complications (odds ratio = 1.135, confidence interval = 1.02-1.26). Interestingly, the bottom income quartile experienced lower mean hospital costs ($17 041 vs $17 958, P < .001). CONCLUSION: Patients in the lowest income group experienced more complications even after adjusting for comorbidities. Therefore, risk adjustment models, including socioeconomic status, may be necessary to avoid potential problems with access to orthopedic spine care for this patient population.

National trends in total hip arthroplasty for traumatic hip fractures: An analysis of a nationwide all-payer database.

BACKGROUND: Hemiarthroplasty (HA) has traditionally been the treatment of choice for elderly patients with displaced femoral neck fractures. Ideal treatment for younger, ambulatory patients is not as clear. Total hip arthroplasty (THA) has been increasingly utilized in this population however the factors associated with undergoing HA or THA have not been fully elucidated. AIM: To examine what patient characteristics are associated with undergoing THA or HA. To determine if outcomes differ between the groups. METHODS: We queried the Nationwide Inpatient Sample (NIS) for patients that underwent HA or THA for a femoral neck fracture between 2005 and 2014. The NIS comprises a large representative sample of inpatient hospitalizations in the United States. International Classifications of Disease, Ninth Edition (ICD-9) codes were used to identify patients in our sample. Demographic variables, hospital characteristics, payer status, medical comorbidities and mortality rates were compared between the two procedures. Multivariate logistic regression analysis was then performed to identify independent risk factors of treatment utilized. RESULTS: Of the total 502060 patients who were treated for femoral neck fracture, 51568 (10.3%) underwent THA and the incidence of THA rose from 8.3% to 13.7%. Private insurance accounted for a higher percentage of THA than hemiarthroplasty. THA increased most in urban teaching hospitals relative to urban non-teaching hospitals. Mean length of stay (LOS) was longer for HA. The mean charges were less for HA, however charges decreased steadily for both groups. HA had a higher mortality rate, however, after adjusting for age and comorbidities HA was not an independent risk factor for mortality. Interestingly, private insurance was an independent predictor for treatment with THA. CONLUSION: There has been an increase in the use of THA for the treatment of femoral neck fractures in the United States, most notably in urban hospitals. HA and THA are decreasing in total charges and LOS.

Short-term Outcomes Following Cervical Laminoplasty and Decompression and Fusion With Instrumentation.

STUDY DESIGN: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2010 to 2015. OBJECTIVE: Investigate which short-term outcomes differ for cervical laminoplasty and laminectomy and fusion surgeries. SUMMARY OF BACKGROUND DATA: Conflicting reports exist in spine literature regarding short-term outcomes following cervical laminoplasty and posterior laminectomy and fusion. The objective of this study was to compare the 30-day outcomes for these two treatment groups for multilevel cervical pathology. METHODS: Patients who underwent cervical laminoplasty or posterior laminectomy and fusion were identified in National Surgical Quality Improvement Program (NSQIP) based on Current Procedural Terminology (CPT) code: laminoplasty 63,050 and 63,051, posterior cervical laminectomy 63,015 and 63,045, and instrumentation 22,842. Propensity-adjusted multivariate regressions assessed differences in postoperative length of stay, adverse events, discharge disposition, and readmission. RESULTS: Three thousand seven hundred ninety-six patients were included: 2397 (63%) underwent cervical laminectomy and fusion and 1399 (37%) underwent cervical laminoplasty. Both groups were similar in age, sex, body mass index (BMI), American Society of Anesthesiologist Classification (ASA), Charleston Comorbidity Index (CCI), and had similar rates of malnutrition, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and history for steroid use. Age more than 70 and age less than 50 were not associated with one treatment group over the other (P > 0.05). Compared with laminoplasty patients, laminectomy and fusion patients had increased lengths of stay (LOS) (4.5 vs. 3.7 d, P < 0.01) and increased rates of adverse events (41.7% vs. 35.9%, P < 0.01), discharge to rehab (16.4% vs. 8.6%, P < 0.01), and skilled nursing facilities (12.2% vs. 9.7%, P = 0.02), and readmission (6.2% vs. 4.5%, P = 0.05). Both groups experienced similar rates of death, pulmonary embolus, deep vein thrombosis, deep and superficial surgical site infection, and reoperation (P > 0.05 for all). CONCLUSION: Posterior cervical laminectomy and fusion patients were found to have increased LOS, readmissions, and complications despite having similar pre-op demographics and comorbidities. Patients and surgeons should consider these risks when considering surgical treatment for cervical pathology. LEVEL OF EVIDENCE: 3.

Intraoperative bladder perforation during primary total hip arthroplasty.

We present a unique case of bladder perforation occurring intraoperatively during primary total hip arthroplasty. It is suspected that the patient's aberrant bladder anatomy, with idiopathic erosion of the quadrilateral space, predisposed the patient to bladder injury. Several preoperative risk factors for bladder injury were identified in the literature. These factors include cemented acetabular components, previous history of hip arthroplasty, history of pelvic trauma or intrapelvic surgery, and poor bone quality. Management of bladder injury, should it occur, includes bladder decompression with a Foley catheter, antibiotic administration, hemodynamic monitoring, and urology consult with close follow-up. This case reinforces the importance of urologic preoperative evaluation for anatomic variations of the bladder. In such cases, intraoperative Foley catheters to prevent distension may reduce the risk of perforation.

Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients.

BACKGROUND: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. METHODS: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. RESULTS: Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). CONCLUSIONS: This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Two-Year Results of the Prospective Spine Treatment Outcomes Study: Analysis of Postoperative Clinical Outcomes Between Patients with and without a History of Previous Cervical Spine Surgery.

OBJECTIVE: History of previous cervical spine surgery is a frequently cited cause of worse outcomes after cervical spine surgery. The purpose of this study was to determine any differences in clinical outcomes after cervical spine surgery between patients with and without a history of previous cervical spine surgery. METHODS: A multicenter prospective database was reviewed retrospectively to identify patients with cervical spondylosis undergoing surgery with a minimum 2-year follow-up. Patients were divided into 2 groups: patients with (W) or without (WO) previous history of cervical spine surgery. Statistical analyses of Health-Related Quality of Life scores were analyzed with statistical software to fit linear mixed models for continuous longitudinal outcome. RESULTS: A total of 1286 patients (377 W, 909 WO) met criteria for inclusion. Overall, patients in both groups experienced an improvement in their Health-Related Quality of Life scores. However, patients in the W group had significantly decreased improvement compared with WO patients in the Neck Disability Index score and the following SF-36 domain scores: Role Physical, Bodily Pain, General Health, Vitality, Social Functioning, Health Transition, and Physical Component Summary at all time points (P < 0.05). There was no statistically significant difference between the W and WO groups in operative time, estimated blood loss, length of stay, or complications (P > 0.05). CONCLUSIONS: Patients with a history of previous cervical spine surgery had inferior improvement in quality of life outcome scores. Patients with a history of previous surgical intervention who elect to undergo subsequent surgeries should be appropriately counseled about expected results.

Cervical spondylotic myelopathy: National trends in the treatment and peri-operative outcomes over 10years.

BACKGROUND: Recent studies show increases in cervical spine surgery prevalence and cervical spondylotic myelopathy (CSM) diagnoses in the US. However, few studies have examined outcomes for CSM surgical management, particularly on a nationwide scale. OBJECTIVE: Evaluate national trends from 2001 to 2010 for CSM patient surgical approach, postoperative outcomes, and hospital characteristics. METHODS: A retrospective nationwide database analysis provided by the Nationwide Inpatient Sample (NIS) including CSM patients aged 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty from 2001 to 2010. Patients with fractures, 9+ levels fused, or any cancer were excluded. Measures included demographics, hospital data, and procedure-related complications. Yearly trends were analyzed using linear regression modeling. RESULTS: 54,348 discharge cases were identified. ACDF, posterior only, and combined anterior/posterior approach volumes significantly increased from 2001 to 2010 (98.62%, 303.07%, and 576.19%; respectively, p<0.05). However, laminoplasty volume remained unchanged (p>0.05). Total charges for ACDF, posterior only, combined anterior/posterior, and laminoplasty approaches all significantly increased (138.72%, 176.74%, 182.48%, and 144.85%, respectively; p<0.05). For all procedures, overall mortality significantly decreased by 45.34% (p=0.001) and overall morbidity increased by 33.82% (p=0.0002). For all procedures except ACDF, which saw a significantly decrease by 8.75% (p<0.0001), length of hospital stay was unchanged. CONCLUSIONS: For CSM patients between 2001 and 2010, combined surgical approach increased sixfold, posterior only approach increased threefold, and ACDF doubled; laminoplasties without fusion volume remained the same. Mortality decreased whereas morbidity and total charges increased. Length of stay decreased only for ACDF approach. This study provides clinically useful data to direct future research, improving patient outcomes.

Emerging Techniques for Posterior Fixation of the Lumbar Spine.

Pedicle screw fixation is the preferred method of posterior fusion in lumbar spinal surgery. The technique provides three-column support of the vertebrae, contributing to the biomechanical strength of the construct. However, open pedicle screw fixation often necessitates wide posterior exposure and dissection with soft-tissue disruption of the facet joint. Alternative posterior fixation techniques have been developed to reduce surgical time, soft-tissue dissection, disruption of the adjacent facet joint capsule, neurologic risk, and implant cost. Results of these techniques are comparable to those of standard pedicle screw fixation systems. Certain patients, especially those at a lower risk of nonunion or those who require posterior fixation only as an adjunct to anterior column support, may benefit from the shorter surgical time and limited posterior exposure of the alternative techniques. However, the decreased rigidity of these alternative constructs can result in excessive motion, which can lead to nonunion and early hardware failure.