Search

Background: In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns., Methods: A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection., Results: From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population., Conclusions: Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes., Methods: A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann-Whitney U test, and gender was compared with a chi-squared test., Results: During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P < .001) and younger (P < .001)., Conclusion: Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To analyze characteristics and trends of strabismus surgeries in an Israeli hospital over 2 decades., Methods: A descriptive, retrospective study including all strabismus surgeries (666) performed during 2000-2019 at an Israeli tertiary hospital. Electronic medical records (EMRs) were directly retrieved to produce an anonymized database., Results: No trends were evident for age, sex, or ethnicity ( p  = .294, 0.914 and p  = .167, respectively). The mean number of horizontal muscles remained stable, while an increase was noted in the mean number of muscles operated on to repair vertical strabismus ( p  < .0001). Among acquired cases, a 2.67-fold increase was noted in the proportion of spontaneous strabismus and a decrease of traumatic causes to a third ( p  < .001). An increase was noted in the proportion of exotropia among horizontal strabismus corrections ( p  = .022), and esotropia correction techniques distribution changed ( p  = .004). Reoperations comprised a third of all cases during both decades ( p  = .198). Reoperations were more prevalent among younger and Jewish patients ( p  < .001 and p  = .024, respectively). Techniques to correct esotropia and exotropia differed significantly between primary surgeries and reoperations ( p  < .00001 each)., Conclusions: The complexity of surgical techniques increased over time. Ethnic minorities were less prone to reoperations.

Abstract: Retrospective cohort studyTo characterize the learning curve of a spine surgeon during the first 2 years of independent practice by comparing to an experienced colleague. To stratify learning curves based on procedure to evaluate the effect of experience on surgical complexity.The learning curve for spine surgery is difficult to quantify, but is useful information for hospital administrators/surgical programs/new graduates, so appropriate expectations and accommodations are considered.Data from a retrospective cohort (2014-2016) were analyzed at a quaternary academic institution servicing a geographically-isolated, mostly rural area. Procedures included anterior cervical discectomy and fusion, posterior cervical decompression and stabilization, single and 2-level posterior lumbar interbody fusion, lumbar discectomy, and laminectomy. Data related to patient demographics, after-hours surgery, and revision surgery were collected. Operative time was the primary outcome measure, with secondary measures including cerebrospinal fluid leak and early re-operation. Time periods were stratified into 6 month quarters (quarter [Q] 1-Q4), with STATA software used for statistical analysis.There were 626 patients meeting inclusion criteria. The senior surgeon had similar operative times throughout the study. The new surgeon demonstrated a decrease in operative time from Q1 to Q4 (158 minutes-119 minutes, P < .05); however, the mean operative time was shorter for the senior surgeon at 2 years (91 minutes, P < .05). The senior surgeon performed more revision surgeries (odds ratio [OR] 2.5 [95% confidence interval [CI] 1.7-3.6]; P < .001). Posterior interbody fusion times remained longer for the new surgeon, while laminectomy surgery was similar to the senior surgeon by 2 years. There were no differences in rates of cerebrospinal fluid leak (OR 1.2 [95% CI 0.6-2.5]; P > .05), nor reoperation (OR 1.16 [95% CI 0.7-1.9]; P > .05) between surgeons.A significant learning curve exists starting spine practice and likely extends beyond the first 2 years for elective operations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

We aimed to answer the following questions: (1) How did numbers of revision knee arthroplasty procedures develop in Germany over the last decade compared to primary TKA? (2) How high was the percentage of septic interventions in knee prosthesis revisions? (3) Which treatment strategy was chosen for surgical treatment of knee PJI? Revision arthroplasty rates as a function of age, gender, infection and type of prosthesis were quantified based on Operation and Procedure Classification System codes using revision knee arthroplasty data from 2008 to 2018, provided by the Federal Statistical Office of Germany (Destatis). In 2018, a total number 23,812 revision knee arthroplasties were performed in Germany, yielding an overall increase of 20.76% between 2008 and 2018. In comparison, primary TKA procedures increased by 23.8% from 152,551 performed procedures in 2008 to 188,866 procedures in 2018. Hence, 12.6% of knee arthroplasties required a revision in 2018. Septic interventions increased by 51.7% for all revisions. A trend towards higher numbers in younger patients was observed. Compared to 2008, 17.41% less DAIR procedures were performed, whereby single-stage and two- or multi-stage change increased by 38.76% and 42.76% in 2018, respectively. The increasing number of revision knee arthroplasty in Germany, especially in younger patients and due to infection, underlines the need for future efforts to improve treatment strategies to delay primary arthroplasty and avoid periprosthetic joint infection., (© 2021. The Author(s).)

Background: An overall assessment of how patient demographic characteristics and comorbidities are improving or worsening can allow better understanding of the value of revision total joint arthroplasty (TJA). Therefore, the purpose of this study was to identify patient demographic characteristics and comorbidities trends and episode-of-care outcome trends from 2008 to 2018 in patients undergoing revision TJA., Methods: The National Surgical Quality Improvement Program database was queried to identify patient demographic characteristics, comorbidities, and episode-of-care outcomes in patients undergoing revision TJA from 2008 to 2018 (n = 45,706). Pairwise t tests and pairwise chi-square tests were performed on consecutive years with Bonferroni correction. Trends were assessed using the 2-tailed Mann-Kendall test of the temporal trend., Results: Among patients undergoing revision TJA, there was no clinically important difference, from 2008 to 2018, in age, body mass index (BMI), percentages with >40 kg/m2 BMI, diabetes (18.8% to 19%), chronic obstructive pulmonary disease (4.1% to 5.4%), congestive heart failure within 30 days (0% to 1%), or acute renal failure (0% to 0.2%). However, modifiable comorbidities including smoking status (14.7% to 12.0%; p = 0.01), hypertension (66% to 26.0%; p = 0.02), anemia (34.5% to 26.3%; p < 0.001), malnutrition (10.4% to 9.3%; p = 0.004), and overall morbidity or mortality probability have improved, with a decrease in the hospital length of stay and 30-day readmission and a significant increase in home discharge (p < 0.001 for all)., Conclusions: Time-difference analysis demonstrated that the overall health status of patients undergoing revision TJA improved from 2008 to 2018. However, formal time-trend analysis demonstrated improvements to a lesser degree. The multidisciplinary effort to improve value-based metrics including patient comorbidity optimization and episode-of-care outcomes for primary TJA has been shown to potentially have an impact on revision TJA., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G522)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Investigations into reimbursement trends for primary and revision arthroplasty procedures have demonstrated a steady decline over the past several years. Revision total hip arthroplasty (rTHA) due to infection (rTHA-I) has been associated with higher resource utilization and complexity, but long-term inflation-adjusted data have yet to be compared between rTHA-I and rTHA due to aseptic complications (rTHA-A). The present study was performed to analyze temporal reimbursement trends regarding rTHA-I procedures compared with those for rTHA-A procedures., Methods: The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool was used to extract Medicare reimbursements associated with 1-stage and 2-stage rTHA-I as well as 1-stage rTHA-A procedures from 2002 to 2019. Current Procedural Terminology (CPT) codes for rTHA were grouped according to the American Academy of Orthopaedic Surgeons coding reference guide. Monetary values were adjusted for inflation using the consumer price index (U.S. Bureau of Labor Statistics; reported as 2019 U.S. dollars) and used to calculate the cumulative and average annual percent changes in reimbursement., Results: Following inflation adjustment, the physician fee reimbursement for rTHA-A decreased by a mean [and standard deviation] of 27.26% ± 3.57% (from $2,209.11 in 2002 to $1,603.20 in 2019) for femoral component revision, 27.41% ± 3.57% (from $2,130.55 to $1,542.91) for acetabular component revision, and 27.50% ± 2.56% (from $2,775.53 to $2,007.61) for both-component revision. Similarly, for a 2-stage rTHA-I, the mean reimbursement declined by 18.74% ± 3.87% (from $2,063.36 in 2002 to $1,673.36 in 2019) and 24.45% ± 3.69% (from $2,328.79 to $1,755.45) for the explantation and reimplantation stages, respectively. The total decline in physician fee reimbursement for rTHA-I ($1,020.64 ± $233.72) was significantly greater than that for rTHA-A ($580.72 ± $107.22; p < 0.00001)., Conclusions: Our study demonstrated a consistent devaluation of both rTHA-I and rTHA-A procedures from 2002 to 2019, with a larger deficit seen for rTHA-I. A continuation of this trend could create substantial disincentives for physicians to perform such procedures and limit access to care at the population level., Level of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G422)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Most existing anterior cervical discectomy and fusion (ACDF) outcome studies omit emergency department (ED) use. To our knowledge, this study on ED use following ACDF surgery is the first to use a direct patient chart review and the first to include revision patients, 1-5 levels of ACDFs, and performance of corpectomy in the analysis. This study examines the frequency and basis of hospital service use within 30 days of ACDF surgery, specifically ED visits, hospital readmissions, and returns to the operating room. A retrospective chart review was performed for 1273 consecutive patients who underwent ACDF surgery at one institution from July 2013 to June 2016. Of the 1273 patients with ACDF, 97 (7.6%) presented to the ED within 30 days after surgery. Of 43 patients with revision ACDF, 9 (20.9%) returned to the ED, compared with 88 (7.2%) of 1230 patients with primary ACDF (P = 0.001). Of the 111 ED visits by 97 patients, 40 (36%) were for cervicalgia, 13 (12%) were for dysphagia, 8 (7%) were for trauma, 7 (6%) were for nausea, 4 (4%) were for medication refill, 3 (3%) were for dehiscence, 3 (3%) were for pneumonia, and 3 (3%) were for urinary tract infection. Of the ED presentations, 8 (7%) occurred during the first 2 days after surgery, and 46 (41%) occurred within the first postoperative week., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region., Method: We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair., Results: In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence., Conclusions: Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Background: The American Thyroid Association (ATA) published the 2015 Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer, recommending a shift to less aggressive diagnostic, surgical, and postoperative treatment strategies. At the same time and perhaps related to the new guidelines, there has been a shift to outpatient thyroid surgery. The aim of the current study was to assess physician adherence to these recommendations by identifying and quantifying temporal trends in the rates and indications for thyroid procedures in the inpatient and outpatient settings. Methods: Using the IBM ® MarketScan ® Commercial database, we identified employer-insured patients in the United States who underwent outpatient and inpatient thyroid surgery from 2007 to 2018. Thyroid surgery was classified as total thyroidectomy (TT), thyroid lobectomy (TL), or a completion thyroidectomy. The surgical indication diagnosis was also determined and classified as either benign or malignant thyroid disease. We compared outpatient and inpatient trends in surgery between benign and malignant thyroid disease both before and after the release of the 2015 ATA guidelines. Results: A total of 220,088 patients who underwent thyroid surgery were included in the analysis. Approximately 80% of TLs were performed in the outpatient setting versus 70% of TTs. Longitudinal analysis showed a statistically significant changepoint for TT proportion occurring in November 2015. The proportion of TT as compared with TL decreased from 80% in September 2015 to 39% by December 2018. For thyroid cancer, there is an increasing trend in performing TL over TT, increasing from 17% in 2015 to 28% by the end of 2018. Conclusions: There was a significant changepoint occurring in November 2015 in the operative and management trends for benign and malignant thyroid disease.

Both posterior decompression and fusion (PDF) and laminoplasty (LAMP) have been used to treat cervical myelopathy due to multilevel ossification of posterior longitudinal ligament (OPLL). However, considerable controversy exists over the choice of the two surgical strategies. Thus, the aim of this study is to compare clinical outcomes of PDF and LAMP for treatment of cervical myelopathy due to multilevel OPLL. We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials database to identify relevant clinical studies compared with clinical outcomes of PDF and LAMP for cervical OPLL. The primary outcomes including Japanese Orthopaedic Association (JOA) score and recovery rate of JOA were evaluated, and the secondary outcomes involving visual analogue scale (VAS), cervical curvature, OPLL progression rate, complication rate, reoperation rate and surgical trauma were also evaluated using Stata software. A total of nine studies were included in the current study, involving 324 patients. The current study suggests that compared with LAMP, PDF achieves a lower OPLL progression rate, better postoperative cervical curvature and similar neurological improvement in the treatment of multilevel cervical OPLL. However, PDF has a higher complication rate, more surgical trauma and higher postoperative VAS than LAMP.

A preferred treatment for residual/recurrent pituitary adenomas has not been established. The existence of higher complication rates for revision surgeries remains under debate. This study aimed to compare complication rates of primary and revision transsphenoidal endoscopic surgeries and to identify risk factors for complications. Data from 144 primary and 39 revision surgeries were analysed. The surgical complications evaluated were intraoperative and postoperative cerebrospinal fluid (CSF) leaks; meningitis; permanent diabetes insipidus (DI) and hypopituitarism; worsening visual acuity; ophthalmoplegias; visual field defects; otorhinolaryngological, systemic and vascular complications; and death. The variables that were potentially associated with surgical complications were gender, age, comorbidities, lumbar drain use, duration of lumbar drain use, invasion of the sphenoid and cavernous sinuses, presence and degree of suprasellar expansion, preoperative identification of the pituitary, CSF leaks and intraoperative pituitary identification. Intraoperative CSF leaks, visual field losses and worsening visual acuity were more common for revision surgeries. There were no between-group differences in the occurrence of postoperative CSF leaks; systemic, vascular and otorhinolaryngological complications; meningitis; DI and hypopituitarism; ophthalmoplegias; or death. Intraoperative identification of the pituitary was associated with lower rates of permanent DI and hypopituitarism, systemic complications, intraoperative CSF leaks and worsening visual acuity. Suprasellar expansion increased the risk of intraoperative CSF leaks but not endocrinological deficits or visual impairment. Intraoperative CSF leaks were associated with postoperative CSF leaks, meningitis, anterior hypopituitarism, DI and worsening visual acuity. Intraoperative CSF leaks, worsening visual acuity and visual field losses were more common in reoperated patients.

Study Design: A retrospective cohort study with chart review., Objective: The aim of this study was to compare the reoperation rates for symptomatic nonunions (operative nonunion rates) between posterolateral fusions with pedicle screws (PLFs) and posterior interbody fusion with pedicle screws (PLIFs)., Summary of Background Data: Although radiographic nonunions in PLFs and PLIFs are well documented in the literature, there is no consensus on which technique has lower nonunions. Since some radiographic nonunions may be asymptomatic, a more clinically useful measure is operative nonunions, of which there is minimal research., Methods: A retrospective cohort study, using data from the Kaiser Permanente Spine Registry, identified adult patients (≥18 years' old) who had elective single and multilevel PLFs and PLIFs. Descriptive statistics and 2-year incidence rates for operative nonunions were calculated by fusion-level (1-3), fusion type (PLF vs. PLIF), and levels fused (L3 to S1). Time-dependent multivariable Cox-Proportional Hazards regression was used to evaluate nonunion reoperation rates with adjustment for covariates., Results: The cohort consisted of 3065 patients with PLFs (71.6%) and PLIFs (28.4%). Average age was 65.0 ± 11.7, average follow-up time was 4.8 ± 3.1 years, and average time to operative nonunion was 1.6 (±1.3) years. Single and multilevel incidence rates for nonunions after PLF versus PLIF were similar except for three-level fusions (2.9% [95% confidence interval, CI = 1.0-6.7] vs. 7.1% [95% CI = 0.2-33.9]). In adjusted models, there was no difference in risk of operative nonunions in PLIF compared to PLF (hazard ratio [HR]: 0.8, 95% CI = 0.4-1.6); however, patients with L5-S1 constructs with PLFs had 2.8 times the risk of operative nonunion compared to PLIFs (PLF: HR = 2.8, 95% CI = 1.3-6.2; PLIF: HR = 1.5, 95% CI = 0.4-5.1)., Conclusion: In a large cohort of patients with >4 years of follow-up, we found no difference in operative nonunions between PLF and PLIF except for constructs that included L5-S1 in which the risk of nonunion was limited to PLF patients.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to evaluate the safety of two-level cervical disc replacement (CDR) in the outpatient setting., Summary of Background Data: Despite growing interest in CDR, limited data exist evaluating the safety of two-level CDR in the outpatient setting., Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for all two-level anterior cervical discectomy and fusion (ACDF) and CDR procedures between 2015 and 2018. Demographics, comorbidities, and 30-day postoperative complication rates of outpatient two-level CDR were compared to those of inpatient two-level CDR and outpatient two-level ACDF. Radiographic data are not available in the NSQIP., Results: A total of 403 outpatient CDRs were compared to 408 inpatient CDRs and 4134 outpatient ACDFs. Outpatient CDR patients were older and more likely to have pulmonary comorbidities compared to inpatient CDR (P < 0.03). Outpatient CDR patients were less likely to have an American Society of Anesthesiologists class ≥2 and have hypertension compared to outpatient ACDF patients (P < 0.0001). Outpatient CDR had a lower 30-day readmission rate (0.5% vs. 2.5%, P = 0.02) and lower 30-day reoperation rate (0% vs. 1%, P = 0.047) compared to inpatient CDR. Outpatient CDR had a lower readmission rate (0.5% vs. 2.1%, P = 0.03) compared to outpatient ACDF, but there was no difference in reoperation rates between the two procedures (0% vs. 0.8%, P = 0.07). Outpatient CDR had an overall complication rate of 0.2%, inpatient CDR had a complication rate of 0.9%, and outpatient ACDF had a complication rate of 1.3%. These differences were not significant., Conclusion: To our knowledge, this is the largest multicenter study examining the safety of two-level outpatient CDR procedures. Outpatient two-level CDR was associated with similarly safe outcomes when compared to inpatient two-level CDR and outpatient two-level ACDF. This suggests that two-level CDR can be performed safely in the outpatient setting.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective review., Objective: Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure that may be complicated by airway compromise postoperatively. This life-threatening complication may necessitate reintubation and reoperation. We evaluated the cost utility of conventional postoperative x-ray., Summary of Background Data: Studies have demonstrated minimal benefit in obtaining an x-ray on postoperative day 1, but there is some utility of postanesthesia care unit (PACU) x-rays for predicting the likelihood of reoperation., Methods: We retrospectively reviewed the records of consecutive patients who underwent ACDF between September 2013 and February 2017. Patients were dichotomized into those who received PACU x-rays and those who did not (control group). Primary outcomes were reoperation, reintubation, mortality, and health care costs., Results: Eight-hundred and fifteen patients were included in our analysis: 558 had PACU x-rays; 257 did not. In those who received PACU x-rays, mean age was 53.7 ± 11.3 years, mean levels operated on were 2.0 ± 0.79, and mean body mass index (BMI) was 30.3 ± 6.9. In those who did not, mean age was 51.8 ± 10.9 years, mean levels operated on were 1.48 ± 0.65, and mean BMI was 29.9 ± 6.3. Complications in the PACU x-ray group were reintubation-0.4%, reoperation-0.7%, and death-0.3% (due to prevertebral swelling causing airway compromise). Complications in the control group were reintubation-0.4%, reoperation-0.8%, and death-0. There were no differences between groups with respect to reoperation (P = 0.92), reintubation (P = 0.94), or mortality (P = 0.49). The mean per-patient cost was significantly higher (P = 0.009) in those who received PACU x-rays, $1031.76 ± 948.67, versus those in the control group, $700.26 ± 634.48. Mean length of stay was significantly longer in those who had PACU x-rays (P = 0.01)., Conclusion: Although there were no differences in reoperation, reintubation, or mortality, there was a significantly higher cost for care and hospitalization in those who received PACU x-rays. Further studies are warranted to validate the results of the presented study.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Robotic-assisted unicompartmental knee arthroplasty (RAUKA) is an emerging area of interest. The purpose of this study was to compare (1) different patient demographic profiles; (2) annual primary and revision utilization rates; (3) risk factors for revision procedures; and (4) survivorship between RAUKA and manual UKA (MUKA). Using the PearlDiver database, patients who underwent RAUKA or MUKA between 2005 and 2014 within the Medicare database were identified, yielding a total of 35,061 patients (RAUKA = 13,617; manual = 21,444). Patient demographics (age, gender, comorbidities, Charlson-Comorbidity Index, and geographic region) were compared between cohorts. Annual primary and revision utilization rates as well as risk factors for revision procedures were also compared. Kaplan-Meier survivorship was also calculated. The Pearson χ 2 test was used to test for significance in patient demographics, whereas the Welch t -test was used to compare the incidence of revisions as well as the revision burden (proportion of revisions to total sum of primary and revision procedures). Multivariate binomial logistic regression analysis was performed to compare risk factors for revision procedures. There were statistically significant differences in RAUKA versus MUKA patients with respect to age ( p <  0.001), gender ( p <  0.001), and region ( p <  0.001). RAUKA procedures performed increased over 12-fold compared with manual, which increased only 4.5-fold. RAUKA procedures had significantly lower revision incidence (0.99 vs. 4.24%, p  = 0.003) and revision burden (0.91 vs. 4.23%, p  = 0.005) compared with manuals. For patients undergoing RAUKA, normal (19-24 kg/m 2 ) and obese (30-39 kg/m 2 ) body mass index ( p  < 0.05), congestive heart failure ( p  = 0.004), hypothyroidism ( p <  0.001), opioid dependency ( p  = 0.002), and rheumatoid arthritis ( p <  0.001) were risk factors for a revision procedure. Kaplan-Meier survival curve 3 years following the index procedure to all-cause revisions demonstrated that RAUKA patients maintained nearly 100% survivorship compared with manual patients who had 97.5% survivorship. The data demonstrate increased utilization of RAUKA in the United States. The current data indicated that RAUKA has significantly lower revision rates and improved survivorship compared with patients undergoing non-RAUKA within Medicare patients., Competing Interests: None declared., (Thieme. All rights reserved.)

Study Design: Retrospective case series., Objective: We sought to identify risk factors associated with surgical site infection (SSI) after posterior long segment spinal fusion (PLSF)., Summary of Background Data: Patients who undergo PLSF may be at elevated risk of SSI. Identifying factors associated with SSI in these operations can help risk stratify patients and tailor management., Methods: We analyzed PLSFs-seven or more levels-at our institution from 2000 to 2015. Data on patients' clinical characteristics, procedural factors, and antimicrobial management were collected. Multivariable analysis identified factors independently associated with outcomes of interest., Results: In 628 cases, SSI was associated with steroid use (P = 0.024, odds ratio [OR] = 2.54) and using cefazolin (P < 0.001, OR = 4.37) or bacitracin (P = 0.010, OR 3.49) irrigation, as opposed to gentamicin or other irrigation. Gram-positive infections were more likely with staged procedures (P = 0.021, OR 4.91) and bacitracin irrigation (P < 0.001, OR = 17.98), and less likely with vancomycin powder (P = 0.050, OR 0.20). Gram-negative infections were more likely with a history of peripheral arterial disease (P = 0.034, OR = 3.21) or cefazolin irrigation (P < 0.001, OR 25.47). Readmission was more likely after staged procedures (P = 0.003, OR = 3.31), cervical spine surgery (P = 0.023, OR = 2.28), or cefazolin irrigation (P = 0.039, OR = 1.85). Reoperation was more common with more comorbidities (P = 0.022, OR 1.09), staged procedures (P < 0.001, OR = 4.72), cervical surgeries (P = 0.013, OR = 2.36), more participants in the surgery (P = 0.011, OR = 1.06), using cefazolin (P < 0.001, OR = 3.12) or bacitracin (P = 0.009, OR = 3.15) irrigation, and higher erythrocyte sedimentation rate at readmission (P = 0.009, OR = 1.04). Washouts were more likely among patients with more comorbidities (P = 0.013, OR = 1.16), or who used steroids (P = 0.022, OR = 2.92), and less likely after cervical surgery (P = 0.028, OR = 0.24). Instrumentation removal was more common with bacitracin irrigation (p = 0.013, OR = 31.76)., Conclusion: Patient factors, whether a procedure is staged, and choice of antibiotic irrigation affect the risk of SSI and ensuing management required.Level of Evidence: 4., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective study., Objective: To identify the risk factors for revision surgery among neurologically intact patients with proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery., Summary of Background Data: PJF following long fusion for ASD is a well-recognized complication that negatively affects clinical outcomes. However, revision surgery is not required for every patient with PJF especially if the patient does not present with neurologic deficit. Identifying the risk factors of revision surgery is necessary to determine who will need revision surgery as well as when is the right time for the revision surgery., Methods: Sixty-nine neurologically intact patients with PJF following ASD surgery were followed up with more than 2 years after PJF development or until undergoing revision surgery. PJF was divided into ligamentous failure (proximal junctional angle [PJA] of more than 20°) and bony failure. According to the conduct of revision surgery, two groups (revision and no revision) were created. Risk factors for revision surgery were analyzed in univariate and multivariate analysis with regard to patient, surgical and radiographic variables., Results: The mean age at the time of PJF development was 70.9 years. There were 45 patients with bony failure and 24 with ligamentous failure. Revision surgery was performed for 23 patients (33.3%). Multivariate analysis revealed that bony failure (odds ratio: 10.465) and PJA (odds ratio: 1.131) were significant risk factors. For those with bony failure, the cutoff value of PJA for performing revision surgery was calculated as 22°. The revision rate was significantly highest in patients (63.6%) with bony failure + PJA 22° or higher followed by patients (26.1%) with bony failure + PJA less than 22° and patients (12.5%) with ligamentous failure (P = 0.002)., Conclusion: Bony failure with PJA of greater than 22° increased the likelihood for revision surgery. Therefore, early surgical intervention should be considered in these patients.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective., Objective: The purpose of this study is to evaluate the effect of posterior cervical fusion lowest instrumented vertebra (PCF LIV) selection on incidence of mechanical failure, revision surgery, and patient-reported outcomes (PROs)., Summary of Background Data: Recent studies indicate that the LIV in PCF may contribute to the risk of mechanical failure. To date, the evidence available to guide spine surgeons in the selection of PCF LIV remains limited., Methods: All patients undergoing PCF at a single institution were prospectively entered into a spine registry which was retrospectively queried. Data collection included demographics, pathology, operative variables, construct LIV, outcomes of mechanical failure, revision surgery, and patient-reported disability, pain, and quality of life., Results: Of 438 patients undergoing PCF from 2006 to 2019, 106 patients had an LIV of C7, T1, or T2, a minimum of 1-year follow-up, and met all study inclusion criteria. LIV cohorts were C7 LIV (36), T1 LIV (42), and T2 LIV (28). There were no between-group differences in patient demographics, operative variables, or postoperative follow-up across the three LIV cohorts. Mechanical failure rates for C7, T1, and T2 LIV were 30.6%, 23.8%, and 0%, respectively (P = 0.007). Revision rates for C7, T1, and T2 LIV were 25.0%, 11.9%, and 0%, respectively (P = 0.013). No difference was noted in average time to revision/failure between C7 (39.68 months) and T1 (29.85 months) LIV cohorts. No differences in baseline, 3-month, and 12-month postoperative PRO measures were noted in the C7 and T1 LIV cohort when compared to the T2 LIV cohort., Conclusion: The findings in this study indicate that PCF LIV selection may play a significant role in the development of mechanical complications and need for revision surgery. T2 LIV selection demonstrated a significantly lower rate of mechanical failure and revision surgery. Postoperative PROs up to 36 months are needed to evaluate effect of LIV selection on PROs.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: A retrospective multicenter cohort study., Objective: The aim of this study was to identify the incidence and risk factors for UPROR within minimum 2-year follow-up in primary definitive fusion for pediatric spinal deformity., Summary of Background Data: Several previous reports have elucidated the incidence of complications after pediatric scoliosis surgery; however, there has been no study that described the incidence and risk factors for unplanned return to the operating room (UPROR) with long-term follow-up in surgery for pediatric scoliosis with every etiology., Methods: We retrospectively extracted data of patients aged <19 years, from 14 institutes in Japan, who underwent primary definitive fusion surgery for spinal deformity between January 1, 2015 and December 31, 2017. The primary outcomes were the incidence of UPROR within the minimum 2-year follow-up period for any reason. Univariate and multivariate logistical analyses were conducted to identify potential risk factors associated with UPROR., Results: We identified 1417 eligible patients (287 males and 1130 females) with a mean age of 13.9 years. UPROR for any reason within minimum 2-year follow-up was identified in 68 patients (4.8%). The most frequent cause for UPROR was implant failure found in 29 patients, followed by surgical site infection in 14 patients, junctional problems in 10 patients, and neurological complications in six patients. The multivariate logistic regression analysis revealed that a diagnosis of kyphosis (odds ratio [OR], 2.65; 95% confidence interval [CI] 1.16-6.04), etiology of congenital or structural type (OR 2.21; 95% CI 1.08-4.53), etiology of syndromic type (OR 2.67; 95% CI 1.27-5.64), and increased operation time of ≥300 minutes (OR 1.81; 95% CI 1.07-3.07) were the risk factors for the incidence of UPROR., Conclusion: The present multicenter study identified for the first time the incidence and risk factors for UPROR with minimum 2-year follow-up after primary definitive fusion surgery for pediatric spinal deformity with every etiology.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients undergoing valve-sparing aortic root replacement, is reimplantation superior to remodelling? The purpose of this best evidence topic was to re-review the updated evidence that has become available in the near decade since the previous review published in 2011. Altogether more than 300 papers were found using the reported search, of which 8 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The included studies have significant limitations relating to low-level evidence study design, variable outcome collection and limited significance testing with direct comparison. Long-term outcomes such as survival, recurrence of aortic regurgitation and valve reintervention were largely equal between the two procedures across the studies. This review, updated from the previous best evidence topic, continues to suggest that there are no clear recommendations or even consensus to guide clinical decision-making when choosing between remodelling or reimplantation approaches to valve-sparing aortic root replacement. To date, no study provides strong clinical benefit to favour either procedure in terms of perioperative outcomes, medium-long term survival or reintervention of the aortic valve. As such, procedure selection should be based upon patient factors and valve evaluation, combined with surgeon preference and experience., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Revision total elbow arthroplasty (TEA) has increased, especially in young patients with high functional expectations. The objective of this study was to evaluate the long-term results of revision TEA with a single semiconstrained prosthesis., Methods: Thirty-four revision TEAs were performed with a Coonrad/Morrey prosthesis in 32 patients; 2 patients had bilateral procedures. The mean patient age was 61 years (range, 22 to 76 years), and the revision TEA was performed at a mean time of 7.8 years (range, 1.6 to 21 years) after the primary TEA. Etiologies for revisions were humeral and ulnar aseptic loosening (n = 14), ulnar aseptic loosening (n = 8), humeral aseptic loosening (n = 6), septic arthritis (n = 4), and unstable unlinked prostheses (n = 2). Clinical and radiographic evaluations were performed with systematic preoperative infection workup and quantification of bone loss. The mean follow-up was 11.4 years (range, 2 to 21 years)., Results: The Mayo Elbow Performance Score (MEPS) at the last follow-up was excellent in 6 cases, good in 18 cases, fair in 8 cases, and poor in 2 cases, with a mean improvement (and standard deviation) between the preoperative values at 42.4 ± 16.1 points and the postoperative values at 81.8 ± 12 points (p < 0.001). The mean pain scores improved significantly from 6.7 ± 1.3 points preoperatively to 1.4 ± 1.4 points postoperatively (p < 0.001). The flexion-extension arc increased significantly (p = 0.02) from 74° ± 27° preoperatively to 100° ± 31° postoperatively. The total number of complications was 29 in 19 revision TEAs (56%). Twenty of the 29 complications simply required monitoring without surgical intervention. Six repeat surgical procedures were required, and 3 implant revisions (9%) were performed., Conclusions: Revision TEA with a semiconstrained prosthesis can provide good clinical results that can be maintained during follow-up. The rate of complications is high. Proper evaluation of the risk-benefit ratio is essential for each revision TEA and should be discussed with the patient., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G356)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background and purpose - Studies describing time-related change in reasons for knee replacement revision have been limited to single regions or institutions, commonly analyze only 1st revisions, and may not reflect true caseloads or findings from other areas. We used revision procedure data from 3 arthroplasty registries to determine trends and differences in knee replacement revision diagnoses.Patients and methods - We obtained aggregated data for 78,151 revision knee replacement procedures recorded by the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) for the period 2003-2017. Equivalent diagnosis groups were created. We calculated the annual proportions of the most common reasons for revision.Results - Infection, loosening, and instability were among the 5 most common reasons for revision but magnitude and ranking varied between registries. Over time there were increases in proportions of revisions for infection and decreases in revisions for wear. There were inconsistent proportions and trends for the other reasons for revision. The incidence of revision for infection showed a uniform increase.Interpretation - Despite some differences in terminology, comparison of registry-recorded revision diagnoses is possible, but defining a single reason for revision is not always clear-cut. There were common increases in revision for infection and decreases in revision for wear, but variable changes in other categories. This may reflect regional practice differences and therefore generalizability of studies regarding reasons for revision is unwise.

The long-term stability of coil embolization (CE) of complex intracranial aneurysms (CIAs) is fraught with high rates of recanalization. Surgery of precoiled CIAs, however, deviates from a common straightforward procedure, demanding sophisticated strategies. To shed light on the scope and limitations of microsurgical re-treatment, we present our experiences with precoiled CIAs. We retrospectively analysed a consecutive series of 12 patients with precoiled CIAs treated microsurgically over a 5-year period, and provide a critical juxtaposition with the literature. Five aneurysms were located in the posterior circulation, 8 were large-giant sized, 5 were calcified/thrombosed. One presented as a dissecting-fusiform aneurysm, 9 ranked among wide neck aneurysms. Eight lesions were excluded by neck clipping (5 necessitating coil extraction); 1 requiring adjunct CE. The dissecting-fusiform aneurysm was resected with reconstruction of the parent artery using a radial artery graft. Three lesions were treated with flow alteration (parent artery occlusion under bypass protection). Mean interval coiling-surgery was 4.6 years (range 0.5-12 years). Overall, 10 aneurysms were successfully excluded; 2 lesions treated with flow alteration displayed partial thrombosis, progressing over time. Outcome was good in 8 and poor in 4 patients (2 experiencing delayed neurological morbidity), and mean follow-up was 24.3 months. No mortality was encountered. Microsurgery as a last resort for precoiled CIAs can provide-in a majority of cases-a definitive therapy with good outcome. Since repeat coiling increases the complexity of later surgical treatment, we recommend for this subgroup of aneurysms a critical evaluation of CE as an option for re-treatment.

Although endovascular or surgical treatment has been performed for preventing the rupture of saccular cerebral aneurysms (sCA), in some patients, the aneurysms may recur and require retreatment. We aimed to investigate the clinical and radiological outcomes of treating recurrent sCA. We retrospectively evaluated the data of 52 patients with 60 recurrent sCAs who were retreated and 1534 patients with 1817 sCAs who received initial treatment. The primary outcome was a recurrence of the aneurysm. Secondary outcomes were an additional treatment, rupture after treatment, and a neurological worsening, which was defined as an increase of 1 or more scores using the modified Rankin Scale at 12-month. Safety outcomes included postoperative ischemic and hemorrhagic complications. We compiled the 120 (60 each) propensity score-matched cohort based on a propensity score for the treatment of recurrent sCA. In the propensity score-matched cohort, recurrence after treatment was observed in 25% and 6.7% of cases in the retreatment and initial treatment groups, respectively. The odds ratio of recurrence after treatment was 4.7 (95% CI, 1.4-15; P = 0.011). The secondary and safety outcomes were not significantly different between the two groups. This study showed that the treatment of recurrent sCA was a risk factor for recurrence after treatment but not for additional treatment, rupture after treatment, or neurological worsening. Although decision-making regarding the treatment varies depending on the institutional protocols and personal experience of the physicians, endovascular or surgical retreatment could be performed without hesitation.

Background: Discectomy is sometimes associated with recurrence of disc herniation and pain after surgery. The evidence to use an interspinous dynamic stabilization system or instrumented fusion in association with disc excision to prevent pain and re-operation remains controversial. In this study, we analyzed if adding interspinous spacer or fusion, offers advantages in relation to microdiscetomy alone., Methods: Patients with lumbar disc herniation were divided in 3 groups; microdiscectomy alone (MD), microdiscectomy plus interspinous spacer (IS) and open discectomy plus posterior lumbar interbody fusion (PLIF). The clinical efficacy was measured using the Owestry Disability Index (ODI). Other outcome parameters including visual analogue scale for pain (VAS) back and legs, length of stay, direct in-hospital cost, 90-day complication rate, and 1-year re-operation rate were also evaluated., Results: A total of 103 patients whose mean age was 39.1 (±8.5) years were included. A significant improvement of the ODI and VAS back and legs pain baseline score was detected in the 3 groups. After 1 year, no significant differences in ODI, VAS back and legs pain were found between the 3 groups. There was an increase of 169% of the total direct in- hospital cost in IS group and 287% in PLIF group, in relation to MD (p < 0.001). Length of stay was 86% higher in the IS group and 384% longer in the PLIF group compared to MD (p < 0.001). The 1 year re-operation rates were 5.6%, 10% and 16.2% (p = 0.33). Discectomy seems to be the main responsible for the clinical improvement, without the interspinous spacer or fusion adding any benefit. The addition of interspinous spacer or fusion increased direct in-hospital cost, length of stay, and did not protect against re-operation., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests. The authors declare that they have no financial or personal relationship with any institution or manufactures of spinal implants related to the content of this publication that could cause a conflict of interest., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective register study., Objective: The aim of this study was to assess the incidence and trends of lumbar disc surgeries in Finland from 1997 through 2018., Summary of Background Data: The evidence on lumbar spine discectomy has shifted from supporting surgical treatment toward nonoperative treatment. Still, the incidence of lumbar discectomy operations increased until the 1990 s. In the United States, the incidence began to decline after a downward turn in 2008, yet recent trends from countries with public and practically free health care are not widely known., Methods: Data for this study were obtained from the Finnish nationwide National Hospital Discharge Register. The study population covered all patients 18 years of age or older in Finland during a 22-year period from January 1, 1997, to December 31, 2018., Results: A total of 65,912 lumbar discectomy operations were performed in Finland from 1997 through 2018. The annual population-based incidence of lumbar discectomy decreased 29% during the 22-year period, from 83 per 100,000 person-years in 1997 to 58 per 100,000 person-years in 2018. In addition, the incidence of microdiscectomy increased 12%, from 41 per 100,000 person-years in 1997 to 47 per 100,000 person-years in 2018, whereas the incidence of open discectomy decreased 71%, from 41 per 100,000 person-years in 1997 to 12 per 100,000 person-years in 2018. The total reoperation rate for microendoscopic, microscopic, and open discectomy surgeries was 16.3%, 15.3%, and 14.9%, respectively., Conclusion: The nationwide incidence of lumbar discectomy decreased in Finland from 1997 through 2018. Additionally, the incidence of open discectomy is decreasing rapidly, whereas the incidence of microsurgical techniques is increasing.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

BACKGROUND Patients with hip joint infections in childhood often have many aftereffects of different degrees, regardless of the kind of treatment or natural course. Total hip arthroplasty is currently the most effective treatment for sequelae of childhood hip septic or tuberculous infection. This is a mid-term follow-up study of treatment results of patients who had undergone total hip arthroplasty (THA) with cementless prostheses. MATERIAL AND METHODS We retrospectively analyzed and followed 45 patients (45 hips) who underwent THA with cementless prostheses between 2010 and 2017. There were 45 patients, including 17 men and 28 women. The average age of the patients was 46 years (range, 18-67 years). All hip infections occurred in early childhood or adolescence, and the mean interval between initial infection and THA was 38.2 years (range, 15-60 years). The mean follow-up was 6.1 years (range, 2.7-9.5 years). RESULTS Two patients underwent revision surgery because of loosening of the prosthesis, and 1 patient underwent revision surgery because of a new infection with no relationship with childhood infection during the follow-up. The average Harris hip scores significantly increased from 43.1 to 86.4 (P<0.01), and the average visual analog scale significantly increased from 4.6 to 1.7 (P<0.01). The hip dysfunction and osteoarthritis outcome scores were also significantly changed (P<0.01) at the final follow-up. There were 2 cases of transient sciatic nerve palsy and intraoperative periprosthetic fractures in 3 cases. During follow-up, single revision was performed after 6 years of primary arthroplasty because of aseptic loosening in 2 cases and prosthesis infection in 1 case, which was not related to childhood pathogens. CONCLUSIONS THA for patients with sequelae of hip joint infection has a satisfactory effect that can effectively relieve joint pain and improve hip function. The recurrence rate of infection after either pyogenic infection or tuberculous is very low. The mid-term outcomes of THA in this setting were satisfactory, with high prosthesis survivorship and hip function scores.

Background: Surgery for degenerative cervical spine disease has escalated since the 1990s. Fusion has become the mainstay of surgery despite concerns regarding adjacent segment degeneration. The patient-specific trends in reoperations have not been studied previously., Objective: To analyze the occurrence, risk factors, and trends in reoperations in a long-term follow-up of all the patients operated for degenerative cervical spine disease in Finland between 1999 and 2015., Methods: The patients were retrospectively identified from the Hospital Discharge Registry. Reoperations were traced individually; only reoperations occurring >365 d after the primary operation were included. Time trends in reoperations and the risk factors were analyzed by regression analysis., Results: Of the 19 377 identified patients, 9.2% underwent a late reoperation at a median of 3.6 yr after the primary operation. The annual risk of reoperation was 2.4% at 2 yr, 6.6% at 5 yr, 11.1% at 10 yr, and 14.2% at 15 yr. Seventy-five percent of the late reoperations occurred within 6.5 yr of the primary operation. Foraminal stenosis, the anterior cervical decompression and fusion (ACDF) technique, male gender, weak opiate use, and young age were the most important risk factors for reoperation. There was no increase in the risk of reoperations over the follow-up period., Conclusion: The risk of reoperation was stable between 1999 and 2015. The reoperation risk was highest during the first 6 postoperative years and then declined. Patients with foraminal stenosis had the highest risk of reoperation, especially when ACDF was performed., (© Congress of Neurological Surgeons 2020.)

Objective: Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align with objective measures of procedural complexity within neurosurgery., Methods: The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures., Results: Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R 2  = 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU = 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU = 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU = -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU = -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU = -11.29) were associated with lower than predicted RVU., Conclusions: Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions., (Published by Elsevier Inc.)

Background: Mitral valve-in-valve (ViV) and valve-in-ring (ViR) are alternatives to surgical reoperation in patients with recurrent mitral valve failure after previous surgical valve repair or replacement. Our aim was to perform a large-scale analysis examining midterm outcomes after mitral ViV and ViR., Methods: Patients undergoing mitral ViV and ViR were enrolled in the Valve-in-Valve International Data Registry. Cases were performed between March 2006 and March 2020. Clinical endpoints are reported according to the Mitral Valve Academic Research Consortium (MVARC) definitions. Significant residual mitral stenosis (MS) was defined as mean gradient ≥10 mm Hg and significant residual mitral regurgitation (MR) as ≥ moderate., Results: A total of 1079 patients (857 ViV, 222 ViR; mean age 73.5±12.5 years; 40.8% male) from 90 centers were included. Median STS-PROM score 8.6%; median clinical follow-up 492 days (interquartile range, 76-996); median echocardiographic follow-up for patients that survived 1 year was 772.5 days (interquartile range, 510-1211.75). Four-year Kaplan-Meier survival rate was 62.5% in ViV versus 49.5% for ViR ( P <0.001). Mean gradient across the mitral valve postprocedure was 5.7±2.8 mm Hg (≥5 mm Hg; 61.4% of patients). Significant residual MS occurred in 8.2% of the ViV and 12.0% of the ViR patients ( P =0.09). Significant residual MR was more common in ViR patients (16.6% versus 3.1%; P <0.001) and was associated with lower survival at 4 years (35.1% versus 61.6%; P =0.02). The rates of Mitral Valve Academic Research Consortium-defined device success were low for both procedures (39.4% total; 32.0% ViR versus 41.3% ViV; P =0.01), mostly related to having postprocedural mean gradient ≥5 mm Hg. Correlates for residual MS were smaller true internal diameter, younger age, and larger body mass index. The only correlate for residual MR was ViR. Significant residual MS (subhazard ratio, 4.67; 95% CI, 1.74-12.56; P =0.002) and significant residual MR (subhazard ratio, 7.88; 95% CI, 2.88-21.53; P <0.001) were both independently associated with repeat mitral valve replacement., Conclusions: Significant residual MS and/or MR were not infrequent after mitral ViV and ViR procedures and were both associated with a need for repeat valve replacement. Strategies to improve postprocedural hemodynamics in mitral ViV and ViR should be further explored.

Aim: To define the natural course of kyphosis, and to evaluate the efficiency of a new technique in surgical correction of kyphosis seen in myelomeningocele(MM) patients., Material and Methods: We retrospectively reviewed our patients with MM. The rate of kyphosis, mean angle of progression and mean angle of surgical correction were evaluated. Surgical correction was achieved with the same technique in all patients; kyphectomy, short segment instrumentation with plate system and long segment instrumentation with screw-rod system., Results: A total of 14 patients were treated surgically and the mean age at the surgery was 39 months. The incidence of kyphosis rate was %21 in this study. The mean angle of kyphosis was 85.8°. Average angle of progression was 15.7° whereas it was 6.3° degree in patients whose kyphosis angle ?90 and > 90 degree, respectively, at birth. 14 patients were treated surgically and the mean age at the surgery was 39 months. The mean angle of correction of kyphosis was 86 degree. The most common complications were wound dehiscence and cerebro-spinal fluid leak. One patient died 3 months after surgery, and one patient was reoperated due to pull-out of screws., Conclusion: Effective surgical correction of kyphosis in MM patients can be achieved with the described surgical technique even in younger ages. Prospective studies in larger study population are necessary for more accurate definition of natural history of kyphosis in MM patients.

Study Design: Retrospective Study., Objective: This investigation examined matched cohorts of lumbar spinal fusion (LSF) patients undergoing robot-assisted and conventional LSF to compare risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization., Summary of Background Data: Patient outcomes and complication rates associated with robot-assisted LSF compared to conventional fusion techniques are incompletely understood., Methods: The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary LSF between 2011 and 2017. Patients receiving robot-assisted or conventional LSF were matched using key demographic and comorbidity variables. Indication for revision was also studied. Risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization at 1 and 6 months was compared between the cohorts using multivariable logistic regression additionally controlling for age, sex, and Charlson Comorbidity Index., Results: The percent of LSFs that were robot-assisted rose by 169% from 2011 to 2017, increasing linearly each year (p = 0.0007). Matching resulted in 2528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (adjusted odds ratio [aOR] = 2.35, P ≤ 0.0001), 30-day readmission (aOR = 1.39, P = 0.0002), and total 30-day complications (aOR = 1.50, P < 0.0001), specifically respiratory (aOR = 1.56, P = 0.0006), surgical site infection (aOR = 1.56, P = 0.0061), and implant-related complications (aOR = 1.74, P = 0.0038). The risk of revision due to infection after robot-assisted LSF was an estimated 4.5-fold higher (aOR = 4.46, 95% confidence interval [CI] 1.95-12.04, P = 0.0011). Furthermore, robot-assisted LSF had increased risk of revision due to instrument failure (aOR = 1.64, 95% CI 1.05-2.58, P = 0.0300), and pseudarthrosis (aOR = 2.24, 95%CI = 1.32-3.95, P = 0.0037). A higher percentage of revisions were due to infection in robot-assisted LSF (19.0%) than in conventional LSF (9.2%) (P = 0.0408)., Conclusion: Robotic-assisted posterior LSF is independently associated with increased risk of revision surgery, infection, instrumentation complications, and postoperative opioid utilization compared to conventional fusion techniques. Further research is needed to investigate long-term postoperative outcomes following robot-assisted LSF. Spine surgeons should be cautious when considering immediate adoption of this emerging surgical technology., Level of Evidence: 3.

Background: Ventriculoperitoneal shunts (VPS) are placed for a variety of etiologies. It is common for general surgery to assist with insertion of the distal portion in the peritoneum., Objective: To determine if there is a difference in revision rates in patients undergoing VPS placement with general surgery as well as those undergoing laparoscopic insertion., Methods: A retrospective review of all consecutive patients undergoing VPS placements was performed in a three-year period (2017-2019). Those that underwent placement with general surgery were compared to those without general surgery. Additionally, patients undergoing distal placement via mini-laparotomy versus laparoscopy were compared. Multivariable logistic regression was used to examine risk factors for distal VPS failure., Results: 331 patients were included. 202 (61.0 %) underwent VPS placement with general surgery. 121 (36.6 %) patients underwent insertion via laparoscopic technique. General surgery involvement reduced operative times, decreased length of stay, and lowered overall revision rates with distal revision rates being most significant (1.5 % vs 8.5 %; p = 0.0034). Patients undergoing VPS placement via laparoscopic technique had decreased operative time, length of stay, in-hospital complications and revision rates, with significant decrease in shunt infection (1.7 % vs 7.1 %; p = 0.0366). A history of prior shunt or abdominal surgery (OR 3.826; p = 0.0282) and lack of general surgery involvement (OR 20.98; p = 0.0314) are independent risk factors for distal shunt revision in our cohort., Conclusion: The use of general surgeons in VPS insertion can be of benefit by decreasing operative time, length of stay, total revisions, and distal revision rates. Further prospective studies are warranted to determine true benefit., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The primary goal of this study is to determine trends in patient 30-day postoperative readmission and reoperation following elective posterior lumbar fusion (PLF) between 2006-2016., Methods: We retrospectively identified patients in the ACS-NSQIP database who underwent elective, non-emergent PLF from 2006 to 2016. Descriptive statistical and time trend analyses were performed on demographic, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission within 30 days and secondary outcomes were medical and surgical complications reported within 30 days of the operation. Linear and binary logistic regression were performed to adjust for patient specific confounders., Results: A total of 26,265 patients underwent elective PLF over the study period. Overall case volume increased from 0.02 % (n = 27) of all total cases in ACS-NSQIP in 2006 to 0.82 % (n = 8228) in 2016. Mean age increased from 51.22 [SE: 2.77] in 2006 to 60.57 [SE: 0.14] in 2016 (p < 0.001). For comorbidities, there was a decrease in smokers and increase in hypertension requiring medication and ASA Class 3. A readmission rate of around 5% per year did not vary significantly over the study period (p = 0.531). Unplanned reoperations declined from 7.4 % in 2006 to 3.1 % in 2016, but the overall trend from 2006 to 2016 was not statistically significant (p = 0.139). Reoperation demonstrated a significant association between age and BMI, but did not vary with admission year. Surgical site infections followed by hematomas and seromas were listed as the most common cause of both readmission and reoperation in PLF patients., Conclusion: Since the establishment of the ACS-NSQIP database, reoperation rates due to complications declined after 2006 and remained relatively stable. Readmissions were added as a variable in 2011 and had no significant changes over time., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Data on the frequency and outcome of repeated mechanical thrombectomy (MT) in patients with short-term re-occlusion of intracranial vessels is limited. Addressing this subject, we report our multicenter experience with a systematic review of the literature., Methods: A retrospective analysis was conducted of consecutive acute stroke patients treated with MT repeatedly within 30 days at 10 tertiary care centers between January 2007 and January 2020. Baseline demographics, etiology of stroke, angiographic outcome and clinical outcome evaluated by the modified Rankin Scale (mRS) at 90 days were noted. Additionally, a systematic review of reports with repeated MT due to large vessel occlusion (LVO) recurrence was performed., Results: We identified 30 out of 7844 (0.4%) patients who received two thrombectomy procedures within 30 days due to recurrent LVO. Through systematic review, three publications of 28 participants met the criteria for inclusion. Combined, a total of 58 participants were analyzed: cardioembolic events were the most common etiology for the first (65.5%) and second LVO (60.3%), respectively. Median baseline NIHSS (National Institutes of Health Stroke Scale) was 13 (IQR 8-16) before the first MT and 15 (IQR 11-19) before the second MT (p=0.031). Successful reperfusion was achieved in 91.4% after the first MT and in 86.2% patients after the second MT (p=0.377). The rate of functional independence (mRS 0-2) was 46% at 90 days after the second procedure., Conclusion: Repeated MT in short-term recurrent LVO is a rarity but appears to be safe and effective. The second thrombectomy should be pursued with the same extensive effort as the first procedure as these patients may achieve similar good outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: An epidemiological study using national administrative data from the MarketScan database., Objective: The aim of this study was to identify the impact of bone morphogenetic protein (BMP) on postoperative outcomes in patients undergoing adult cervical deformity (ACD) surgery., Summary of Background Data: BMP has been shown to stimulate bone growth and improve fusion rates in spine surgery. However, the impact of BMP on reoperation rates and postoperative complication rate is controversial., Methods: We queried the MarketScan database to identify patients who underwent ACD surgery from 2007 to 2015. Patients were stratified by BMP use in the index operation. Patients <18 years and those with any history of tumor or trauma were excluded. Baseline demographics and comorbidities, postoperative complication rates, and reoperation rates were analyzed., Results: A total of 13,549 patients underwent primary ACD surgery, of which 1155 (8.5%) had intraoperative BMP use. The overall 90-day complication rate was 27.6% in the non-BMP cohort and 31.1% in the BMP cohort (P < 0.05). Patients in the BMP cohort had longer average length of stay (4.0 days vs. 3.7 days, P < 0.05) but lower revision surgery rates at 90 days (14.5% vs. 28.3%, P < 0.05), 6 months (14.9% vs. 28.6%, P < 0.05), 1 year (15.7% vs. 29.2%, P < 0.05), and 2 years (16.5% vs. 29.9%, P < 0.05) postoperatively. BMP use was associated with higher payments throughout the 2-year follow-up period ($107,975 vs. $97,620, P < 0.05). When controlling for baseline group differences, BMP use independently increased the odds of postoperative complication (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.1-1.4) and reduced the odds of reoperation throughout 2 years of follow-up (OR 0.49, 95% CI 0.4-0.6)., Conclusion: Intraoperative BMP use has benefits for fusion integrity in ACD surgery but is associated with increased postoperative complication rate. Spine surgeons should weigh these benefits and drawbacks to identify optimal candidates for BMP use in ACD surgery., Level of Evidence: 3.

Background: Anticoagulant therapy is common and complicates the operative management of acute and mixed-density subdural hematomas (SDHs). The risk of reoperation inferred by anticoagulant (AC) medication and the ability of reversal agents to reduce hemorrhagic complications in patients presenting with AC-associated SDHs are not fully understood., Methods: Data were collected for 288 consecutive patients treated with craniotomy or craniectomy for evacuation of an acute or mixed-density SDH between 2012 and 2017 at 2 academic institutions. Primary end points were reoperation within 30 days and functional outcome at discharge. Groups were compared based on AC use. Logistic regression models were used to identify predictors of reoperation and functional outcome at discharge., Results: Forty-six patients on ACs and 242 with no AC history were analyzed. All patients on AC underwent AC reversal before hematoma evacuation. Reoperation rates between groups were not significantly different (10.9% vs. 12.4%; P = 1.00); however, time to reoperation was significantly shorter in those on ACs (0.8 ± 1.1 days vs. 6.8 ± 10.4 days; P = 0.04). Aspirin use was independently associated with the need for reoperation (odds ratio, 3.05; confidence interval, 1.30-7.19; P = 0.01). Patients taking ACs were significantly older, had more medical comorbidities and were more likely to have a higher modified Rankin Scale score at discharge., Conclusions: Anticoagulant use was not associated with an increased reoperation rate, suggesting that reversal of AC may have eliminated the hemorrhagic risk conferred by these medications. Patients on ACs were significantly older, harbored more medical comorbidities, and had a worse functional outcome at discharge., (Published by Elsevier Inc.)

Background The likelihood of undergoing reoperative coronary artery bypass graft surgery (CABG) is important for older patients who are considering first-time CABG. Trends in the reoperative CABG for these patients are unknown. Methods and Results We used the Medicare fee-for-service inpatient claims data of adults undergoing isolated first-time CABG between 1998 and 2017. The primary outcome was time to first reoperative CABG within 5 years of discharge from the index surgery, treating death as a competing risk. We fitted a Cox regression to model the likelihood of reoperative CABG as a function of patient baseline characteristics. There were 1 666 875 unique patients undergoing first-time isolated CABG and surviving to hospital discharge. The median (interquartile range) age of patients did not change significantly over time (from 74 [69-78] in 1998 to 73 [69-78] in 2017); the proportion of women decreased from 34.8% to 26.1%. The 5-year rate of reoperative CABG declined from 0.77% (95% CI, 0.72%-0.82%) in 1998 to 0.23% (95% CI, 0.19%-0.28%) in 2013. The annual proportional decline in the 5-year rate of reoperative CABG overall was 6.6% (95% CI, 6.0%-7.1%) nationwide, which did not differ across subgroups, except the non-white non-black race group that had an annual decline of 8.5% (95% CI, 6.2%-10.7%). Conclusions Over a recent 20-year period, the Medicare fee-for-service patients experienced a significant decline in the rate of reoperative CABG. In this cohort of older adults, the rate of declining differed across demographic subgroups.

Study Design: A multicenter retrospective analysis of a prospectively maintained database., Objective: To examine the characteristics of reoperation for surgical site infection (SSI) after spinal instrumentation surgery, including the efficacy of treatment for SSI and instrumentation retention., Summary of Background Data: Aging of the population and advances in surgical techniques have increased the demand for spinal surgery in elderly patients. Treatment of SSI after this surgery has the main goals of eliminating infection and retaining instrumentation., Methods: The subjects were 16,707 patients who underwent spine surgery with instrumentation in 11 hospitals affiliated with the Nagoya Spine Group from 2004 to 2015. Details of those requiring reoperations for SSI were obtained from surgical records at each hospital., Results: There were significant increases in the mean age at the time of surgery (54.6-63.7 years) and the number of instrumentation surgeries (726-1977) from 2004 to 2015. The incidence of reoperation for SSI varied from 0.9% to 1.8%, with a decreasing trend over time. Reoperation for SSI was performed in 206 cases (115 men, 91 women; mean age 63.2 years). The average number of reoperations (1.4 vs. 2.3, P < 0.05), time from SSI to first reoperation (4.3 vs. 9.5 days, P < 0.05), and the methicillin-resistant Staphylococcus identification rate (20% vs. 37%, P < 0.01) were all significantly lower in cases with instrumentation retention (n = 145) compared to those with instrumentation removal (n = 61)., Conclusion: There were marked trends of aging of patients and an increase in operations over the study period; however, the incidences of reoperation and instrumentation removal due to SSI significantly decreased over the same period. Rapid debridement after SSI diagnosis may have contributed to instrumentation retention. These results can serve as a guide for developing strategies for SSI treatment and for improved planning of spine surgery in an aging society., Level of Evidence: 3.

Background: There has been much attention recently on whether the involvement of neurosurgical residents during surgery impacts patient outcomes. Our goal was to perform a meta-analysis of all existing studies in order to determine the true effect of resident involvement., Methods: We performed a systematic review and identified studies that compared resident involvement during surgery to attending neurosurgeons alone. Event rates and adjusted odds ratios were collected and pooled to generate estimates., Results: Eleven studies were identified, of which 9 reported adjusted odds ratios. Meta-analysis showed that there were no significant differences in patient baseline characteristics (age, gender, the majority of medical comorbidities). Analysis of operative variables showed increases in a number of complications. However, adjustment of odds ratios for confounders eliminated most of these effects but continued to show a mild increase in overall complications with an odds ratio of 1.14 (P = 0.02). Notably, for both adjusted and unadjusted estimates, no significant differences were seen in 30-day mortality., Conclusions: We found that, when adjusted for comorbidities, complexity, and procedure type, there was no difference in outcomes in terms of surgical complications, reoperation, length of stay more than 5 days, and mortality. While these results suggest that our apprenticeship teaching model is safe for developing independent physicians, using new educational modalities such as simulation and resident-directed labs may be useful to attenuate potential patient complications in higher-risk procedures and in patients with comorbidities., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Treatment of patients with Crohn's disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated., Methods: In this nationwide cohort study, incident patients of all ages with Crohn's disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990-1995 and 1996-2000 with use of inpatient registries, 2001, and 2002-2008 and 2009-2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan-Meier method., Results: Among 21 273 patients with Crohn's disease, the cumulative incidence of first abdominal surgery within 5 years of Crohn's disease diagnosis decreased continuously from 54·8 per cent in 1990-1995 to 40·4 per cent in 1996-2000 (P < 0·001), and again from 19·8 per cent in 2002-2008 to 17·3 per cent in 2009-2014 (P < 0·001). Repeat 5-year surgery rates decreased from 18·9 per cent in 1990-1995 to 16·0 per cent in 1996-2000 (P = 0·009). After 2000, no further significant decreases were observed., Conclusion: The 5-year rate of surgical intervention for Crohn's disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy., (© 2020 The Authors. British Journal of Surgery published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Study Design: Retrospective cohort study of a nationwide sample database., Objective: The objective of the present study was to compare the long-term incidence of reoperation for lumbar spinal stenosis (LSS) after anterior fusion, posterior fusion, and decompression., Summary of Background Data: Surgical treatment for LSS can be largely divided into 2 categories: decompression only and decompression with fusion. A previous nationwide study reported that fusion surgery was performed in 10% of patients with LSS, and the 10-year reoperation rate was approximately 17%. However, with the development of surgical techniques and changes in surgical trends, these results should be reassessed., Methods: The National Health Insurance Service-National Sample Cohort of the Republic of Korea was utilized to establish a cohort of adult patients (N = 1400) who first underwent surgery for LSS during 2005 to 2007. Patients were followed for 8 to 10 years. Considering death before reoperation as a competing event, reoperation hazards were compared among surgical techniques using a Fine and Gray regression model after adjustment for sex, age, diabetes, osteoporosis, Charlson comorbidity index, severity of disability, type of medical coverage, and type of hospital., Results: The overall cumulative incidence of reoperation was 6.2% at 2 years, 10.8% at 5 years, and 18.4% at 10 years. The cumulative incidence of reoperation was 20.6%, 12.6%, and 18.6% after anterior fusion, posterior fusion, and decompression, respectively, at 10 years postoperatively (P = 0.44). The first surgical technique did not affect the reoperation type (P = 0.27). Decompression was selected as the surgical technique for reoperation in 83.5% of patients after decompression, in 72.7% of patients after anterior fusion, and in 64.3% of patients after posterior fusion., Conclusion: The initial surgical technique did not affect reoperation during the 10-year follow-up period. Decompression was the most commonly used technique for reoperation., Level of Evidence: 4.

Study Design: Retrospective, single-center analysis., Objective: To calculate the total clinical hospital cost of the Adult Spinal Deformity (ASD) care trajectory, to explain cost variability by patient and surgery characteristics, and to identify areas of process improvement opportunities., Summary of Background Data: ASD is associated with a high financial and clinical burden on society. ASD care thus requires improved insights in costs and its drivers as a critical step toward the improvement of value, i.e., the ratio between delivered health outcome and associated costs., Methods: Patient characteristics and surgical variables were collected following ethical approval in a cohort of 139 ASD patients, treated between December, 2014 and January, 2018. Clinical hospital costs were calculated, including all care activities, from initial consultation to 1 year after initial surgery (excl. overhead) in a university hospital setting. Multiple linear regression analysis was performed to analyze the impact of patient and surgical characteristics on clinical costs., Results: 75.5% of the total clinical hospital cost (&OV0556;27,865) was incurred during initial surgery with costs related to the operating theatre (80.3%), nursing units (11.9%), and intensive care (2.9%) being the largest contributors. 57.5% of the variation in total cost could be explained in order of importance by surgical invasiveness, age, coronary disease, single or multiple-staged surgery, and mobility status. Revision surgery, unplanned surgery due to complications, was found to increase average costs by 87.6% compared with elective surgeries (&OV0556; 44,907 (± &OV0556; 23,429) vs. &OV0556; 23,944 (± &OV0556; 7302))., Conclusion: This study identified opportunities for process improvement by calculating the total clinical hospital costs. In addition, it identified patient and treatment characteristics that predict 57.5% of cost variation, which could be taken into account when developing a payment system. Future research should include outcome data to assess variation in value., Level of Evidence: 4.

Introduction: Despite the recent emergence of expensive biologic therapies, hospitalization and surgery remain important contributors for the overall costs of inflammatory bowel disease (IBD). In this study, we aimed to describe the burden of reoperations in patients with IBD by evaluating reoperation rates, charges, and risk factors over 16 years., Methods: We performed a retrospective analysis of all hospital discharges, with focus on reoperations and with a primary diagnosis of IBD, in public hospitals between 2000 and 2015 in mainland Portugal from the Central Administration of the Health System's national registry. We collected data on patient, clinical, and healthcare charges. We used multivariate regressions to estimate the risk factors of IBD-related reoperations., Results: We found that 5% of IBD-related hospitalizations were related to reoperations. The number of reoperations per year increased by approximately 200%. However, when corrected by the prevalence of the disease, IBD reoperation rates decreased. Mean IBD-related charges per hospitalization were 7,780 &OV0556; in 2000 and 10,592 &OV0556; in 2015, with total charges reaching 6.7 million euros by the end of the study. Risk factors for reoperation include urgent hospitalization, in patients with ulcerative colitis (odds ratio 1.94, 95% confidence interval 1.19-3.17, P = 0.008), and colic disease, in patients with Crohn's disease (odds ratio 1.57, 95% confidence interval 1.06-2.34, P = 0.025)., Discussion: To obtain an accurate scenario of reoperations among patients with IBD, it is mandatory to adjust the number of reoperations to the prevalence of the disease. Reoperation and its risk factors should be closely monitored to decrease the burden of IBD to the healthcare system.

Background There is a paucity of data on the trends and outcomes of reoperative coronary artery bypass graft (CABG) surgery during the current decade in the United States. Methods and Results We queried the National Inpatient Sample database (2002-2016) for all hospitalizations with isolated CABG procedure. We reported the temporal trends and outcomes of reoperative CABG versus primary CABG procedures. The main outcome was in-hospital mortality. Among 3 212 768 hospitalizations with CABG, 46 820 (1.5%) had reoperative CABG. Over the 15-year study period, there were no changes in the proportion of reoperative CABG (1.8% in 2002 versus 2.2% in 2016, P tren =0.08), and the related in-hospital mortality (3.7% in 2002 versus 2.7% in 2016, P trend =0.97). Reoperative CABG was performed in patients with increasingly higher risk profile. Compared with primary CABG, hospitalizations for reoperative CABG were associated with higher in-hospital mortality (3.2% versus 1.9%, P <0.001), cardiac arrest, cardiogenic shock, vascular complications, and respiratory complications. Among hospitalizations for reoperative CABG, the predictors of higher mortality included history of heart failure and chronic kidney disease. Conclusions In this 15-year nationwide analysis, reoperative CABG procedures were increasingly performed in patients with higher risk profile. In-hospital mortality rates were relatively low and did not change during the examined period. Compared with primary CABG, reoperative CABG is associated with higher in-hospital mortality.

Study Design: A retrospective study with prospectively-collected data., Objective: To determine how type, location, and size of endplate lesions on magnetic resonance imaging (MRI) may be associated with symptoms and clinical outcomes after anterior cervical discectomy and fusion (ACDF)., Summary of Background Data: Structural endplate abnormalities are important, yet understudied, phenomena in the cervical spine. ACDF is a common surgical treatment for degenerative disc disease; however, adjacent segment degeneration/disease (ASD) may develop., Methods: Assessed the imaging, symptoms and clinical outcomes of 861 patients who underwent ACDF at a single center. MRI and plain radiographs of the cervical spine were evaluated. Endplate abnormalities on MRI were identified and stratified by type (atypical, typical), location, relation to operative levels, presence at the adjacent level, and size. These strata were assessed for association with presenting symptoms, patient-reported, and postoperative outcomes., Results: Of 861 patients (mean follow-up: 17.4 months), 57.3% had evidence of endplate abnormalities, 39.0% had typical abnormalities, while 18.2% had atypical abnormalities. Patients with any endplate abnormality had greater odds of myelopathy irrespective of location or size, while sensory deficits were associated with atypical lesions (P = 0.016). Typical and atypical abnormalities demonstrated differences in patient-reported outcomes based on location relative to the fused segment. Typical variants were not associated with adverse surgical outcomes, while atypical lesions were associated with ASD (irrespective of size/location; P = 0.004) and reoperations, when a large abnormality was present at the proximal adjacent level (P = 0.025)., Conclusion: This is the first study to examine endplate abnormalities on MRI of the cervical spine, demonstrating distinct risk profiles for symptoms, patient-reported, and surgical outcomes after ACDF. Patients with typical lesions reported worsening postoperative pain/disability, while those with atypical abnormalities experienced greater rates of ASD and reoperation. This highlights the relevance of a degenerative spine phenotypic assessment, and suggests endplate abnormalities may prognosticate clinical outcomes after surgery., Level of Evidence: 3.

Objective: Patients with osteopenia or osteoporosis who require surgery for symptomatic degenerative spondylolisthesis may have higher rates of postoperative pseudarthrosis and need for revision surgery than patients with normal bone mineral densities (BMDs). To this end, the authors compared rates of postoperative pseudarthrosis and need for revision surgery following single-level lumbar fusion in patients with normal BMD with those in patients with osteopenia or osteoporosis. The secondary outcome was to investigate the effects of pretreatment with medications that prevent bone loss (e.g., teriparatide, bisphosphonates, and denosumab) on these adverse outcomes in this patient cohort., Methods: Patients undergoing single-level lumbar fusion between 2007 and 2017 were identified. Based on 1:1 propensity matching for baseline demographic characteristics and comorbidities, 3 patient groups were created: osteopenia (n = 1723, 33.3%), osteoporosis (n = 1723, 33.3%), and normal BMD (n = 1723, 33.3%). The rates of postoperative pseudarthrosis and revision surgery were compared between groups., Results: The matched populations analyzed in this study included a total of 5169 patients in 3 groups balanced at baseline, with equal numbers (n = 1723, 33.3%) in each group: patients with a history of osteopenia, those with a history of osteoporosis, and a control group of patients with no history of osteopenia or osteoporosis and with normal BMD. A total of 597 complications were recorded within a 2-year follow-up period, with pseudarthrosis (n = 321, 6.2%) being slightly more common than revision surgery (n = 276, 5.3%). The odds of pseudarthrosis and revision surgery in patients with osteopenia were almost 2-fold (OR 1.7, 95% CI 1.26-2.30) and 3-fold (OR 2.73, 95% CI 1.89-3.94) higher, respectively, than those in patients in the control group. Similarly, the odds of pseudarthrosis and revision surgery in patients with osteoporosis were almost 2-fold (OR 1.92, 95% CI 1.43-2.59) and > 3-fold (OR 3.25, 95% CI 2.27-4.65) higher, respectively, than those in patients in the control group. Pretreatment with medications to prevent bone loss prior to surgery was associated with lower pseudarthrosis and revision surgery rates, although the differences did not reach statistical significance., Conclusions: Postoperative pseudarthrosis and revision surgery rates following single-level lumbar spinal fusion are significantly higher in patients with osteopenia and osteoporosis than in patients with normal BMD. Pretreatment with medications to prevent bone loss prior to surgery decreased these complication rates, although the observed differences did not reach statistical significance.

Background In March 2011, the Fukushima Daiichi nuclear power plant disaster inflicted radiation damage across the Tohoku region of Northern Japan. The consequent harm to pregnant mothers and newborns was a matter of concern. We performed a registry-based analysis of the incidence of congenital heart disease during 2010 to 2013 using the Japan Cardiovascular Surgery Database. Methods and Results We selected patients who had complex congenital heart disease and who were born between January 1, 2010 and December 31, 2013 undergoing surgery, and assessed the trend in the number of first-time surgeries performed for patients aged 2 years and younger by birth year over time. The numbers of first-time surgeries for birth years 2010 to 2013 were 2978, 2924, 3077, and 2940, and no increasing trend was detected. Additionally, no increasing yearly trend was detected when the number of cases was divided by the total number of births in Japan in each birth month. The mortality of first-time surgeries performed for complex diseases, which often involves multiple subsequent surgeries, decreased from 4.7% in 2010 to 2.2% in 2013. Conclusions Our analyses showed no increase in the number of patients with congenital heart disease during 2010 to 2013. The yearly increase in the total number of surgeries following the Fukushima Daiichi nuclear disaster in a previous report can be explained by the decline in the mortality of first-time surgeries for complex cases. Such use of only the increase in the total yearly number of surgeries to claim the effects of a nuclear disaster on the incidence of congenital heart disease is a far too simplistic and dangerous proposition.

Objective: Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation., Methods: Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss., Results: The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room., Conclusions: Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)