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Case A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting. Conclusion The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

Background Total knee arthroplasty (TKA) is one of the most common elective surgical procedures in the United States, with more than 650,000 performed annually. Computer navigation technology has recently been introduced to assist surgeons with planning, performing, and assessing TKA bone cuts. The aim of this study is to assess postoperative complication rates after TKA performed using computer navigation assistance versus conventional methods. Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for unilateral TKA cases from 2008 to 2016. The presence of the CPT modifier for use of computer navigation was used to separate cases of computer-navigated TKA from conventional TKA. Multivariate and propensity-matched logistic regression analyses were performed to control for demographics and comorbidities. Results There were 225,123 TKA cases included; 219,880 were conventional TKA (97.7%) and 5,243 were navigated (2.3%). Propensity matching identified 4,811 case pairs. Analysis demonstrated no significant differences in operative time, length of stay, reoperation, or readmission, and no differences in rates of post-op mortality at 30 days postoperatively. Compared to conventional cases, navigated cases were at lower risk of serious medical morbidity (18% lower, p = 0.009) within the first 30 days postoperatively. Conclusion After controlling for multiple known risk factors, navigated TKA patients demonstrated lower risk for medical morbidity, predominantly driven by lower risk for blood transfusion. Given these findings, computer-navigation is a safe surgical technique in TKA.

BACKGROUND: With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown. QUESTIONS/PURPOSES: (1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA? METHODS: This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence. RESULTS: Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008). CONCLUSIONS: Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoing TJA, which may include participation in preoperative rehabilitation (pre-habilitation) or more aggressive follow-up in the 30 days after surgery. Further research is needed to determine whether severe ADL dependence can be modified before surgery, and whether these changes in dependency can reduce readmission risk after TJA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Retrospective cohort study OBJECTIVE.: The aim of this study was to compare perioperative adverse events for patients with lumbar spondylolysis treated with transforaminal lumbar interbody fusion (TLIF), posterior spinal fusion (PSF), combined anterior and posterior fusion (AP fusion), or anterior lumbar interbody fusion (ALIF).Previous cohort studies have shown similar long-term outcomes for different surgical approaches for this indication, but potential differences in 30-day perioperative adverse events have not been well characterized.The present study uses data extracted from the American College of Surgeons National Surgical Quality Improvement Database. Patients undergoing fusion with different approaches for lumbar spondylolysis were identified. Propensity score matching was utilized to account for potential differences in demographic and comorbidity factors. Comparisons among perioperative outcomes were then made among the propensity score-matched study groups.Of 1077 cases of spondylolysis identified, 556 underwent TLIF, 327 underwent PSF, 108 underwent AP fusion, and 86 underwent ALIF. After propensity score matching, there were no differences in the rates of any of the 30-day individual adverse events studied and no differences in the aggregated groupings of any adverse event, serious adverse event, or minor adverse event. There was a significantly increased operative time in the AP fusion group, but there were no differences in hospital length of stay or readmission rates.Because perioperative adverse event rates were similar, even with a slightly longer operative time in the AP fusion group, these findings suggest that surgeon preference and long-term outcomes are better used to determine the recommendation of one surgical approach over another for single level fusions for lumbar spondylolysis.3.

A retrospective cohort study.The aim of this study was to determine the independent effects of operative time and surgical invasiveness on perioperative outcomes after posterior spinal fusions for adult spinal deformity.Morbidity is high after posterior fusions for adult spinal deformity. Although previous reports have demonstrated an association between perioperative outcomes and the extent of correction and fusion (number of posterior levels fused, pelvic fixation, combined anterior-posterior fusion), no study has looked at the independent effects of the surgical invasiveness after controlling for operative time.All adult patients, undergoing posterior spinal fusion for spinal deformity, were identified in the 2010 to 2014 National Surgical Quality Improvement Program (NSQIP) database. Multivariate analysis was used to determine the independent effects of longer operative timing and the surgical invasiveness (number of levels fused, anterior or transforaminal interbody fusions, osteotomies, and pelvic fixation) on 30-day complications.A total of 1540 patients undergoing posterior spinal fusion for adult spinal deformity were identified. The overall rate of complications was 15.3%. In multivariate analysis, greater operative timing was associated with increased inpatient complications [odds ratio (95% confidence interval, 95% CI) from 2.23 (1.25-3.98) for 7-8 hours to 4.46 (2.61-7.64) for 9+ hours; P 0.001]. Although the number of levels fused, anterior/interbody fusions, osteotomies, and pelvic fixation were associated with complications on bivariate analysis, these factors were not associated with increased complications in multivariate analysis when controlling for other factors such as operative time.For adult deformity surgery, longer operative time appears to be a better predictor of the overall rate perioperative complications than surgical invasiveness in multivariate analysis. Rather than avoidance of a more extensive and invasive surgical procedure, which may be indicated to improve alignment and stability, these data suggest the importance of safely and efficiently minimizing overall operative time.4.

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

Background Quality improvement in orthopaedic surgery has received increasing attention; however, there is insufficient information available about the perioperative safety of many common pediatric orthopaedic procedures. This study aimed to characterize the incidence of adverse events in a national pediatric patient sample to understand the risk profiles of common pediatric orthopaedic procedures, and to identify patients and operations that are associated with increased rates of adverse outcomes. Methods A retrospective cohort study was conducted using the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Pediatric patients who underwent 29 different orthopaedic procedures were identified in the 2012 NSQIP Pediatric database. The occurrence of any adverse event, infection, return to the operating room, and readmission within 30 days, were reported for each procedure. Multivariate regression was then used to identify the association of patient and operative characteristics with the occurrence of each adverse outcome. Results A total of 8975 pediatric patients were identified. Supracondylar humerus fracture fixation was the most common procedure performed in this sample (2274 patients or 25.57% of all procedures), followed by posterior spinal fusion (1894 patients or 21.10% of all procedures). Adverse events occurred in 352 patients (3.92% of all patients). Four deaths were noted (0.04% of all patients), which only occurred in patients with nonidiopathic scoliosis undergoing spinal fusion. Infections occurred in 143 patients (1.59%), and 197 patients (2.19%) were readmitted within 30 days. Multiple patient characteristics and procedures were found to be associated with each adverse outcome studied. Conclusions Spinal fusion, multiaxial external fixation, and fasciotomy were procedures associated with increased rates of adverse outcomes within 30 days. Patients with obesity, ASA class ≥3, and impaired cognitive status also had increased rates of adverse outcomes. The results from this study of a large, national sample of pediatric orthopaedic patients are important for benchmarking and highlight areas for quality improvement. Level of evidence Level III-Prognostic.

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

Background Safety data for outpatient total hip arthroplasty (THA) remains scarce. Methods The present study retrospectively reviews prospectively collected data from the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program Database. Patients who underwent THA were categorized by day of hospital discharge to be outpatient (length of stay [LOS] 0 days) or inpatient (LOS 1-5 days). Those with extended LOS beyond 5 days were excluded. To account for baseline nonrandom assignment between the study groups, propensity score matching was used. The propensity matched populations were then compared with multivariate Poisson regression to compare the relative risks of adverse events during the initial 30 postoperative days including readmission. Results A total of 63,844 THA patients were identified. Of these, 420 (0.66%) were performed as outpatients and 63,424 (99.34%) had LOS 1-5 days. Outpatients tended to be younger, male, and to have fewer comorbidities. After propensity score matching, outpatients had no difference in any of 18 adverse events evaluated other than blood transfusion, which was less for outpatients than those with a LOS of 1-5 days (3.69% vs 9.06%, P Conclusion After adjusting for potential confounders using propensity score matching and multivariate logistic regression, patients undergoing outpatient THA were not at greater risk of 30 days adverse events or readmission than those that were performed as inpatient procedures. Based on the general health outcome measures assessed, this data supports the notion that outpatient THA can appropriately be considered in appropriately selected patients.

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

Study design A retrospective study of patients undergoing anterior cervical discectomy and fusion (ACDF) in the prospective National Surgical Quality Improvement Program (NSQIP) database. Objective To determine the most common reasons for readmission within 30 days after elective ACDF. Summary of background data ACDF is a commonly performed surgery that is safe and effective for treating a variety of cervical spine pathologies. With new quality-based reimbursements tied to readmissions within 30 days of discharge, better understanding of the causes of readmissions is, however, needed. Methods Patients undergoing ACDF in the NSQIP database from 2012 to 2014 were reviewed. The overall rate of readmission and documented reasons for readmission were collected. Multivariate regression was then used to determine risk factors for readmissions. Results A total of 17,088 patients undergoing elective ACDF were identified. There were 545 (3.2%) readmissions within 30 postoperative days. Of the readmitted patients, 293 (53.8%) were readmitted for nonsurgical site-related reasons, with neuropsychiatric (n = 44), cardiovascular (n = 39), and pneumonia (n = 37) being the most common reasons. A total of 184 patients (33.8%) were readmitted for surgical site-related reasons, with surgical site infection (n = 42), hemorrhage/hematoma (n = 42), and dysphagia (n = 32) being the most common reasons. A total of 84 patients (15.6%) had undocumented reasons for readmission. In multivariate analysis, only older age and higher American Society of Anesthesiologists class were independently associated with readmissions. Conclusion Most readmissions after ACDF were due to nonsurgical site-related reasons, suggesting the importance of careful patient selection, aggressive preoperative medical optimization, and adequate postoperative management. Level of evidence 3.

Metabolic syndrome can adversely affect surgical outcomes. This study evaluated the postoperative outcomes of patients with metabolic syndrome after total shoulder arthroplasty (TSA). A retrospective cohort study of 4751 patients undergoing TSA was conducted with use of the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013. Metabolic syndrome was defined as hypertension, diabetes, and body mass index of 30.0 kg/m 2 or greater. Multivariable logistic regression analysis was performed for the outcomes of any postoperative complications and extended length of stay. Patients classified as obese III had a significantly increased risk of extended length of stay ( P =.011) compared with control subjects who were of normal weight. In the multivariable adjusted models, compared with nonobese patients, those classified as obese I and obese II had a significantly decreased risk of postoperative complications (odds ratio, 0.84, P =.020, and odds ratio, 0.82, P =.045, respectively), whereas those classified as obese I were less likely to have extended length of stay (odds ratio, 0.79, P =.004). Metabolic syndrome was not a significant predictor of postoperative complications or extended length of stay. Morbidly obese patients undergoing TSA have an increased risk of postoperative complications and extended length of stay. Those classified as obese I and obese II may have a decreased risk of postoperative complications and shorter length of stay. Despite the hypothesized negative effect of metabolic syndrome on outcomes, the overall effect of metabolic syndrome was insignificant. These results are consistent with previous studies on obesity in patients undergoing TSA and may explain why recent studies have not shown differences in the rate of complications after TSA in obese patients with a body mass index of 30 to 40 mg/kg 2 . [ Orthopedics. 2016; 39(5):309–316.]

Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports. The National Trauma Data Bank was queried for patients presenting to emergency departments due to injuries sustained from skiing and snowboarding during 2011 and 2012. Patient demographics, comorbidities, and injury patterns were tabulated and compared between skiing and snowboarding. Risk factors for increased injury severity score and lack of helmet use were identified using multivariate logistic regression. Of the 6055 patients identified, 55.2 % were skiers. Sixty-one percent had fractures. Lower extremity fractures were the most common injury and occurred more often in skiers (p

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.

Traditionally, patients with significant hip pain due to degenerative hip disease, who are not surgical candidates for a total hip arthroplasty (THA), or are wary of the procedure, have been managed with various modalities with variable effectiveness.We have recently developed an anterior release of the contracted hip capsule along with par- tial denervation ofthe hip joint performed on an out- patient basis to relieve pain and improve function.A case series of 24 patients.From November 2007 to April 2009, 24 partial,denervation procedures through an anterior approach were performed by a single surgeon. A clinical survey was conducted five years following the intervention.Eighteen ofthe 24 patients were alive at the time of follow-up. Four of the six patients who were deceased at the time of follow-up had not undergone aTHA while two had. Fifteen ofthe 18 patients who were still living received a THA while three did not. Ihe interval time to arthroplasty was 19 months.

STUDY DESIGN Retrospective review of the prospective American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database with 30-day follow-up of 2164 patients undergoing elective anterior cervical discectomy and fusion (ACDF). OBJECTIVE To determine factors independently associated with increased length of stay (LOS) and complications after ACDF to facilitate preoperative planning and setting of realistic expectations for patients and providers. SUMMARY OF BACKGROUND DATA The effect of individual preoperative factors on LOS and complications has been evaluated in small-scale studies. Large database analysis with multivariate analysis of these variables has not been reported. METHODS The ACS NSQIP database from 2005 to 2010 was queried for patients undergoing ACDF procedures. Preoperative and perioperative variables were collected. Multivariate regression determined significant predictors (P

To determine (1) the incidence of delayed surgical treatment, (2) risk factors associated with delayed surgical intervention, (3) inpatient adverse events and discharge disposition, and (4) the association of delayed surgery with inpatient adverse events.Retrospective cohort study.2011 and 2012 National Trauma Data Bank.All adult patients younger than 50 years of age with femoral neck fractures.Not applicable.(1) Time to surgical intervention after inpatient admission, (2) odds ratio (OR) for delayed surgery (later than 24 hours after admission), (3) incidence of inpatient adverse events and discharge disposition, (3) rates of inpatient adverse events and discharge disposition, and (4) OR for occurrence of serious adverse events, minor adverse events, and any adverse events.Of a total of 1361 patients, 67.8% of patients underwent surgery within 24 hours of presentation. In multivariate analysis (controlling for patient and injury characteristics), Charlson comorbidity index of 3+ compared with Charlson comorbidity index of 0 (OR: 3.62), pelvic fracture (OR: 2.01), and treatment at an American College of Surgeons level I trauma center (compared with levels II-IV; OR: 1.56) were associated with delayed surgery. The overall rate of mortality and inpatient adverse events was 0.2% and 12.1%, respectively. Delayed surgery was independently associated with increased occurrence of serious adverse events, minor adverse events, and any adverse events.Although a majority of nonelderly patients with femoral neck fractures underwent surgery within the first 24 hours of admission and had good outcomes in the short-term, certain subpopulations have a higher risk of delayed surgery. As delayed surgery is associated with worse outcomes, and short-term and long-term outcomes, efforts should focus on expediting care of these patients.Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN Retrospective cohort study OBJECTIVE.: To determine the rate of venous thromboembolism event (VTE) and risk factors for their occurrence in patients with vertebral fractures. SUMMARY OF BACKGROUND DATA Deep vein thrombosis or pulmonary embolism (VTE) events are a significant source of potentially preventable morbidity and mortality in trauma patients. In patients with traumatic vertebral fractures, a common high-energy injury sometimes resulting in spinal cord injury, there is debate about what factors may be associated with such VTEs. METHODS All patients with vertebral fractures in the American College of Surgeons National Trauma Data Bank Research Data Set (NTDB RDS) from years 2011 and 2012 were identified. Multivariate logistic regression was used to determine factors associated with the occurrence of VTE while considering patient factors, injury characteristics, and hospital course. RESULTS A total of 190,192 vertebral fractures patients were identified. The overall rate of VTE was 2.5%. In multivariate analysis, longer inpatient length of stay was most associated with increased VTEs with an odds ratio (OR) of up to 96.60 (95% CI: 77.67 - 129.13) for length of stay longer than 28 days (compared to 0 - 3 days). Additional risk factors in order of decreasing odds ratios were older age (OR of up to 1.65 [95% CI: 1.45 - 1.87] for patients age 70 - 79 years [compared to age 18 - 29 years]), complete spinal cord injuries (OR: 1.49 [95% CI: 1.31 - 1.68]), cancer (OR: 1.37 [95% CI: 1.25 - 1.50]), and obesity (OR: 1.32 [95% CI: 1.18 - 1.48]). Multiple associated non-spinal injuries were also associated with increased rates of VTE. CONCLUSION While the overall rate of VTE is relatively low after vertebral fractures, longer LOS and other defined factors to lesser extents were predisposing factors. By determining patients at greatest risk, protocols to prevent such adverse outcomes can be developed and optimized. LEVEL OF EVIDENCE 3.

Background: The purpose of this study was to assess impact of the surgeon consultation and informed consent process on patient education in an international hand surgery mission compared with a US academic hand surgery practice. These two groups were selected to evaluate communication difficulties in a surgical mission setting compared with standard of care in a high-income country.Methods: A multi-part survey was administered to patients presenting to a hand surgery mission during March 2012 and new patients of a university hand center in a 3-month period during 2011. Surveys were administered prior to and following surgeon consultation with one fellowship-trained hand surgeon. The survey assessed knowledge of basic hand anatomy, physiology, disease, individual diagnosis, and surgical risks.Results: 71 patients participated in the study (university n=36, mission n=35). Pre-consultation quiz score averaged 58% in the university group versus 27% in the mission group. Post-consultation quiz scores averaged 62% in the university group versus 40% in the mission group. Only the mission group’s quiz score increase was statistically significant. 93% of the university group reported learning about their condition and diagnosis, but only 40% demonstrated correct insight into their diagnosis. In the mission group, 73% reported learning about their condition and diagnosis while 53% demonstrated correct insight into their diagnosis. Although all consultations involved discussion of surgical risks, only 62% of the university group and 52% of the mission group recalled discussing surgical risks.Conclusions: The hand surgeon consultation was more effective in improving hand knowledge in the surgery mission group compared to in a university hand practice. This suggests that the surgeon consultation should be pursued despite communication barriers in surgical missions. However, the discrepancy between patient perception of knowledge gains and correct insight into diagnosis, and the deficit of patient retention of surgical risks need to be improved.

Although uncommon, stroke can be a catastrophic inpatient complication for patients with hip fractures. The current study determines the incidence of inpatient stroke after hip fractures in elderly patients, identifies risk factors associated with such strokes, and determines the association of stroke with short-term inpatient outcomes. A retrospective review of all patients aged 65 years or older with isolated hip fractures in the 2011 and 2012 National Trauma Data Bank was conducted. A total of 37,584 patients met inclusion criteria. Of these patients, 162 (0.4%) experienced a stroke during their hospitalization for the hip fracture. In multivariate analysis, a history of prior stroke (odds ratio [OR], 13.24), coronary artery disease (OR, 2.05), systolic blood pressure 180 mm Hg or higher (OR, 1.66), and bleeding disorders (OR, 1.65) were associated with inpatient stroke. Inpatient stroke was associated with increased mortality (OR, 7.17) and inpatient serious adverse events (OR, 6.52). These findings highlight the need for vigilant care of high-risk patients, such as those with a history of prior stoke, and for an understanding that patients who experience an inpatient stroke after a hip fracture are at significantly increased risk of mortality and inpatient serious adverse events. [ Orthopedics. 2018; 41(1):e27–e32.]

STUDY DESIGN: A retrospective study of surgically treated patients with acute traumatic central cord syndrome (ATCCS) from the National Trauma Data Bank Research Data Set. OBJECTIVE: To determine the association of time to surgery, pre-existing comorbidities, and injury severity on mortality and adverse events in surgically treated patients with ATCCS. SUMMARY OF BACKGROUND DATA: Although earlier surgery has been shown to be beneficial for other spinal cord injuries, the literature is mixed regarding the appropriate timing of surgery after ATCCS. Traditionally, this older population has been treated with delayed surgery because medical optimization is often indicated preoperatively. METHODS: Surgically treated patients with ATCCS in the National Trauma Data Bank Research Data Set from 2011 and 2012 were identified. Time to surgery, Charlson Comorbidity Index, and injury severity scores were tested for association with mortality, serious adverse events, and minor adverse events using multivariate logistic regression. RESULTS: A total of 1060 patients with ATCCS met inclusion criteria. After controlling for pre-existing comorbidity and injury severity, delayed surgery was associated with a decreased odds of inpatient mortality (odds ratio = 0.81, P = 0.04), or a 19% decrease in odds of mortality with each 24-hour increase in time until surgery. The association of time to surgery with serious adverse events was not statistically significant (P = 0.09), whereas time to surgery was associated with increased odds of minor adverse events (odds ratio = 1.06, P CONCLUSION: Although the potential neurological effect of surgical timing for patients with ATCCS remains controversial, the decreased mortality with delayed surgery suggests that waiting to optimize general health and potentially allow for some spinal cord recovery in these patients may be advantageous. LEVEL OF EVIDENCE: 3. Language: en

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

Background context Vertebral body–derived bone marrow aspirate (BMA, with an appropriate carrier) is a potential alternative to traditional iliac crest bone graft for use in spinal fusion surgery. No studies have looked at the effect of different temporary handling/storage conditions on the osteoprogenitor potential of BMA. This is especially important because aspirate, as with cancellous and/or cortical grafts, may be extracted some time before actual implementation in regular clinical use. Purpose To characterize factors that affect BMA cell concentration during routine spinal instrumentation, this study examined whether cell counts change significantly between the second pedicle aspirated and the first pedicle harvested at the same vertebral level. This study also aims to examine the optimal perioperative storage conditions for BMA obtained from the vertebral body. Study design In vitro concentrations of viable cells were determined in BMA harvested from the first and second pedicles on every vertebral level, and after 1 hour of storage in different perioperative conditions. Patient sample BMA was harvested from 28 pedicles from seven patients undergoing lumbar instrumented fusion surgeries. Outcome measures The outcome measure included viable nucleated cell concentrations in BMA. Methods After obtaining HIC approval from our institution, 28 vertebral marrow aspirates (obtained from seven patients) were evaluated. Based on prior work, 4-mL aspirates from each pedicle were evaluated. BMA was aspirated from both pedicles of two vertebral levels per patient. Samples were divided and placed in different storage conditions to examine the effect of laterality (first versus second pedicle aspirated per level), temperature, media, and time, on nucleated cell counts. No funding was received for this study, and the authors disclose no study specific conflicts of interest. Results Cell count was not significantly different between the first or second side aspirated for each vertebral level. Similarly, no significant differences were found for samples after 1 hour of storage at different temperatures (0°C, room temperature, or 37°C) or media (none, saline, essential media). Of the conditions examined, time from aspiration was the only variable found to have an impact on nucleated cell counts (p=.003). The viable cell count decreased to less than half by 4 hours. Conclusion As vertebral BMA is increasingly considered as a bone grafting option, the field would be remiss not to consider factors that could affect cell viability after abstraction and before implementation. We expected a greater effect of perioperative storage conditions than was observed. Although the variables evaluated might show small effects on cell viability in a larger study, this would not be expected to be significant. In the current study, only prolonged time from abstraction could be shown to have a significant effect on cell viability.

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. 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. 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. 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. 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 III, therapeutic study.

STUDY DESIGN A retrospective cohort study of prospectively collected data. OBJECTIVE As an initial effort to address readmissions after lumbar discectomy, reasons for hospital readmission are identified and discussed. SUMMARY OF BACKGROUND DATA Lumbar discectomy is a commonly performed procedure. The Affordable Care Act codifies penalties for hospital readmissions. New quality-based reimbursements tied to readmissions call for a better understanding of the causes of readmission after procedures such as lumbar discectomy. METHODS Lumbar discectomies performed in 2012 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics, surgical variables, and reasons for readmissions within 30 days were recorded. Pearson chi square was used to compare rates of demographics and surgical variables between readmitted and nonreadmitted patients. Multivariate regression was used to identify risk factors for readmission. RESULTS Of 20,376 lumbar discectomies, 533 patients (2.62%) were readmitted within 30 days of surgery. The most common reasons for readmission were surgical site infections (n = 130, 0.64% of all discectomies, 24.4% of all readmissions), followed by pain issues (n = 89, 0.44%, 16.7%), and thromboembolic events (43, 0.21%, 8.1%). Overall time to readmission was 13.0 ± 8.0 days (mean ± standard deviation). Factors most associated with readmission after lumbar discectomy were higher American Society of Anesthesiologists class (relative risk = 1.49, P

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.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.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.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.

The hormonal basis of vasomotor symptoms (VMS) in hypogonadal men is incompletely understood.To determine the contributions of testosterone and estradiol deficiency to VMS in hypogonadal men.Two randomized trials were conducted sequentially between September 2004 and April 2011. Controls were recruited separately.A single-site academic medical center.Healthy men ages 20-50, with normal serum testosterone levels.Cohort 1 (n = 198, 81% completion) received goserelin acetate every 4 weeks to suppress gonadal steroids and were randomized to placebo or 1.25, 2.5, 5, or 10 g of testosterone gel daily for 16 weeks. Cohort 2 (n = 202, 78% completion) received the same regimen as cohort 1 plus anastrozole to block aromatization of testosterone. Controls (n = 37, 89% completion) received placebos for goserelin acetate and testosterone.Incidence of visits with VMS. This was a preplanned secondary analysis.VMS were reported at 26% of visits in cohort 1, and 35% of visits in cohort 2 (P = .02), demonstrating an effect of estradiol deficiency. When adjacent estradiol level groups in cohort 1 were compared, the largest difference in VMS incidence was observed between the 5-9.9 and 10-14.9 pg/mL groups (38% vs 16%, P.001). In cohort 2, the 10-g testosterone group differed significantly from placebo (16% vs 43%, P = .048) after adjustment for small differences in estradiol levels, indicating that high testosterone levels may suppress VMS.Estradiol deficiency is the key mediator of VMS in hypogonadal men. At high levels, testosterone may have a suppressive effect.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The primary aim of this study was to determine the incidence and risk factors for 30-day adverse events after revision posterior lumbar fusion. The secondary aim was to determine the incidence and risk factors for 30-day readmission after revision posterior lumbar fusion. SUMMARY OF BACKGROUND DATA The need for revision of a lumbar fusion is an unfortunate occurrence, and there is little known about specific risk factors for morbidity and readmission after this procedure. The purpose of this study is to use a large, national sample to identify patient and operative factors that may contribute to the development of these adverse outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing revision posterior lumbar fusion from 2005 to 2013. Patient characteristics were tested for association with any adverse event (AAE), severe adverse events (SAEs), minor adverse events (MAEs), and readmission within 30 days postoperatively using multivariate analysis. RESULTS Of the 1287 patients identified, 8.2% had an AAE, 5.6% had an SAE, and 3.2% had an MAE. AAE was independently associated with American Society of Anesthesiologists (ASA) classification ≥3 and operative time ≥310 minutes (P

Medicare currently reimburses hospitals for inpatient admissions with "bundled" payments based on patient Diagnosis-related Groups (DRGs) regardless of true hospital costs. At present, DRG 536 (fractures of the hip and pelvis) includes a broad spectrum of patients with orthopaedic trauma, likely with varying inpatient resource utilization. With the growing incidence of fractures in the elderly, inadequate reimbursements from Medicare for certain patients with DRG 536 may lead to growing financial strain on healthcare institutions caring for these patients with higher costs.The purposes of the study were to determine whether (1) inpatient length of stay; (2) intensive care unit stay; and (3) ventilator time differ among subpopulations with Medicare DRG 536.A total of 56,683 patients, 65 years or older, with fractures of the hip or pelvis were identified in the 2011 and 2012 National Trauma Data Bank. This clinical registry contains data on trauma cases from more than 900 participating trauma centers, allowing analysis of resource utilization in centers across the United States. Patients were grouped in the following subgroups: hip fractures (n = 35,119), nonoperative pelvic fractures (n = 15,506), acetabulum fractures, operative and nonoperative, (n = 7670), and operative pelvic fractures (n = 682). Total inpatient length of stay, intensive care unit (ICU) stay, and ventilator time were compared across groups using multivariate analysis that controlled for hospital factors.After controlling for patient and hospital factors, difference in inpatient length of stay was -0.2 days for patients with nonoperative pelvis fractures compared with inpatient length of stay for patients with hip fractures (95% CI, -0.4 to -0.1 days; p = 0.001); 1.7 days for patient with acetabulum fractures (95% CI, 1.4-1.9 days; p0.001); and 7.7 days for patients with operative pelvic fractures (95% CI, 7.0-8.4 days; p0.001). The difference in ICU length of stay for patients with nonoperative pelvis fractures was 0.8 days compared with ICU length of stay for patients with hip fractures (95% CI, 0.7-0.9 days; p0.001); 1.9 days for patients with acetabulum fractures (95% CI, 1.8-2.1 days; p0.001); and 6.3 days for patients with operative pelvic fractures (95% CI, 5.9-6.7 days; p0.001). The difference in mechanical ventilation time for patients with nonoperative fractures was 0.5 days compared with ventilation time for patients with hip fractures (95% CI, 0.4-0.6 days; p0.001); 1.1 days for patients with acetabulum fractures (95% CI, 1.0-1.2 days; p0.001); and 3.9 days for patients with operative fractures (95% CI, 2.5-3.2 days; p0.001).In our current multitiered trauma system, certain centers will see higher proportions of patients with acetabulum and operative pelvic fractures. Because hospitals are reimbursed equally for these subgroups of Medicare DRG 536, centers that care for a greater proportion of patients with more-complex pelvic trauma will experience lower financial margins per trauma patient, limiting their potential for growth and investment compared with competing institutions that may not routinely see patients with high-energy trauma. Because of this, we believe reevaluation of this Medicare Prospective Payment System DRG is warranted.Level IV, economic and decision analysis.

Study design A retrospective cohort. Objective The aim of this study was to characterize spinal fractures in patients with ankylosing spondylitis. Summary of background data Patients with ankylosing spondylitis are susceptible to fractures of the spinal column, even from minor trauma. However, the literature describing patients with ankylosing spondylitis and spinal fractures consists largely of case reports and small case series. The purpose of this study is to better characterize fractures of the ankylosed spine, including the patient population, locations of fracture, and outcomes in a large, nationally representative sample. Methods All patients with diagnoses of both fracture of the spinal column and ankylosing spondylitis admitted between 2005 and 2011 were identified in the National Inpatient Sample (NIS). Patient demographics, fracture regions, and complications were characterized with descriptive statistics. The associations between injury characteristics and outcomes were assessed using Poisson regression. Results A total of 939 patients with ankylosing spondylitis admitted with a spinal fracture were identified in NIS. The average age was 68.4 ± 14.7 years, and 85% of patients were male. Cervical fractures were the most common (53.0%), followed by thoracic (41.9%), lumbar (18.2%), and sacral (1.5%). Spinal cord injury was present in 27.5% of cervical fractures, 16.0% of thoracic fractures, and 21.1% of cases overall. Fractures involving more than 1 region of the spine occurred in 13.1% of patients. Patients were treated with fusion in 49.9% of cases. In-hospital adverse events occurred in 29.4% of patients, and 6.6% of patients died during their admission. Conclusion More than 10% of patients had fractures in more than 1 region of the spine. There is a high risk of adverse events in this population, and 6.6% of patients died during their inpatient stay. These results provide clinicians with a better understanding of the distribution and the high morbidity and mortality of fractures in the ankylosed spine. Level of evidence 3.

Retrospective cohort study.To compare short-term morbidity for primary and revision posterior lumbar fusions.Revision lumbar fusions are unfortunately relatively common. Previous studies have described an increased risk of postoperative complications after revision lumbar fusion; however, these studies have been limited by small sample sizes, poor data quality, and/or narrow outcome measures. There is a need to validate these findings using a high-quality, national cohort of patients to have an accurate assessment of the relative risk of revision posterior lumbar fusions compared with primary lumbar fusion.The prospectively-collected American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients that underwent undergoing primary and revision posterior lumbar fusion from 2005 to 2013. The occurrence of individual and aggregated postoperative complications within 30 days, along with rates of blood transfusion and readmission, were compared between primary and revision procedures using bivariate and multivariate Poisson regression with robust error variance to control for patient and operative characteristics. Operative time and postoperative length of stay were compared between groups using bivariate and multivariate linear regression.Of the 14,873 posterior lumbar fusion procedures that met inclusion criteria, 1287 (8.7%) were revision cases. There were no differences in the rates of 30-day postoperative complications or readmission between primary and revision posterior lumbar fusion using multivariate analysis to control for patient and operative characteristics. Similarly, no significant differences were found for operative time or postoperative length of stay. There was an increased rate of blood transfusion for revision surgery compared with primary surgery (relative risk 1.4, P 0.001).This study suggests that revision posterior lumbar fusion does not carry significantly increased risk of complications or readmission compared with a primary posterior lumbar fusion. Patients undergoing revision surgery were more likely to receive a blood transfusion. This information suggests that general health risk stratification for revision procedures can be similar to that considered for primary cases.3.

STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to determine the incidence and risk factors for short-term morbidity following posterior spinal fusion (PSF) for neuromuscular scoliosis (NMS). SUMMARY OF BACKGROUND DATA NMS is a challenging spinal deformity for which PSF is often recommended. There is a lack of information on risk factors for short-term adverse outcomes after PSF for NMS. METHODS Patients who underwent PSF for NMS during 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database. Patient characteristics were tested for association with adverse events, infectious complications, extended length of stay (LOS), and readmission using multivariate regression. RESULTS Of the 940 NMS patients identified, 133 (14.1%) had an adverse event and 99 (10.5%) had a severe adverse event. American Society of Anesthesiologists (ASA) classification ≥3 was found to be the only independent risk factor for any adverse event (relative risk [RR] 2.2, P = 0.012) and severe adverse events (RR 2.5, P = 0.008). Infectious complications were associated with body mass index (BMI)-for-age ≥95th percentile (RR 2.8, P = 0.005), ASA classification ≥3 (RR 5.9, P = 0.003), and instrumentation to the pelvis (RR 1.8, P = 0.039).A total of 254 patients (27%) spent longer than a week in the hospital postoperatively, and ASA classification ≥3 (RR 2.3, P < 0.001), preoperative seizure disorder (RR 1.4, P = 0.002), previous cardiac surgery (RR 1.6, P = 0.004), operative time ≥470 minutes (RR 1.8, P < 0.001), and ≥13 levels instrumented (RR 1.9, P = 0.001) were associated with extended LOS.Seventy-six patients (8.1%) were readmitted, and BMI-for-age ≥95th percentile (RR 1.8, P = 0.033) was the only risk factor found for readmission. CONCLUSION The identified factors associated with poor short-term outcomes after PSF for NMS can be used as benchmark data, be useful for optimizing patient care, and can inform future studies in these patients. LEVEL OF EVIDENCE 3.

Study design Retrospective cohort study. Objective To characterize the timing of complications after spinal fusion procedures. Summary of background data Despite many publications on risk factors for complications after spine surgery, there are few publications on the timing at which such complications occur. Methods Patients undergoing anterior cervical decompression and fusion (ACDF) or posterior lumbar fusion (PLF; with or without interbody) procedures during 2011-2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. For each of 8 different complications, the median time from surgery until complication was determined, along with the interquartile range and middle 80%. Results A total of 12,067 patients undergoing ACDF and 11,807 patients undergoing PLF were identified. For ACDF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-5; 0-15), pneumonia 4 (2-9; 1-14), pulmonary embolism 5 (2-9; 1-10), deep vein thrombosis 10.5 (7-16.5; 5-21), sepsis 10.5 (4-18; 1-23), surgical site infection 13 (8-19; 5-25), and urinary tract infection 17 (8-22; 4-26). For PLF, the median day of diagnosis (and interquartile range; middle 80%) for anemia requiring transfusion was 0 (0-1; 0-2), myocardial infarction 2 (1-4; 1-8), pneumonia 4 (2-9; 1-17), pulmonary embolism 5 (3-11; 2-17), urinary tract infection 7 (4-14; 2-23), deep vein thrombosis 8 (5-16; 3-20), sepsis 9 (4-16; 2-22), and surgical site infection 17 (13-22; 9-27). Conclusion These precisely described postoperative time periods enable heightened clinical awareness among spine surgeons. Spine surgeons should have the lowest threshold for testing for each complication during the time period of greatest risk. Authors, reviewers, and surgeons utilizing research on postoperative complications should carefully consider the impact that the duration of follow-up has on study results. Level of evidence 3.

Study design Retrospective cohort study. Objective To identify factors associated with blood transfusion for primary posterior lumbar fusion surgery, and to identify associations between blood transfusion and other postoperative complications. Summary of background data Blood transfusion is a relatively common occurrence for patients undergoing primary posterior lumbar fusion. There is limited information available describing which patients are at increased risk for blood transfusion, and the relationship between blood transfusion and short-term postoperative outcomes is poorly characterized. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing primary posterior lumbar fusion from 2011 to 2013. Multivariate analysis was used to find associations between patient characteristics and blood transfusion, along with associations between blood transfusion and postoperative outcomes. Results Out of 4223 patients, 704 (16.7%) had a blood transfusion. Age 60 to 69 (relative risk [RR] 1.6), age greater than equal to 70 (RR 1.7), American Society of Anesthesiologists class greater than equal to 3 (RR 1.1), female sex (RR 1.1), pulmonary disease (RR 1.2), preoperative hematocrit less than 36.0 (RR 2.0), operative time greater than equal to 310 minutes (RR 2.9), 2 levels (RR 1.6), and 3 or more levels (RR 2.1) were independently associated with blood transfusion. Interbody fusion (RR 0.9) was associated with decreased rates of blood transfusion. Receiving a blood transfusion was significantly associated with any complication (RR 1.7), sepsis (RR 2.6), return to the operating room (RR 1.7), deep surgical site infection (RR 2.6), and pulmonary embolism (RR 5.1). Blood transfusion was also associated with an increase in postoperative length of stay of 1.4 days (P Conclusion 1 in 6 patients received a blood transfusion while undergoing primary posterior lumbar fusion, and risk factors for these occurrences were characterized. Strategies to minimize blood loss might be considered in these patients to avoid the associated complications. Level of evidence 3.

STUDY DESIGN This is a retrospective cohort study. OBJECTIVE To compare the infection rates in the Scoliosis Research Society (SRS) morbidity and mortality database to those in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. SUMMARY OF BACKGROUND DATA Surgical databases have demonstrated value in orthopaedic surgery. However, few studies in the literature have used the SRS database relative to other available databases. To validate the surgeon-reported data of the SRS database, we compared the rate of postoperative infection in this database to that in the chart-abstracted ACS-NSQIP database. METHODS International Classification of Disease, ninth revision (ICD-9) codes were used to group patients from the 2012 and 2013 ACS-NSQIP database into groups corresponding to spinal deformity diagnoses delineated by SRS. Postoperative infection rates after surgical correction of these deformities compared with those reported in the 2012 and 2013 SRS database using χ tests. RESULTS The overall rate of acute postoperative infection was slightly lower in the SRS database than in the ACS-NSQIP database (1.21% compared to 2.05% in ACS-NSQIP, a difference of only 0.84%, statistically significant, P < 0.001).The infection rates of most diagnoses did not differ; these included scoliosis (idiopathic

STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate whether myelopathy is associated with increased morbidity and mortality after anterior cervical discectomy and fusion (ACDF) compared with other indications for this procedure. SUMMARY OF BACKGROUND DATA ACDF is the most common surgical procedure for the management of a spectrum of cervical spine pathologies. As a more advanced condition, myelopathy is generally thought to be associated with higher morbidity and mortality after this procedure, but there is limited evidence to support this supposition. The current study compares outcomes of ACDF procedures performed for myelopathy with those performed for other indications, controlling for other patient factors. METHODS Patients who underwent ACDF between 2010 and 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with myelopathy were identified by diagnosis codes for cervical myelopathy. Bivariate and multivariate logistic regressions were performed to compare 30-day adverse events and readmission between groups. Multivariate analyses controlled for patient and surgical characteristics. RESULTS A total of 5256 ACDF procedures met inclusion criteria, of which 1425 (27.3%) were performed for cervical myelopathy. Patients with myelopathy were older and were less healthy than patients without myelopathy. Multivariate analysis controlling for baseline patient characteristics found that patients with myelopathy were at significantly increased risk of any adverse event (odds ratio = 1.5), any severe adverse event (odds ratio = 1.8), and death (odds ratio = 8.9) compared with patients without myelopathy. CONCLUSION After adjusting for baseline patient characteristics, not only were any adverse events and serious adverse events more common after ACDF for patients with myelopathy than for patients without myelopathy, but mortality was approximately 9 times more likely. It is important for surgical planning and patient counseling to keep this significant difference in mind for this common procedure that has different morbidities based on the pathology for which it is performed. LEVEL OF EVIDENCE 3.

Background Context Magnetic resonance imaging (MRI) is often used in the evaluation of degenerative conditions of the cervical spine. However, the agreement of interpreting and reporting varying degenerative findings on cervical MRI has not been well assessed. Purpose This study aimed to compare the inter -rater and intra -rater agreement of MRI findings between common degenerative findings of the cervical spine. Study Design A retrospective diagnostic study was used as study design. Patient Sample The sample consisted of 48 patients who underwent routine cervical spine MRI at our institution between January 2011 and June 2012. Outcome Measures Reviewers evaluated each MRI study at each vertebral level for disc hydration, disc space height, central stenosis, foraminal stenosis, end plate changes, spondylolisthesis, and cord signal change. Methods A panel of two orthopedic spine surgeons and four musculoskeletal radiologists independently reviewed 48 sets of T2-weighted axial and sagittal MRI sequences for a series of preselected criteria, and their findings were compared with those of the other panelists to determine inter-rater agreement. Each panelist also re-reviewed the first 10 studies to determine intra-rater agreement. Absolute inter-rater and intra-rater agreements were then calculated and compared for different findings. A modified analysis ignored disagreements between the least severe grades of findings to determine the inter-rater and intra-rater agreements of the most clinically important severity grades. Results Absolute inter-rater agreement ranged from 54.6% to 95.0%. Disc hydration (54.6%), central stenosis (72.7%), and foraminal stenosis (73.1%) demonstrated the lowest inter-rater agreement, whereas spondylolisthesis (95.0%) and cord signal change (92.9%) demonstrated the highest agreement. The modified analysis found better inter-rater agreement, ranging from 80.9% to 95.0%. Absolute intra-rater agreement ranged from 74.2% to 94.7%. The modified analysis again found better agreement, ranging from 85.0% to 94.7%. As would be expected, overall intra-rater agreement (81.6%, 95% CI 78.9%–84.3%) was higher than inter-rater agreement (75.7%, 95% CI 74.4%–77.0%). The clinical specialty of the reviewer had no significant impact on inter- or intra-rater agreement. Conclusions MRI findings play an important role in the management of patients with cervical spine conditions. For this reason, consistent descriptions of these findings are essential and physicians should be aware of the relative reliability of these findings. This systematic study developed standardized grading criteria and nomenclature for common clinically significant MRI findings in the cervical spine. Even in this optimized research setting, we found significant ranges in agreement across these MRI findings. In the clinical setting, inter- and intra-rater agreements may be lower, and the range of agreements between findings may be greater. Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others.

Study design Retrospective cohort analysis of anterior cervical discectomy and fusion (ACDF) surgical procedures using a prospectively collected database. Objective To characterize the 30-day postoperative outcomes in elderly patients undergoing ACDF after adjustment for comorbidities using a multi-institutional database. Summary of background data Prior studies on the effect of age after ACDF have mostly focused on in-hospital complications, have come from single institutions, or have included ACDF in pooled analyses and have not distinctly analyzed the specific complications associated with age after ACDF. Methods Patients undergoing ACDF were selected in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were stratified into 4 age-groups: 18 to 39 years, 40 to 64 years, 65 to 74 years, and 75 years or more (based on standard deviation cohorts). Patients in the different age categories were compared using the χ statistic, the Fisher exact test, and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative comorbidities. Significance was defined as P Results Data were available for 6253 patients who underwent ACDF. On multivariate logistic regression, both groups of elderly patients (65-74 and ≥75 yr) were more likely to have blood transfusions, reoperations, urinary complications, extended length of stays, and 1 or more complication, overall. Only patients 65 to 74 years were more likely to have a pulmonary embolism/deep vein thrombosis, whereas only patients aged 75 years or older were more likely to experience respiratory complications, central nervous system complications, or death. There were no differences in complication rates between the 18- to 39-year age-group and 40- to 64-year age-group. The 18- to 39-year age-group and 75-year age-group had shorter operating room times. Conclusion Older age is an independent risk factor for greater morbidity and longer hospitalizations after ACDF, even after adjustment for comorbidities when compared with younger patients. Surgeons should be aware of the increased risk of multiple complications for patients of advanced age in their surgical decision making. Level of evidence 3.

STUDY DESIGN Retrospective cohort study of 13,927 patients, 820 of whom received iliac crest bone graft (ICBG). OBJECTIVE To compare adverse events, length of stay (LOS), and readmission for patients receiving ICBG with those who did not using multivariate analysis to control for potentially confounding factors. SUMMARY OF BACKGROUND DATA The use of ICBG in spinal fusion has been associated with increased surgical time, LOS, and donor site morbidity. Development of expensive bone graft substitutes has been predicated on these issues. Data on the effect of bone graft harvest on LOS and readmission rate are sparse, and multivariate analysis has not been used to control for confounding factors. METHODS Prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Project 2010-2012 database were retrospectively reviewed. This includes demographics, comorbidities, surgical data, and hospital and 30-day follow-up outcomes data including adverse events, LOS, and readmission. RESULTS Only 5.9% of spinal fusions use ICBG. Bivariate logistic regression (used for categorical variables) found the ICBG cohort was more likely to have a postoperative blood transfusion (11.6% vs. 5.5%, P < 0.001). Bivariate linear regression (used for continuous variables) found the ICBG cohort to have an extended operative time (+36.0 min, P < 0.001) and extended LOS (+0.6 d, P < 0.001).Multivariate analyses controlling for comorbidities, demographics, and approach-determined postoperative blood transfusion (odds ratio, 1.5), extended operative time (+22.0 min, P < 0.001), and LOS (+0.2 d, P = 0.037) to be significantly associated with ICBG use.No other adverse event was significantly associated with ICBG use. Readmission rates were not significantly different. CONCLUSION This study used a large national database cohort and identified increased postoperative blood transfusion, extended operative time, and increased LOS as short-term outcomes associated with ICBG on multivariate analysis. Other short-term morbidities were not significantly associated with ICBG. Readmission rates were not affected. LEVEL OF EVIDENCE 4.

Lumbar pathology is often associated with axial pain or neurologic complaints. It is often presumed that such pain is associated with decreased lumbar motion; however, this correlation is not well established. The utility of various outcome measures that are used in both research and clinical practice have been studied, but the connection with range of motion (ROM) has not been well documented.The current study was performed to assess objectively the postulated correlation of lumbar complaints (based on standardized outcome measures) with extremes of lumbar ROM and functional ROM (fROM) with activities of daily living (ADLs) as assessed with an electrogoniometer.This study was a clinical cohort study.Subjects slated to undergo a lumbar intervention (injection, decompression, and/or fusion) were enrolled voluntarily in the study.The two outcome measures used in the study were the Visual Analogue Scale (VAS) for axial extremity, lower extremity, and combined axial and lower extremity, as well as the Oswestry Disability Index (ODI).Pain and disability scores were assessed with the VAS score and ODI. A previously validated electrogoniometer was used to measure ROM (extremes of motion in three planes) and fROM (functional motion during 15 simulated activities of daily living). Pain and disability scores were analyzed for statistically significant association with the motion assessments using linear regression analyses.Twenty-eight men and 39 women were enrolled, with an average age of 55.6 years (range, 18-79 years). The ODI and VAS were associated positively (p.001). Combined axial and lower extremity VAS scores were associated with lateral and rotational ROM (p.05), but not with flexion/extension or any fROM. Similar findings were noted for separately analyzed axial and lower extremity VAS scores. On the other hand, the ODI correlated inversely with ROM in all planes, and fROM in at least one plane for 10 of 15 ADLs (p.05).Extremes of lumbar motion and motions associated with ADLs are of increasing clinical interest. Although the ODI and VAS are associated with each other, the ODI appears to be a better predictor of these motion parameters than the VAS (axial extremity, lower extremity, or combined) and may be more useful in the clinical setting when considering functional movement parameters.

Study design A retrospective study of surgically treated patients with cervical spinal cord injury (SCI) from the National Trauma Data Bank Research Data Set. Objective To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays. Summary of background data Studies have shown that patients with cervical SCI undergoing surgery within 24 hours after injury have superior neurological outcomes to patients undergoing later surgery, with most evidence coming from the incomplete SCI subpopulation. Methods Surgically treated patients with cervical SCI from 2011 and 2012 were identified in National Trauma Data Bank Research Data Set and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression. Results A total of 2636 patients with cervical SCI were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for patients with complete SCI, 55.3 hours for patients with incomplete SCI, and 83.1 hours for patients with central SCI. Only 44% of patients with SCI underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical SCIs and greater Charlson Comorbidity Index were associated with later surgery in all 3 SCI subpopulations. Conclusion The majority of patients with SCI do not undergo surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations. Level of evidence 4.