Telemedicine in Arthroplasty Patients: Which Factors Are Associated With High Satisfaction?

Background

During the initial coronavirus pandemic lockdown period, remote hip and knee arthroplasty care was heavily employed out of necessity. However, data on patient satisfaction with telemedicine specific to hip and knee arthroplasty patients remains unknown.

Methods

All patients who had a telemedicine visit in the hip and knee arthroplasty department and completed a telemedicine satisfaction survey at a specialty hospital from April 1, 2020, to December 31, 2020, were identified. Patient satisfaction with telemedicine, gauged through a series of questions, were analyzed and evaluated over time. Independent factors associated with high satisfaction, defined as the "Top Box" response to the survey question "Likelihood of your recommending our video visit service to others," were identified.

Results

Overall, 29,003 patients who had an in-person or telemedicine visit in the hip and knee arthroplasty department during the study period were identified. During the initial coronavirus pandemic lockdown period, defined as April 1, 2020-May 31, 2020, rate of overall telemedicine utilization was approximately 84%. After the initial lockdown period, the rate of overall telemedicine utilization was approximately 8% of all visits per month. Average satisfaction scores for a series of 14 questions were consistently above 4.5 out of 5. Multivariable regression revealed younger age, particularly 18-64 years old, to be the only independent factor associated with high satisfaction with telemedicine. The rate of high satisfaction remained statistically similar throughout the study period (P > .05).

Conclusions

Patient satisfaction with telemedicine was consistently high in various domains and remained high throughout the study period, regardless of loosened pandemic restrictions. This technology will most likely continue to be utilized, but perhaps it should be targeted at patients younger than 65 years of age.

Correcting Hip Dysplasia in Young Adults: Intraoperative Navigation and Outcomes

Developmental dysplasia of the hip (DDH) often leads to characteristic acetabular dysplasia and typical femoral anomalies. There are numerous treatments for skeletally mature patients with DDH including hip arthroscopy, pelvic and femoral osteotomies, as well as total hip arthroplasty. Before proceeding to an arthroplasty procedure, it can be helpful to obtain an opinion of a hip preservation specialist to ascertain if alternative surgical treatments could contribute to the patient's care. In general, the use of robotic navigation has been associated with a higher proportion of cups placed in the Lewinnek safe zone, larger improvements in Harris Hip Scores, and no difference in overall complication rates in comparison to manual total hip arthroplasty. The use of robotic navigation allows for both 2-dimensional and 3-dimensional preoperative templating, enabling the surgeon to plan the position of the construct such that it achieves maximum bony purchase and hip stability. In complex DDH cases, surgeons can work with a biomechanics department to complete a fit check assessment, which utilizes 3-dimensional templating software to ascertain the appropriateness of the implant's geometry with the patient's anatomy. Furthermore, a 3-dimensional printed plastic model of the pelvis and/or femur can be constructed in order to complete a rehearsal procedure, which may be particularly helpful for those cases involving osteotomies. The literature on the use of robotic-assisted total hip arthroplasty in patients with DDH demonstrates improved component positioning in comparison to navigated as well as manual methods; however, studies with long-term follow-up in this patient population are lacking.

Variability of pre-operative functional pelvic tilt in total hip arthroplasty patients

PURPOSE

Pelvic tilt (PT) is important to consider when planning total hip arthroplasty (THA) due to its dynamic impact on acetabular orientation. The degree of sagittal pelvic rotation varies during functional activities and can be difficult to measure without proper imaging. The purpose of this study was to evaluate PT variation in the supine, standing, and seated positions.

METHODS

A multi-centre cross-sectional study was performed that included 358 THA patients who had preo-perative PT measured from supine CT scan and standing and upright seated lateral radiographs. Supine, standing, and seated PT and associated changes between functional positions were evaluated. Anterior PT was assigned a positive value.

RESULTS

In the supine position, mean PT was 4° (range, -35° to 20°), where 23% had posterior PT and 69% anterior PT. In the standing position, mean PT was 1° (range, -23° to 29°), where 40% had posterior PT and 54% anterior PT. In the seated position, mean PT was -18° (range, -43° to 47°), where 95% had posterior PT and 4% anterior PT. From standing to seated, the pelvis rotated posteriorly in 97% of cases (maximum 60°) with 16% of cases considered stiff (change ≤ 10°) and 18% of cases considered hypermobile (change ≥ 30°).

CONCLUSION

Patients undergoing THA have marked PT variation in the supine, standing, and seated positions. There was wide variability in PT change from standing to seated, with 16% of patients considered stiff and 18% considered hypermobile. Functional imaging should be performed on patients prior to THA to allow for more accurate planning.

Ambulatory Single-level Posterior Cervical Foraminotomy for Cervical Radiculopathy: A Propensity-matched Analysis of Complication Rates

STUDY DESIGN

Retrospective cohort comparison study.

OBJECTIVE

The aim was to compare perioperative complications and 30-day readmission between ambulatory and inpatient posterior cervical foraminotomy (PCF) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

SUMMARY OF BACKGROUND DATA

Single-level PCF for cervical radiculopathy is increasingly being performed as an ambulatory procedure. Despite this increase, there is a lack of published literature documenting the safety of ambulatory PCF.

MATERIALS AND METHODS

Patients who underwent PCF (through laminotomy or laminectomy) were identified in the 2005-2018 NSQIP database. Ambulatory procedures were defined as cases that had hospital length of stay=0 days. Inpatient procedures were defined as cases that had length of stay=1-4 days. Patient characteristics, comorbidities, and procedural variables (laminotomy or laminectomy performed) were compared between the 2 cohorts. Propensity score matched comparisons were then performed for postoperative complications and 30-day readmissions between the 2 groups.

RESULTS

In total, 795 ambulatory and 1789 inpatient single-level PCF cases were identified. After matching, there were 795 ambulatory and 795 inpatient cases. Statistical analysis after propensity score matching revealed no significant difference in individual complications including 30-day readmission, thromboembolic events, wound complications, and reoperation, or aggregated complications between ambulatory versus matched inpatient procedures. Overall 30-day readmissions after ambulatory single-level PCF were noted for 2.46% of the study population, and the most common reasons were surgical site infections (46%) and pain control (15%).

CONCLUSIONS

The perioperative outcomes assessed in this study support the conclusion that single-level PCF for cervical radiculopathy can be performed for correctly selected patients in the ambulatory setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient procedures.

LEVEL OF EVIDENCE

Level III.

Patients Who Undergo Early Aseptic Revision TKA Within 90 Days of Surgery Have a High Risk of Re-revision and Infection at 2 Years: A Large-database Study

BACKGROUND

Early aseptic revision within 90 days after primary TKA is a devastating complication. The causes, complications, and rerevision risks of aseptic revision TKA performed during this period are poorly described.

QUESTIONS/PURPOSES

(1) What is the likelihood of re-revision within 2 years after early aseptic TKA revision within 90 days compared with that of a control group of patients undergoing primary TKA? (2) What are the indications for early aseptic TKA revision within 90 days? (3) What are the differences in revision risk between different indications for early aseptic revision TKA?

METHODS

Patients who underwent unilateral aseptic revision TKA within 90 days of the index procedure were identified in a national insurance claims database (PearlDiver Technologies) using administrative codes. The exclusion criteria comprised revision for infection, history of bilateral TKA, and age younger than 18 years. The PearlDiver database was selected for its large and geographically diverse patient base and the availability of outpatient follow-up data that are unavailable in other databases focused on inpatient care. A total of 481 patients met criteria for early aseptic revision TKA, with 14% (67) loss to follow-up at 2 years. This final cohort of 414 patients was compared with a control group of patients who underwent primary TKA without revision within 90 days. For the control group, 137,661 patients underwent primary TKA without early revision, with 13% (18,138) loss to follow-up at 2 years. Among these patients, 414 controls were matched using a one-to-one propensity score method; no differences in age, gender, and Charlson comorbidity index score were observed between the groups. Indications for initial revision and 2-year re-revision were recorded. The Kaplan-Meier method was used to assess survival between the early revision and control groups.

RESULTS

Two-year survivorship free from additional revision surgery was lower in the early aseptic revision cohort compared with the control (78% [95% confidence interval 77% to 79%] versus 98% [95% CI 96% to 99%]; p < 0.001). Among early revisions, 10% (43 of 414) of the patients underwent re-revision for periprosthetic infection with an antibiotic spacer within 2 years. The reasons for early aseptic revision TKA were instability/dislocation (37% [153 of 414]), periprosthetic fracture (23% [96 of 414]), aseptic loosening (23% [95 of 414]), pain (11% [45 of 414]), and arthrofibrosis (6% [25 of 414]). Early revision for pain was associated with higher odds of re-revision than early revisions performed for other all other reasons (44% [20 of 45] versus 29% [100 of 344]; odds ratio 2.0 [95% CI 1.0 to 3.7]; p = 0.04).

CONCLUSION

Acute early aseptic revision TKA carries a high risk of re-revision at 2 years and a high risk of subsequent periprosthetic joint infection. Patients who undergo an early revision should be carefully counseled regarding the very high risk of repeat revision and discouraged from having early revision unless the indications are absolutely clear and compelling. Early aseptic revision for pain alone carries an unacceptably high risk of repeat revision and should not be performed. Adjunctive measures for infection prophylaxis should be strongly considered. Specific interventions to reduce surgical complications in this subset of patients have not been adequately studied; additional investigation of strategies to minimize the risk of reoperation or infection is warranted.

LEVEL OF EVIDENCE

Level III, therapeutic study.

What Are the Reasons and Risk Factors for 30-Day Readmission After Outpatient Total Hip Arthroplasty?

BACKGROUND

A higher volume of primary total hip arthroplasty (THA) is starting to be performed as an outpatient procedure. However, data on appropriate patient selection for this surgical protocol is scarce.

METHODS

Patients who underwent primary THA were identified in the 2012-2018 National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days. The primary outcome was a readmission within the 30-day postoperative period. Risk factors for and effect of overnight hospital stay on 30-day readmission after outpatient THA were identified through multivariable models. Reasons for and timing of readmission were also identified.

RESULTS

A total of 5245 outpatient THA patients and 44,171 patients who stayed 1 night were identified. The incidence of 30-day readmission after outpatient THA was 1.60% (95% confidence interval [CI] 1.26-1.94). Risk factors for 30-day readmission after outpatient THA include the following: older age relative to 18-60 years old (most notably 71-75 years old, relative risk [RR] = 2.3, 95% CI = 1.15-4.62; 76-80 years old, RR = 6.6, 95% CI = 3.55-12.43; and >80 years old, RR = 5.6, 95% CI = 2.43-12.89, P < .001) and bleeding disorders (RR = 4.5, 95% CI = 1.45-14.31, P = .010). For patients who had some of these risk factors, their risk of medically related 30-day readmission was reduced if they had stayed 1 night at the hospital (P < .05). The majority of readmissions were surgically related (62%), including wound complications (27%) and periprosthetic fractures (25%).

CONCLUSION

The rate of 30-day readmission after outpatient THA was low. Patients who are at high risk for 30-day readmission after outpatient THA include those with older age and bleeding disorders. Some of these patients may benefit from an inpatient hospital stay.

Spinal fractures and/or spinal cord injuries are associated with orthopedic and internal organ injuries in proximity to the spinal injury

Background

the demographics, mechanisms of injury, and concurrent injuries associated with cervical, thoracic and lumbar spinal fracture and/or spinal cord injury remain poorly characterized.

Methods

Patients aged 18 and older with spinal injury between 2011 and 2015 in the National Trauma Data Bank (NTDB) were identified. Patient demographics, comorbidity burden, mechanism of injury, and associated injuries were analyzed.

Results

in total, 520,183 patients with acute spinal injury were identified including 216,522 cervical, 191,218 thoracic, and 220,294 lumbar. The age distributions were trimodal with peaks in incidence at around 2155 and a lesser peak around 85 years of age. The number of comorbidities increased while injury severity decreased with advancing patient age. Motor vehicle accidents (MVAs) were the most common mechanism of injury. Associated bony and internal organ injuries were common and occurred in 63% of cervical spine injury patients, 79% of thoracic spine injury patients, and 71% of lumbar spine injury patients. In all three sub-populations, there was a predominance of injuries in the local area of the primary injury. For cervical, these were rib injuries (28%), thoracic spine injuries (22%), skull fractures (20%), intracranial injuries (26%) and lung injuries (21%). For thoracic, these were rib injuries (47%), lumbar spine injuries (26%), cervical spine injuries (25%), lung injuries (35%) and intracranial injuries (24%). For lumbar, these were rib injuries (38%), thoracic spine injuries (22%), pelvic fractures (20%), lung injuries (26%) and intracranial injuries (19%). Multivariate regression analysis demonstrated that increased injury severity was strongly correlated with increased mortality, with lesser contributions from increased age and comorbidity burden.

Conclusions

the current study revealed spinal fractures and/or cord injuries had high incidences of associated injuries that had a predominance of local distribution. These findings, in combination with the mortality analysis, demonstrate the importance of local targeted evaluations for associated injuries.

Etiology and Complications of Early Aseptic Revision Total Hip Arthroplasty Within 90 Days

BACKGROUND

The etiology, complications, and rerevision risks of early aseptic revision total hip arthroplasty (THA) within 90 days are insufficiently documented.

METHODS

A national insurance claims database (PearlDiver Technologies, Fort Wayne, IN) was queried for patients who underwent unilateral aseptic revision THA within 90 days of the index procedure using administrative codes. Patients who underwent revision for infection, without minimum 2-year follow-up, and younger than 18 years were excluded. This cohort was matched based on gender, age, and Charlson Comorbidity Index to a control group of patients who underwent primary THA without revision within 90 days. Two-year rerevision and 90-day complication rates were recorded. Chi-square and Fisher exact tests were used as appropriate for statistical comparison.

RESULTS

Four hundred two patients met the inclusion criteria for early aseptic revision within 90 days of the index procedure and were matched to the control group. The overall 2-year rerevision rate was higher in the early revision group compared with control group (14.9% vs 2.5%, P < .001). Complications within 90 days occurred more frequently in the early revision group, including blood transfusion (10.2% vs 3.2%, P < .001), deep vein thrombosis (9.0% vs 3.2%, P = .001), and pulmonary embolism (2.74% vs 0.75%, P = .031). The most common reasons for early aseptic revision were dislocation (41.5%), fracture (38.1%), and loosening (17.4%).

CONCLUSION

Early aseptic revision THA is associated with significantly higher 90-day complication rates and 2-year rerevision rates compared with a control group of primary THA without revision. The most common reasons for acute early revision were dislocation, fracture, and mechanical loosening.

LEVEL OF EVIDENCE

Level III.

Local antibiotics in posterior lumbar fusion procedures for neuromuscular scoliosis: a case for their use

BACKGROUND CONTEXT

Surgical site infections (SSIs) are medically devastating and financially costly complications after posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS). Many strategies exist to reduce their occurrence. The efficacy of intraoperative antibiotics in the wound or bone graft is gaining in popularity, but this practice has not been well-studied in the PSF NMS population.

PURPOSE

To assess the potential utility of intraoperative local antibiotics in patients with NMS undergoing PSF.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Pediatric patients who underwent PSF for NMS were identified from the 2016-2018 National Surgical Quality Improvement Program (NSQIP) pediatric spinal fusion datasets.

OUTCOME MEASURES

Perioperative adverse outcome variables assed included the occurrence of SSI, renal complications, and adverse hospital metrics.

METHODS

Patient demographic factors, comorbidities, and the use of intraoperative antibiotics in the wound were recorded (a specifically assessed variable in the dataset). The association between the use of intraoperative antibiotics and the occurrence of adverse outcomes/infection was assessed for the entire study population and higher risk sub-populations.

RESULTS

In total, 1,990 patients met the inclusion criteria, of which 87% received local antibiotics. Higher risk patients were more likely to receive local antibiotics in the wound as part of their procedure. When controlling for potentially confounding factors, the use of local antibiotics was not statistically significantly associated with any of the studied adverse outcomes for the overall study population. Subgroup analysis of higher risk patient populations (≥13 levels fused, osteotomy performed, prior deformity surgery, nonasthma lung condition) revealed a significantly decreased risk of SSI in patients undergoing ≥13 level fusions (relative risk: 0.48, 95% confidence interval: 0.25-0.91).

CONCLUSIONS

With no increased overall risks and reduced SSIs in higher risk NMS patients undergoing PSF, the use of intrawound antibiotics appears to be supported by this dataset.

Perioperative Outcomes of Hemiarthroplasty Versus Total Hip Arthroplasty for Geriatric Hip Fracture: The Importance of Studying Matched Populations

BACKGROUND

Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study.

METHODS

Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.

RESULTS

In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P < .001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation.

CONCLUSION

Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Preoperative laboratory testing for total hip arthroplasty: Unnecessary tests or a helpful prognosticator

BACKGROUND

The last decade has seen increasing initiatives to improve health care delivery while decreasing financial expenditures, as particularly exemplified by the implementation of bundled payments for lower extremity arthroplasty, which hold the providers responsible for the both the quality and cost of these procedures. In this context, the utility of routine preoperative laboratory testing is unknown. The present study characterizes the associations, if any, between preoperative sodium, blood urea nitrogen (BUN), and creatinine values and the occurrence of general health adverse outcomes following total hip arthroplasty (THA).

METHODS

Patients undergoing primary THA were identified in the 2011-2015 National Surgical Quality Improvement Program. Cases with traumatic, oncologic, or infectious indications were excluded. Preoperative levels of sodium, BUN, and creatinine were tested for associations with perioperative adverse events and adverse hospital metrics using multivariate regressions that adjusted for patient baseline characteristics.

RESULTS

A total of 92,093 patients were included, of which 5.25% had an abnormal preoperative sodium level, 24.20% had an abnormal preoperative BUN level, and 11.95% had an abnormal preoperative creatinine level. Abnormal preoperative sodium levels (odds ratios: 1.23-1.50, p < 0.007) and creatinine levels (odds ratios: 1.27-1.55, p < 0.007) were associated with the occurrence of all studied adverse outcomes and abnormal preoperative BUN levels (odds ratios: 1.15-1.52, p < 0.007) were associated with the occurrence of all adverse outcomes except for hospital readmission.

CONCLUSIONS

Abnormal preoperative laboratory testing is significantly associated with adverse outcomes following THA, supporting the added value of laboratory evaluation of patients before elective arthroplasty procedures.

STUDY DESIGN

Clinical, Level III.

Demographics, mechanism of injury, and associated injuries of 25,615 patients with talus fractures in the National Trauma Data Bank

BACKGROUND

Extensive research has been conducted concerning the epidemiology of fractures of the calcaneus and ankle. However, less work has characterized the population sustaining talus fractures, necessitating the analysis of a large, national sample to assess the presentation of this important injury.

METHODS

The current study included adult patients from the 2011 through 2015 National Trauma Data Bank (NTDB) who had talus fractures. Modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), Injury Severity Score (ISS), and associated injuries were evaluated.

RESULTS

Out of 25,615 talus fracture patients, 15,607 (61%) were males. The age distribution showed a general decline in frequency as age increased after a peak incidence at 21 years of age. As expected, CCI increased as age increased. The mechanism of injury analysis showed a decline in motor vehicle accidents (MVAs) and an increase in falls as age increased. ISS was generally higher for MVAs compared to falls and other injuries.Overall, 89% of patients with a talus fracture had an associated injury. Among associated bony injuries, non-talus lower extremity fractures were common, with ankle fractures (noted in 42.7%) and calcaneus fractures (noted in 27.8%) being the most notable. The most common associated internal organ injuries were lung (noted in 19.0%) and intracranial injuries (noted in 14.9%).

CONCLUSION

This large cohort of patients with talus fractures defined the demographics of those who sustain this injury and demonstrated ankle and calcaneus fractures to be the most commonly associated injuries. Other associated orthopaedic and non-orthopaedic injuries were also defined. In fact, the incidence of associated lumbar spine fracture was similar to that seen for calcaneus fractures (14%) and nearly 1 in 5 patients had a thoracic organ injury. Clinicians need to maintain a high suspicion for such associated injuries for those who present with talus fractures.

LEVEL OF EVIDENCE

Level II, retrospective study.

Surgical Treatment of Septic Shoulders: A Comparison Between Arthrotomy and Arthroscopy

PURPOSE

To compare the efficacy, as measured through the rate of reoperation, and rates of other 30-day perioperative complications between arthrotomy and arthroscopy for the treatment of septic native shoulders in a national patient population.

METHODS

Patients who were diagnosed with septic arthritis in a native shoulder and underwent irrigation and debridement through arthrotomy or arthroscopy were identified in the 2005-2016 National Surgical Quality Improvement Program database. Patient preoperative characteristics were characterized. Rate of reoperation, a proxy used to measure treatment efficacy, and other perioperative complications were compared between the 2 procedures.

RESULTS

In total, 100 patients undergoing shoulder arthrotomy and 155 patients undergoing shoulder arthroscopy for septic shoulder were identified. On univariate analysis, there were no statistically significant differences in patient preoperative characteristics, operative time (60 vs. 48 minutes, P = .290), length of stay (7.5 vs. 6.6 days, P = .267), or time to reoperation (8.9 vs. 7.2 days, P = .594) between the 2 surgical groups. On multivariate analysis controlling for patient characteristics, there were no statistically significant differences in risk of reoperation (relative risk [RR] = 1.914, 99% confidence interval [CI] = 0.730-5.016, P = .083), any adverse events (RR = 1.254, 99% CI = 0.860-1.831, P = .122), minor adverse events (RR = 1.304, 99% CI = 0.558-3.047, P = .421), serious adverse events (RR = 1.306, 99% CI = 0.842-2.025, P = .118), or readmission (RR = 0.999, 99% CI = 0.441-2.261, P = .998) comparing arthrotomy with arthroscopy.

CONCLUSIONS

By demonstrating similar rates of reoperation, other postoperative complications, and 30-day readmissions, the current study suggests that arthrotomy and arthroscopic surgery have similar efficacy in treating septic shoulders. However, owing to the small sample size, there is still the possibility of a type II error.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective comparative study.

Management of Degenerative Spondylolisthesis: Analysis of a Questionnaire Study, Correlation With a National Sample, and Perioperative Outcomes of Treatment Options

Background

Surgical treatment for lumbar degenerative spondylolisthesis has been shown to provide better long-term outcomes than conservative treatment. However, there is variation in surgical approaches employed by surgeons. This study investigates current surgical practice patterns and compares perioperative outcomes of 3 common surgical treatments for this pathology.

Methods

A survey was administered to surgeons who attended the Lumbar Spine Research Society (LSRS) meeting in 2014. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2014 to characterize the same responses. The 2 data sets were compared. Perioperative outcomes of those in the ACS-NSQIP posterior fusion subcohorts were characterized and compared.

Results

Posterior surgical approaches utilized by surgeons who responded to the LSRS survey were similar to those captured by ACS-NSQIP where 72% of those with degenerative spondylolisthesis were fused. Of those that were fused, 8% had an uninstrumented posterior fusion, 33% had an instrumented posterior fusion, and 59% had an instrumented posterior fusion with interbody. On multivariate analysis, there was no difference in risk of postoperative adverse events, readmission, or length of stay between these 3 common types of fusion.

Conclusions

Practice patterns for the posterior management of lumbar degenerative spondylolisthesis were similar between LSRS survey responses and ACS-NSQIP data. The ACS-NSQIP perioperative outcome measures assessed were similar regardless of surgical technique. These findings highlight that cost-benefit considerations and longer-term outcomes have to be the measures by which surgical technique is chosen for degenerative spondylolisthesis.

Incidence and considerations of 90-day readmissions following posterior lumbar fusion

BACKGROUND CONTEXT

Posterior lumbar fusion (PLF) is a commonly performed procedure. The evolution of bundled payment plans is beginning to require physicians to more closely consider patient outcomes up to 90 days after an operation. Current quality metrics and other databases often consider only 30 postoperative days. The relatively new Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD) tracks patient-linked hospital admissions data for up to one calendar year.

PURPOSE

To identify readmission rates within 90 days of discharge following PLF and to put this in context of 30 day readmission and baseline readmission rates.

STUDY DESIGN

Retrospective study of patients in the HCUP-NRD.

PATIENT SAMPLE

Any patient undergoing PLF performed in the first 9 months of 2013 were identified in the HCUP-NRD.

OUTCOME MEASURES

Readmission patterns up to a full calendar year after discharge.

METHODS

PLFs performed in the first 9 months of 2013 were identified in the HCUP-NRD. Patient demographics and readmissions were tracked for 90 days after discharge. To estimate the average admission rate in an untreated population, the average daily admission rate in the last quarter of the year was calculated for a subset of PLF patients who had their operation in the first quarter of the year. This study was deemed exempt by the institution's Human Investigation Committee.

RESULTS

Of 26,727 PLFs, 1,580 patients (5.91%) were readmitted within 30 days of discharge and 2,603 patients (9.74%) were readmitted within 90 days of discharge. Of all readmissions within 90 days, 54.56% occurred in the first 30 days. However, if only counting readmissions above the baseline admission rate of a matched population from the 4th quarter of the year (0.08% of population/day), 89.78% of 90 day readmissions occurred within the first 30 days.

CONCLUSIONS

The current study delineates readmission rates after PLF and puts this in the context of 30-day readmission rates and baseline readmission rates for those undergoing PLF. These results are important for patient counseling, planning, and preparing for potential bundled payments in spine surgery.

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

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

High Publication Rate of Abstracts Presented at Lumbar Spine Research Society Meetings

Background

Although publication rates from multiple orthopedic research conferences have been published in the literature, the publication rates of abstracts presented at the Lumbar Spine Research Society (LSRS) meetings have never been reported. The purpose of this study is to evaluate the publication rates from the LSRS annual meeting years 2008-2012 and then to compare those rates with that of other spine research society meetings.

Methods

Podium presentations from 2008 to 2012 and poster presentations from 2010 to 2012 were reviewed. For each presentation, a PubMed search was performed to determine if a full-text publication existed. χ² tests were used to compare LSRS publication rates to those of other spine meetings. In addition, impact of published articles was evaluated by average citation count and average journal impact factor.

Results

From 2008 to 2012, a total of 332 podium and poster presentations were identified. The overall publication rate was 55.1% (183/332). For podium presentations, this was greatest in 2012 (66.0%) and lowest in 2008 (51.5%). For poster presentations, this was greatest in 2012 (53.6%) and lowest in 2010 (25.0%). The publication rate of presentations is statistically greater than the publication rates of Eurospine (37.8%, P < .001), North American Spine Society (40.0%, P < .001), The International Society for the Study of the Lumbar Spine (45.0%, P = .012), and the Scoliosis Research Society (47.0%, P = .042) but not statistically different than that of Cervical Spine Research Society (65.7%, P = .059). In addition, the average citation count per published article categorized by year ranged from 13 to 31. The average journal impact factor of published articles categorized by year ranged from 2.31 to 2.55.

Conclusions

While LSRS is a relatively young society, these findings point to the high quality of presentations at this scientific meeting. These findings speak to the scientific rigor of presentations at LSRS.

Clinical Relevance

This study helps clinicians and scientists gauge the quality of a research meeting and make informed choices on which gatherings to attend.

Missing data treatments matter: an analysis of multiple imputation for anterior cervical discectomy and fusion procedures

BACKGROUND CONTEXT

The presence of missing data is a limitation of large datasets, including the National Surgical Quality Improvement Program (NSQIP). In addressing this issue, most studies use complete case analysis, which excludes cases with missing data, thus potentially introducing selection bias. Multiple imputation, a statistically rigorous approach that approximates missing data and preserves sample size, may be an improvement over complete case analysis.

PURPOSE

The present study aims to evaluate the impact of using multiple imputation in comparison with complete case analysis for assessing the associations between preoperative laboratory values and adverse outcomes following anterior cervical discectomy and fusion (ACDF) procedures.

STUDY DESIGN/SETTING

This is a retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients undergoing one-level ACDF were identified in NSQIP 2012-2015.

OUTCOME MEASURES

Perioperative adverse outcome variables assessed included the occurrence of any adverse event, severe adverse events, and hospital readmission.

METHODS

Missing preoperative albumin and hematocrit values were handled using complete case analysis and multiple imputation. These preoperative laboratory levels were then tested for associations with 30-day postoperative outcomes using logistic regression.

RESULTS

A total of 11,999 patients were included. Of this cohort, 63.5% of patients had missing preoperative albumin and 9.9% had missing preoperative hematocrit. When using complete case analysis, only 4,311 patients were studied. The removed patients were significantly younger, healthier, of a common body mass index, and male. Logistic regression analysis failed to identify either preoperative hypoalbuminemia or preoperative anemia as significantly associated with adverse outcomes. When employing multiple imputation, all 11,999 patients were included. Preoperative hypoalbuminemia was significantly associated with the occurrence of any adverse event and severe adverse events. Preoperative anemia was significantly associated with the occurrence of any adverse event, severe adverse events, and hospital readmission.

CONCLUSIONS

Multiple imputation is a rigorous statistical procedure that is being increasingly used to address missing values in large datasets. Using this technique for ACDF avoided the loss of cases that may have affected the representativeness and power of the study and led to different results than complete case analysis. Multiple imputation should be considered for future spine studies.

Evaluating the effect of growing patient numbers and changing data elements in the National Surgical Quality Improvement Program (NSQIP) database over the years: a study of posterior lumbar fusion outcomes

BACKGROUND CONTEXT

The use of national databases in spinal surgery outcomes research is increasing. A number of variables collected by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) changed between 2010 and 2011, coinciding with a rapid increase in the number of patients included per year. However, there has been limited study evaluating the effect that these changes may have on the results of outcomes studies.

PURPOSE

The present study aimed to investigate the influence of changing data elements and growth of the NSQIP database on results of lumbar fusion outcomes studies.

STUDY DESIGN/SETTING

This is a retrospective cohort study of prospectively collected data.

PATIENT SAMPLE

The NSQIP database was retrospectively queried to identify 19,755 patients who underwent elective posterior lumbar fusion surgery with or without interbody fusion between 2005 and 2014. Patients were split into two groups based on year of surgery: 2,802 from 2005 to 2010 and 16,953 from 2011 to 2014.

OUTCOME MEASURES

The occurrence of adverse events after discharge from the hospital, within postoperative day 30, was determined.

METHODS

Preoperative characteristics and 30-day perioperative outcomes were compared between the era groups using bivariate analysis. To illustrate the effect of such changing data elements, the association between age and postoperative outcomes in the era groups was analyzed using multivariate Poisson regression. The present study had no funding sources, and there were no study-related conflicts of interest for any authors.

RESULTS

There were significant differences between the era groups for a variety of preoperative characteristics. Postoperative events such blood transfusion and deep vein thrombosis were also significantly different between the era groups. For the 2005-2010 cohort, age was significantly associated with septic shock by multivariate analysis. For the 2011-2014 cohort, age was significantly associated with septic shock, urinary tract infection, blood transfusion, myocardial infarction, and extended length of stay.

CONCLUSIONS

The NSQIP database has undergone substantial changes between 2005 and 2014. These changes may contribute to different results in analyses, such as the association between age and postoperative outcomes, when using older versus newer data. Conclusions from early studies using this database may warrant reconsideration.

Adverse Events Following Posterior Lumbar Fusion: A Comparison of Spine Surgeons Perceptions and Reported Data for Rates and Risk Factors

Background

Postoperative complications and risks factors for adverse events play an important role in both decision making and patient expectation setting. The present study serves to contrast surgeons' perceived and reported rates of postoperative adverse events following posterior lumbar fusion (PLF) and to assess the accuracy of predicting the impact of patient factors on such outcomes.

Methods

A survey investigating perceived rates of adverse events and the impact of patient risk factors on them following PLF for degenerative conditions was distributed to spine surgeons at the Lumbar Spine Research Society (LSRS) 2016 annual meeting. For comparison, the corresponding rates and patient risk factors were assessed in patients undergoing elective PLF from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data years 2011-2014.

Results

From the survey, there were 53 responses (response rate of 79%) from attending physicians at LSRS. From NSQIP, there were 16,589 patients who met the inclusion criteria. Adverse event rates estimated by the surgeons at LSRS were close to those determined by NSQIP data (no greater than 2.81% different). The largest differences were for deep vein thrombosis (overestimation of 2.81%, P < .001), anemia requiring transfusion (overestimation of 2.47%, P = .018), and urinary tract infection (overestimation of 2.29%, P < .001). Similarly, the estimated impact of patient factors was similar to the data (within relative risk of 2.02). The largest differences were for current smoking (overestimation of 2.02 relative risk, P < .001), insulin dependent diabetes (overestimation of 1.36, P < .001), and obesity (overestimation of 1.35, P < .001).

Conclusions

The current study noted that surgeon estimates were relatively close to national numbers for estimating the adverse events and impact of patient factors on such outcomes after PLF for degenerative conditions. The estimates are roughly appropriate with a bias toward overestimation for planning and expectation setting.

The Rothman Index as a predictor of postdischarge adverse events after elective spine surgery

BACKGROUND CONTEXT

The Rothman Index (RI) is a comprehensive rating of overall patient condition in the hospital setting. It is used at many medical centers and calculated based on vital signs, laboratory values, and nursing assessments in the electronic medical record. Previous research has demonstrated an association with adverse events, readmission, and mortality in other fields, but it has not been investigated in spine surgery.

PURPOSE

The present study aims to determine the potential utility of the RI as a predictor of adverse events after discharge following elective spine surgery.

STUDY DESIGN/SETTING

This retrospective cohort study was carried out at a large academic medical center.

PATIENT SAMPLE

A total of 2,687 patients who underwent elective spine surgery between 2013 and 2016 were included in the present study.

OUTCOME MEASURES

The occurrence of adverse events and readmission after discharge from the hospital, within postoperative day 30, was determined in the present study.

METHODS

Patient characteristics and 30-day perioperative outcomes were characterized, with events being classified as "major adverse events" or "minor adverse events" using standardized criteria. Rothman Index scores from the hospitalization were analyzed and compared for those who did or did not experience adverse events after discharge. The association of lowest and latest scores on adverse events was determined with multivariate regression, controlling for demographics, comorbidities, surgical procedure, and length of stay.

RESULTS

Postdischarge adverse events were experienced by 7.1% of patients. The latest and lowest RI values were significantly inversely correlated with any adverse events, major adverse events, minor adverse events and readmissions after controlling for age, gender, body mass index, American Society of Anesthesiologists (ASA) class, surgical site, and hospital length of stay. Rates of readmission and any adverse event consistently had an inverse correlation with lowest and latest RI scores, with patients at increased risk with lowest score below 65 or latest score below 85.

CONCLUSIONS

The RI is a tool that can be used to predict postdischarge adverse events after elective spine surgery that adds value to commonly used indices such as patient demographics and ASA. It is found that this can help physicians identify high-risk patients before discharge and should be able to better inform clinical decisions.

Longer Operative Time Is Associated With Increased Adverse Events After Anterior Cervical Diskectomy and Fusion: 15-Minute Intervals Matter

Little is known about the impact of operative time, as an independent and interval variable, on general health perioperative outcomes following anterior cervical diskectomy and fusion. Therefore, patients undergoing a 1-level anterior cervical diskectomy and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program. Operative time (as an interval variable) was tested for association with perioperative outcomes using a multivariate regression that was adjusted for differences in baseline characteristics. A total of 15,241 patients were included. Increased surgical duration was consistently correlated with a rise in any adverse event postoperatively, with each additional 15 minutes of operating time raising the risk for having any adverse event by an average of 10% (99.64% confidence interval, 3%-17%, P<.001). In fact, 15-minute increases in surgical duration were associated with incremental increases in the rates of venous thromboembolism, sepsis, unplanned intubation, extended length of hospital stay, and hospital readmission. Greater operative time, despite controlling for other patient variables, increases the risk for overall postoperative adverse events and multiple individual adverse outcomes. This increased risk may be attributed to anesthetic effects, physiologic stresses, and surgical site issues. Although it is difficult to fully isolate operative time as an independent variable because it may be closely related to the complexity of the surgical pathology being addressed, the current study suggests that surgeons should maximize operative efficiency as possible (potentially using strategies that have been shown to improve operative time in the 15-minute magnitude), without compromising the technical components of the procedure. [Orthopedics. 2018; 41(4):e483-e488.].

Outpatient elective posterior lumbar fusions appear to be safely considered for appropriately selected patients

BACKGROUND CONTEXT

There has been growing interest in performing posterior lumbar fusions (PLFs) in the outpatient setting to optimize patient satisfaction and reduce cost. Although still done in only a small percentage of cases, this has been more possible because of advances in surgical techniques and anesthesia. However, data on the perioperative course of outpatient compared with inpatient PLF in a large sample size are scarce.

PURPOSE

This study aimed to compare perioperative complications between outpatient and inpatient PLF in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

STUDY DESIGN/SETTING

A retrospective cohort comparison study was carried out.

PATIENT SAMPLE

Patients undergoing PLF with or without interbody fusion from the 2005 to 2015 NSQIP database comprised the sample.

OUTCOME MEASURES

Outcome measures were postoperative complications within 30 days and readmission within 30 days.

METHODS

Patients who underwent PLF with or without interbody fusion were identified in the 2005-2015 NSQIP database. Outpatient procedures were defined as cases that had hospital length of stay (LOS)=0 days, whereas inpatient procedures were defined as LOS=1-30 days. Patient characteristics, comorbidities, and procedural variables (inclusion of interbody fusion, instrumentation, and number of levels fused) were compared between the two cohorts. Propensity score-matched comparisons were then performed for postoperative complications and 30-day readmissions between the two groups.

RESULTS

The current study included 360 outpatient and 36,610 inpatient PLF cases. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in postoperative adverse events other than significantly lower blood transfusions in the outpatient group (2.78% vs. 10.83%, p<.001). Notably, the rate of readmissions was not different between the groups.

CONCLUSIONS

Based on the lack of differences in rates of most perioperative complications and 30-day readmissions between the outpatient and inpatient cohorts, it seems that outpatient PLF may be appropriately considered for select patients. However, extremely careful patient selection should be exercised.

Risk factors and pharmacologic prophylaxis for venous thromboembolism in elective spine surgery

BACKGROUND CONTEXT

Venous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery.

PURPOSE

The objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery.

STUDY DESIGN/SETTING

This is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center.

PATIENT SAMPLE

This study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery.

OUTCOME MEASURES

The incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort.

MATERIALS AND METHODS

Associations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression.

RESULTS

Among 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048).

CONCLUSIONS

Pharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.

General Health Adverse Events Within 30 Days Following Anterior Cervical Discectomy and Fusion in US Patients: A Comparison of Spine Surgeons' Perceptions and Reported Data for Rates and Risk Factors

STUDY DESIGN

Survey study and retrospective review of prospective data.

OBJECTIVES

To contrast surgeons' perceptions and reported national data regarding the rates of postoperative adverse events following anterior cervical discectomy and fusion (ACDF) and to assess the accuracy of surgeons in predicting the impact of patient factors on such outcomes.

METHODS

A survey investigating perceived rates of perioperative complications and the perceived effect of patient risk factors on the occurrence of complications following ACDF was distributed to spine surgeons at the Cervical Spine Research Society (CSRS) 2015 Annual Meeting. The equivalent reported rates of adverse events and impacts of patient risk factors on such complications were assessed in patients undergoing elective ACDF from the National Surgical Quality Improvement Program (NSQIP).

RESULTS

There were 110 completed surveys from attending physicians at CSRS (response rate = 44%). There were 18 019 patients who met inclusion criteria in NSQIP years 2011 to 2014. The rates of 11 out of 17 (65%) postoperative adverse events were mildly overestimated by surgeons responding to the CSRS questionnaire in comparison to reported NSQIP data (overestimates ranged from 0.24% to 1.50%). The rates of 2 out of 17 (12%) postoperative adverse events were mildly underestimated by surgeons (range = 0.08% to 1.2%). The impacts of 5 out of 10 (50%) patient factors were overestimated by surgeons (range relative risk = 0.56 to 1.48).

CONCLUSIONS

Surgeon estimates of risk factors for and rates of adverse events following ACDF procedures were reasonably nearer to national data. Despite an overall tendency toward overestimation, surgeons' assessments are roughly appropriate for surgical planning, expectation setting, and quality improvement initiatives.

The Rothman Index Is Associated With Postdischarge Adverse Events After Hip Fracture Surgery in Geriatric Patients

BACKGROUND

The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population.

QUESTIONS/PURPOSES

(1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes?

METHODS

One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes.

RESULTS

We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05).

CONCLUSIONS

The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care.

LEVEL OF EVIDENCE

Level II, diagnostic study.

How Common-and How Serious- Is Clostridium difficile Colitis After Geriatric Hip Fracture? Findings from the NSQIP Dataset

BACKGROUND

Patients with geriatric hip fractures may be at increased risk for postoperative Clostridium difficile colitis, which can cause severe morbidity and can influence hospital quality metrics. However, to our knowledge, no large database study has calculated the incidence of, factors associated with, and effect of C. difficile colitis on geriatric patients undergoing hip fracture surgery.

QUESTIONS/PURPOSES

To use a large national database with in-hospital and postdischarge data (National Surgical Quality Improvement Program [NSQIP®]) to (1) determine the incidence and timing of C. difficile colitis in geriatric patients who underwent surgery for hip fracture, (2) identify preoperative and postoperative factors associated with the development of C. difficile colitis in these patients, and (3) test for an association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality.

PATIENTS AND METHODS

This is a retrospective study. Patients who were 65 years or older who underwent hip fracture surgery were identified in the 2015 NSQIP database. The primary outcome was a diagnosis of C. difficile colitis during the 30-day postoperative period. Preoperative and procedural factors were tested for association with the development of C. difficile colitis through a backward stepwise multivariate model. Perioperative antibiotic type and duration were not included in the model, as this information was not recorded in the NSQIP. The association between C. difficile colitis and postoperative length of stay, 30-day readmission, and 30-day mortality were tested through multivariate regressions, which adjusted for preoperative and procedural characteristics such as age, comorbidities, and surgical procedure. A total of 6928 patients who were 65 years or older and underwent hip fracture surgery were identified.

RESULTS

The incidence of postoperative C. difficile colitis was 1.05% (95% CI, 0.81%-1.29%; 73 of 6928 patients). Of patients who had C. difficile colitis develop, 64% (47 of 73 patients) were diagnosed postdischarge and 79% (58 of 73 patients) did not have a preceding infectious diagnosis. Preoperative factors identifiable before surgery that were associated with the development of C. difficile colitis included admission from any type of chronic care facility (versus admitted from home; relative risk [RR] = 1.98; 95% CI, 1.11-3.55; p = 0.027), current smoker within 1 year (RR = 1.95; 95% CI, 1.03-3.69; p = 0.041), and preoperative anemia (RR = 1.76; 95% CI, 1.07-2.92; p = 0.027). Patients who had pneumonia (RR = 2.58; 95% CI, 1.20-5.53; p = 0.015), sepsis (RR = 4.20; 95% CI, 1.27-13.82; p = 0.018), or "any infection" (RR = 2.26; 95% CI, 1.26-4.03; p = 0.006) develop after hip fracture were more likely to have C. difficile colitis develop. Development of C. difficile colitis was associated with greater postoperative length of stay (22 versus 5 days; p < 0.001), 30-day readmission (RR = 3.41; 95% CI, 2.17-5.36; p < 0.001), and 30-day mortality (15% [11 of 73 patients] versus 6% [439 of 6855 patients]; RR = 2.16; 95% CI, 1.22-3.80; p = 0.008).

CONCLUSIONS

C. difficile colitis is a serious infection after hip fracture surgery in geriatric patients that is associated with 15% mortality. Patients at high risk, such as those admitted from any type of chronic care facility, those who had preoperative anemia, and current smokers within 1 year, should be targeted with preventative measures. From previous studies, these measures include enforcing strict hand hygiene with soap and water (not alcohol sanitizers) if a provider is caring for patients at high risk and those who are C. difficile-positive. Further, other studies have shown that certain antibiotics, such as fluoroquinolones and cephalosporins, can predispose patients to C. difficile colitis. These medications perhaps should be avoided when prescribing prophylactic antibiotics or managing infections in patients at high risk. Future prospective studies should aim to determine the best prophylactic antibiotic regimens, probiotic formula, and discharge timing that minimize postoperative C. difficile colitis in patients with hip fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Revision Total Knee Arthroplasty in Octogenarians: An Analysis of 957 Cases

BACKGROUND

The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (<70 and 70-79 year olds).

METHODS

Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups: <70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions.

RESULTS

This study included 6523 (<70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to <70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations.

CONCLUSION

These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age.

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

BACKGROUND CONTEXT

As research tools, the American Society of Anesthesiologists (ASA) physical status classification system, the modified Charlson Comorbidity Index (mCCI), and the modified Frailty Index (mFI) have been associated with complications following spine procedures. However, with respect to clinical use for various adverse outcomes, no known study has compared the predictive performance of these indices specifically following posterior lumbar fusion (PLF).

PURPOSE

This study aimed to compare the discriminative ability of ASA, mCCI, and mFI, as well as demographic factors including age, body mass index, and gender for perioperative adverse outcomes following PLF.

STUDY DESIGN/SETTING

A retrospective review of prospectively collected data was performed.

PATIENT SAMPLE

Patients undergoing elective PLF with or without interbody fusion were extracted from the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

OUTCOME MEASURES

Perioperative adverse outcome variables assessed included the occurrence of minor adverse events, severe adverse events, infectious adverse events, any adverse event, extended length of hospital stay, and discharge to higher-level care.

METHODS

Patient comorbidity indices and characteristics were delineated and assessed for discriminative ability in predicting perioperative adverse outcomes using an area under the curve analysis from the receiver operating characteristics curves.

RESULTS

In total, 16,495 patients were identified who met the inclusion criteria. The most predictive comorbidity index was ASA and demographic factor was age. Of these two factors, age had the larger discriminative ability for three out of the six adverse outcomes and ASA was the most predictive for one out of six adverse outcomes. A combination of the most predictive demographic factor and comorbidity index resulted in improvements in discriminative ability over the individual components for five of the six outcome variables.

CONCLUSION

For PLF, easily obtained patient ASA and age have overall similar or better discriminative abilities for perioperative adverse outcomes than numerically tabulated indices that have multiple inputs and are harder to implement in clinical practice.

Discriminative Ability of Elixhauser's Comorbidity Measure is Superior to Other Comorbidity Scores for Inpatient Adverse Outcomes After Total Hip Arthroplasty

BACKGROUND

Identifying patients at highest risk for a complex perioperative course following total hip arthroplasty (THA) is more important than ever in order to educate patients, optimize outcomes, and to minimize cost and length of stay. There are no known studies comparing the clinically relevant discriminative ability of 3 commonly used comorbidity indices for adverse outcomes following THA: Elixhauser Comorbidity Measure (ECM), the Charlson Comorbidity Index (CCI), and the modified Frailty Index (mFI).

METHODS

Patients undergoing THA were extracted from the 2013 National Inpatient Sample. The discriminative ability of ECM, CCI, and mFI, as well as the demographic factors age, body mass index, and gender for the occurrence of index admission Centers for Medicare & Medicaid Services procedure-specific complication measures, extended length of hospital stay, and discharge to a facility were assessed using the area under the curve analysis from receiver operating characteristic curves.

RESULTS

ECM outperformed CCI and mFI for the occurrence of all 5 adverse outcomes. Age outperformed gender and obesity for the occurrence of all 5 adverse outcomes. ECM (the best performing comorbidity index) outperformed age (the best performing demographic factor) in discriminative ability for the occurrence of 3 of 5 adverse outcomes.

CONCLUSION

The less commonly used ECM outperformed the more often utilized CCI and newer mFI as well as demographic factors in correctly preoperatively identifying patients' probabilities of experiencing an adverse outcome suggesting that wider adoption of ECM should be considered in both identifying likelihoods of adverse patient outcomes and for research purposes in future studies.

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

BACKGROUND

There has been great interest in performing outpatient THA and TKA. Studies have compared such procedures done as outpatients versus inpatients. However, stated "outpatient" status as defined by large national databases such as the National Surgical Quality Improvement Program (NSQIP) may not be a consistent entity, and the actual lengths of stay of those patients categorized as outpatients in NSQIP have not been specifically ascertained and may in fact include some patients who are "observed" for one or more nights. Current regulations in the United States allow these "observed" patients to stay more than one night at the hospital under observation status despite being coded as outpatients. Determining the degree to which this is the case, and what, exactly, "outpatient" means in the NSQIP, may influence the way clinicians read studies from that source and the way hospital systems and policymakers use those data.

QUESTIONS/PURPOSES

The purposes of this study were (1) to utilize the NSQIP database to characterize the differences in definition of "inpatient" and "outpatient" (stated status versus actual length of stay [LOS], measured in days) for THA and TKA; and (2) to study the effect of defining populations using different definitions.

METHODS

Patients who underwent THA and TKA in the 2005 to 2014 NSQIP database were identified. Outpatient procedures were defined as either hospital LOS = 0 days in NSQIP or being termed "outpatient" by the hospital. The actual hospital LOS of "outpatients" was characterized. "Outpatients" were considered to have stayed overnight if they had a LOS of 1 day or longer. The effects of the different definitions on 30-day outcomes were evaluated using multivariate analysis while controlling for potential confounding factors.

RESULTS

Of 72,651 patients undergoing THA, 529 were identified as "outpatients" but only 63 of these (12%) had a LOS = 0. Of 117,454 patients undergoing TKA, 890 were identified as "outpatients" but only 95 of these (11%) had a LOS = 0. After controlling for potential confounding factors such as gender, body mass index, functional status before surgery, comorbidities, and smoking status, we found "inpatient" THA to be associated with increased risk of any adverse event (relative risk, 2.643, p = 0.002), serious adverse event (relative risk, 2.455, p = 0.011), and readmission (relative risk, 2.775, p = 0.010) compared with "outpatient" THA. However, for the same procedure and controlling for the same factors, patients who had LOS > 0 were not associated with any increased risk compared with patients who had LOS = 0. A similar trend was also found in the TKA cohort.

CONCLUSIONS

Future THA, TKA, or other investigations on this topic should consistently quantify the term "outpatient" because different definitions, stated status or actual LOS, may lead to different assignments of risk factors for postoperative complications. Accurate data regarding risk factors for complications after total joint arthroplasty are crucial for efforts to reduce length of hospital stay and minimize complications.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Demographics, Mechanisms of Injury, and Concurrent Injuries Associated With Calcaneus Fractures: A Study of 14 516 Patients in the American College of Surgeons National Trauma Data Bank

BACKGROUND

This study uses the American College of Surgeons National Trauma Data Bank (NTDB) to update the field on the demographics, injury mechanisms, and concurrent injuries among a national sample of patients admitted to the hospital department with calcaneus fractures.

METHODS

Patients with calcaneus fractures in the NTDB during 2011-2012 were identified and assessed.

RESULTS

A total of 14 516 patients with calcaneus fractures were included. The most common comorbidity was hypertension (18%), and more than 90% of fractures occurred via traffic accident (49%) or fall (43%). A total of 11 137 patients had concurrent injuries. Associated lower extremity fractures had the highest incidence and occurred in 61% of patients (of which the most common were other foot and ankle fractures). Concurrent spine fractures occurred in 23% of patients (of which the most common were lumbar spine fractures). Concurrent nonorthopaedic injuries included head injuries in 18% of patients and thoracic organ injuries in 15% of patients.

CONCLUSION

This national sample indicates that associated injuries occur in more than three quarters calcaneus fracture patients. The most common associated fractures are in close proximity to the calcaneus. Although the well-defined association of calcaneus fractures with lumbar spine fractures was identified, the data presented highlight additional strong associations of calcaneus fractures with other orthopaedic and nonorthopaedic injuries.

LEVELS OF EVIDENCE

Prognostic, Level III: Retrospective review of a prospectively collected cohort.

Comparison of Outpatient vs Inpatient Total Knee Arthroplasty: An ACS-NSQIP Analysis

BACKGROUND

There has been a recent surge of interest in performing primary total knee arthroplasty (TKA) in the outpatient setting to reduce cost and increase patient satisfaction. Detailed information on the safety of outpatient TKA in large sample sizes is scarce.

METHODS

Patients who underwent primary, elective TKA were identified in the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program database. Outpatient procedure was defined as having a hospital length of stay of 0 days, whereas inpatient procedure was defined as having a length of stay ≥1 days. To reduce the effect of confounding factors and nonrandom assignment of treatment, propensity score matching was used. Multivariate analyses on the matched samples were used to compare the rates of adverse events that happened any time during the 30-day postoperative period, postdischarge adverse events, and readmissions between the outpatient and inpatient cohorts.

RESULTS

A total of 112,922 TKA patients met the inclusion criteria. Of these, only 642 (0.57%) were outpatient procedures. Outpatients tended to be men, slightly younger, and have less comorbidity. After propensity matching, multivariate analysis revealed a higher rate of postdischarge blood transfusions (P < .001) in the outpatient cohort. There were no other significant differences in 30-day postoperative individual adverse events or readmissions.

CONCLUSION

Based on the perioperative outcome measures studied here, outpatient TKA can be appropriately considered in select patients based on rates of overall perioperative adverse events and readmissions. However, higher surveillance of these patients postdischarge may be warranted.

Analysis of Bony and Internal Organ Injuries Associated With 26,357 Adult Femoral Shaft Fractures and Their Impact on Mortality

The spectrum of injuries associated with femoral shaft fractures and those injuries' association with mortality have not been well delineated previously. Patients in the National Trauma Data Bank who presented with femoral shaft fractures from 2011 to 2012 were analyzed in 3 age groups (18-39, 40-64, and 65+ years). For each group, modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), injury severity score (ISS), and associated injuries were reported. Multivariate logistic regression was used to identify predictors of mortality. Among the 26,357 patients with femoral shaft fractures, modified CCIs gradually increased with increasing age category and ISS decreased. Motor vehicle accidents were the most common MOI in the younger 2 age groups, whereas falls were the most common MOI in the 65 years and older age group. The top 3 associated bony injuries for the study cohort as a whole were tibia/fibula (20.5%), ribs/sternum (19.1%), and non-shaft femur (18.9%, of which 5.8% of the total cohort were femoral neck) fractures. The top 3 associated internal organ injuries were lung (18.9%), intracranial (13.5%), and liver (6.2%), injuries. A multivariate mortality analysis showed that increasing age, increasing comorbidity burden, and associated injuries all had independent associations with mortality. The injuries most associated with mortality were thoracic organ injuries (adjusted odds ratio [AOR]=3.53), head injuries (AOR=2.93), abdominal organ injuries (AOR=2.78), and pelvic fractures (AOR=1.80). This study used a large, nationwide sample of trauma patients to profile injuries associated with femoral shaft fractures. Associations between injuries and mortality underscore the importance of these findings. [Orthopedics. 2017; 40(3):e506-e512.].

Differences in Short-Term Outcomes Between Primary and Revision Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare short-term morbidity for primary and revision anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Revision ACDF procedures are relatively common, yet their risks are poorly characterized in the literature. There is a need to assess the relative risk of revision ACDF procedures compared with primary surgery.

METHODS

The prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent primary and revision ACDF from 2005 to 2014. The occurrence of 30-day postoperative complications, readmission, operative time, and postoperative length of stay were compared between primary and revision procedures using multivariate regression to control for patient and operative characteristics.

RESULTS

A total of 20,383 ACDF procedures were identified, 1219 (6.0%) of which were revision cases. On multivariate analysis, revision procedures were associated with significantly increased risk of any adverse event (relative risk [RR] 2.3, P < 0.001), any severe adverse event (RR 2.2, P < 0.001), thromboembolic events (RR 3.3, P = 0.001), surgical site infections (RR 3.2, P < 0.001), return to the operating room (RR 1.9, P = 0.001), any minor adverse event (RR 2.5, P < 0.001), and blood transfusion (RR 8.3, P < 0.001). Revision procedures had significantly increased risk of readmission within 30 days (RR = 1.6, P = 0.001). Minor, but statistically significant increases in average operative time and postoperative length of stay were identified for revisions procedures (7 min and half a day, respectively [P < 0.001 for both]).

CONCLUSION

Revision procedures were associated with significantly increased risk of multiple adverse outcomes, including thromboembolic events, surgical site infections, return to the operating room, blood transfusion, and readmission within 30 days. These results are important for patient counseling and risk stratification.

LEVEL OF EVIDENCE

3.

Tibial shaft fracture: A large-scale study defining the injured population and associated injuries

This is the first large-scale study to define the injured population and examine associated injuries for patients with tibial shaft fractures. Patients over 18 years of age in the National Trauma Data Bank (NTDB) who presented with tibial shaft fractures during 2011 and 2012 were identified. Modified Charlson Comorbidity Index (CCI), mechanism of injury (MOI), injury severity score (ISS), and specific associated injuries were described. Multivariate logistic regression was used to identify predictors of mortality.