Jun S. Kim

Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis

BACKGROUND We performed a meta-analysis of studies with at least Level IV evidence to compare outcomes between hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures. METHODS Three electronic databases (PubMed, Cochrane, and EMBASE) were searched. The quality of each study was investigated, and data on radiographic and functional outcomes were extracted and analyzed. RESULTS The analysis included 1 Level I study, 1 Level II study, 3 Level III studies, and 2 Level IV studies. Reverse shoulder arthroplasty was more favorable than hemiarthroplasty in forward elevation (P < .001), abduction (P < .001), tuberosity healing (P = .002), Constant score (P < .001), American Shoulder and Elbow Surgeons score (P < .001), and Disabilities of the Arm, Shoulder and Hand score (P = .001). Only external rotation (P = .85) was not in favor of reverse shoulder arthroplasty. CONCLUSIONS The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication.

A meta-analysis of cervical foraminotomy: open versus minimally-invasive techniques

BACKGROUND CONTEXT The posterior cervical foraminotomy (PCF) may be performed using an open or minimally-invasive (MIS) approach using a tubular retractor. Although there are theoretical advantages such as less blood loss and shorter hospitalizations, there is no consensus in the literature regarding the best approach for treatment. PURPOSE To assess clinical outcomes of PCF treated with either an open or an MIS approach using a tubular retractor. STUDY DESIGN Systematic literature review and meta-analysis of English language studies for the treatment of cervical radiculopathy treated with foraminotomy. PATIENT SAMPLE Pooled patient results from Level I studies and Level IV retrospective studies. OUTCOME MEASURES Meta-analysis for clinical success as determined by Odom and Prolo criteria, and visual analog scale scores for arm and neck pain. METHODS A literature search of three databases was performed to identify investigations performed in the treatment of PCF with an open or MIS approach. The pooled results were performed by calculating the effect size based on the logit event rate. Studies were weighted by the inverse of the variance, which included both within and between-study errors. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I-squared, where I-squared is the estimate of the percentage of error due to between-study variation. RESULTS The initial literature search resulted in 195 articles, of which, 20 were determined as relevant on abstract review. An open foraminotomy approach was performed in six; similarly, an MIS approach was performed in three studies. The pooled clinical success rate was 92.7% (CI: 88.9, 95.3) for open foraminotomy and 94.9% (CI: 90.5, 97.4) for MIS foraminotomy, which was not statistically significant (p=.418). The open group demonstrated relative homogeneity with Q value of 7.6 and I(2) value of 34.3%; similarly, the MIS group demonstrated moderate study heterogeneity with Q value of 4.44 and I(2) value of 54.94%. CONCLUSIONS Patients with symptomatic cervical radiculopathy from foraminal stenosis can be effectively managed with either a traditional open or an MIS foraminotomy. There is no significant difference in the pooled outcomes between the two groups.

Open Versus Minimally Invasive Fixation Techniques for Thoracolumbar Trauma: A Meta-Analysis

Study Design Systematic literature review and meta-analysis of studies published in English. Objective This study evaluated differences in outcome variables between percutaneous and open pedicle screws for traumatic thoracolumbar fractures. Methods A systematic review of PubMed, Cochrane, and Embase was performed. The variables of interest included postoperative visual analog scale (VAS) pain score, kyphosis angle, and vertebral body height, as well as intraoperative blood loss and operative time. The results were pooled by calculating the effect size based on the standardized difference in means. The studies were weighted by the inverse of the variance, which included both within- and between-study error. Confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I 2. Results After two-reviewer assessment, 38 studies were eliminated. Six studies were found to meet inclusion criteria and were included in the meta-analysis. The combined effect size was found to be in favor of percutaneous fixation for blood loss and operative time (p < 0.05); however, there were no differences in vertebral body height (VBH), kyphosis angle, or VAS scores between open and percutaneous fixation. All of the studies demonstrated relative homogeneity, with I 2 < 25. Conclusions Patients with thoracolumbar fractures can be effectively managed with percutaneous or open pedicle screw placement. There are no differences in VBH, kyphosis angle, or VAS between the two groups. Blood loss and operative time were decreased in the percutaneous group, which may represent a potential benefit, particularly in the polytraumatized patient. All variables in this study demonstrated near-perfect homogeneity, and the effect is likely close to the true effect.

Relationship Between ASA Scores and 30-Day Readmissions in Patients Undergoing Anterior Cervical Discectomy and Fusion.

Study Design. Retrospective study of prospectively collected data. Objective. To assess the American Society of Anesthesiologists (ASA)score as an independent predictor of 30-readmissions after anterior cervical discectomy and fusion (ACDF). Summary of Background Data. The ASA classification scheme was introduced in 1941 to establish a scoring system to evaluate the overall health status and comorbidities of patients before surgery10–12. Although the score was designed to predict postoperative complications, it may also be used as a predictor of perioperative risk. Methods. Data collected for the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database in the period 2005 to 2012 were used in the present analysis. Current Procedural Terminology codes were used to identify elective ACDF cases (CPT codes: 22551, 22554, and 63075). The primary study outcome was 30-day readmission rates after elective ACDF in adults. Univariate and multivariate analysis was used to determine whether any of age, sex, race, body mass index, comorbidities, operative variables, or ASA class were predictors of 30-day readmission rates after ACDF. Results. From the ACS-NSQIP database, 1701 elective ACDF cases were included for analysis, including 92 (5.5%) ASA class 1,955 (56.1%) ASA class 2,618 (36.3%) ASA class 3 and 34 (2.0%) ASA class 4 patients. Using ASA class 1 as a reference, significant independent predictors included being in ASA class 4 [odds ratio (OR) 5.7; 95% confidence interval (CI) 0.58–56.7; P = 0.039], having cardiac comorbidities (OR 2.2; 95% CI 1.2–4.2; P = 0.017), and prior strokes (OR 3.8; 95% CI 1.4–10.1; P = 0.0086). Conclusion. In conclusion, the unplanned readmission rate for patients undergoing ACDF was 3.2%. There was a significant and independent association between a high ASA class (class 4), cardiac comorbidities and prior strokes with 30-day unplanned readmissions after ACDF. The ASA score may be a valuable tool for the preoperative assessment of ACDF patients for risk of unplanned readmissions. Level of Evidence: 3

Frailty Index as a Predictor of Adverse Postoperative Outcomes in Patients Undergoing Cervical Spinal Fusion.

Study Design. Retrospective study of prospectively collected data. Objective. To investigate the applicability of the modified frailty index (mFI) as a predictor of adverse postoperative events in patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). Summary of Background Data. Prior studies have investigated the mFI and shown it as an independent predictor of adverse postoperative outcomes across multiple surgical specialties. However, this topic has not still been studied in patients undergoing cervical fusion or in spinal surgery. Methods. The National Surgical Quality Improvement Program is a multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent elective ACDF and PCF between 2005 and 2012. The mFI was calculated for each patient. Univariate analysis and multivariate logistic regression were used to analyze the mFI as a predictor for postoperative complications. Results. For ACDF group, Clavien-Dindo grade IV complications rate increased from 0.8% to 9.0% as mFI increased from 0 to ≥0.27, and mFI = 0.27 was found to be an independent predictor of Clavien-Dindo grade IV complications (odds ratio, OR, = 4.67, 95% confidence interval, CI, = 2.27–9.62, P < 0.001). For PCF groups, Clavien-Dindo grade IV complications rate increased from 0.7% to 20.0% as mFI increased from 0 to ≥0.36, and mFI ≥ 0.36 was identified as an independent predictor of Clavien-Dindo grade IV complications (OR = 41.26, 95% CI = 6.62–257.15, P < 0.001). Conclusion. The mFI was shown to be an independent predictor of Clavien-Dindo grade IV complications in patients undergoing ACDF or PCF. The mFI itself may be used to stratify risks in patients undergoing cervical fusion, or, the mFI scheme could be used as a platform upon which more efficient risk stratification could be done with addition of other variables. Level of Evidence: 4

Frailty is associated with morbidity in adults undergoing elective anterior lumbar interbody fusion (ALIF) surgery

BACKGROUND CONTEXT Prior studies have suggested no significant differences in functional status and postoperative complications of elderly versus nonelderly patients undergoing posterior lumbar interbody fusion; however, similar studies have not been comprehensively investigated in the setting of anterior lumbar interbody fusion (ALIF). PURPOSE The objective was to quantify the ability of the modified Frailty Index (mFI) to predict postoperative events in patients undergoing ALIF. STUDY DESIGN Secondary analysis of prospectively collected data. PATIENT SAMPLE Patients undergoing ALIF in the National Surgical Quality Improvement Program (NSQIP) participant files for the period 2010 through 2014. OUTCOMES MEASURES Outcome measures included any postoperative complication, return to operating room (OR), and length of stay >5 days. METHODS NSQIP participant files from 2010 to 2014 were used to identify patients undergoing ALIF. The mFI used in the present study is an 11-variable assessment that maps 16 NSQIP variables to 11 variables in the Canadian Study of Health and Ageing Frailty Index. Univariate analysis and multivariable logistic regression models were used to compare the relative strength of association between mFI with outcome variables of interest. RESULTS In total, 3,920 ALIF cases were identified and grouped according to their mFI score: 0 (n=2,025), 0.09 (n=1,382), 0.18 (n=464), or ≥0.27 (n=49). As the mFI increased from 0 (no frailty-associated variables) to 0.27 (4 of 11) or higher, there was a significant stepwise increase in any complication from 10.8% to 32.7%. After multivariable regression analysis, no significant association was found between higher mFI scores with urinary tract infections and venous thromboembolism. High frailty scores were significant predictors of any complication (mFI of ≥0.27 [reference: 0]; OR 2.4; p=.040) and pulmonary complications (mFI score ≥0.27; OR 7.5; p=.001). CONCLUSIONS In summary, high mFI scores were found to be independently associated with any complication and pulmonary complications in patients who underwent ALIF. The use of mFI together with traditional risk factors may help better identify high-surgical risk patients, which may be useful for preoperative and postoperative care optimization.

Impact of Obesity on Outcomes in Adults Undergoing Elective Posterior Cervical Fusion

Study Design. Retrospective study of prospectively collected data. Objective. To determine the effect of obesity (body mass Index > 30) on postoperative morbidity and mortality after elective posterior cervical fusion in adults. Summary of Background Data. In those with spine disease, obesity has been shown to portend poorer general and disease-specific functional health status. The effect of obesity on outcomes after spine surgery, especially posterior cervical fusion, however, remains unclear. Previous studies have been contradictory to one another and largely limited by small sample sizes. Methods. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent posterior cervical fusion between 2005 and 2012. Patients were separated into cohorts based on obesity status. Univariate analysis and multivariate logistic regression were used to analyze the effect of obesity on postoperative morbidity and mortality. Results. There was a significantly higher rate of only venous thromboembolism (VTE) in the obese group compared with nonobese cohort (3.5% vs. 0.6%, P = 0.015). On multivariate analysis, obesity was found to be an independent predictor (odds ratio 6.15; 95% confidence interval [CI], 1.26–30.20; P = 0.02) for VTE. Conclusion. The present study demonstrated that patients with obesity can safely undergo posterior cervical fusion surgery. Although obesity predisposed to an elevated risk of VTE, postoperative mortality and morbidity were otherwise not significantly increased in this population. Level of Evidence: 3

Impact of Age on 30-day Complications after Adult Deformity Surgery.

Study Design. A retrospective analysis. Objective. The aim of this study was to identify whether age is a risk factor for postoperative complications after adult deformity surgery (ADS). Summary of Background Data. Spinal deformity is a prevalent cause of morbidity in the elderly population, occurring in as many as 68% of patients older than 60 years. Given the increasing prevalence of adult spinal deformities and an aging population, understanding the safety of ADS in elderly patients is becoming increasingly important. Methods. A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing ADS were separated into age-based cohorts (⩽52, 53–61, 62–69, and ≥70 years of age). Age groups were determined by interquartile analysis. Chi-squared, t tests, and multivariate logistic regression models were used to identify independent risk factors. Results. A total of 5805 patients met the inclusion criteria. Age groups 1, 2, 3, and 4 contained 1518 (26.1%), 1478 (25.4%), 1451 (25.0%), and 1358 (23.4%) patients, respectively. Multivariate logistic regression analysis revealed increasing age (relative to age group 1) to be an independent risk factor for prolonged length of stay [odds ratio (OR) 1.39, confidence interval (CI) 1.12–1.69], all complications (OR 1.64, CI 1.35–2.00), renal complications (OR 3.45, CI 1.43–8.33), urinary tract infection (OR 2.70, CI 1.49–4.76), postoperative transfusion (OR 1.47, CI 1.20–1.82), and unplanned readmission (OR 1.64, CI 1.18–2.23). Gradations in ORs existed between the different cohorts, such that the deleterious effect of age was less pronounced in cohort 3 compared with cohort 4, and even more less so between cohort 2 and cohort 4. Conclusion. Age has been shown to be an independent risk factor for increased length of stay, all complications, renal complications, urinary tract infection, transfusion, and unplanned readmission. Level of Evidence: 3

Analysis of Risk Factors for Major Complications Following Elective Posterior Lumbar Fusion

Study Design. Retrospective study of prospectively collected data. Objective. To identify risk factors for the development of any major complication after elective posterior lumbar fusion (PLF). Summary of Background Data. PLF is one of the most performed fusion techniques with utilization rates increasing by 356% between 1993 and 2001. Surgical and anesthetic advances have made the option of surgery more accessible for elderly patients with a larger comorbidity burden. Identifying risk factors for the development of major complications after elective PLF is important for patient risk stratification and patient safety efforts. Methods. The 2011 to 2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology codes 22612, 22630, and 22633. Patients were divided into two cohorts based on the development of any major complication. Bivariate and multivariate logistic regression analyses were employed to identify predictors for the development of ≥ 1, ≥ 2, and ≥ 3 major complications. Results. A total of 7761 patients met the inclusion criteria for the study of which, 2055 (26.5%) patients developed one major complication, 249 (3.2%) patients developed two major complications, and 151 (1.9%) patients developed three major complications. The most common complication was intra/postoperative red blood cell transfusion (23.2%). Three multivariate logistic regression models were employed to identify factors associated with ≥ 1, ≥ 2, and ≥ 3 major complications. Patient variables present across all three models were osteotomy, pelvic fixation, operation time ≥4 hours, bleeding disorder, and American Society of Anesthesiology Class ≥ 3. Conclusion. Several risk factors were identified for the development of major complications after elective PLF. Identification of these factors can improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety. Level of Evidence: 3

Impact of Insulin Dependence on Perioperative Outcomes Following Anterior Cervical Discectomy and Fusion.

Study Design. A retrospective analysis of prospectively collected data. Objective. Our objective was to analyze insulin-dependent and noninsulin-dependent diabetes mellitus (IDDM and NIDDM) as potential risk factors for complications, reoperations, and readmissions within 30 days following anterior cervical discectomy and fusion (ACDF). Summary of Background Data. ACDF is a common surgical procedure with growing utilization and good long-term outcomes. Readmissions and reoperations are associated with increased morbidity and inferior long-term outcomes. IDDM and NIDDM are often associated with increased complication rates. Methods. This was a retrospective analysis of prospectively collected data from the ACS NSQIP database. Patients ≥18 years old undergoing ACDF from 2005 to 2012 were included. Readmission, perioperative events, and reoperation within 30 days following ACDF were measured. Patient demographics, perioperative data, preoperative labs, and postoperative events were assessed. Patients with NIDDM or IDDM were compared with nondiabetic patients using multivariate logistic regression analysis with significance defined as P < 0.05. Odds ratio (OR) was calculated with a 95% confidence interval (CI). Results. Three thousand seven hundred twenty-six patients were included of whom 270 were NIDDM and 171 IDDM. Readmissions and reoperation data were available only from 2011 to 2012, including 1423 nondiabetes mellitus (non-DM), 193 NIDDM, and 87 IDDM cases. NIDDM was associated with higher rates of urinary tract infection (UTI) (P < 0.007), and return to operating room (P = 0.012) than nondiabetic patients. IDDM was associated with higher rates of reoperations (P = 0.04), readmissions (P < 0.0001), and total length of stay (LOS) >5 days (P < 0.0001). Following adjusted multivariate analysis, only IDDM status remained an independent predictor for 30-day readmission (OR 4.8, 95% CI 2.3–10.1). Conclusion. Patients with NIDDM and IDDM were at an increased risk for several postoperative complications following ACDF. IDDM was independently associated with increased 30-day readmission rates. Diabetic patients should be counseled appropriately, and the importance of close perioperative care is highlighted in this study. Level of Evidence: 3