Symptomatic Radial Neck Nonunion Following Traumatic Impacted Radial Neck Fracture.

PURPOSE: Minimally displaced or impacted radial neck fractures are commonly sustained after elbow trauma, although few require surgical treatment or result in lasting complications. Whereas they are rare, radial neck nonunion after this injury can have adverse implications for patient function and quality of life. The current study presents a case series of 8 radial neck nonunions after minimally displaced or impacted radial neck fractures. METHODS: Using our institution's electronic medical record database, referred to as the Synthetic Derivative database, we performed a retrospective review of all radial neck fractures that presented to our institution over 15 years. RESULTS: Of 472 minimally displaced or impacted radial neck fractures, 8 progressed to symptomatic nonunion. Average age of these patients was 54 ± 9.3 years. One patient presented with bilateral radial neck nonunions. CONCLUSIONS: Nonunion after an impacted radial neck fracture is a rare yet frustrating outcome for patients and providers alike. Our results estimate the rate of symptomatic radial neck nonunion after minimally displaced or impacted radial neck fractures to be 1.7%. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Comparison of Perioperative Adverse Event Rates After Total Knee Arthroplasty in Patients With Diabetes: Insulin Dependence Makes a Difference.

BACKGROUND: Total knee arthroplasty (TKA) is an effective treatment option for patients with advanced osteoarthritis and has become one of the most frequently performed orthopedic procedures. With the increasing prevalence of diabetes mellitus (DM), the burden of its sequela and associated surgical complications has also increased. For these reasons, it is important to understand the association between DM and the rates of perioperative adverse events after TKA. METHODS: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent TKA between 2005 and 2014 were identified and characterized as having insulin-dependent DM (IDDM), non-insulin-dependent DM (NIDDM), or not having DM. Multivariate Poisson regression was used to control for demographic and comorbid factors and to assess the relative risks of multiple adverse events in the initial 30 postoperative days. RESULTS: A total of 114,102 patients who underwent TKA were selected (IDDM = 4881 [4.3%]; NIDDM = 15,367 [13.5%]; and no DM = 93,854 [82.2%]). Patients with NIDDM were found to be at greater risk for 2 of 17 adverse events studied relative to patients without DM. However, patients with IDDM were found to be at greater risk for 12 of 17 adverse events studied relative to patients without DM. CONCLUSION: In comparison with patients with NIDDM, patients with IDDM are at greater risk for many more perioperative adverse outcomes relative to patients without DM. These findings have important implications for patient selection, preoperative risk stratification, and postoperative expectations.

Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients.

BACKGROUND: Diabetes and hip fractures in geriatric patients are common, and many elderly patients have a history of diabetes. However, the influence of diabetes on surgical complications may vary based on which particular type of diabetes a patient has. To our knowledge, no prior study has stratified patients with diabetes to compare patients with noninsulin-dependent and insulin-dependent diabetes regarding rates of postoperative adverse events, length of hospitalization, and readmission rate after surgical stabilization of hip fractures in geriatric patients. QUESTIONS/PURPOSES: We asked whether patients with noninsulin-dependent or insulin-dependent diabetes are at increased risk (1) of sustaining an aggregated serious adverse event, aggregated minor adverse event, extended length of stay, or hospital readmission within 30 days of hip fracture surgery; (2) of experiencing any individual serious adverse event within 30 days of hip fracture surgery; and (3) of experiencing any individual minor adverse event within 30 days of hip fracture surgery. METHODS: Patients older than 65 years undergoing surgery for hip fracture between 2005 and 2012 were identified (n = 9938) from the American College of Surgeons National Surgical Quality Improvement Program(®) database. This database reports events within 30 days of the surgery. Demographics were compared between three groups of patients: patients with noninsulin-dependent diabetes, patients with insulin-dependent diabetes, and patients without diabetes. Patients without diabetes served as the reference group, and the relative risks for aggregated serious adverse events, aggregated minor adverse events, length of stay greater than 9 days, and readmission within 30 days were calculated for patients with noninsulin-dependent and with insulin-dependent diabetes. We then calculated relative risks for each specific serious adverse event and minor adverse event using multivariate analyses. RESULTS: Patients with noninsulin-dependent and insulin-dependent diabetes were at no greater risk of sustaining an aggregated serious adverse event, aggregated minor adverse event, extended postoperative length of stay, or readmission. Among individual serious adverse events, only postoperative myocardial infarction was found to be increased in the diabetic groups (relative risk [RR] = 1.9 for noninsulin-dependent diabetes, 95% CI, 1.3-2.8; RR = 1.5 for insulin-dependent diabetes, CI, 0.9-2.6; p = 0.003). Patients with noninsulin-dependent and insulin-dependent diabetes were at no greater risk of sustaining any individual minor adverse event. CONCLUSIONS: Despite previously reported and perceived risks associated with diabetes, we found little difference in terms of perioperative risk among geriatric patients with hip fracture with noninsulin-dependent or insulin-dependent diabetes relative to patients without diabetes. Clinically, the implications of these findings will help to improve, specify, and increase the efficiency of the preoperative workup and counseling of patients with diabetes who need hip fracture surgery. LEVEL OF EVIDENCE: Level III, case-control study. See Instructions for Authors for a complete description of levels of evidence.

Patient factors are associated with poor short-term outcomes after posterior fusion for adolescent idiopathic scoliosis.

BACKGROUND: Posterior spinal fusion (PSF) is commonly performed for patients with adolescent idiopathic scoliosis (AIS). Identifying factors associated with perioperative morbidity and PSF may lead to strategies for reducing the frequency of adverse events (AEs) in patients and total hospital costs. QUESTIONS/PURPOSES: What is the frequency of and what factors are associated with postoperative: (1) AEs, (2) extended length of stay (LOS), and (3) readmission in patients with AIS undergoing PSF? PATIENTS AND METHODS: Patients, aged 11 to 18 years, who underwent PSF for AIS during 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Pediatric database. Patient were assessed for characteristics associated with AEs, extended LOS (defined as more than 6 days), and hospital readmission using multivariate logistic regression. Individual AEs captured in the database were grouped into two categories, "any adverse event" (AAE) and "severe adverse events" (SAEs) for analysis. A total of 733 patients met inclusion criteria. RESULTS: Twenty-seven patients (3.7%) had AAE and 19 patients (2.6%) had SAEs. Both AAE and SAEs were associated with BMI-for-age ninety-fifth percentile or greater (AAE: odds ratio [OR], 3.31; 95% CI, 1.43-7.65; p=0.005. SAE: OR, 3.46; 95% CI, 1.32-9.09; p=0.012). Extended LOS occurred for 60 patients (8.2%) and was associated with greater than 13 levels instrumented (OR, 2.00; 95% CI, 1.11-3.61; p=0.021) and operative time of 365 minutes or more (OR, 2.57; 95% CI, 1.39-4.76; p=0.003). Readmission occurred for 11 patients (1.5%), most often for surgical site infection, and was associated with the occurrence of any complication during the initial hospital stay (OR, 180.44; 95% CI, 35.47-917.97; p<0.001). CONCLUSIONS: Further research on prevention and management of obesity and surgical site infections may reduce perioperative morbidity for patients with AIS undergoing PSF. LEVEL OF EVIDENCE: Level III, prognostic study. See Instructions for Authors for a complete description of levels of evidence.

Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics.

BACKGROUND: Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized. QUESTIONS/PURPOSES: The purpose of our study was to determine patient rates and risk factors for (1) any adverse event; (2) severe adverse events; (3) infectious complications; and (4) readmission after ORIF of ankle fractures. METHODS: Patients who underwent ORIF for ankle fracture from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP(®)) database using International Classification of Diseases, 9(th) Revision and Current Procedural Terminology codes. Patients with missing perioperative data were excluded from this study. Patient characteristics were tested for association with any adverse event, severe adverse events, infectious complications, and readmission using bivariate and multivariate logistic regression analyses. RESULTS: Of the 4412 patients identified, 5% had an adverse event. Any adverse event was associated with insulin-dependent diabetes mellitus (IDDM; odds ratio [OR], 2.05; 95% confidence interval [CI], 1.35-3.1; p = 0.001), age ≥ 60 years (OR, 1.97; 95% CI, 1.22-3.2; p = 0.006), American Society of Anesthesiologists classification ≥ 3 (OR, 1.69; 95% CI, 1.2-2.37; p = 0.002), bimalleolar fracture (OR, 1.6; 95% CI, 1.08-2.37; p = 0.020), hypertension (OR, 1.47; 95% CI, 1.04-2.09; p = 0.031), and dependent functional status (OR, 1.47; 95% CI, 1.02-2.14; p = 0.040) on multivariate analysis. Severe adverse events occurred in 3.56% and were associated with ASA classification ≥ 3 (OR, 2.01; p = 0.001), pulmonary disease (OR, 1.9; p = 0.004), dependent functional status (OR, 1.8; p = 0.005), and hypertension (OR, 1.65; p = 0.021). Infectious complications occurred in 1.75% and were associated with IDDM (OR, 3.51; p < 0.001), dependent functional status (OR, 2.4; p = 0.002), age ≥ 60 years (OR, 2.28; p = 0.028), and bimalleolar fracture (OR, 2.19; p = 0.030). Readmission occurred in 3.17% and was associated with ASA classification ≥ 3 (OR, 2.01; p = 0.017). CONCLUSIONS: IDDM was associated with an increased rate of adverse events after ankle fracture ORIF, whereas noninsulin-dependent diabetes mellitus was not. IDDM management deserves future study, particularly with respect to glycemic control, a potential confounder that could not be assessed with the ACS-NSQIP registry. Increased ASA class was associated with readmission, and future prospective investigations should evaluate the effectiveness of increasing the discharge threshold, discharging to extended-care facilities, and/or home nursing evaluations in this at-risk population. LEVEL OF EVIDENCE: Level III, prognostic study.

Nationwide Inpatient Sample and National Surgical Quality Improvement Program give different results in hip fracture studies.

BACKGROUND: National databases are being used with increasing frequency to conduct orthopaedic research. However, there are important differences in these databases, which could result in different answers to similar questions; this important potential limitation pertaining to database research in orthopaedic surgery has not been adequately explored. QUESTIONS/PURPOSES: The purpose of this study was to explore the interdatabase reliability of two commonly used national databases, the Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP), in terms of (1) demographics; (2) comorbidities; and (3) adverse events. In addition, using the NSQIP database, we identified (4) adverse events that had a higher prevalence after rather than before discharge, which has important implications for interpretation of studies conducted in the NIS. METHODS: A retrospective cohort study of patients undergoing operative stabilization of transcervical and intertrochanteric hip fractures during 2009 to 2011 was performed in the NIS and NSQIP. Totals of 122,712 and 5021 patients were included from the NIS and NSQIP, respectively. Age, sex, fracture type, and lengths of stay were compared. Comorbidities common to both databases were compared in terms of more or less than twofold difference between the two databases. Similar comparisons were made for adverse events. Finally, adverse events that had a greater postdischarge prevalence were identified from the NSQIP database. Tests for statistical difference were thought to be of little value given the large sample size and the resulting fact that statistical differences would have been identified even for small, clinically inconsequential differences resulting from the associated high power. Because it is of greater clinical importance to focus on the magnitude of differences, the databases were compared by absolute differences. RESULTS: Demographics and hospital lengths of stay were not different between the two databases. In terms of comorbidities, the prevalences of nonmorbid obesity, coagulopathy, and anemia in found in the NSQIP were more than twice those in the NIS; the prevalence of peripheral vascular disease in the NIS was more than twice that in the NSQIP. Four other comorbidities had prevalences that were not different between the two databases. In terms of inpatient adverse events, the frequencies of acute kidney injury and urinary tract infection in the NIS were more than twice those in the NSQIP. Ten other inpatient adverse events had frequencies that were not different between the two databases. Because it does not collect data after patient discharge, it can be implied from the NSQIP data that the NIS does not capture more than ½ of the deaths and surgical site infections occurring during the first 30 postoperative days. CONCLUSIONS: This study shows that two databases commonly used in orthopaedic research can identify similar populations of operative patients but may generate very different results for specific commonly studied comorbidities and adverse events. The NSQIP identified higher rates of morbid obesity, coagulopathy, and anemia. The NIS identified higher rates of peripheral vascular disease, acute kidney injury, and urinary tract infection. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

The "July effect" in primary total hip and knee arthroplasty: analysis of 21,434 cases from the ACS-NSQIP database.

The "July effect" is the hypothetical increase in morbidity thought to be associated with the training of new residents during the first portion of the academic year. We evaluated for the presence of the July effect in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database among 21,434 patients who underwent primary total hip or knee arthroplasty. There was no association of an interaction term for academic quarter and resident involvement with "serious adverse events" (P = 0.656) or "any adverse events" (P = 0.578). As a result, this study could not demonstrate a July effect. Patients can be reassured that undergoing total joint arthroplasty during the first part of the academic year is without increased risk of adverse events related to the training of residents.

Perioperative Complications Associated With Limited Surgical Fasciectomy After Collagenase Clostridium Histolyticum for Dupuytren Contracture.

BACKGROUND: The purpose of this study was to determine the perioperative complication rate of surgical fasciectomy following previous treatment with collagenase clostridium histolyticum (CCH) treatment in patients with Dupuytren disease. METHODS: A retrospective review of all patients at a large health system undergoing CCH treatment and subsequent limited surgical fasciectomy for recurrence on the same digit between 2010 and 2020 was performed. Fifty-two patients with 62 affected digits met inclusion criteria, and cases were reviewed for preoperative demographics, treatment characteristics, clinical outcomes, and perioperative complications. RESULTS: Fifty-five digits in 48 patients were treated with CCH and underwent subsequent limited surgical fasciectomy. Of all digits in the present study, 3 (6.3%) had a documented surgical complication following open surgical fasciectomy. There were zero postoperative infections, vascular injuries, or tendon injuries. The rate of nerve injury was 2.1%. The rate of postoperative skin necrosis was 4.2%. These rates were comparable or lower than those of historical published data. CONCLUSIONS: The rate of perioperative complications in patients undergoing limited surgical fasciectomy after previous CCH treatment is low. The findings of this study will aid the counseling of Dupuytren patients in deciding whether to pursue treatment with CCH versus open surgical fasciectomy.

Upper Extremity Immobilization and Driving: Limitations and Liability.

Orthopaedic injuries of the upper extremity remain common, often requiring prolonged immobilization after surgical or nonsurgical management. Upper extremity immobilization often has a profound effect on a patient's daily life, including one's ability to safely operate a motor vehicle. Current literature on the safety of driving while immobilized is varied, although above-elbow immobilization of the upper extremity is generally thought to present a particular hazard to safe driving. Unfortunately, as common as this situation is, currently little to no guidance exists for patients, physicians, or lawmakers with regard to deciding whether a patient is safe to return to driving with upper extremity immobilization. Similar discord exists with the issue of patient and physician liability in such cases. In this review, we seek to present both historical precedent and a contemporary update of this complex, though a frequently encountered situation.

Fingertip Injury and Management.

Fingertip injuries are common and can be difficult to manage because of unique anatomical considerations. Optimal treatment minimizes residual pain while preserving the function, length, and sensation of the affected digit. Several types of fingertip injury, including sharp or crush injuries, partial or complete amputations, and those involving the nail plate or nail bed, can occur. Depending on the type of injury, location within the fingertip, degree of soft-tissue loss, and involvement of perionychium, the most effective management may be one of several options. Knowledge of local and regional anatomy is paramount in selecting and performing the procedure that provides the best outcome. To address the array of possible fingertip injuries, we demonstrate several treatment options including (1) local flap reconstruction, (2) regional flap reconstruction, (3) revision or completion amputation, (4) nail bed repair, (5) acellular dermal regeneration templating, and (6) replantation. Outcomes are generally favorable but can be affected by injury and patient characteristics. The most common complications include nail deformity, cold intolerance, and painful neuroma formation.

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

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

Severity Weighting of Postoperative Adverse Events in Orthopedic Surgery.

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

Perioperative Outcomes After Cervical Laminoplasty Versus Posterior Decompression and Fusion: Analysis of 779 Patients in the ACS-NSQIP Database.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the short-term outcomes for patients undergoing cervical laminoplasty versus posterior decompression and fusion for multilevel cervical pathology. SUMMARY OF BACKGROUND DATA: There are conflicting data regarding the merits of cervical laminoplasty and posterior decompression and fusion for the treatment of multilevel cervical pathology. METHODS: Patients who underwent cervical laminoplasty or posterior decompression and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2012. Baseline patient characteristics were compared using bivariate logistic regression. Propensity-adjusted multivariate regressions were performed to assess differences in postoperative length of stay, adverse events, and 30-day readmission. RESULTS: A total of 779 patients were included in this study: 437 (56.1%) underwent cervical decompression and fusion and 342 (43.9%) underwent cervical laminoplasty. Decompression and fusion patients were found to be more comorbid at baseline than laminoplasty patients based on increased American Society of Anesthesiologists scores and Charlson Comorbidity Index.Propensity-adjusted multivariate analysis was used to control for differences in baseline patient characteristics, and found that compared with laminoplasty patients, decompression and fusion patients had increased length of stay (+1.2 d, P<0.001), greater rates of any adverse event (OR=1.7, P=0.018), and were more likely to be readmitted (OR=2.3, P=0.028). CONCLUSIONS: Posterior cervical decompression and fusion patients were found to have moderately worse short-term outcomes than laminoplasty patients. The information provided here can be used to inform patients and surgeons about the likely perioperative experience after they have made the decision to pursue 1 of these 2 procedures.

Adverse events, length of stay, and readmission after surgery for tibial plateau fractures.

OBJECTIVES: To identify factors that are associated with short-term outcomes after open reduction and internal fixation (ORIF) for tibial plateau fracture. METHODS: Patients who underwent ORIF for tibial plateau fracture from 2009 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with any adverse event (AAE), severe adverse events (SAEs), infectious complications, extended length of stay (LOS), and readmission within 30 days. RESULTS: A total of 519 tibial plateau fracture patients met inclusion criteria. Ten percent had AAE, 7% had SAEs, and 4% had an infectious complication. Extended LOS was defined as LOS >3 days (75th percentile LOS). Four percent of patients were readmitted. AAE was associated with increased American Society of Anesthesiologists (ASA) class [relative risk (RR) = 3.8] and history of pulmonary disease (RR = 2.1) on multivariate analysis. SAE was associated with male sex (RR = 2.2) and increased ASA class (RR = 3.6). Infectious complications were associated with male sex (RR = 3.0), increased ASA class (RR = 3.3), smoking (RR = 2.8), pulmonary disease (RR = 2.9), and bicondylar fracture (RR = 2.7). Extended LOS was associated with increased age (RR = 2.1), increased ASA class (RR = 2.0), diabetes (RR = 1.6), pulmonary disease (RR = 1.8), bicondylar fracture (RR = 1.6), and increased operative time (RR = 1.6). Readmission was associated with increased ASA class (RR = 3.9), diabetes (RR = 2.9), dependent functional status (RR = 8.1), and discharge to home (RR = 5.7). CONCLUSIONS: The above-identified factors associated with outcomes after ORIF for tibial plateau fracture may be useful for patient counseling. LEVEL OF EVIDENCE: Prognostic level II. See Instructions for authors for a complete description of levels of evidence.

Comparison of the lumbar disc herniation patients randomized in SPORT to 6,846 discectomy patients from NSQIP: demographics, perioperative variables, and complications correlate well.

BACKGROUND CONTEXT: The Spine Patient Outcomes Research Trial (SPORT) is a highly referenced clinical trial that randomized patients with lumbar pathology to receive surgery or continued conservative treatment. PURPOSE: The purpose of this study was to compare the SPORT lumbar disc herniation cohort and an analogous cohort from the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN/SETTING: This is a retrospective cohort study comparing a national database population to a randomized clinical trial. PATIENT SAMPLE: Elective lumbar discectomies from NSQIP between 2010 and 2012 were used. OUTCOME MEASURES: Demographics were compared between the randomized SPORT cohorts (surgical and nonoperative) and NSQIP. Perioperative factors and complications were then compared between SPORT discectomy patients and NSQIP. METHODS: Using current procedural terminology and International Classification of Diseases, ninth revision codes, all elective lumbar discectomies from NSQIP between 2010 and 2012 were identified. Where possible based on the published data and variables available in each cohort, the two populations were compared. RESULTS: A total of 6,846 NSQIP discectomy patients were compared with the randomized SPORT surgical and nonoperative cohorts. Demographic comparisons showed that NSQIP patients were older (average age 48.2±14.5 years [mean±standard deviation] vs. 41.7±11.8 and 43.0±11.3 years, respectively [p<.001]) and had higher body mass index (29.6±6.2 kg/m(2) vs. 27.8±5.6 and 28.2±5.4 kg/m(2), respectively [p<.001]). No statistical differences existed for gender or race. Smoking status was not different between the SPORT nonoperative group and NSQIP but was higher in NSQIP compared with SPORT surgical patients (p=.020 by 7%). Comparisons of perioperative factors and complications between the SPORT surgical cohort and NSQIP showed no statistical difference in average operative time, length of stay, deep wound infections, wound dehiscence, total wound complications, or blood transfusions. Spine Patient Outcomes Research Trial superficial wound infection rates were higher than NSQIP (p=.029 by 1.4%). As expected, SPORT 1-year reoperation rates were higher than NSQIP 30-day rates (7% vs. 2%, p<.001). CONCLUSIONS: Spine Patient Outcomes Research Trial lumbar disc herniation results are similar to those from a large national patient sample. Even statistically significant differences would be considered clinically similar. These findings support the generalizability of the SPORT lumbar disc herniation results.

General compared with spinal anesthesia for total hip arthroplasty.

BACKGROUND: Total hip arthroplasty may be performed under general or spinal anesthesia. The purpose of the current study was to compare perioperative outcomes between anesthetic types for patients undergoing primary elective total hip arthroplasty. METHODS: Patients who had undergone primary elective total hip arthroplasty from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Operating room times, length of stay, thirty-day adverse events, and readmission were compared between patients who had received general anesthesia and those who had received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. RESULTS: A total of 20,936 patients who had undergone total hip arthroplasty met inclusion criteria for this study. Of these, 12,752 patients (60.9%) had received general anesthesia and 8184 patients (39.1%) had received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia for total hip arthroplasty was associated with increased operative time (+12 minutes [95% confidence interval, +11 to +13 minutes]; p < 0.001) and postoperative room time (+5 minutes [95% confidence interval, +4 to +6 minutes]; p < 0.001). General anesthesia was also associated with the occurrence of any adverse event (odds ratio, 1.31 [95% confidence interval, 1.23 to 1.41]; p < 0.001), prolonged postoperative ventilator use (odds ratio, 5.81 [95% confidence interval, 1.35 to 25.06]; p = 0.018), unplanned intubation (odds ratio, 2.17 [95% confidence interval, 1.11 to 4.29]; p = 0.024), stroke (odds ratio, 2.51 [95% confidence interval, 1.02 to 6.20]; p = 0.046), cardiac arrest (odds ratio, 5.04 [95% confidence interval, 1.15 to 22.07]; p = 0.032), any minor adverse event (odds ratio, 1.35 [95% confidence interval, 1.25 to 1.45]; p = 0.001), and blood transfusion (odds ratio, 1.34 [95% confidence interval, 1.25 to 1.45]; p < 0.001). General anesthesia was not associated with any difference in preoperative room time, postoperative length of stay, or readmission. CONCLUSIONS: General anesthesia was associated with an increased rate of adverse events and mildly increased operating room times.

Comparison of 368 patients undergoing surgery for lumbar degenerative spondylolisthesis from the SPORT trial with 955 from the NSQIP database.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To compare demographics and perioperative outcomes between the Spine Patient Outcomes Research Trial (SPORT) lumbar degenerative spondylolisthesis arm and a similar population from the National Surgical Quality Improvement Program (NSQIP) database. SUMMARY OF BACKGROUND DATA: SPORT is a well-known surgical trial that investigated the benefits of surgical versus nonsurgical treatment in patients with various lumbar pathologies. However, the external validity of SPORT demographics and outcomes has not been fully established. METHODS: Surgical degenerative spondylolisthesis cases were identified from NSQIP between 2010 and 2012. This population was then compared with the SPORT degenerative spondylolisthesis study. These comparisons were based on published data from SPORT and included analyses of demographics, perioperative factors, and complications. RESULTS: The 368 surgical patients with degenerative spondylolisthesis in SPORT were compared with 955 patients identified in NSQIP. Demographic comparisons were as follows: average age and race (no difference; P > 0.05 for each), sex (9.1% more female patients in SPORT; P = 0.002), smoking status (6.6% more smokers in NSQIP; P = 0.002), and average body mass index (1.1 kg/m greater in NSQIP; P = 0.005). Larger differences were noted in what surgical procedure was performed (P < 0.001), with the most notable difference being that the NSQIP population was much more likely to include interbody fusion than the SPORT population (52.4% vs. 12.5%). Most perioperative factors and complication rates were similar, including average operative time, wound infection, wound dehiscence, postoperative transfusion, and postoperative mortality (no differences; P > 0.05 for each). Average length of stay was shorter in NSQIP compared with SPORT (3.7 vs. 5.8 d; P = 0.042). CONCLUSION: Though important differences in the distribution of surgical procedures were identified, this study supports the greater generalizability of the surgical SPORT degenerative spondylolisthesis study based on similar demographics and perioperative outcomes when compared with patients from the NSQIP database. LEVEL OF EVIDENCE: 3.

Risk Factors for Thromboembolic Events After Surgery for Ankle Fractures.

We conducted a retrospective national-cohort study to determine the incidence of and independent risk factors for venous thromboembolic events (VTEs) after open reduction and internal fixation (ORIF) of ankle fractures. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent ORIF for ankle fracture between 2005 and 2012. VTE was defined as the occurrence of a deep vein thrombosis or a pulmonary embolism within the first 30 postoperative days. Of the 4412 ankle fracture patients who met the inclusion criteria, 33 (0.8%) had a VTE. Multivariate analysis revealed that body mass index (BMI) of 30 to 35 kg/m2 (odds ratio [OR], 4.77; 95% confidence interval [CI], 1.05-21.72; P = .044), BMI of 35 kg/m2 or higher (OR, 4.71; 95% CI, 1.03-21.68; P = .046), heart disease (OR, 3.28; 95% CI, 1.20-8.97; P = .020), and dependent functional status (OR, 2.59; 95% CI, 1.11-6.04; P = .028) were independently associated with occurrence of VTE after ankle fracture ORIF. Patients with higher BMI and patients with heart disease or dependent functional status may be considered for VTE prophylaxis.

Undertapping of Lumbar Pedicle Screws Can Result in Tapping With a Pitch That Differs From That of the Screw, Which Decreases Screw Pullout Force.

STUDY DESIGN: Survey of spine surgeons and biomechanical comparison of screw pullout forces. OBJECTIVE: To investigate what may be a suboptimal practice regularly occurring in spine surgery. SUMMARY OF BACKGROUND DATA: In order for a tap to function in its intended manner, the pitch of the tap should be the same as the pitch of the screw. Undertapping has been shown to increase the pullout force of pedicle screws compared with line-to-line tapping. However, given the way current commercial lumbar pedicle screw systems are designed, undertapping may result in a tap being used that has a different pitch from that of the screw (incongruent pitch). METHODS: A survey asked participants questions to estimate the proportion of cases each participant performed in the prior year using various hole preparation techniques. Participant responses were interpreted in the context of manufacturing specifications of specific instrumentation systems. Screw pullout forces were compared between undertapping with incongruent pitch and undertapping with congruent pitch using 0.16 g/cm polyurethane foam block and 6.5-mm screws. RESULTS: Of the 3679 cases in which participants reported tapping, participants reported line-to-line tapping in 209 cases (5%), undertapping with incongruent pitch in 1156 cases (32%), and undertapping with congruent pitch in 2314 cases (63%). The mean pullout force for undertapping with incongruent pitch was 56 N (8%) less than the mean pullout force for undertapping with congruent pitch. This is equivalent to 13 lb. CONCLUSION: This study estimates that for about 1 out of every 3 surgical cases with tapping of lumbar pedicle screws in the United States, hole preparation is being performed by undertapping with incongruent pitch. This study also shows that undertapping with incongruent pitch results in a decrease in pullout force by 8% compared with undertapping with congruent pitch. Steps should be taken to correct this suboptimal practice. LEVEL OF EVIDENCE: 3.