Arya G. Varthi

Patient characteristics associated with increased postoperative length of stay and readmission after elective laminectomy for lumbar spinal stenosis.

Study Design. Retrospective cohort. Objective. To identify factors that were independently associated with increased postoperative length of stay (LOS) and readmission in patients who underwent elective laminectomy for lumbar spinal stenosis. Summary of Background Data. Lumbar spinal stenosis is a common pathology that is traditionally treated with decompressive laminectomy. Risk factors associated with increased LOS and readmission have not been fully characterized for laminectomy. Methods. Patients who underwent laminectomy for lumbar spinal stenosis during 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patient characteristics were tested for association with LOS and readmission using bivariate and multivariate analyses. Patients with LOS more than 10 days were excluded from the readmission analysis as the American College of Surgeons National Surgical Quality Improvement Program only captures readmissions within 30 postoperative days, and the window for potential readmission was deemed too short for patients staying longer than 10 days. Results. A total of 2358 patients who underwent laminectomy met inclusion criteria. The average age was 66.4 ± 11.7 years (mean ± standard deviation). Average postoperative LOS was 2.1 ± 2.6 days. Of those meeting criteria for readmission analysis, 3.7% of patients (86 of 2339) were readmitted within 30 days postoperatively. Independent risk factors for prolonged LOS were increased age (P < 0.001), increased body mass index (P = 0.004), American Society of Anesthesiologists class 3–4 (P = 0.005), and preoperative hematocrit less than 36.0 (P = 0.001). Independent risk factors for readmission were increased age (P = 0.013), increased body mass index (P = 0.040), American Society of Anesthesiologists class 3–4 (P < 0.001), and steroid use (P = 0.001). The most common reason for readmission was surgical site-related infections (25.0% of patients readmitted in 2012). Conclusion. The identified factors associated with LOS and readmission after lumbar laminectomy may be useful for optimizing patient care. Level of Evidence: 3

Complication rates following elective lumbar fusion in patients with diabetes: insulin dependence makes the difference.

Study Design. Retrospective cohort. Objective. To determine the effect of non–insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) on postoperative complications after elective lumbar fusion surgery. Summary of Background Data. Diabetes mellitus (DM) is a common chronic disease. The effects of NIDDM and IDDM on rates of postoperative complications, extended length of stay, and readmission after lumbar fusion surgery are not well established. Methods. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing lumbar fusion between 2005 and 2012 were identified and characterized as having NIDDM, IDDM, or neither. Bivariate and multivariate analyses were used to test patients with NIDDM and IDDM for increased risk of adverse postoperative outcomes over the initial 30 postoperative days. Results. A total of 15,480 patients who underwent lumbar fusion were identified (13,043 were patients without DM, 1,650 patients had NIDDM, and 787 patients had IDDM). NIDDM was independently associated with an increased risk of wound dehiscence (relative risk = 2.3; P = 0.033) and extended length of stay (1.2; P < 0.003). IDDM was independently associated with an increased risk of death (2.7; P = 0.020), sepsis (2.2; P = 0.002), septic shock (3.3; P = 0.032), unplanned intubation (2.8; P = 0.003), ventilator-assisted respiration for more than 48 hours postoperatively (2.8; P = 0.005), wound-related infection (1.9; P = 0.001), urinary tract infection (1.6; P = 0.011), pneumonia (3.1; P < 0.001), extended length of stay (1.5; P < 0.001), and readmission within 30 days (1.5; P = 0.036). Conclusion. Compared with patients without DM, IDDM was associated with an increased risk of a considerably higher number of postoperative complications than NIDDM. These complications were also of greater severity. This important designation may improve preoperative risk stratification and counseling of patients with diabetes prior to lumbar fusion surgery. Level of Evidence: 3

Spinal Fracture in Patients With Ankylosing Spondylitis: Cohort Definition, Distribution of Injuries, and Hospital Outcomes.

Study Design. A retrospective cohort. Objective. The aim of this study was to characterize spinal fractures in patients with ankylosing spondylitis. Summary of Background Data. Patients with ankylosing spondylitis are susceptible to fractures of the spinal column, even from minor trauma. However, the literature describing patients with ankylosing spondylitis and spinal fractures consists largely of case reports and small case series. The purpose of this study is to better characterize fractures of the ankylosed spine, including the patient population, locations of fracture, and outcomes in a large, nationally representative sample. Methods. All patients with diagnoses of both fracture of the spinal column and ankylosing spondylitis admitted between 2005 and 2011 were identified in the National Inpatient Sample (NIS). Patient demographics, fracture regions, and complications were characterized with descriptive statistics. The associations between injury characteristics and outcomes were assessed using Poisson regression. Results. A total of 939 patients with ankylosing spondylitis admitted with a spinal fracture were identified in NIS. The average age was 68.4 ± 14.7 years, and 85% of patients were male. Cervical fractures were the most common (53.0%), followed by thoracic (41.9%), lumbar (18.2%), and sacral (1.5%). Spinal cord injury was present in 27.5% of cervical fractures, 16.0% of thoracic fractures, and 21.1% of cases overall. Fractures involving more than 1 region of the spine occurred in 13.1% of patients. Patients were treated with fusion in 49.9% of cases. In-hospital adverse events occurred in 29.4% of patients, and 6.6% of patients died during their admission. Conclusion. More than 10% of patients had fractures in more than 1 region of the spine. There is a high risk of adverse events in this population, and 6.6% of patients died during their inpatient stay. These results provide clinicians with a better understanding of the distribution and the high morbidity and mortality of fractures in the ankylosed spine. Level of Evidence: 3

Risk Factors for Short-term Adverse Events and Readmission After Arthroscopic Meniscectomy Does Age Matter?

Background: Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery. Purpose: To investigate if age and medical comorbidities were risk factors for postoperative adverse events and readmission after meniscectomy. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent arthroscopic meniscectomy between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Age ≥65 years and medical comorbidities were evaluated as risk factors for any adverse event (AAE), severe adverse events (SAEs), and readmission after meniscectomy using univariate and multivariate analyses. Results: A total of 17,774 patients who underwent meniscectomy were identified. The mean age was 53.0 ± 13.6 years. A total of 3420 patients (19.2%) were ≥65 years. Overall, 208 patients (1.17%) had AAE, 203 patients (1.14%) had an SAE, and 102 patients were readmitted (0.97%). Multivariate logistic regression analyses demonstrated no significant differences between age groups for the occurrence of AAE, SAEs, and readmission. Patients with American Society of Anesthesiologists classification ≥3 had increased odds of AAE (odds ratio [OR], 1.58), SAEs (OR, 1.59), and readmission (OR, 1.99). Patients with diabetes had increased odds of AAE (OR, 1.57) and SAEs (OR, 1.51). Smokers had increased odds of readmission (OR, 1.67). Patients with pulmonary disease had increased odds of AAE (OR, 1.76) and SAEs (OR, 1.70). Conclusion: Meniscectomy is a safe procedure in older patients, as age over 65 years did not increase the odds of any of the adverse events studied. However, regardless of age, patients with an increased comorbidity burden and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure. Clinical Relevance: Knowledge of these risk factors for adverse events and readmission provides essential information for patient selection and preoperative counseling.

Overall Similar Infection Rates Reported in the Physician-reported Scoliosis Research Society Database and the Chart-abstracted American College of Surgeons National Surgical Quality Improvement Program Database.

Study Design. This is a retrospective cohort study. Objective. To compare the infection rates in the Scoliosis Research Society (SRS) morbidity and mortality database to those in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Summary of Background Data. Surgical databases have demonstrated value in orthopaedic surgery. However, few studies in the literature have used the SRS database relative to other available databases. To validate the surgeon-reported data of the SRS database, we compared the rate of postoperative infection in this database to that in the chart-abstracted ACS-NSQIP database. Methods. International Classification of Disease, ninth revision (ICD-9) codes were used to group patients from the 2012 and 2013 ACS-NSQIP database into groups corresponding to spinal deformity diagnoses delineated by SRS. Postoperative infection rates after surgical correction of these deformities compared with those reported in the 2012 and 2013 SRS database using &khgr;2 tests. Results. The overall rate of acute postoperative infection was slightly lower in the SRS database than in the ACS-NSQIP database (1.21% compared to 2.05% in ACS-NSQIP, a difference of only 0.84%, statistically significant, P < 0.001). The infection rates of most diagnoses did not differ; these included scoliosis (idiopathic <10 yr of age/congenital/neuromuscular/other scoliosis), spondylolisthesis (isthmic/dysplastic), and kyphosis (congenital and other). The only differences noted were in Scheuermann kyphosis (difference of 5.49%, P = 0.003), degenerative spondylolithesis (difference of 0.69%, P = 0.003), and idiopathic scoliosis in the age 10 to18 yr and adult age ranges (differences of 1.10% and 1.28%, P < 0.001 for both). Conclusion. Although some statistical differences were found in infection rates between the surgeon-reported SRS database and the chart-abstracted ACS-NSQIP database, these small differences likely reflect differences in surgical cases and data collection methods. This finding supports the validity of the surgeon-reported SRS morbidity and morality database. Level of Evidence: 3

Osteonecrosis of the knee - which joint preservation procedures work?

There is no consensus with respect to the best procedures to preserve the knee joint in patients with osteonecrosis of the knee. We performed a systematic review of the literature between 1999 and 2012. Only 10 of 1057 studies met our inclusion criteria. Core decompression prevented additional surgical treatment in pre-collapse knees with a failure rate of 10.4% (7 of 67 knees). Autogenous and osteochondral grafts decreased the need for additional surgery in both pre-collapse (0%, 20 of 20) and post-collapse knees (10.5%, 8 of 76 knees). Although these results are quite promising multi-center randomized trials are needed to identify the optimal procedures to treat this disease.

Is Outpatient Total Hip Arthroplasty Safe

BACKGROUND Safety data for outpatient total hip arthroplasty (THA) remains scarce. METHODS The present study retrospectively reviews prospectively collected data from the 2005-2014 American College of Surgeons National Surgical Quality Improvement Program Database. Patients who underwent THA were categorized by day of hospital discharge to be outpatient (length of stay [LOS] 0 days) or inpatient (LOS 1-5 days). Those with extended LOS beyond 5 days were excluded. To account for baseline nonrandom assignment between the study groups, propensity score matching was used. The propensity matched populations were then compared with multivariate Poisson regression to compare the relative risks of adverse events during the initial 30 postoperative days including readmission. RESULTS A total of 63,844 THA patients were identified. Of these, 420 (0.66%) were performed as outpatients and 63,424 (99.34%) had LOS 1-5 days. Outpatients tended to be younger, male, and to have fewer comorbidities. After propensity score matching, outpatients had no difference in any of 18 adverse events evaluated other than blood transfusion, which was less for outpatients than those with a LOS of 1-5 days (3.69% vs 9.06%, P < .001). CONCLUSION After adjusting for potential confounders using propensity score matching and multivariate logistic regression, patients undergoing outpatient THA were not at greater risk of 30 days adverse events or readmission than those that were performed as inpatient procedures. Based on the general health outcome measures assessed, this data supports the notion that outpatient THA can appropriately be considered in appropriately selected patients.

Factors predictive of increased surgical drain output after anterior cervical discectomy and fusion.

Study Design. Retrospective cohort study. Objective. To identify factors that are independently associated with increased surgical drain output in patients who have undergone ACDF. Summary of Background Data. Surgical drains are typically placed after ACDF to reduce the risk of complications associated with neck hematoma. The orthopedic literature has repeatedly challenged the use of surgical drains after many procedures, and there are currently no guidelines for determining which patients are most likely to benefit from drain placement after ACDF. Methods. Consecutive patients who underwent elective ACDF with surgical drain placement at a single academic institution between January 2011 and February 2013 were identified using billing records. Patient information was abstracted from the medical record. Patients were categorized on the basis of normal or increased total drain output, with increased drain output defined as total drain output 50th percentile (30 mL) or more. A multivariate logistic regression was used to determine which factors were independently associated with increased drain output. Results. A total of 151 patients with ACDF met inclusion criteria. Total drain output was in the range from 0 mL to 265 mL. The average drain output for this cohort was 42.3 ± 45.5 mL (mean ± standard deviation). Among all patients in the study, 80 patients had increased drain output (drain output ≥50th percentile or 30 mL). Multivariate analysis identified 3 independent predictors of increased drain output: age 50 years or more (odds ratio [OR] = 3.9), number of levels (2 levels, OR = 2.7; 3–4 levels, OR = 17.0), and history of smoking (OR = 2.8). One patient developed a postoperative neck hematoma while a drain was in place. Conclusion. Patients with the factors associated with increased drain output identified in the earlier text may benefit most from surgical drain placement after ACDF. Nonetheless, neck hematoma is still possible even with drain use. Level of Evidence: 3

Do we really know our patient population in database research?: A comparison of the femoral shaft fracture patient populations in three commonly used national databases

AIMS While use of large national clinical databases for orthopaedic trauma research has increased dramatically, there has been little study of the differences in populations contained therein. In this study we aimed to compare populations of patients with femoral shaft fractures across three commonly used national databases, specifically with regard to age and comorbidities. PATIENTS AND METHODS Patients were identified in the Nationwide Inpatient Sample (NIS), National Surgical Quality Improvement Program (NSQIP) and National Trauma Data Bank (NTDB). RESULTS The distributions of age and Charleston comorbidity index (CCI) reflected a predominantly older population with more comorbidities in NSQIP (mean age 71.5; sd 15.6), mean CCI 4.9; sd 1.9) than in the NTDB (mean age 45.2; sd 21.4), mean CCI = 2.1; sd 2.0). Bimodal distributions in the NIS population showed a more mixed population (mean age 56.9; sd 24.9), mean CCI 3.2; sd 2.3). Differences in age and CCI were all statistically significant (p < 0.001). CONCLUSION While these databases have been commonly used for orthopaedic trauma research, differences in the populations they represent are not always readily apparent. Care must be taken to understand fully these differences before performing or evaluating database research, as the outcomes they detail can only be analysed in context. TAKE HOME MESSAGE Researchers and those evaluating research should be aware that orthopaedic trauma populations contained in commonly studied national databases may differ substantially based on sampling methods and inclusion criteria.

Different Fusion Approaches for Single-level Lumbar Spondylolysis Have Similar Perioperative Outcomes

Study Design. Retrospective cohort study Objective. The aim of this study was to compare perioperative adverse events for patients with lumbar spondylolysis treated with transforaminal lumbar interbody fusion (TLIF), posterior spinal fusion (PSF), combined anterior and posterior fusion (AP fusion), or anterior lumbar interbody fusion (ALIF). Summary of Background Data. Previous cohort studies have shown similar long-term outcomes for different surgical approaches for this indication, but potential differences in 30-day perioperative adverse events have not been well characterized. Methods. The present study uses data extracted from the American College of Surgeons National Surgical Quality Improvement Database. Patients undergoing fusion with different approaches for lumbar spondylolysis were identified. Propensity score matching was utilized to account for potential differences in demographic and comorbidity factors. Comparisons among perioperative outcomes were then made among the propensity score-matched study groups. Results. Of 1077 cases of spondylolysis identified, 556 underwent TLIF, 327 underwent PSF, 108 underwent AP fusion, and 86 underwent ALIF. After propensity score matching, there were no differences in the rates of any of the 30-day individual adverse events studied and no differences in the aggregated groupings of any adverse event, serious adverse event, or minor adverse event. There was a significantly increased operative time in the AP fusion group, but there were no differences in hospital length of stay or readmission rates. Conclusion. Because perioperative adverse event rates were similar, even with a slightly longer operative time in the AP fusion group, these findings suggest that surgeon preference and long-term outcomes are better used to determine the recommendation of one surgical approach over another for single level fusions for lumbar spondylolysis. Level of Evidence. 3