A Matched-Cohort Analysis of Outcomes in Patients with Hereditary Hemochromatosis After Anterior Cervical Discectomy and Fusion

BACKGROUND

Hereditary hemochromatosis (HH) is a common autosomal recessive disorder. This disease affects gut iron transport, leading to iron overload, which affects immune function, coagulation mechanics, and bone health. Within the spine, HH contributes to decreased bone mineral density and accelerated intervertebral disc degeneration. The purpose of this study was to discover the differences in the rates of common 90-day postoperative complications and 1-year and 2-year surgical outcomes in patients with and without HH after anterior cervical discectomy and fusion (ACDF).

METHODS

Using the PearlDiver database, patients with active diagnoses of HH before ACDF were matched to patients without HH using a 1:5 ratio on the basis of age, sex, body mass index, and comorbidities. Postoperative complications were assessed at 90 days, and 1-year and 2-year surgical outcomes were assessed. All outcomes and complications were analyzed using multivariate logistic regression with significance achieved at P < 0.05.

RESULTS

Patients with HH had significantly higher rates of 1-year and 2-year reoperation rates compared with patients without HH (29.19% vs. 3.94% and 37.1% vs. 5.93%, respectively; P < 0.001). The rates of 90-day postoperative complications significantly increased in patients with HH including dysphagia, pneumonia, cerebrovascular accident, deep vein thrombosis, acute kidney injury, urinary tract infection, hyponatremia, surgical site infection, iatrogenic deformity, emergency department visit, and hospital readmission.

CONCLUSIONS

Patients with HH undergoing ACDF showed increased 90-day postoperative complications and significantly increased rates of 1-year and 2-year reoperation compared with patients without HH. These findings suggest that iron overload may contribute to adverse outcomes in patients with HH undergoing 1-level and 2-level ACDF.

A 10-year perspective on the question of whether surgeries for adolescent idiopathic scoliosis are "one and done"?

PURPOSE

Posterior scoliosis fusion (PSF) for adolescent idiopathic scoliosis (AIS) is considered a highly successful surgery with excellent outcomes. However, especially as many patients "graduate" from their pediatric surgeons, there is the need to quantify the long-term outcomes of such surgeries.

METHODS

The 2010-2022 Pearldiver M161 dataset was queried for those who were 10 to 18 years old with AIS undergoing PSF with at least 10 years follow-up. Patient characteristics were abstracted. Reoperations were identified based on coding for any subsequent thoracic/lumbar surgery/revision. The 10-year reoperation rate and reasons for reoperation were determined, and multivariate regression was performed to determine risk factors.

RESULTS

In total, 3,373 AIS PSF patients were identified. Of the study cohort, 324 (9.6%) underwent reoperation within 10-years with an interquartile range for timing of surgery of 81-658 days, of which 29.6% were done for infection. Reoperations were done within the first three months for 152 (46.9% of reoperations), three months to 2 years for 97 (29.9%), and 2 years to 10 years for 74 (22.8%). Based on multivariate regression, need for reoperation was associated with male sex (OR: 1.70), asthma (OR: 1.36) and greater than thirteen segments of instrumentation (OR: 1.48) (p < 0.05 for each) but not age, other comorbidities, or insurance.

CONCLUSIONS

The current study of a large national AIS PSF population found 9.6% to undergo reoperation in the 10 years following their index operation. Although specifics about the curve pattern could not be determined, the reoperation incidence and correlation with specific risk factors are notable and important for patient counselling.

Single-level posterior lumbar fusions in patients with Ehlers Danlos Syndrome not found to be associated with increased postoperative adverse events or five-year reoperations

Background

Ehlers Danlos Syndrome (EDS) is a rare connective tissue disorder that results from mutations in collagen genes. Potentially related to laxity and resultant degenerative changes, adult EDS patients may require posterior lumbar fusion (PLF). However, with low numbers, adequately powered outcome studies have been limited. The purpose of this study was to investigate risk of complications, readmissions and reoperations in adult patients with EDS following single-level PLF.

Methods

A retrospective study using the 2010 to 2020 MSpine Pearldiver dataset was performed. Adult patients undergoing single-level PLF (excluding any with anterior procedures) with and without EDS for which at least 90-day follow up was available were identified. Any cases performed for trauma, tumor, or infection were excluded.Single-level PLF EDS patients were then matched 1:4 with PLF non-EDS patients based on age, sex, and Elixhauser Comorbidity Index (ECI). Rates of ninety-day any, severe, and minor adverse events as well as readmissions were tabulated and compared with chi-square tests. Multivariate logistical regression was then performed (controlling for age, sex, and ECI).Reoperation surgeries over five years were assessed, Kaplan-Meier survival curves generated, and curves of those with and without EDS were compared with log rank test.

Results

In total, there were 170,100 single-level PLF case identified, of which 242 (0.14%) had EDS. After matching, there were 957 without EDS and 239 with EDS. On multivariate regression, there were no significant differences in 90-day any, severe, or minor adverse events, or readmissions (p>0.05 for each). Over five years, there were also not significant differences in rates of reoperation (p> 0.05).

Conclusions

For EDS patients undergoing PLF, the current study identified similar 90-day adverse events and 5-year reoperation rates compared to those without EDS. These findings may be useful for patient counseling and surgical planning for those with this rare condition.

Certificate-of-Need State Laws and Elective Posterior Lumbar Fusions: Is It Time to Repeal the Mandate?

OBJECTIVES

Our study aimed to assess whether elective posterior lumbar fusions (PLFs) performed in states with Certificate-of-Need (CON) laws versus states without CON laws had lower utilization rates, lower costs, and better quality of care.

METHODS

The 2005-2014 100% Medicare Standard Analytical File was queried to identify patients undergoing elective 1- to 3-level PLF. Differences in per-capita utilization, 90-day reimbursements, and proportion of high-volume between CON and No-CON states were reported. Multivariate analyses were used to analyze 90-day complications and readmissions.

RESULTS

A total of 188,687 patients underwent an elective 1- to 3-level PLF in a CON state and 167,642 patients in a No-CON state during 2005-2014. The average per capita utilization of PLFs was lower in CON states as compared with No-CON states (14.5 vs. 15.4 per 10,000 population; P < 0.001). Average 90-day reimbursements between CON and No-CON states differed by a small amount ($22,115 vs. $21,802). CON states had a higher proportion of high-volume facilities (CON vs. No CON-40.9% vs. 29.9%; P < 0.05) and lower proportion of low-volume facilities (CON vs. No-CON-37.2% vs. 45.0%; P < 0.05). PLFs performed in CON states had slightly lower odds of 90-day complications (odds ratio 0.97 [95% confidence interval 0.96-0.99]; P < 0.001) and readmissions (odds ratio 0.95 [95% confidence interval 0.93-0.97]; P < 0.001).

CONCLUSIONS

The presence of CON laws was associated with lower utilization of elective 1- to 3-level PLFs and a greater number of high-volume facilities. However, their effect on quality of care, via reduction of 90-day readmissions and 90-day complications, is minimally significant.

Declining trend in osteoporosis management and screening following vertebral compression fractures - a national analysis of commercial insurance and medicare advantage beneficiaries

BACKGROUND CONTEXT

Despite the increasing national incidence, osteoporosis and its associated comanagement, often remain an overlooked issue in the orthopedic world. Screening and associated management of osteoporosis is often only considered by providers when patients present with multiple fragility fractures. Current evidence with regard to the trends in screening and medical comanagement/antiosteoporotic therapy of osteoporotic vertebral compression fractures (VCFs) remains limited.

PURPOSE

To understand trends, costs, and clinical impact associated the utilization of antiosteoporotic medication and screening with the 1 year following occurrences of sentinel/primary osteoporotic VCFs.

STUDY DESIGN/SETTING

Retrospective review of 2008-2015Q3 Humana Administrative Claims (HAC) database.

PATIENT SAMPLE

The 2008-2015Q3 HAC database was queried using International Classification of Diseases 9th Edition (ICD-9) diagnosis codes 805.2 and 805.4 to identify patients with primary closed osteoporotic thoracolumbar VCFs. Patients with a concurrent diagnosis of trauma and/or malignancy were excluded. Patients experiencing a fragility fracture of the hip, distal radius or proximal humerus, and/or those already on osteoporotic medications within the year before the VCF were excluded to prevent an overlap in the screening and/or antiresorptive medication rates. Finally, only those patients who had complete 2-year follow-up data were analyzed.

OUTCOME MEASURES

To understand trends over time in the utilization of medication for osteoporosis and screening within 1 year following sentinel VCFs. The study also aimed to report per-prescription and per-patient average costs associated with different antiosteoporotic medications. As secondary objectives, we also assessed (1) risk factors associated with not receiving antiosteoporotic medication within the year following sentinel VCFs and (2) differences in rates of experiencing a secondary fragility fracture of vertebrae, hip, distal radius, and proximal humerus between patients who received medication following the sentinel VCF versus those who did not receive any medication.

RESULTS

A total of 6,464 primary osteoporotic VCFs were retrieved from the database. A majority of the VCFs were seen in females (N=5,199; 80.4%). Only 28.8% (N=1,860) patients received some form of medication for osteoporosis medication in the year following the VCF. Over a 6-year interval, treatment with medication for osteoporosis declined from 38% in 2008 to 24% in 2014. The average cost of antiosteoporotic treatment per patient was $1,511. The most commonly prescribed treatment and associated average cost/patient was alendronate sodium (N=1,239; 66.6% to $120/patient). The most costly prescribed treatment was Forteo (N=177; 2.7%) with an average cost/patient of $12,074 and cost/injection being $2,373. Only 36.7% (N=2,371) received a dual-energy X-ray absorptiometry/bone density scan in the year following the VCF with an average cost/patient of $76. Risk factors associated with no prescription of medication for osteoporosis within 1 year of VCF were male gender (odds ratio [OR] 1.17 [95% confidence interval {CI} 1.01-1.35]; p=.027), history of cerebrovascular accident/stroke (OR 1.56 [95% CI 1.08-2.32]; p=.022), history of diabetes mellitus (OR 1.28 [95% CI 1.04-1.58]; p=.023). Of note, patients in the West versus Midwest (OR 1.26 [95% CI 1.04-1.51]; p=.016) and commercial insurance beneficiaries (OR 1.95 [95% CI 1.08-3.52]; p=.027) were more likely to receive antiosteoporotic medication. Patients who were placed on antiosteoporotic medication were significantly less likely to suffer a second fragility fracture compared with patients that did not receive medication (OR 0.27 [95% CI 0.24-0.31]; p=.033).

CONCLUSIONS

The proportion of patients starting antiosteoporotic medication within a year after a VCF remains low (28.8%). Furthermore, a declining trend of antiosteoporotic medication prescription was noted over time. Providers who care for patients with sentinel VCFs need to be more diligent in their efforts to diagnose and treat the underlying osteoporosis to reduce the burden of future fragility fractures.

Complications Following Operatively Treated Ankle Fractures in Insulin- and Non-Insulin-Dependent Diabetic Patients

BACKGROUND

Diabetics with ankle fractures experience more complications than the general population, but it is unclear whether complications differ between type 1 and 2 diabetics and between insulin- and non-insulin-dependent diabetics. This study aims to determine if there is a difference in postoperative complication rates between these groups.

METHODS

An administrative health care database from a large commercial insurer was queried to identify operatively treated ankle fractures in patients with type 1 (T1D), type 2 (T2D), type 2 insulin-dependent (T2ID), and type 2 non-insulin-dependent (T2NID) diabetes. Postoperative complications were identified to include postoperative stiffness, posttraumatic arthritis, amputation, implant removal, and infection. Subgroup analysis was performed to control for comorbidities.

RESULTS

A total of 20 703 closed and 2873 open operatively treated ankle fractures were identified. Patients with T1D experienced higher rates of amputation, postoperative infection, and total complications than patients with T2D (P < .05). Patients with T2ID experienced higher rates of amputation, infection, and total complications than those with T2NID (P < .0001). Subgroup analysis controlling for comorbidities showed a higher total complication rate for T1D compared with T2D in closed ankle fractures (P < .02) and for T2ID compared with T2NID in both open and closed ankle fractures (P < .0001).

CONCLUSIONS

Patients with T1D and T2ID have higher complication rates than patients with T2D and T2NID, respectively. Foot and ankle surgeons should be cautioned not to classify diabetics as one cohort and should use these findings to stratify risk among this patient population.

LEVELS OF EVIDENCE

Level III: Diagnostic.