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Study Design: This is an analysis of a prospective 2-year study on nonoperative patients enrolled in the Adult Symptomatic Lumbar Scoliosis (ASLS) National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) trial.Objective: The purpose was to evaluate the impact of serious adverse events (SAEs) on patient-reported outcomes (PROs) in nonoperative management of ASLS as measured by Scoliosis Research Society-22 (SRS-22), Oswestry Disability Index (ODI), and Short Form-12 (SF-12) at 2-year follow-up.Summary Of Background Data: Little is known about PROs in the nonoperative management of ASLS or the prevalence and impact of SAEs on PROs.Methods: The ASLS trial dataset was analyzed to identify adult lumbar scoliosis patients electively choosing or randomly assigned to nonoperative treatment with minimum 2-year follow-up. Patient data were collected prospectively from 2010 to 2015 as part of NIAMS R01-AR055176-01A2 "A Multi-Centered Prospective Study of Quality of Life in Adult Scoliosis." SAEs were defined as life-threatening medical events, new significant or permanent disability, new or prolonged hospitalization, or death.Results: One hundred five nonoperative patients were studied to 2-year follow-up. Twenty-seven patients (25.7%) had 42 SAEs; 15 (14.3%) had a SAE during the first year. The SAE group had higher body mass index (29.4 vs. 25.2; P = 0.008) and reported worse SRS-22 Function scores than the non-SAE group at baseline (3.3 vs. 3.6; P = 0.024). At 2-year follow-up, SAE patients experienced less improvement (change) in SRS-22 Self-Image (-0.07 vs. 0.26; P = 0.018) and Mental Health domains (-0.19 vs. 0.25; P = 0.002) than non-SAE patients and had lower SRS-22 Function, Self-Image, Subscore, and SF-12 Mental and Physical component scores (MCS/PCS). Fewer SAE patients reached minimal clinically important difference (MCID) threshold in SRS-22 Mental Health (14.8% vs. 43.6%; P = 0.01).Conclusion: A high percentage (25.7%) of ASLS patients managed nonoperatively experienced SAEs. Those patients who sustained a SAE had less improvement in reported outcomes.Level Of Evidence: 2. [ABSTRACT FROM AUTHOR]

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]

Research is a foundational component of an orthopaedic residency. It fosters intellectual curiosity and pursuit of excellence, while teaching discipline and the scientific method. These are the key principles for careers in both community-based practice and academia. Currently, no consensus exists on how to best engage residents and support their research endeavors. In 2014, the American Academy of Orthopaedic Surgeons Board of Specialty Societies Research and Quality Committee convened a Clinician-Scientist Collaboration Workgroup. The workgroup's task was to identify barriers to clinical and basic science research, and to propose feasible recommendations to overcome these barriers. Herein, we have compiled the opinions of various stakeholder constituencies on how to foster scholarly pursuits during an orthopaedic residency. These opinions reflect the workgroup's conclusions that research is directly and indirectly influenced by funding, departmental support, and mentorship, and that early exposure and dedicated time to pursue scholarly activities may have a positive impact on lifelong research interests. [ABSTRACT FROM AUTHOR]

The use of large-scale national databases for observational research in orthopaedic surgery has grown substantially in the last decade, and the data sets can be grossly categorized as either administrative claims or clinical registries. Administrative claims data comprise the billing records associated with the delivery of health-care services. Orthopaedic researchers have used both government and private claims to describe temporal trends, geographic variation, disparities, complications, outcomes, and resource utilization associated with both musculoskeletal disease and treatment. Medicare claims comprise one of the most robust data sets used to perform orthopaedic research, with >45 million beneficiaries. The U.S. government, through the Centers for Medicare & Medicaid Services, often uses these data to drive changes in health policy. Private claims data used in orthopaedic research often comprise more heterogeneous patient demographic samples, but allow longitudinal analysis similar to that offered by Medicare claims. Discharge databases, such as the U.S. National Inpatient Sample, provide a wide national sampling of inpatient hospital stays from all payers and allow analysis of associated adverse events and resource utilization. Administrative claims data benefit from the high patient numbers obtained through a majority of hospitals. Using claims, it is possible to follow patients longitudinally throughout encounters irrespective of the location of the institution delivering health care. Some disadvantages include lack of precision of ICD-9 (International Classification of Diseases, Ninth Revision) coding schemes. Much of these data are expensive to purchase, complicated to organize, and labor-intensive to manipulate-often requiring trained specialists for analysis. Given the changing health-care environment, it is likely that databases will provide valuable information that has the potential to influence clinical practice improvement and health policy for years to come. [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]

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]

Spinal deformity constitutes a spectrum of disorders affecting the spinal curvature. Management of spinal deformities often involves multidisciplinary teams and can be resource intense in patients requiring a prompt surgical correction for axial stability. Operative management warrants adequate subspecialty (fellowship) training and expertise for optimized health care delivery. With recent advances in diagnostic modalities and operative techniques in conjunction with an aging population, assessing the current and forecasting the future impact of spinal deformity spectrums on health care can be beneficial for meticulous planning and resource allocation to meet rising demands, ensuring the future economic viability of these procedures in the setting of cost-containment reforms. To forecast the health care burden and socioeconomics of spinal deformity disorders in the United States from 2015 to 2040. Epidemiological-based, time-series forecasting. A total of 2,424,941 patients with underlying spinal deformity (based on extrapolated, weighted sampling across non-federal inpatient admissions). Forecasting crude estimates of hospitalization burden and socioeconomics [operative utilization, costs, length of stay (LOS)] related to spinal deformities in the US from 2015 to 2040. A time-series, computation modeling using autoregressive integrated moving average (ARIMA) and seasonal ARIMA algorithms were constructed to forecast the impact of spinal deformities on health care delivery and resource utilization until 2040. Modeling of annual estimates for forecasting analysis relied upon the epidemiological data obtained from the Healthcare Cost and Utilization (HCUP) national datasets [National Inpatient Sample 2001-2014]. All forecast estimates were compared to the baseline 2014 year and evaluated as a percent change in primary endpoints. Diagnostics for forecasting models were assessed prior to model selection. In 2030 and 2040, hospital admissions from spine deformities will increase by approximately 75% and 122% from their baseline 2014 crude admission rates. From 2014-2030, crude annual admissions related to scoliotic disorders will witness highest increment (+80.9%), followed by lordotic (+77%) and kyphotic (73.8%) disorders, respectively. Between 2030 and 2040, the crude annual admissions from lordotic disorders of the spine will surpass scoliosis by a 10-year cumulative net marginal increase of 3.72% (change in lordosis and scoliosis in 2040 from 2014: 131.34% and 131.54% respectively). The rate of surgical correction of deformity will outpace conservative management techniques and likely to see increases of 87.9% (in 2030) and 143% (in 2040) above 2014 rates. The cost of care will increase by 48% (2030) and 76% (2040) compared to 2014 estimates ($23,031) despite the decrease in LOS (−11.6% in 2030 and −18.1% in 2040 vs 5.54 days in 2040). The current investigation provides projection forecasting for various spectrums of spinal deformities and for operative spinal correction. The study notes that operative utilization for deformity surgery will outpace conservative strategies. From a policymaking perspective, the data call for preparedness in establishing focused fellowship curriculae for training the adequate number of orthopedic or neurosurgeons specializing in spine deformity surgery to meet the increasing demand, reducing access disparities, and appropriately allocating resources for optimized care. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Objective: The American Spine Registry (ASR) is a collaborative effort between the American Academy of Orthopaedic Surgeons and the American Association of Neurological Surgeons. The goal of this study was to evaluate how representative the ASR is of the national practice with spinal procedures, as recorded in the National Inpatient Sample (NIS)., Methods: The authors queried the NIS and the ASR for cervical and lumbar arthrodesis cases performed during 2017-2019. International Classification of Diseases, 10th Revision and Current Procedural Terminology codes were used to identify patients undergoing cervical and lumbar procedures. The two groups were compared for the overall proportion of cervical and lumbar procedures, age distribution, sex, surgical approach features, race, and hospital volume. Outcomes available in the ASR, such as patient-reported outcomes and reoperations, were not analyzed due to nonavailability in the NIS. The representativeness of the ASR compared to the NIS was assessed via Cohen's d effect sizes, and absolute standardized mean differences (SMDs) of < 0.2 were considered trivial, whereas > 0.5 were considered moderately large., Results: A total of 24,800 arthrodesis procedures were identified in the ASR for the period between January 1, 2017, and December 31, 2019. During the same time period, 1,305,360 cases were recorded in the NIS. Cervical fusions comprised 35.9% of the ASR cohort (8911 cases) and 36.0% of the NIS cohort (469,287 cases). The two databases presented trivial differences in terms of patient age and sex for all years of interest across both cervical and lumbar arthrodeses (SMD < 0.2). Trivial differences were also noted in the distribution of open versus percutaneous procedures of the cervical and lumbar spine (SMD < 0.2). Among lumbar cases, anterior approaches were more common in the ASR than in the NIS (32.1% vs 22.3%, SMD = 0.22), but the discrepancy among cervical cases in the two databases was trivial (SMD = 0.03). Small differences were illustrated in terms of race, with SMDs < 0.5, and a more significant discrepancy was identified in the geographic distribution of participating sites (SMDs of 0.7 and 0.74 for cervical and lumbar cases, respectively). For both of these measures, SMDs in 2019 were smaller than those in 2018 and 2017., Conclusions: The ASR and NIS databases presented a very high similarity in proportions of cervical and lumbar spine surgeries, as well as similar distributions of age and sex, and distribution of open versus endoscopic approach. Slight discrepancies in anterior versus posterior approach among lumbar cases and patient race, and more significant discrepancies in geographic representation were also identified, yet decreasing trends in differences suggested the improving representativeness of the ASR over the course of time and its progressive growth. These conclusions are important to underline the external validity of quality investigations and research conclusions to be drawn from analyses in which the ASR is used.

Study Design: Retrospective Database Study., Objective: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014., Summary of Background Data: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued., Methods: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year., Results: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863)., Conclusions: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends., Competing Interests: C.S. has stocks in Vertera Acquisition by Nuvasive and in Gilead. Z.S. has speaking/teaching arrangements with Medtronic and Stryker. A.J.P. has consulted for Globus Medical, United Healthcare and Medtronic. He has also received royalties from Globus Medical. V.M.A. had consulted for Medtronic, Stryker, Zimmer, Camber Spine, Spine Up, Johnson and Johnson and NuVasive. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: During the novel Coronavirus 2019 (COVID-19) worldwide pandemic, viral testing has largely focused on patients presenting with fever and respiratory symptoms. Although Centers for Disease Control has reported 1,551,095 cases in the United States as of May 21, 2020, asymptomatic infection rates remain unknown within the U.S., especially in geographically disparate regions., Methods: On April 7, 2020 our hospital established universal SARS-CoV-2 screening using RT-PCR RNA detection from nasopharyngeal swabs from asymptomatic patients prior to essential and elective surgeries. This study included 1,997 asymptomatic patients undergoing surgical procedures and 1,797 admitted for medical management at a Midwestern academic hospital between April 7, 2020 and May 21, 2020., Results: As of May 21, asymptomatic testing for SARS-CoV-2 infection had been completed for 1,997 surgical patients and 1,797 non-surgical patients. Initial testing was positive in 26 patients, with an additional four positive tests occurring during repeat testing when greater than 48 hours had elapsed since initial testing. Overall asymptomatic infection rate was 0.79%. Asymptomatic infection rate was significantly lower in surgical patients (0.35% vs. 1.28%, p=0.001). Surgical patients tended to be older than non-surgical patients, although this was not statistically significant (51, IQR 27-65 vsx 46, IQR 28-64, p=0.057). Orthopedic surgery patients were significantly younger than those from other surgical services (42 vs. 53 yrs, p<0.001), however orthopedic and non-orthopedic surgical patients had similar asymptomatic infection rates (0.70% vs. 0.25%, p=0.173)., Conclusion: Among asymptomatic patients tested at a Midwestern academic medical center, 0.79% were infected with SARS-CoV-2 virus. These findings will help guide screening protocols at medical centers while providing essential and elective procedures during the COVID-19 pandemic. While the asymptomatic infection rate was low, this data substantiates the threat of asymptomatic infections and potential for community viral spread. These results may not be generalizable to large urban population centers or areas with high concentrations of COVID-19, each region must use available data to evaluate the risk-benefit ratio of universal testing vs universal contact precautions. Level of Evidence: IV., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2021.)

Background: Current surgical management guidelines for pediatric spondylolisthesis (PS) are reliant on data from single-center cohorts., Objective: To analyze national trends and predictors of short-term outcomes in spinal fusion surgery for PS by performing a retrospective cross-sectional analysis of the Kids' Inpatient Database (KID)., Methods: The KID (sampled every 3 yr) was queried from 2003 to 2012 to identify all cases (age 5-17) of spinal fusion for PS (n = 2646). We analyzed trends in patient characteristics, surgical management, and short-term outcomes. Both univariate and multivariable analyses were utilized., Results: The 2646 spinal fusions for PS included posterior-only fusions (86.8%, PSF), anterior lumbar interbody fusions (4.8%, ALIF), and combined anterior and posterior fusions (8.4%, APLF) procedures. The utilization of APLF decreased over time (9.9%-6.4%, P = .023), whereas the number of total spinal fusions and the proportion of PSF and ALIF procedures have not changed significantly. Uptrends in Medicaid insured individuals (1.2%-18.9%), recombinant human bone morphogenetic protein-2 insertion (8.8%-16.6%), decompression (34.7%-42.8%), and mean inflation-adjusted hospital costs ($21 855-$32 085) were identified (all P < .001). In multivariable analysis, Medicaid status (odds ratio [OR] = 1.93, P = .004), teaching hospitals (OR = 1.94, P = .01), decompression (OR = 1.78, P = .004), and the APLF procedure (OR = 2.47, P = .001) increased the likelihood of complication occurrence (all P < .001)., Conclusion: The addition of decompression during fusion and the APLF procedure were associated with more in-hospital complications, though this may have been indicative of greater surgical complexity. The utilization of the APLF procedure has decreased significantly, while costs associated with the treatment of PS have increased over time.

Background: Total joint arthroplasty is the most frequently performed orthopaedic procedure in the United States. The purpose of the present study was to identify differences in thirty-day morbidity and mortality following primary total hip and total knee arthroplasty according to smoking status and pack-year history of smoking., Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients who had undergone primary total hip or total knee arthroplasty between 2006 and 2012. Patients were stratified by smoking status and pack-year history of smoking. Thirty-day rates of mortality, wound complications, and total complications were compared with use of univariate and multivariate analyses., Results: We identified 78,191 patients who had undergone primary total hip or total knee arthroplasty. Of these, 81.8% (63,971) were nonsmokers, 7.9% (6158) were former smokers, and 10.3% (8062) were current smokers. Current smokers had a higher rate of wound complications (1.8%) compared with former smokers and nonsmokers (1.3% and 1.1%, respectively; p < 0.001). Former smokers had a higher rate of total complications (6.9%) compared with current smokers and nonsmokers (5.9% and 5.4%, respectively; p < 0.001). Multivariate analysis identified current smokers as being at increased risk of wound complications (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21 to 1.78), particularly deep wound infection, while both current smokers (OR, 1.18; 95% CI, 1.06 to 1.31) and former smokers (OR, 1.20; 95% CI, 1.08 to 1.34) were at increased total complication risk. Increasing pack-year history of smoking resulted in increasing total complication risk., Conclusions: On the basis of our findings, current smokers have an increased risk of wound complications and both current and former smokers have an increased total complication risk following total hip or total knee arthroplasty., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Retrospective review of prospectively collected data., Objective: To determine a cutoff below which worsening renal function is associated with increased risk of morbidity and to determine the types and magnitude of morbidity associated with renal impairment., Summary of Background Data: Renal impairment is associated with an increased risk of morbidity after lumbar spine surgery. However, the degree to which increasing levels of renal dysfunction are associated with morbidity has not been well defined., Methods: A large, multicenter, clinical registry was queried for all adult patients undergoing lumbar spine surgery in 2012, and 13,576 cases were identified. An estimated glomerular filtration rate (eGFR) was calculated for each patient. Propensity scores were used to match patients on the basis of preoperative comorbidities and the procedure-type performed. The incidence of 30-day morbidity was then compared between patients with no or mild renal impairment (eGFR ≥60 mL/min/1.73 m) and those with moderate or severe disease (eGFR <60 mL/min/1.73 m). Separately, the morbidity risk associated with eGFR was analyzed as a continuous variable., Results: The risk of morbidity increased with worsening eGFR in an inverse-logarithmic fashion (R = 0.84), and the magnitude of risk increased substantially for eGFR below 60 mL/min/1.73 m (odds ratio of ≥1.8). There was a 26% relative increase in morbidity for patients with moderate to severe renal impairment, as compared with the propensity score-matched cohort of patients with no or mild disease (5% absolute increase, 24% vs. 19%, P = 0.004). Wound complications (3% vs. 2.1%), reoperation rates (4.6% vs. 3.3%), and need for blood transfusions (16.3% vs. 12.8%) trended higher in patients with moderate or severe disease, but only the need for blood transfusion reached significance. Patients with preoperative moderate or serve renal impairment were 10 times more likely to develop acute renal failure postoperatively (0.6% vs. 0.06%, P = 0.01)., Conclusion: Thirty-day morbidity risk after lumbar spine surgery is strongly associated with renal impairment. These data may be useful for preoperative patient counseling, and surgeons should consider the relative magnitude of risks and benefits before operating on a patient with severe renal disease, particularly in elective cases., Level of Evidence: 3.

Background: Shoulder arthroplasty is increasing in the United States. Reverse shoulder arthroplasty (RSA) has emerged as an alternative treatment for end-stage glenohumeral pathology. Until recently, administrative coding practices have not differentiated RSA from traditional total shoulder arthroplasty (TSA), and thus national procedural volume has been unknown. The purpose of this study was to define the utilization, patient characteristics, indications and complications for RSA, and contrast these to TSA and hemiarthroplasty (HA)., Methods: The 2011 Nationwide Inpatient Sample (HCUP-NIS) dataset was queried using ICD-9-CM codes to identify patients undergoing RSA, TSA, or HA. We used weighted estimates of national procedure volume, per-capita utilization, patient comorbidities, and inpatient complications denned by the Agency for Healthcare Research and Quality (AHRQ) and identified them using standard methods described by Elixhauser. ANOVA statistical analysis was used and significance was denned as p value <0.05., Results: In 2011, 66,485 patients underwent shoulder arthroplasty; there were 21,692 cases of RSA, 29,359 of TSA, and 15,434 of HA. Utilization of RSA and TSA increased between 2002-2011, and decreased for HA. RSA patients were older (72.7 years vs 67.4 TSA vs 66.8 HA) and more commonly female. Comorbidity burden was highest in patients undergoing HA. Inpatient complications were highest after RSA (p < 0.001). When compared to TSA, RSA was more commonly used in the setting of rotator cuff disease, and posttraumatic sequelae (p<0.001)., Conclusions: Our findings represent the first national estimates of RSA within the United Sates. RSA is a significant contributor to increasing shoulder arthroplasty utilization nationally representing one-third of arthroplasty cases. Conditions traditionally managed with HA in older populations appear to now be more commonly managed with RSA. RSA is performed on older patients with expanded indications.

The release of new hospital-specific Medicare data was heralded as a major development in transparency that would empower consumers. Using this data, we sought to investigate differences in payments and outcomes for total joint arthroplasty (TJA). We compared the fifty hospitals top-ranked by U.S. News & World Report for orthopedics to non-ranked hospitals. Available surgical outcome metrics were similar for all hospital groups. Top-ranked hospitals discharged a significantly higher volume of TJAs compared to other hospitals. Top-ranked hospitals submitted higher average charges to Medicare, and received higher payments in return. This premium was the direct result of Medicare's own reimbursement policies, and reveals little about consumer pricing. While comprehensive, Medicare's new databases provide little help to consumers wishing to compare hospitals for TJA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of prospectively collected data., Objective: To determine the incidence and risk factors for 30-day wound complication after spinal arthrodesis in pediatric patients., Summary of Background Data: Although multiple prior studies have reported on wound complications in pediatric spine, the majority have been single-center retrospective series., Methods: The National Surgical Quality Improvement Program (NSQIP) employs on-site personnel to prospectively collect 30-day morbidity data from 50 pediatric centers. Year 2012 was the first year of enrollment, and 1915 cases with thoracic or lumbar spinal fusion were included. Patients were divided into cohorts of those with and without a wound complication, with univariate and multivariate analyses used to identify risk factors. A P value of less than 0.05 was considered significant., Results: Wound complications occurred in 67 patients (3.5%). The incidence was significantly higher in patients with congenital (4.35%) or neuromuscular (4.67%) diagnoses, as opposed to idiopathic (2.7%) or infantile (1.61%). Procedures with fusions extending to the pelvis (9.91%) or an osteotomy (4.99%) were associated with higher risk. Longer hospital lengths of stay, increased operative time, increased patient body mass index, and patients with cardiac, gastrointestinal, neurological, or pulmonary comorbidities were also associated with a higher risk. In the multivariate analysis, a body mass index of more than 30 kg/m2, patients with cardiac risk factors, and fusions extending to the pelvis were independent risk factors., Conclusions: Data from this large prospective multicenter study confirm that the incidence of early wound complications in pediatric spine surgery is low. Patients with a fusion extending to the pelvis, obese patients, and patients with significant cardiac conditions were independently associated with higher risk for this complication. These data should be useful for patients' counseling and for preoperative risk stratification. Interventions for minimizing wound complication risk may be most applicable to the high-risk groups identified here., Level of Evidence: 2.

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: Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA) for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. The objective of this study was to use longitudinal data to examine temporal trends in TAR and AA., Methods: We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between 1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity, nationwide and hospital volume, per capita utilization, and length of stay (LOS)., Results: Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates of diabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888 in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167 procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentage of all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportion performing AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 in TAR and from 5.5 days to 3.2 days in AA (P < .001)., Conclusion: Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medically complex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. At the same time, mean hospital volume for both procedures remained low. Further research should be directed toward determining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has become increasingly used for the treatment of ankle arthritis., Level of Evidence: Level III, comparative series.

Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and 8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age (P=0.002), male gender (P=0.03), cancer history (P=0.008), elevated BUN (P=0.002), a bleeding disorder (P<0.001) and high ASA class (P<0.001) as predictors of readmission. In THA, obesity (P=0.008), steroid use (P=0.037), a bleeding disorder (P=0.002), dependent functional status (P=0.022), and high ASA class (P<0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification., (© 2013.)

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.

Background: Although numerous studies have demonstrated improved short-term outcomes after laparoscopic resection of colon cancer, the benefits of laparoscopic-assisted proctectomy (LAP) for rectal cancer are less clear. The current report addresses the need for a large multi-institutional study on early outcomes after proctectomy for cancer., Study Design: Patients who underwent elective LAP or open proctectomy for cancer during 2005 to 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The frequency of postoperative complications and other early outcomes was determined. Multivariate logistic regression identified predictors of 30-day morbidity. Propensity scores, stratified by quintiles, were included in all multivariable models to partially adjust for nonrandom assignment of treatment., Results: Of 5,420 patients who underwent surgery for rectal cancer, 4,380 underwent open proctectomy and 1,040 (19.2%) LAP. The LAP group had a lower frequency of blood transfusion (12.3% versus 4.3%; p < 0.0001) and a longer mean operative time (242 versus 219 minutes; p < 0.0001). Median length of stay was 5 days after LAP and 7 days after open resection (p < 0.0001). Although no difference in 30-day mortality was detected, the frequency of complications was less after LAP (20.5% versus 28.8%; p < 0.0001). Specifically, the frequencies of superficial surgical site infection, sepsis, respiratory complications, renal failure, and venous thromboembolism were each lower in the LAP group. After adjusting for potential confounders, the likelihood of 30-day morbidity was significantly greater in open versus laparoscopic proctectomy (odds ratio = 1.41; 95% CI, 1.19-1.68)., Conclusions: Compared with open proctectomy, LAP is associated with decreased length of stay and 30-day morbidity. If ongoing randomized clinical trials confirm oncologic equivalency, LAP might eventually replace open resection as the standard of care for the treatment of patients with resectable rectal cancer., (Copyright © 2011 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)