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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. [ABSTRACT FROM AUTHOR]

Background: Infection after total knee arthroplasty (TKA) can result in disastrous consequences. Previous research regarding injections and risk of TKA infection have produced conflicting results and in general have been limited by small cohort size.Questions/purposes: The purpose of this study was to evaluate if intraarticular injection before TKA increases the risk of postoperative infection and to identify if time between injection and TKA affect the risk of TKA infection.Methods: The Humana data set was reviewed from 2007 to 2014 for all patients who received a knee injection before TKA. Current Procedural Terminology (CPT) codes and laterality modifiers were used to identify patients who underwent knee injection followed by ipsilateral TKA. Postoperative infection within 6 months of TKA was identified using International Classification of Diseases, 9th Revision/CPT codes that represent two infectious endpoints: any postoperative surgical site infection (encompasses all severities of infection) and operative intervention for TKA infection (surrogate for deep TKA infection). The injection cohort was stratified into 12 subgroups by monthly intervals out to 12 months corresponding to the number of months that had elapsed between injection and TKA. Risk of postoperative infection was compared between the injection and no injection cohorts. In total, 29,603 TKAs (35%) had an injection in the ipsilateral knee before the TKA procedure and 54,081 TKA cases (65%) did not. The PearlDiver database does not currently support line-by-line output of patient data, and so we were unable to perform a multivariate analysis to determine whether other important factors may have varied between the study groups that might have had a differential influence on the risk of infection between those groups. However, the Charlson Comorbidity index was no different between the injection and no injection cohorts (2.9 for both) suggesting similar comorbidity profiles between the groups.Results: The proportion of TKAs developing any postoperative infection was higher among TKAs that received an injection before TKA than in those that did not (4.4% versus 3.6%; odds ratio [OR], 1.23; 95% confidence interval [CI], 1.15-1.33; p < 0.001). Likewise, the proportion of TKAs developing infection resulting in return to the operating room after TKA was also higher among TKAs that received an injection before TKA than those that did not (1.49% versus 1.04%; OR, 1.4; 95% CI, 1.3-1.63; p < 0.001). Month-by-month analysis of time between injection and TKA revealed the odds of any postoperative infection remained higher for the injection cohort out to a duration of 6 months between injection and TKA (ORs ranged 1.23 to 1.46 when 1-6 months between injection and TKA; p < 0.05 for all) as did the odds of operative intervention for TKA infection when injection occurred within 7 months of TKA (OR ranged from 1.38 to 1.88 when 1-7 months between injection and TKA; p < 0.05 for all). When the duration between injection and TKA was longer than 6 or 7 months, the ORs were no longer elevated at these endpoints, respectively.Conclusions: Injection before TKA was associated with a higher risk of postoperative infection and appears to be time-dependent with closer proximity between injection and TKA having increased odds of infection. Further research is needed to better evaluate the risk injection before TKA poses for TKA infection; a more definitive relationship could be established with a multivariate analysis to control for other known risk factors for TKA infection.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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/m2, 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. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Proximal junctional kyphosis (PJK) is an unsolved radiographic phenomenon after corrective spinal deformity surgery with a high, but variable reported incidence. While known to influence outcomes in adults, the long-term clinical significance and natural history in children has not been well defined.Identifying incidence, risk-factors and natural course of PJK based on several proposed definitions in the literature using a large cohort may aid in enhancing our understanding of the disease entity. PURPOSE In a single-surgeon series of AIS patients undergoing deformity correction using hybrid hooks or screw constructs, the study attempted to identify potential risk-factors associated with the long-term development of PJK. Additionally, the study also defines PJK incidence and highlights the natural course of PJK development in children based on commonly proposed definitions in the literature. STUDY DESIGN/SETTING Retrospective, single-surgeon series with a minimum 2-year follow-up. PATIENT SAMPLE Overall, 253 eligible AIS patients with complete information on the proximal junctional angle (PJA) that underwent spinal deformity fusion (PSF) surgery by a single surgeon (SLW) at the University of Iowa between 2006 and 2015 that met the minimal criteria of 2-year follow-up were included. OUTCOME MEASURES The primary outcome was to assess incidence of PJK development form preoperative to postoperative measurements based on two commonly utilized definitions: Glattes et al. that defines PJK as PJA> 10°, and Bridwell et al. classification that defines the disease entity based on the critical PJA above 20°. Secondary outcome was to investigate factors associated with PJK development based on patient demographics, radiological indices and outcomes, and describe the natural course of PJK development in AIS patients undergoing deformity correction. METHODS AIS patients aged between 9 and 18 years undergoing primary long-construct PSF (UIV T2-4) between 2006 and 2015 with a minimum 2 years follow-up were included. Proximal junctional kyphosis was defined as a change in the PJA, according to Glattes et al. and Bridwell et al. classification from preop to postop. The incidence of PJK was defined at 6-week and last follow-up. Multivariable regression models were used to assess risk factors (patient characteristics, disease severity, radiographic parameters) associated with long-term PJK development. RESULTS A total of 253 eligible patients (mean age: 13.7 years; 82% female) with an average follow-up of 3.7 years (range: 24-123 months). Proximal junctional kyphosis (10°) occurred in 10.3% at 6 weeks (PJK 20: 0.4%) and 25.7% at final FU (PJK 20: 4.3%). Based on Glattes definition, a high proportion of patients developing PJK had Risser grade 3(19 vs. 6%; p=.003) and Lenke 5(13% vs. 5%; p=.028) at baseline. In an unadjusted analysis, Risser grade 3(OR:3.6; p=.01), Lenke 5(OR:3.0; p=.03) and those with UIV as T4 (vs. T2) were associated with higher odds of PJK development. In multivariable model, we noted Risser grade 3(OR:4.6; p=.045) as a factor for PJK development. Low reoperation rate (0.04%;1/253) was noted. CONCLUSIONS PJK after AIS deformity surgery varies according to follow up time and definition. In contrast to adults, there does not appear to be any clear risk factors for PJK in an AIS population. Long-term reoperation for PJK appears to be exceedingly low at 0.4%. Radiographic PJK should be followed but generally thought of a benign condition in pediatric deformity surgery. Likely risk factors for PJK include short instrumentation (upto T4 compared to T2), Risser grade 3 and Lenke 5. Consensus on PJK definition is warranted to better define the pathological entity. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Limited or no data exist evaluating risk-factors associated with prolonged opioid use following cervical arthrodesis. PURPOSE To assess trends in postoperative narcotic use amongst preoperative opioid users (OU) versus nonopioid users (NOU), and identify factors associated with postoperative narcotic use at one year following cervical arthrodesis. STUDY DESIGN/SETTING Retrospective, observational cohort study with longitudinal follow-up. PATIENT SAMPLE A total of 17,391 patients (OU: 52.4%) registered in the Humana Inc. claims dataset that underwent anterior (ACF) or posterior cervical fusions (PCF) between 2007 and 2015. OUTCOME MEASURES Prolonged opioid usage defined as narcotic prescription filling at one year following cervical arthrodesis. METHODS Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3-months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU, and trended for 1-year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at one year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis: https://www.neurosurgerycost.com/opioid/opioid%5fuse RESULTS Overall, 87.4% patients (n=15,204) underwent ACF while 12.6% (n=2,187) underwent PCF. At one month following surgery, 47.7% NOU and 82% OUs had a filled opioid prescription. At three months, rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs, while plateauing at 6-12 month postoperative period (NOU:5.7-6.7%; OU:44.9-46.9%). At one year, significantly higher narcotic prescription filling rates were observed in OUs compared to NOUs (45.3% vs. 6.3%;p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (OR:7.02;p<.001) and PCF (OR:6.98;p<.001) along with younger age (<=50 years), history of drug dependence and lower back pain. CONCLUSIONS Over 50% patients used opioids prior to cervical arthrodesis. Postoperative opioid-use fell dramatically during the first three months in NOU, but nearly half of the preop opioid users will remain on narcotics at one year postop. Our findings serve as a baseline in identifying patients at risk for chronic use and encourage discontinuation of opioids prior to cervical spinal surgery FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective, observational study.Objective: To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS).Summary Of Background Data: Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability.Methods: A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated.Results: In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05.Conclusion: Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]