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Background: To our knowledge, no prior study has evaluated outcomes after elective lumbar spinal surgery in human immunodeficiency virus (HIV) patients without acquired immunodeficiency syndrome (AIDS). This review investigated the impact of HIV-positive status (without AIDS) on outcomes after elective lumbar fusion for degenerative disc disease (DDD)., Methods: Adult patients registered in the Nationwide Inpatient Sample (2002-2011) undergoing elective lumbar fusion for DDD were extracted. Multivariable regression techniques were used to explore the association of HIV positivity with outcomes after lumbar fusion., Results: This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. Compared with HIV-negative patients undergoing lumbar fusion, HIV-positive patients were younger (47 vs. 55 years), male (61% vs. 42%), largely insured by Medicare (30% vs. 5%), and had higher rates of chronic obstructive pulmonary disease (23.7% vs. 14.6%) (all P < 0.001) but had lower rates of obesity, hypertension, and diabetes (all P < 0.001). Multivariable models demonstrated HIV positivity to be associated with higher odds for an adverse event (odds ratio [OR], 1.92; P < 0.001), in-hospital mortality (OR, 39.91; P < 0.001), wound complications (OR, 2.60; P = 0.004), respiratory (OR, 5.43; P < 0.001) and neurologic (OR, 1.96; P = 0.039) complications, and higher costs (7.1% higher; P = 0.011) compared with non-HIV patients. There were no differences in thromboembolic events, cardiac or gastrointestinal complications, discharge disposition, or length of stay., Conclusions: Even in this selected cohort of well-controlled HIV patients, there were high complications, with concerning rates of death and respiratory complications. These data shed new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with older papers., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Use of large clinical and administrative databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and varies in their methodology of data acquisition, which makes it possible that similar research questions posed to different databases might result in answers that differ in important ways., Questions/purposes: (1) What are the differences in reported demographics, comorbidities, and complications for patients undergoing primary TKA among four databases commonly used in orthopaedic research? (2) How does the difference in reported complication rates vary depending on whether only inpatient data or 30-day postoperative data are analyzed?, Methods: Patients who underwent primary TKA during 2010 to 2012 were identified within the National Surgical Quality Improvement Programs (NSQIP), the Nationwide Inpatient Sample (NIS), the Medicare Standard Analytic Files (MED), and the Humana Administrative Claims database (HAC). NSQIP is a clinical registry that captures both inpatient and outpatient events up to 30 days after surgery using clinical reviewers and strict definitions for each variable. The other databases are administrative claims databases with their comorbidity and adverse event data defined by diagnosis and procedure codes used for reimbursement. NIS is limited to inpatient data only, whereas HAC and MED also have outpatient data. The number of patients undergoing primary TKA from each database was 48,248 in HAC, 783,546 in MED, 393,050 in NIS, and 43,220 in NSQIP. NSQIP definitions for comorbidities and surgical complications were matched to corresponding International Classification of Diseases, 9 Revision/Current Procedural Terminology codes and these coding algorithms were used to query NIS, MED, and HAC. Age, sex, comorbidities, and inpatient versus 30-day postoperative complications were compared across the four databases. Given the large sample sizes, statistical significance was often detected for small, clinically unimportant differences; thus, the focus of comparisons was whether the difference reached an absolute difference of twofold to signify an important clinical difference., Results: Although there was a higher proportion of males in NIS and NSQIP and patients in NIS were younger, the difference was slight and well below our predefined threshold for a clinically important difference. There was variation in the prevalence of comorbidities and rates of postoperative complications among databases. The prevalence of chronic obstructive pulmonary disease (COPD) and coagulopathy in HAC and MED was more than twice that in NIS and NSQIP (relative risk [RR] for COPD: MED versus NIS 3.1, MED versus NSQIP 4.5, HAC versus NIS 3.6, HAC versus NSQIP 5.3; RR for coagulopathy: MED versus NIS 3.9, MED versus NSQIP 3.1, HAC versus NIS 3.3, HAC versus NSQIP 2.7; p < 0.001 for all comparisons). NSQIP had more than twice the obesity as NIS (RR 0.35). Rates of stroke within 30 days of TKA had more than a twofold difference among all databases (p < 0.001). HAC had more than twice the rates of 30-day complications at all endpoints compared with NSQIP and more than twice the 30-day infections as MED. A comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of wound infections and deep vein thromboses is captured when data are analyzed out to 30 days after TKA (p < 0.001 for all comparisons)., Conclusions: When evaluating research utilizing large databases, one must pay particular attention to the type of database used (administrative claims, clinical registry, or other kinds of databases), time period included, definitions utilized for specific variables, and the population captured to ensure it is best suited for the specific research question. Furthermore, with the advent of bundled payments, policymakers must meticulously consider the data sources used to ensure the data analytics match historical sources., Level of Evidence: Level III, therapeutic study.

Background: The purpose of this study is to (1) identify the incidence of surgical delay in hip fractures, (2) evaluate the time point surgical delay puts patients at increased risk for complications, and (3) identify risk factors for surgical delay in the setting of surgical management of hip fractures., Methods: A multi-center database was queried for patients of 60 years of age or older undergoing surgical treatment of a hip fracture. Surgical delay was defined by days from admission until surgical intervention. Univariate analyses and multivariate analyses were performed on all groups., Results: A total of 4215 patients underwent surgery for their hip fracture. Of those experiencing surgical delay, 3304 (78%) patients experienced surgical delay of ≥1 day, 1314 (31%) had delay of ≥2 days, and 480 (11%) experienced delay of ≥3 days. There was a significant difference in complications if patients experienced surgical delay of ≥2 days (P ≤ .01). Multivariate analyses identified multiple risk factors for delay of ≥2 days including congestive heart failure (odds ratio 3.09, 95% confidence interval 2.04-4.66) and body mass index ≥40 (odds ratio 2.31, 95% confidence interval 1.31-4.08). Subgroup analysis identified that patients undergoing total hip arthroplasty were not at risk for complications with surgical delay of ≥2 days., Conclusion: Surgical delay of ≥2 days in the setting of hip fractures is common and confers an increased risk of complications in those undergoing non-total hip arthroplasty procedures. We recommend surgical intervention prior to 48 hours from hospital admission when possible. Healthcare systems can utilize our non-modifiable risk factors when performing quality assessment and cost accounting., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: When new technologies are introduced, it is important to evaluate the rate of adoption and outcomes compared with preexisting technology. The purpose of this study was to determine the adoption rate of computer-assisted navigation in total knee arthroplasty (TKA), to determine if the short-term complication rate changed over time with navigation, and to compare short-term complication rates of navigated and traditional TKA., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 108,277 patients undergoing primary TKA between 2010 and 2014, of which 3573 cases (3.30%) were navigated. Rates of adoption of navigated TKA were determined. Differences in short-term complications by year were compared using propensity score matching., Results: Navigation utilization decreased from 4.96% in 2010 to 3.06% in 2014. Blood transfusion rates for the entire cohort decreased from 19% in 2011 to 6% in 2014, and was not decreased with navigation compared with traditional TKA in 2014 (P = .1309). Operative time was not increased by navigation, and average 94.2 minutes. There were no significant differences in all-cause complications, reoperation rate, unplanned readmission, or length of stay for any year., Conclusions: There was a 38.3% decrease in TKA navigation utilization from 2010-2014. Blood transfusion rates decreased 68% over the 5-year study, and were not decreased with navigation in 2014. Navigation was not found to increase operative time. There were no significant differences in short-term complications, readmission rate, or length of stay between navigated and traditional TKA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Increased operative time has been associated with increased complications after total joint arthroplasty (TJA). The purpose of the present study was to investigate the effect of operative time on short-term complications after TJA while also identifying patient and operative factors associated with prolonged operative times., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011-2013 to identify all patients who underwent primary total hip or knee arthroplasty. Patients were stratified by operative time, and 30-day morbidity and mortality data compared using univariate and multivariable analyses., Results: We identified 99,444 patients who underwent primary TJA. The overall incidence of complications after TJA was 4.9%. Overall complications were increased in patients with operative times >120 minutes (5.9%) as compared to patients with operative times <60 minutes or 60-120 minutes (4.6% and 4.8%, respectively; P < .001). Wound complications, including surgical site infection, were also increased for procedures lasting >120 minutes. In a multivariable analysis, operative time exceeding 120 minutes remained an independent predictor of any complication and wound complication, with each 30-minute increase in operative time beyond 120 minutes further increasing risk. Patient age ≤65 years, male sex, black race, body mass index ≥30 kg/m 2 , and an American Society of Anesthesiologists classification of 3 or 4, predicted operative times >120 minutes., Conclusion: We found that operative time >120 minutes was associated with increased short-term morbidity and mortality after primary TJA. Younger age, male sex, black race, obesity, and increased comorbidity were risk factors for operative time exceeding 120 minutes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Length of hospital stay is a quality metric in joint arthroplasty. Rapid recovery protocols have safely reduced the average length of hospitalization, but it is unclear whether there is a difference in complication and readmission rates between patients discharged the day of surgery or on postoperative day 1 (POD 1). We calculated 30-day complication and readmission after total knee arthroplasty (TKA), total hip arthroplasty (THA), and unicompartmental knee arthroplasty (UKA) based on day of discharge. We then analyzed the rapid recovery group by comparing those discharged the day of surgery and those discharged on POD 1., Methods: Patients undergoing joint arthroplasty between 2011 and 2013 were selected from the American College of Surgeons (ACS) National Surgical Quality Improvement Program. Demographics, comorbidities, and 30-day complication and readmission were determined based on discharge date. Propensity-matched comparisons were performed between patients discharged POD 0 vs POD 1. We used multivariate logistic regression to determine independent risk factors for 30-day complication and readmission., Results: There was no difference in complication or readmission after TKA or UKA between POD 0 or POD 1 discharge. In the propensity-matched cohort in THA, however, there was an increased rate of any complication in the POD 0 compared with the POD 1 discharge cohort. Risk factors for complication and readmission among THA, TKA, and UKA include age >80 years and smoking, and discharge after day 3., Conclusion: Increased length of stay is associated with increased complication and readmission after joint arthroplasty for patients with a hospital stay of 3 or more days. However, in THA, there was an increased complication rate in patients discharged POD 0 as compared to POD 1. Efforts to improve patient selection are expected to reduce short-term complications after outpatient joint arthroplasty. Further research is needed to determine which patients can be discharged POD 0 without increased complication after THA., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Total joint arthroplasty is a proven treatment for osteoarthritis of the knee and hip that has failed conservative treatment. While most of total joint arthroplasty is considered elective with surgery on the day of admission, a small subset of patients may require delay in surgery past the day of admission. Recently, surgical delay for primary total knee arthroplasty has been identified. However, the incidence, outcomes, and risk factors for delay in surgery before total hip arthroplasty (THA) have not been previously defined., Questions/purpose: In patients undergoing THA, we sought to define (1) the incidence of and risk factors for delay in surgery, (2) the postoperative complications between surgical delay and no surgical delay cohorts, and (3) association of the Charlson comorbidity index (CCI) in patients with delay of surgery., Methods: We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 7890 THAs performed between 2006 and 2010. Univariate and subsequent multivariate logistic regression analysis were then used to identify risk factors for surgical delay. Correlation between CCI and surgical delay in THA was evaluated., Results: One-hundred seventy-nine patients (2.31%) were identified as experiencing a surgical delay before THA. Multivariate analysis identified congestive heart failure (CHF) (P = .0038), bleeding disorder (P < .0001), sepsis (P < .0001), prior operation in past 30 days (P = .0001), dependent functional status (P < .0001), American Society of Anesthesiologists class 3 (P = .0001), American Society of Anesthesiologists class 4 (P = .0023), significant weight loss (P = .0109), and hematocrit <38% (P < .0001) as independent risk factors for delay in surgery. Compared with the nondelay cohort, those experiencing surgical delay before THA had higher rates of postoperative surgical (8.9% vs 3.1%, P < .0001) and medical complications (23.5% vs 10.1%, P < .0001). Mean CCI was higher in the THA surgical delay cohort (3.16 vs 2.24, P < .0001) compared with the nondelay group., Conclusion: Surgical delay in patients undergoing THA may cause undue disruption in surgeon and hospital resource utilization. In an era of quality assessment and cost consciousness, it is important to understand that the short-term outcomes of elective, same day THA differ dramatically from those hospitalized for medical necessity before surgery. Surgeons should consider thorough medical evaluation in those with CHF, bleeding disorders, sepsis, significant weight loss, and hematocrit <38% before hospital admission., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Study Design: A retrospective review of prospectively collected data., Objective: The aim of this study was to determine the impact of current smoking or prior smoking cessation on 30-day morbidity risk following lumbar spine surgery., Summary of Background Data: Prior studies have reported conflicting data regarding the impact of smoking on morbidity risk, and few studies have investigated smoking cessation., Methods: A large, multicenter, prospectively collected clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012 and 2013, and 35,477 cases were identified. Morbidity data are collected by on-site clinical personnel for 30 days postoperatively. Patients were divided into categories of "never-smoker," for patients with no reported cigarette use (n = 27,246), "former smoker," for patients who quit smoking more than 12 months before surgery (n = 562), and "current smoker," for patients still using cigarettes (n = 7669). A univariate analysis was conducted to identify un-adjusted differences in morbidity risk, and a multivariate analysis was conducted in an attempt to control for confounders., Results: In the multivariate analysis, current smokers had a significantly higher risk of both superficial surgical site infection and overall wound complications, than never-smokers (P < 0.05 for each). Current smokers also had a significantly higher risk of total 30-day morbidity (P = 0.04). There was a trend toward former smokers also having an increased risk, but this did not reach significance in any category. Patients with a pack-year smoking history of 1 to 20 pack-years and more than 40 pack-years both had a significantly higher risk of superficial surgical site infections (P < 0.05 for each)., Conclusion: Current smoking is associated with a small but significant increase in systemic morbidity and wound complications following elective lumbar spine procedures. Increasing pack year history was also associated with wound complication risk, suggesting a dose-related effect. The data provide preliminary support for future studies on smoking cessation., Level of Evidence: 3.

Background: A patient who dies during the followup period of a study about total hip arthroplasty (THA) cannot subsequently undergo a revision. The presence of competing events (such as deaths, in a study on implant durability) violates an assumption of the commonly used Kaplan-Meier (KM) survivorship approach. In that setting, KM-based estimates of revision frequencies will be high relative to alternative approaches that account for competing events such as cumulative incidence methods. However, the degree to which this difference is clinically relevant, and the degree to which it affects different ages of patient cohorts, has been poorly characterized in orthopaedic clinical research., Questions/purposes: The purpose of this study was to compare KM with cumulative incidence survivorship estimators to evaluate the degree to which the competing event of death influences the reporting of implant survivorship at long-term followup after THA in patients both younger than and older than 50 years of age., Methods: We retrospectively reviewed 758 cemented THAs from a prospectively maintained single-surgeon registry, who were followed for a minimum of 20 years or until death. Revision rates were compared between those younger than or older than age 50 years using both KM and cumulative incidence methods. Patient survivorship was calculated using KM methods. A total of 21% (23 of 109) of the cohort who were younger than 50 years at the time of THA died during the 20-year followup period compared with 72% (467 of 649) who were older than 50 years at the time of surgery (p < 0.001)., Results: In the cumulative incidence analysis, 19% of the younger than age 50 years cohort underwent a revision for aseptic causes within 20 years as compared with 5% in the older than age 50 years cohort (p < 0.001). The KM method overestimated the risk of revision (23% versus 8.3%, p < 0.001), which represents a 21% and 66% relative increase for the younger than/older than age 50 years groups, respectively., Conclusions: The KM method overestimated the risk of revision compared with the cumulative incidence method, and the difference was particularly notable in the elderly cohort. Future long-term followup studies on elderly cohorts should report results using survivorship curves that take into account the competing risk of patient death. We observed a high attrition rate as a result of patient deaths, and this emphasizes a need for future studies to enroll younger patients to ensure adequate study numbers at final followup., Level of Evidence: Level III, therapeutic study.

Background: There exists a lack of comparison between large national healthcare databases reporting surgical morbidity and mortality. Prior authors have expressed concern that the Scoliosis Research Society (SRS) membership may have underreported complications in spinal surgery. Thus, the purpose of the present study was to compare the incidence of morbidity between the SRS and National Surgical Quality Improvement Program (NSQIP) databases., Methods: We reviewed patients enrolled between 2012 and 2013, with a total of 96,875 patients identified in the SRS dataset and 15,909 in the combined adult and pediatric NSQIP dataset. Patients were matched based on diagnostic category,and a univariate analysis was used to compare reported complication rates in the categories of perioperative infection, neurologic injury, and mortality. The SRS database only requires detailed demographic data reporting on patients that have had a complication event. We compared the demographics and comorbidities of this subgroup, and used this as a surrogate to assess the potential magnitude of confounders., Results: Small differences existed between the SRS and NSQIP databases in terms of mortality (0.1% v. 0.2%), infection (1.2% v. 2%), and neurologic injury (0.8% v. 0.1%) (p<0.001 for each comparison). Infection rates were consistently lower across multiple diagnostic sub-categories in the SRS database, whereas neurologic injury rates were consistently lower in the NSQIP database. These differences reached statistical significance across several diagnostic subcategories, but the clinical magnitude of the differences was small. Amongst the patients with a complication, modest differences in comorbidities existed between the two cohorts., Conclusion: Overall, the incidence of short-term morbidity and mortality was similar between the two databases. There were modest differences in comorbidities, which may explain the small differences observed in morbidity. Concerns regarding possible under-reporting of morbidity and mortality data by the SRS membership seem largely unfounded. This study may be useful for future investigators using the NSQIP and SRS datasets.

Study Design: Retrospective review of a prospective cohort., Objective: To determine the incidence, risk factors, and causes for 30-day unplanned readmission after pediatric spinal deformity surgery., Summary of Background Data: The government has targeted 30-day readmissions as a quality of care measure. However, few studies have analyzed readmission in pediatric cohorts., Methods: A multicenter registry designed to collect pediatric surgical outcomes was queried for patients undergoing spinal deformity surgery in 2012. Patients were divided into groups of those with and without an unplanned readmission within 30 days postoperatively. Univariate and multivariate logistic regression analyses were used to compare the cohorts, and to identify variables associated with readmission., Results: In total, 75 of 1890 pediatric patients undergoing spinal fusion for deformity had an unplanned 30-day readmission (3.96%). Readmissions were highest in the neuromuscular group (6.83%) and lowest in the idiopathic (2.66%) and infantile (1.31%) cohorts, (P < 0.01). The top reasons for readmission included wound complications (73.3%) and gastrointestinal disturbances (13.3%). In the univariate analysis, increasing surgical complexity, particularly fusions to the pelvis and isolated anterior spinal fusions, as well as increasing medical comorbidity burden were each associated with readmission (P < 0.05 for each). In the subsequent multivariate analysis, isolated anterior spinal fusions (odds ratio, 7.65; 95% confidence interval, 1.32-44.3) structural pulmonary abnormalities (odds ratio, 2.53; 95% confidence interval, 1.22-5.23) and an American Society of Anesthesiologists class of 3 or 4 (odds ratio, 2.18; 95% confidence interval, 1.07-4.47) were independently associated with readmission., Conclusion: The overall rate of 30-day unplanned readmissions after pediatric deformity surgery was low, but not insignificant. Surgeons should consider discharge optimization in the at-risk patient cohorts defined here, and should focus on wound complications and gastrointestinal disturbances to minimize readmissions. Quality reporting metrics should incorporate these risk factors to avoid unduly penalizing surgeons who take on complex cases., Level of Evidence: 3.

Purpose: To identify the incidence and risk factors for 30-day postoperative morbidity and mortality following operative treatment of distal radius fractures in a multicenter cohort., Methods: We retrospectively queried the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005-2011 for cases of closed distal radius fractures treated operatively with internal fixation. Patient demographics, comorbidities, and operative characteristics were analyzed. Thirty-day postoperative complications were identified and separated into categories of major morbidity or mortality, minor morbidity, and any complication. Risk factors were identified using univariate and multivariate analyses., Results: We identified 1,673 cases of closed distal radius fractures managed with internal fixation. The overall incidence of having any early complication was 3%. Major morbidity was 2.1%, which included 4 patient deaths, and minor morbidity was 1%. The most common major morbidity was a return to the operating room (16 patients). The most common minor morbidity was urinary tract infection (6 patients). The multivariate analysis demonstrated ASA class III or IV, dependent functional status, hypertension, and myocardial infarction/congestive heart failure to be significant risk factors for any early complication. There was a 10.0% complication rate in the inpatient group and a 1.3% complication rate in the outpatient group., Conclusions: The incidence of early complications following internal fixation for closed distal radius fractures was low, especially in the outpatient group. In the setting of an isolated injury to the distal radius, the data presented here can provide prognostic information for patients during informed consent for what is considered to be an elective procedure. Surgeons should consider risk of morbidity and mortality when considering surgery for patients with noteworthy cardiopulmonary disease, increased ASA class, or poor functional status., Type of Study/level of Evidence: Prognostic II., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Risk factors for complication after single-level anterior cervical discectomy and fusion remain poorly defined. The purpose of this study was to identify the incidence and risk factors for complication from a large, prospectively collected database, with a separate emphasis on the safety of outpatient procedures., Methods: The American College of Surgeons National Surgical Quality Improvement Program prospectively collects thirty-day morbidity and mortality data from more than 480 hospitals around the United States. We retrospectively queried this database to identify cases of single-level elective anterior cervical discectomy and fusion. Univariate and multivariate analyses were used to identify risk factors for complication, and a propensity score model was used to create matched inpatient and outpatient cohorts., Results: Of 2914 cases identified, 597 (20.5%) received outpatient treatment and 2317 (79.5%) received inpatient treatment. The overall incidence of any systemic morbidity was 3.2%. There were five mortalities (0.2%), four in the inpatient cohort and one in the outpatient cohort. Patient age over sixty-five years, body mass index of >30 kg/m 2 , American Society of Anesthesiologists class of 3 or 4, current dialysis, current corticosteroid use, recent sepsis, and operative times longer than 120 minutes were each independent risk factors for complication in the multivariate analysis. After propensity score matching to control for comorbidities, there were no significant differences in complication rates between inpatients and outpatients, and outpatient treatment was not a risk factor for complication in the multivariate analysis., Conclusions: Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures. It seems reasonable to consider inpatient admission for any patient with the risk factors identified here, particularly difficult airways. This information may be useful to surgeons performing informed consents for medical optimization and for selecting patients most appropriate for outpatient treatment., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective review of a prospective cohort., Objective: To determine the incidence and risk factors for 30-day morbidity and mortality after pediatric deformity spinal surgery., Summary of Background Data: Pediatric deformity spinal surgery is generally considered a safe and effective treatment option. The rising costs associated with spinal surgery and related perioperative complications have received national attention. Few studies with standardized definitions and data collection methods exist., Methods: A large, multicenter clinical registry specifically designed to collect pediatric surgical outcomes was queried for all patients undergoing spinal deformity surgery in 2012. Current Procedural Terminology codes were used to select patients undergoing anterior, posterior, and combined fusions. Detailed patient and case characteristics were analyzed. Thirty-day morbidity and mortality rates were calculated. Univariate and multivariate logistic regression analyses were used to identify patient characteristics, comorbidities, and operative variables predictive of complication., Results: In total, 2005 pediatric patients undergoing deformity spinal fusion were included. The rate of 30-day complications was 10.0%; with a mortality rate of 0.15% (3 patients), a morbidity rate of 8.4%, reoperation rate of 3.74%, and readmission rate of 3.94%. The morbidity rate was highest in the neuromuscular group (13.09%) and lowest in the idiopathic cohort (5.69%), P < 0.01). Compared with posterior fusions, anterior fusions and those extending to the pelvis were associated with higher complication rates (P < 0.01). Risk factors for complication included hepatobiliary disease (P = 0.03), cognitive impairment (P = 0.02), elevated American Society of Anesthesiologists class (P < 0.01), and prolonged operative time (P < 0.01)., Conclusion: The overall rate of 30-day morbidity after pediatric spinal deformity surgery was 10%. Multiple patient comorbidities and surgical duration and invasiveness were associated with an increased complication risk. These data may aid in the informed consent process, facilitate patient risk assessment, and allow quality comparisons between surgeons and institutions., Level of Evidence: 2.

Background: Knee arthroscopy is among the most common orthopaedic surgical procedures. However, the incidence and risk factors for postsurgical morbidity and mortality remain poorly defined., Methods: The American College of Surgeons National Surgical Quality Improvement Program prospectively collects thirty-day morbidity and mortality data from more than 258 hospitals around the United States. We used Current Procedural Terminology codes to retrospectively query the database and identified 12,271 cases of elective knee arthroscopy performed from January 1, 2005, to December 31, 2010. Postoperative complications were divided into categories of minor morbidity, major morbidity or mortality, or any complication. The potential risk factors for complications were analyzed with use of univariate and multivariate analyses., Results: The overall incidence of any complication was 1.6% (199 patients). The major morbidity was 0.76% (ninety-three patients), which included one patient death (0.008%), and the minor morbidity was 0.86% (106 patients). The most frequent major complication was a return to the operating room. The most common minor complication was deep venous thrombosis or thrombophlebitis. The risk factors identified in the univariate analysis for any complication included black race, prior operation within thirty days, American Society of Anesthesiologists class, and operative time of >1.5 hours as compared with ≤1.5 hours (p < 0.05 for each). The independent risk factors identified in the multivariate analysis for any complication included black race (odds ratio, 1.81 [95% confidence interval, 1.13 to 2.89]), prior operation within thirty days (odds ratio, 6.33 [95% confidence interval, 1.45 to 27.66]), operative time of >1.5 hours (odds ratio, 1.84 [95% confidence interval, 1.21 to 2.78]), and age of forty to sixty-five years (odds ratio, 1.46 [95% confidence interval, 1.01 to 2.11])., Conclusions: The incidence of complication following elective knee arthroscopy is low. The data presented here should be useful for providing prognostic information to patients during informed consent. Surgeons should be encouraged to minimize operative time whenever possible, and may wish to delay elective arthroscopy in patients who have had other recent surgical procedures.

Background: Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was searched to identify patients who underwent primary total knee arthroplasty between 2005 and 2010. Complications that occurred within thirty days after the procedure in patients who had been managed with either general or spinal anesthesia were identified. Patient characteristics, thirty-day complication rates, and mortality were compared. Multivariate logistic regression identified predictors of thirty-day morbidity, and stratified propensity scores were used to adjust for selection bias., Results: The database search identified 14,052 cases of primary total knee arthroplasty; 6030 (42.9%) were performed with the patient under spinal anesthesia and 8022 (57.1%) were performed with the patient under general anesthesia. The spinal anesthesia group had a lower unadjusted frequency of superficial wound infections (0.68% versus 0.92%; p = 0.0003), blood transfusions (5.02% versus 6.07%; p = 0.0086), and overall complications (10.72% versus 12.34%; p = 0.0032). The length of surgery (ninety-six versus 100 minutes; p < 0.0001) and the length of hospital stay (3.45 versus 3.77 days; p < 0.0001) were shorter in the spinal anesthesia group. After adjustment for potential confounders, the overall likelihood of complications was significantly higher in association with general anesthesia (odds ratio, 1.129; 95% confidence interval, 1.004 to 1.269). Patients with the highest number of preoperative comorbidities, as defined by propensity score-matched quintiles, demonstrated a significant difference between the groups with regard to the short-term complication rate (11.63% versus 15.28%; p = 0.0152). Age, female sex, black race, elevated creatinine, American Society of Anesthesiologists class, operative time, and anesthetic choice were all independent risk factors of short-term complication after total knee arthroplasty., Conclusions: Patients undergoing total knee arthroplasty who were managed with general anesthesia had a small but significant increase in the risk of complications as compared with patients who were managed with spinal anesthesia; the difference was greatest for patients with multiple comorbidities. Surgeons who perform knee arthroplasty may consider spinal anesthesia for patients with comorbidities.

Study Design: Propensity score-adjusted prospective cohort study., Objective: To compare the incidence of complications in patients undergoing single-level lumbar discectomy between the inpatient and outpatient settings, to determine baseline 30-day complication rates for lumbar discectomy, and to identify independent risk factors for complications., Summary of Background Data: Lumbar discectomy is the most common spinal procedure performed and can be done on an outpatient basis. Lower costs, greater patient satisfaction, and equivalent safety have been reported with outpatient surgery., Methods: Patients undergoing lumbar discectomy between 2005 and 2010 were selected from The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patient selection was based on a single primary current procedural terminology code. To ensure comparable inpatient and outpatient cohorts, patients with multilevel procedures were excluded. Thirty-day postoperative complications and preoperative patient characteristics were identified and compared. Propensity score matching and multivariate logistic regression analysis were used to adjust for selection bias and identify predictors of 30-day morbidity., Results: Of the 4310 lumbar discectomy cases, 2658 (61.7%) underwent an inpatient hospital stay after surgery, whereas 1652 (38.3%) patients had outpatient surgery. Unadjusted overall complication rates (6.5% vs. 3.5%, P < 0. 0001) were higher in those undergoing inpatient surgery. After propensity score matching, overall complication rate was still higher with the inpatient cohort (5.4% vs. 3.5%, P = 0.0068). Adjusted comparison using multivariate logistic regression also demonstrated a significantly higher rate of complication for inpatients (odds ratio, 1.521; 95% confidence interval, 1.048-2.206). Age, diabetes, presence of preoperative wound infection, blood transfusion, operative time, and an inpatient hospital stay were all independent risk factors of short-term complication after lumbar discectomy., Conclusion: After adjusting for confounders using propensity score matching and multivariate logistic regression analysis, patients undergoing outpatient lumbar discectomy had lower overall complication rates than those treated as inpatients. Surgeons should consider outpatient surgery for lumbar discectomy in appropriate candidates.