Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND

Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS).

METHODS

A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05.

RESULTS

A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223).

CONCLUSION

Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

A thoracoscopic anterior approach to the spine for adolescent idiopathic scoliosis does not have a detrimental effect on pulmonary function at 2 years compared to posterior-only surgery

PURPOSE

This study aims to examine pulmonary function outcomes in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with an anterior thoracoscopic release compared to those undergoing PSF alone.

METHODS

A retrospective review of patients with AIS over a 9-year period at a single institution compared 2 groups: PSF with video-assisted thoracoscopic surgery (PSF/VATS) and patients undergoing a posterior spinal fusion (PSF) alone. Standard radiographs and Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were obtained preoperatively and at regular follow up periods up to 2-year post-operatively. Within group and between-group comparisons were performed.

RESULTS

There were 110 patients in the study: 12 in the PSF/VATS cohort and 98 in the PSF only cohort. The PSF/VATS group were younger (12.6 vs. 14.6, p = 0.003) and had larger coronal curves (80.8° vs. 60.7°, p = 0.001), and worse preoperative FVC (64.7% vs. 79.6%, p = 0.018) and FEV1 (62.3% vs. 77.6%, p = 0.003). At 2 years, the percent coronal Cobb correction was greater in the PSF/VATS group (67.9% vs. 48.4%, p < 0.001) with greater improvement in thoracic height (32.8 mm vs. 20.7 mm, p = 0.028). While the 2-year PFTs were the same for FEV1% (75.8% vs. 81.8%, p = 0.368) and FVC% (77.3% vs. 83.7%, p = 0.562), there was greater percent improvement over the 2 years in the PSF/VATS cohort: FEV1% (13.5% vs. 4.2%, p = 0.082) and FVC% (12.7% vs. 4.1%, p = 0.112).

CONCLUSION

AIS patients who have a VATS approach in addition to PSF have greater coronal plane correction and improved pulmonary function compared to PSF alone despite more severe spinal deformity and worse baseline pulmonary function.

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis

OBJECTIVE

To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group.

DESIGN

Multicenter Retrospective Cohort.

SETTING

Three Urban Level I Academic Trauma Centers.

PATIENTS

Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria.

MAIN OUTCOME MEASUREMENTS

Transfusion and postoperative complication rates.

RESULTS

Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications.

CONCLUSIONS

Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Subsequent Surgery Up to 10 Years After Osteochondral Allograft and Osteochondral Autograft: An Analysis of More Than 2000 Patients

Background

Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures.

Hypothesis

We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT.

Study Design

Cohort study; Level of evidence, 3.

Methods

The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test.

Results

In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P = .249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P = .235).

Conclusion

Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery.

Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery

PURPOSE

Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks.

METHODS

Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05.

RESULTS

In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9).

CONCLUSION

While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis

BACKGROUND

Patients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized.

METHODS

The PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts.

RESULTS

In total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001).

CONCLUSION

Compared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA.

LEVEL OF EVIDENCE

Level III.

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.

Total shoulder arthroplasty for osteoarthritis in patients with Parkinson's disease: a matched comparison of 90-day adverse events and 5-year implant survival

BACKGROUND

Patients with Parkinson's disease and shoulder osteoarthritis may be indicated for total shoulder arthroplasty. However, short- and long-term outcomes after total shoulder arthroplasty in this population remain poorly characterized.

METHODS

A retrospective matched case-control study was performed using data abstracted from the 2010-2018 PearlDiver Mariner administrative database. Patients undergoing total shoulder arthroplasty were identified, and those with and without the diagnosis of Parkinson's disease were matched (1:10) based on age, gender, Elixhauser comorbidity index, diabetes, chronic kidney disease, obesity, coronary artery disease, and congestive heart failure. Ninety-day incidence of adverse events were compared with multivariate regressions. Implant survival was also assessed for up to 5 years, based on the occurrence of revision surgery. Kaplan-Meier implant survival curves were compared using a log-rank test.

RESULTS

In total, 478 patients with Parkinson's disease were matched to 4715 patients without Parkinson's disease. After adjusting for demographic and comorbid factors, patients with Parkinson's disease had significantly higher odds of prosthetic dislocation (odds ratio = 3.07, P = .001), but did not experience increased odds of other 90-day adverse events. Five-year follow-up was available for 428 (89.5%) of those with Parkinson's disease and 3794 (80.5%) of those without Parkinson's disease. There was 97.2% implant survival in the Parkinson's disease cohort and 97.7% implant survival in the matched control cohort (not significantly different, P = .463).

CONCLUSIONS

Patients with Parkinson's disease undergoing total shoulder arthroplasty, compared with patients without Parkinson's disease, have 3-fold higher odds of periprosthetic dislocation in the 90-day postoperative period, but equivalent rates of other short-term adverse events as well as implant survival at 5 years. Accordingly, surgeons should be mindful of the short-term risk of implant instability but should have confidence in long-term total shoulder implant success in the Parkinson's disease population.

Total Hip Arthroplasty in Patients With Classic Hemophilia: A Matched Comparison of 90-Day Outcomes and 5-Year Implant Survival

BACKGROUND

Patients with classic hemophilia can develop joint hemarthroses, degenerative changes, and eventually require total hip arthroplasty (THA). Little data exist concerning THA outcomes in this population, and evidence-based guidelines specifically addressing venous thromboembolism (VTE) prophylaxis in this population are lacking.

METHODS

A retrospective study was conducted using the 2010-2020 PearlDiver MHip database. Patients undergoing primary THA were identified, and those with classic hemophilia were matched 1:10 with non-hemophilia patients based on age, gender, and Elixhauser Comorbidity Index. Ninety-day serious adverse events, minor adverse events, and any adverse events were compared with multivariate analysis. Reoperation at 5 years was assessed using Kaplan-Meier analysis.

RESULTS

Five hundred eighteen classic hemophilia THA patients were matched 1:10 with 5,193 non-hemophilia patients. On multivariate analysis, those with classic hemophilia had greater odds of aggregated any adverse events (odds ratio [OR] 1.76), serious adverse events (OR 2.30), and minor adverse events (OR 1.52) (P < .001 for each). Patients with classic hemophilia had greater odds of bleeding issues (transfusion, OR 1.98; hematoma, OR 4.23; P < .001 for both), VTE (deep vein thrombosis, OR 2.67; pulmonary embolism, OR 4.01; P < .001 for both), and acute kidney injury (OR 1.63; P = .03). Five-year implant survival was lower in hemophilia patients (91.9%) relative to matched controls (95.3%; P = .009).

CONCLUSION

Hemophilia patients undergoing THA had elevated risks of both 90-day bleeding complications (transfusion and hematoma) and VTE (deep vein thrombosis and pulmonary embolism) relative to matched controls. These findings emphasize the need to balance factor replacement and VTE prophylaxis. Although the 5-year implant survival was lower in hemophilia patients, this represented a difference of 3.4% at 5 years, suggesting that THA remains effective in this cohort.

Predictors of Physical Abuse in Elder Patients With Fracture

INTRODUCTION

Elder abuse is a public health issue requiring attention. Unlike abuse in the pediatric population, predictors of elder abuse in patients with fracture have not been well defined.

METHODS

Elderly patients with physical abuse and fracture were abstracted using the 2007 to 2017 National Emergency Department Sample database. Univariate comparisons, multivariate regression, and adjusted odds ratios were used to determine independent predictors of elder abuse compared with nonabuse fracture controls.

RESULTS

Thirteen percent of elder physical abuse patients presenting to the emergency department had fracture. Of all patients with fracture, elder abuse patients tended to be younger; be female; belong to lower income quartiles; and have codiagnoses of volume depletion, mental disorders, dementia, and intellectual disability. Presentation with other forms of elder abuse, such as psychological abuse, neglect, and sexual abuse, and multiple fractures were also associated with elder physical abuse. Multivariate regression found elder abuse to be more likely in the setting of skull and rib fractures and less likely in the setting of femur and foot and ankle fractures.

DISCUSSION

This study identified predictors of elder physical abuse in fracture patients older than 60 years. As with pediatric abuse, heightened awareness of potential physical abuse should be considered, especially in higher risk patients.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion

Background

Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use.

Methods

Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression.

Results

Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001).

Conclusions

More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Unicompartmental Knee Arthroplasty in Octogenarians: A National Database Analysis Including Over 700 Octogenarians

Background

Material and methods

Results

Conclusion

The Utility of MRI With Multiacquisition Variable-Resonance Image Combination (MAVRIC) in Diagnosing Deep Total Hip Arthroplasty Infection

Background: The 2010 American Academy of Orthopaedic Surgeons Clinical Practice Guidelines report insufficient evidence to address the diagnostic efficacy of magnetic resonance imaging (MRI) for periprosthetic joint infection (PJI). Questions/Purposes: The purpose of this study was to determine the utility of MRI with multiacquisition variable-resonance image combination (MAVRIC) metal artifact suppression techniques in diagnosing PJI in the setting of total hip arthroplasty (THA). Methods: Multiacquisition variable-resonance image combination MRIs obtained of THAs between November 2012 and November 2016 were queried. Radiology reports were classified as positive (suspicious for infection), negative (no features of infection), or inconclusive (infection cannot be excluded or correlation with aspiration suggested if clinically concerned). Chart review identified cases of deep PJI according to the modified Musculoskeletal Infection Society criteria. Results: Of 2156 MRIs of THAs included, MRI was concerning for infection in 1.8% (n = 39), inconclusive in 1.2% (n = 26), and negative in 97.0% (n = 2091). Deep PJI was identified in 53 (2.5%) patients, 30 of whom (56.6%) had conclusively positive finding on MRI (false-negative rate: 43.4%, sensitivity: 56.6%). Of 2103 aseptic THAs, only 9 (0.4%) MRIs were read as suspicious for infection (false-positive rate: 0.4%; specificity: 99.6%). Conclusion: Magnetic resonance imaging with MAVRIC is a highly specific test for PJI with a low false-positive rate. This indicates that when clinicians are provided with an MRI that unexpectedly suggests infection, a formal evaluation for infection is indicated. In patients with otherwise equivocal diagnostic findings, MRI may help confirm, but not refute, a diagnosis of PJI. Prospective study with more experienced image reviewers may further support the use of MRI in PJI.

Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants

OBJECTIVES

To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups.

DESIGN

Multicenter retrospective cohort.

SETTING

Three tertiary care, academic, Level I trauma centers.

PATIENTS

Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching.

MAIN OUTCOME MEASUREMENTS

The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality.

RESULTS

One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179).

CONCLUSIONS

This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Emergency Department Visits Within 90 Days of Anterior Cruciate Ligament Reconstruction

Background:

Emergency department (ED) visits after orthopaedic surgery such as anterior cruciate ligament reconstruction (ACLR) affect patients and health care systems and should be better understood.

Purpose:

To determine the incidence, predictors, and reasons for ED visits within 90 days after ACLR.

Study Design:

Descriptive epidemiologic study.

Methods:

Patients who had undergone ACLR between 2010 and 2020 were identified in a national database, and 90-day ED visits, readmissions, risk factors, and primary diagnoses for visits were determined. One-year postoperative data were used to establish baseline weekly ED visits for the cohort. Patient age, sex, Elixhauser comorbidity index, region of the country (Northeast, Midwest, West, South), and insurance coverage (Medicare, Medicaid, and commercial) were extracted, and these variables were compared using univariate analysis and multivariate logistic regression.

Results:

Out of 81,179 patients, ED visits were identified for 6764 (8.3%), and readmissions were identified for 592 (0.7%). Overall, 5300 patients had 1 ED visit, 1020 patients had 2 visits, 275 patients had 3 visits, and 169 patients had ≥4 or more visits; visits occurred within 2 weeks of surgery 38% of the time. Notably, weekly visits returned to baseline at week 3. Independent predictors of ED utilization from multivariate analysis were insurance type (relative to commercial insurance: Medicaid [odds ratio [OR], 2.41; 95% CI, 2.23-2.60] and Medicare [OR, 1.38; 95% CI, 1.19-1.60]), higher Elixhauser comorbidity index (per 2-point increase: OR, 2.24; 95% CI, 2.18-2.29), younger age (per 10-year decrease: OR, 1.23; 95% CI, 1.21-1.24), female sex (OR, 1.05; 95% CI, 1.02-1.08), and region of the country (relative to the West: Midwest [OR, 1.33; 95% CI, 1.26-1.39], Northeast [OR, 1.24; 95% CI, 1.18-1.30], and South [OR, 1.17; 95% CI, 1.12-1.23]). In the first 2 weeks, 67.5% of ED visits were for issues involving the surgical site, most commonly surgical-site pain (29% of all visits). In the total 90-day period, 39.4% of visits involved the surgical site.

Conclusion:

Within 90 days of ACLR, >8% of patients visited the ED, while 0.7% were readmitted. ED visits increased in the first 2 postoperative weeks and returned to baseline rates around week 3. Within the first 2 weeks, two-thirds of visits involved the surgical site. Younger patients, patients with greater comorbidity burden, those in certain regions of the country, and those with Medicaid had greater odds of ED utilization.

Characterization of More Than a Third of a Million Toy-Related Fractures

INTRODUCTION

The toy industry has grown substantially over time, with billions of dollars of toys sold each year in the United States alone. Even after safety considerations, injuries can result. This study examined toy-related fractures in the US Emergency Departments (ED).

METHODS

The 1999 to 2018 National Electronic Injury Surveillance System from the US Consumer Product Safety Commission was examined data for fractures involving a toy-related injury. The incidence, trends, and anatomic locations for such fractures were assessed.

RESULTS

In total, 347,135 toy-related fractures were identified, of which 237,754 (68%) were in patients younger than 18 years, 182,516 (53%) were sustained by male subjects, and a 95% yearly incidence increase was observed over the years of the study. Anatomically, 37% were shoulder/arm/elbow, 24% wrist/hand/finger, 19% ankle/toe/foot, 10% leg/knee, 6% face/neck/head, and 4% trunk/pubic region.

DISCUSSION

Despite safety considerations with toy design, more than a third of toy-related fractures were seen in the ED, with a nearly doubling yearly incidence over the study period. This could be contributed to by increased production and prevalence of toys and/or rougher play and increased overall violence. These results are important not only for patient safety but also for orthopaedic surgeons, EDs, toy manufacturers, and policymakers.

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients

BACKGROUND

Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.

METHODS

All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.

RESULTS

Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.

CONCLUSION

Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

Impacts of COVID‐19 on orthopaedic surgery residency / spine trainee application trends

Background

Methods

Results

Conclusions

Does dehydration prior to primary total joint arthroplasty increase risk of perioperative complications?

BACKGROUND

Prior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty.

METHODS

The 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration.

RESULTS

Of 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion.

CONCLUSION

Overall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.

Total Hip Arthroplasty in Patients With Cerebral Palsy: A Matched Comparison of 90-Day Adverse Events and 5-Year Implant Survival

BACKGROUND

People with cerebral palsy (CP) may be considered for total hip arthroplasty (THA). However, short- and long-term outcomes after THA in this population remain poorly characterized.

METHODS

Data from patients undergoing THA were abstracted from the 2010-2018 PearlDiver Mariner administrative database. Those with CP were matched to those without CP based on demographic and comorbid factors (1:4 matching). Ninety-day incidence of postoperative complications and hospital readmission was identified and compared. Five-year implant survival (based on need for revision) was also assessed and compared. Perioperative adverse events were then compared using multivariate logistic regression to adjust for any potential residual differences in demographic and comorbid factors after matching. Implant survival over time was compared with Kaplan-Meier plots with a log-rank test. Significance was set at P < .05 for all comparisons.

RESULTS

In total, 864 patients with CP were matched to 3448 patients without CP. After adjusting for differences in demographics and comorbidities, multivariate analyses demonstrated patients with CP had higher odds of urinary tract infection (odds ratio [OR] = 2.42, P = .007), pneumonia (OR = 3.77, P = .001), and periprosthetic fracture (OR = 2.55, P = .001). Rates of the other studied adverse events, including readmissions, were not significantly different between groups. At five years, 94.2% of the CP cohort and 95.2% of the non-CP cohort THAs remained unrevised (no difference by log rank, P = .195).

CONCLUSION

Compared with patients without CP, patients with CP undergoing THA were found to have higher odds of perioperative urinary tract infection, pneumonia, and periprosthetic fracture but not other perioperative complications or difference in five-year implant survival.

Total Joint Arthroplasty in Patients With Achondroplasia: Comparison of 90-Day Adverse Events and 5-Year Implant Survival

Background

Achondroplasia is the most common skeletal dysplasia, and total joint arthroplasty of the hip and/or knee in this patient population may present unique challenges.

Methods

All patients undergoing primary total hip or total knee arthroplasty (THA or TKA) for osteoarthritis in the 2010-2019 PearlDiver Mariner administrative database with least 90 days of postoperative follow-up were identified. Those with achondroplasia were matched 1:10 to patients without achondroplasia based on age, sex, and medical comorbidities. Ninety-day adverse events were assessed and compared using multivariate logistic regression. Five-year implant survival was determined and compared with Kaplan-Meier implant survival curves. Significance was set at P < .05.

Results

For THA, 150 patients with achondroplasia were matched to 1484 patients without and had significantly higher 90 days odds of surgical site infection (odds ratio [OR] = 3.49, P = .005) and readmission (OR = 2.35, P = .016). For TKA, 285 patients with achondroplasia were matched to 2828 without and had higher odds of aggregated any adverse event (OR = 1.52, P = .006) and transfusion (OR = 2.31, P < .001). Rates of the other studied adverse events were not significant for either set of the analyses. At 5 years, implant survival for those with and without achondroplasia was not different for those undergoing THA (P = .321) or TKA (P = .910).

Conclusions

The present study represents the largest cohort of patients with achondroplasia undergoing total joint arthroplasty to date. Although several short-term adverse events had greater odds for those with achondroplasia, 5-year survival was not different for those with or without achondroplasia after THA or TKA, supporting confidence in longer term implant success.

Postoperative bracing practices after elective lumbar spine surgery: A questionnaire study of U.S. spine surgeons

Background

There is limited data available on the use of orthoses across varying elective spine surgeries. When previously studied in 2009, inconsistent lumbar postoperative bracing practices were reported. The present study aimed to provide a ten-year update regarding postoperative bracing practices after elective lumbar surgery among United States (U.S.) spine surgeons.

Methods

A questionnaire was distributed to attendees of the Lumbar Spine Research Society Annual Meeting (April 2019). The questionnaire collected demographic information, and asked surgeons to identify if they used orthoses postoperatively after ten elective lumbar surgeries. Information regarding type of brace, duration of use, and reason for bracing was also collected. Chi-square tests and one-way analysis of variance (ANOVA) were used for comparisons.

Results

Seventy-three of 88 U.S. attending surgeons completed the questionnaire (response rate: 83%). The majority of respondents were orthopaedic surgery-trained (78%), fellowship-trained (84%), and academic surgeons (73%). The majority of respondents (60%) did not use orthoses after any lumbar surgery. Among the surgeons who braced, the overall bracing frequency was 26%. This rate was significantly lower than that reported in the literature ten years earlier (p<0.0001). Respondents tended to use orthoses most often after stand-alone lateral interbody fusions (43%) (p<0.0001). The average bracing frequency after lumbar fusions (34%) was higher than the average bracing frequency after non-fusion surgeries (16%) (p<0.0001). The most frequently utilized brace was an off the shelf lumbar sacral orthosis (66%), and most surgeons braced patients to improve pain (42%). Of surgeons who braced, most commonly did so for 2–4 months (57%).

Conclusion

Most surgeon respondents did not prescribe orthoses after varying elective lumbar surgeries, and the frequency overall was lower than a similar study conducted in 2009. There continues to be inconsistencies in postoperative bracing practices. In an era striving for evidence-based practices, this is an area needing more attention.

Temporal Utilization of Physical Therapy Visits After Anterior Cruciate Ligament Reconstruction

Background:

Physical therapy (PT) rehabilitation is critical to successful outcomes after anterior cruciate ligament reconstruction (ACLR). Later-stage rehabilitation, including sport-specific exercises, is increasingly recognized for restoring high-level knee function. However, supervised PT visits have historically been concentrated during the early stages of recovery after ACLR.

Purpose/Hypothesis:

To assess the number and temporal utilization of PT visits after ACLR in a national cohort. We hypothesized that PT visits would be concentrated early in the postoperative period.

Study Design:

Descriptive epidemiological study.

Methods:

The Humana PearlDiver database was searched to identify patients who underwent ACLR between 2007 and 2017. Patients with additional structures treated were excluded. The mean ± SD, median and interquartile range (IQR), and range of number of PT visits for each patient were determined for the 52 weeks after ACLR. PT visits over time were also assessed in relation to patient age and sex.

Results:

In total, 11,518 patients who underwent ACLR met the inclusion criteria; the mean age was 32.62 ± 13.70 years, and 42.7% were female patients. Of this study cohort, 10,381 (90.4%) had documented PT postoperatively; the range of PT visits was 0 to 121. On average, patients had 16.90 ± 10.60 PT visits (median [IQR], 16 [9-22]) after ACLR. Patients completed a mean of 52% of their PT visits in the first 6 weeks, 75% in the first 10 weeks, and 90% in the first 16 weeks after surgery. Patients aged 10 to 19 years had the highest number of PT visits (mean ± SD, 19.67 ± 12.09; median [IQR], 18 [12-25]), significantly greater than other age groups (P < .001).

Conclusion:

PT after ACLR is concentrated in the early postoperative period. Physicians, therapists, and patients may consider adjusting the limited access to PT to optimize patient recovery.

Clinical Relevance:

As supervised PT visits may be limited, the appropriate temporal utilization of supervised PT visits must be maximized. Strategies to ensure sessions for later neuromuscular and activity-specific rehabilitation are needed.

Spine coding transition from ICD-9 to ICD-10: Not taking advantage of the specificity of a more granular system

BACKGROUND

The transition from International Classification of Diseases, 9th Edition (ICD-9) to the 10th edition (ICD-10) in 2015 increased the number and specificity of diagnostic codes with the goal of facilitating clinical care and research possibilities.Considering the potential to default to less specified ICD-10 codes, the current study evaluated the number of codes utilized for spine-related conditions before versus after the transition to ICD-10.

METHODS

The numbers of patients with an index encounter for a primary spine-related non-deformity diagnosis codes indexed as "dorsopathies" were abstracted from the Humana PearlDiver dataset. As the transition from ICD-9 to ICD-10 occurred in 2015, the current study compared the year prior (ICD-9) to the year after (ICD-10). The number of ICD-9 and ICD-10 codes was assessed, and distribution of utilization was compared using the Kolmogorov-Smirnov test.

RESULTS

In 2014, 848,623 patients were assigned one of the 100 unique ICD-9 dorsopathy codes, of which 17 codes (17% of available codes) were used for more than 1% of the patients. In 2016, 840,310 patients were assigned one of the 504 unique ICD-10 dorsopathy codes, of which 21 (4% of available codes) were used for more than 1% of the patients. The top 20 codes in 2014 (ICD-9) and the top 20 codes in 2016 (ICD-10) both represented the majority of the patient population and were not statistically differently represented (p = 0.819). Further, analysis of ICD-10 codes demonstrated a clear bias toward utilizing less specified codes.

CONCLUSIONS

Despite a five-fold increase in available diagnostic codes for spine conditions in ICD-10, in the year after implementation providers continued to select a small proportion of less specific diagnostic codes when treating spine patients.

Effect of Myelopathy on Early Clinical Improvement After Cervical Disc Replacement: A Study of a Local Patient Cohort and a Large National Cohort

Objective

Cervical disc replacement (CDR) is an effective long-term treatment for both cervical radiculopathy and myelopathy. However, there may be unique differences in the early postoperative clinical improvement for patients with and without myelopathy. In addition, previous studies using CDR to treat cervical myelopathy were underpowered to determine risk factors for relatively postoperative medical complications.

Methods

Two different cohorts were studied. A local cohort of patients undergoing CDR by a single surgeon was utilized to study the early postoperative course of clinical improvement. In addition, a national cohort of patients undergoing CDR in the 2015 and 2016 National Surgical Quality Improvement Program database was utilized to study differences in postoperative medical complications after CDR. Patients with a preoperative diagnosis of cervical myelopathy were identified in both cohorts, and perioperative outcomes and complications were compared to patients without myelopathy.

Results

A total of 43 patients undergoing CDR were included in the institutional cohort, of those 16 patients (37% of cohort) had a preoperative diagnosis of cervical myelopathy. A total of 3,023 patients undergoing CDR were included in the national cohort, of those 411 (13% of cohort) had a preoperative diagnosis of cervical myelopathy. In the institutional cohort, the nonmyelopathy group had a lower initial Neck Disability Index (NDI) and saw a faster improvement in NDI by 2 weeks postoperative. However, at 24 weeks there was no significant difference between groups in terms of NDI. Interestingly, only the nonmyelopathy cohort had a significant improvement in modified Japanese Orthopaedic Association score by 6 weeks (p<0.05). In the national cohort, myelopathy was associated with longer operative time and length of stay (p<0.05). However, there was no significant difference in perioperative complications (p>0.05) between myelopathy and nonmyelopathy patients.

Conclusion

Significant improvements in NDI, visual analogue scale (VAS)-arm pain, and VAS-neck pain are seen in both myelopathy and nonmyelopathy populations undergoing CDR by 6 weeks postoperatively. However, nonmyelopathy populations improve faster by 2 weeks postoperatively. In the national cohort analysis, medical complications were similarly low in both myelopathy and nonmyelopathy groups.

Treatment for Degenerative Lumbar Spondylolisthesis: Current Concepts and New Evidence

PURPOSE OF REVIEW

Current guidelines for the optimal treatment degenerative spondylolisthesis are weak and based on limited high-quality evidence.

RECENT FINDINGS

There is some moderate evidence that decompression alone may be a feasible treatment with lower surgical morbidity and similar outcomes to fusion when performed in a select population with a low-grade slip. Similarly, addition of interbody fusion may be best suited to a subset of patients with high-grade degenerative spondylolisthesis, although this remains controversial. Minimally invasive techniques are increasingly being utilized for both decompression and fusion surgeries with more and more studies showing similar outcomes and lower postoperative morbidity for patients. This will likely be an area of continued intense research. Finally, the role of spondylolisthesis reduction will likely be determined as further investigation into optimal sagittal balance and spinopelvic parameters is conducted. Future identification of ideal thresholds for sagittal vertical axis and slip angle that will prevent progression and reoperation will play an important role in surgical treatment planning. Current evidence supports surgical treatment of degenerative spondylolisthesis. While posterolateral spinal fusion remains the treatment of choice, the use of interbodies and decompressions without fusion may be efficacious in certain populations. However, additional high-quality evidence is needed, especially in newer areas of practice such as minimally invasive techniques and sagittal balance correction.

Surgical site infections after posterior spinal fusion for neuromuscular scoliosis: a thirty-year experience at a single institution

BACKGROUND

Surgical site infection is a serious complication of posterior spinal fusion for neuromuscular scoliosis, with a reported prevalence of 6% to 24%. A single-institution experience over a thirty-year period was reviewed to determine the prevalence of surgical site infection after posterior spinal fusion for neuromuscular scoliosis, and to identify patient and treatment-related risk factors.

METHODS

Our retrospective review included all patients treated with posterior spinal fusion (alone or in combination with an anterior procedure) for neuromuscular scoliosis from 1980 to 2009 and followed for a minimum of two years. Univariate and multivariate statistical analysis was performed to identify significant risk factors for occurrence of deep surgical site infection (p < 0.05).

RESULTS

The study included 428 patients with an average duration of follow-up of 4.9 years. The mean Cobb angle was 74.3°. Most (74%) were treated with posterior spinal fusion alone. Deep infection developed in forty-four patients (10.3%); 57% of the infections occurred within three months after the surgery and 73%, within twelve months. Nearly half (45%) of the infections were polymicrobial; 59% of the organisms were gram-positive and 41% were gram-negative. Implant removal was required in 58% of the patients. Surgical site infection was more frequent from 1980 to 1989 (20.3%) than it was from 1990 to 2009 (8.4%) (odds ratio [OR] = 2.8, p = 0.01 in univariate analysis). Surgical site infection was more common in patients with spina bifida (21.5%) than in those with other diagnoses (8.3%) (OR = 3.0, p = 0.001). Other patient factors associated with surgical site infection were a body mass index (BMI) of >25 kg/m(2) (OR = 2.4, p = 0.04) and incontinence (OR = 2.4, p = 0.009). Treatment factors associated with surgical site infection were inadequate prophylactic antibiotic dosing (cefazolin ≤ 20 mg/kg) (OR = 3.3, p = 0.0002), length of fusion (p = 0.002), pelvic fixation (OR = 2.4, p = 0.04), length of hospital stay (p = 0.005), and other complications (OR = 3.2, p = 0.0003). Drain output (p = 0.04) and lower hemoglobin levels (p = 0.008) were significantly associated with surgical site infection in patients with spina bifida, and drain use (superficial to the fascia) was protective in those without spina bifida (OR = 0.5, p = 0.046).

CONCLUSIONS

This study identified modifiable factors, especially antibiotic dosing and drain use, associated with surgical site infection in patients with neuromuscular scoliosis.

Cytochrome oxidase activity of mitochondria in sensory nerve endings of mouse palatal rugae

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