Andrew S. Chung

Comparison of Postoperative Complications Associated With Anesthetic Choice for Surgery of the Hand

PURPOSE There is a recent trend toward performing most hand surgery procedures under local and/or regional anesthesia without sedation. However, little evidence exists regarding the postoperative complications associated with local/regional anesthesia without sedation, especially compared with local/regional anesthesia with sedation or general anesthesia. METHODS Patients who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program were identified. Thirty-day postoperative complications were compared among patients who received local/regional anesthesia without sedation, local/regional anesthesia with sedation, and general anesthesia with adjustment for patient and procedural factors. RESULTS We identified 27,041 patients as having undergone hand surgery from 2005 to 2013. A total of 4,614 underwent local/regional anesthesia without sedation (17.1%), 3,527 underwent local/regional anesthesia with sedation (13.0%), and 18,900 underwent general anesthesia (69.9%). Overall, both local/regional anesthesia with and without sedation were associated with fewer postoperative complications compared with general anesthesia. In patients aged over 65 years, there was an additional benefit of avoiding all forms of sedation; these data showed that treatment with local/regional anesthesia without sedation decreased the odds of sustaining a postoperative complication compared with sedation and general anesthesia. CONCLUSIONS Although the overall risk of postoperative complications remains small in hand surgery, these data suggest that avoiding general anesthesia may decrease the overall risk of sustaining postoperative complications. In addition, for patients aged over 65 years, avoiding any form of sedation may decrease the risk of postoperative complications. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Minimum Clinically Important Difference: Current Trends in the Spine Literature

Study Design. Review of the 2011 to 2015 minimum clinically important difference (MCID)-related publications in Spine, Spine Journal, Journal of Neurosurgery-Spine, and European Spine Journal. Objective. To summarize the various determinations of MCID and to analyze its usage in the spine literature of the past 5 years in order to develop a basic reference to help practitioners interpret or utilize MCID. Summary of Background Data. MCID represents the smallest change in a domain of interest that is considered beneficial to a patient or clinician. The many sources of variation in calculated MCID values and inconsistency in its utilization have resulted in confusion in the interpretation and use of MCID. Methods. All articles from 2011 to 2015 were reviewed. Only clinical science articles utilizing patient reported outcome scores (PROs) were included in the analysis. A keyword search was then performed to identify articles that used MCID. MCID utilization in the selected papers was characterized and recorded. Results. MCID was referenced in 264/1591 (16.6%) clinical science articles that utilized PROs: 22/264 (8.3%) independently calculated MCID values and 156/264 (59.1%) used previously published MCID values as a gauge of their own results. Despite similar calculation methods, there was a two- or three-fold range in the recommended MCID values for the same instrument. Half the studies recommended MCID values within the measurement error. Most studies (97.2%) using MCID to evaluate their own results relied on generic MCID. The few studies using specific MCID (MCID calculated for narrowly defined indications or treatments) did not consistently match the characteristics of their sample to the specificity of the MCID. About 48% of the studies compared group averages instead of individual scores to the MCID threshold. Conclusion. Despite a clear interest in MCID as a measure of patient improvement, its current developments and uses have been inconsistent. Level of Evidence: N/A

Evaluating the Effect of Comorbidities on the Success, Risk, and Cost of Digital Replantation

PURPOSE The clinical decision to replant an amputated digit is driven primarily by surgical indication. However, the extent to which patient comorbidity should play into this decision is less well defined. This study was designed to determine the effect of patient comorbidities on the success, risk, and cost of digital replantation. METHODS All amputation injuries and digital replantation procedures captured by the National Inpatient Sample during 2001 to 2012 were identified. A successful replantation procedure was defined as one in which a replantation occurred without a subsequent revision amputation. Patient comorbidities were tested for association with failure of replantation, risk of postoperative complications, and overall hospital costs. RESULTS We identified 11,788 digital replantation procedures. A total of 3,604 patients (30.6%) experienced revascularization failure associated with replantation. The risk for replant failure was highest among patients with psychotic disorders, peripheral vascular disease, and electrolyte imbalances. The risk for postoperative complications was highest among patients with electrolyte imbalances, drug abuse, or chronic obstructive pulmonary disease. Hospital costs were greatest among patients with deficiency anemias, electrolyte imbalances, or psychotic disorders. Patients with more than 3 comorbidities experienced significantly higher failure, risk of postoperative complications, and cost of digital replantation. CONCLUSIONS These data suggest that even when surgical indications are met, patients with more than 3 comorbidities and those who have a history of alcohol abuse, deficiency anemias, electrolyte imbalances, obesity, peripheral vascular disease, or psychotic disorders are at increased risk of replantation failure and associated postoperative complications. Assessment of this risk should have a role in decision making regarding whether a digit should be replanted. Patients at high risk should be carefully counseled regarding the difficult perioperative course before undergoing digital replantation. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.

Inpatient Outcomes in Dialysis-dependent Patients Undergoing Elective Lumbar Surgery for Degenerative Lumbar Disease

Study Design. Retrospective cohort study. Objective. To evaluate hospital outcomes in dialysis-dependent patients undergoing elective lumbar surgeries. Summary of Background Data. Because of their overall poor health status and concomitant comorbidity burden, spinal surgery in dialysis-dependent patients represents a significant challenge to spine surgeons. Large studies evaluating their immediate postoperative outcomes in elective lumbar surgery are lacking. Methods. Utilizing the National Inpatient Sample, an estimated 1834 dialysis-dependent patients undergoing elective lumbar spine surgery for degenerative lumbar conditions were compared to an estimated 2,522,594 non–dialysis-dependent patients undergoing the same procedures between 2002 and 2012. Our primary outcomes measures included postoperative complication rates, hospital length of stay, and total hospital costs. Results. Mean age of dialysis-dependent patients was 64.2 years compared to 59.9 in the non–dialysis-dependent cohort (P < 0.001). Dialysis-dependent patients had substantially higher inpatient mortality rates (1.8% vs 0.1%; P < 0.001), major complication rates (8.1% vs 1.1%; P < 0.001), and an increased need for blood transfusion (18.3% vs 12.5%; P < 0.001). Multivariate analysis revealed that dialysis dependence independently increased odds of in-hospital mortality (odds ratio = 8.30; 95% confidence interval 5.78–11.93; P < 0.001) and odds of a major postoperative complication (odds ratio = 3.63; 95% confidence interval 3.49–3.89; P < 0.001). Dialysis dependence was associated with an increased mean length of stay of 3.3 days (P < 0.001) and a significant increase in hospital costs when stratified by procedure type. Conclusion. Dialysis dependence is associated with poorer immediate postoperative outcomes and increased hospital costs when compared to non–dialysis-dependent patients. In addition, an increased need for postoperative transfusion should be anticipated in this patient population. Further studies are warranted to confirm these findings. Level of Evidence: 3

Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty

In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.