Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment.

Background: Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods: Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results: A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion: Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence: Level III, therapeutic.

Patient-Reported Outcomes Are Similar in the First 2 Years After Staged Versus Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia.

PURPOSE: To compare early patient-reported outcomes after staged versus combined hip arthroscopy and periacetabular osteotomy for hip dysplasia. METHODS: A prospective database was retrospectively reviewed to identify patients that underwent combined or staged hip arthroscopy and periacetabular osteotomy (PAO) from 2012 to 2020. Patients were excluded if they were >40 years of age, had prior ipsilateral hip surgery, or did not have at least 12-24 months of postoperative patient-reported outcome (PRO) data. PROs included the Hip Outcomes Score (HOS) Activities of Daily Living (ADL) and Sports Subscale (SS), Non-Arthritic Hip Score (NAHS), and the Modified Harris Hip Score (mHHS). Paired t-tests were used to compare preoperative to postoperative scores for both groups. Outcomes were compared using linear regression adjusted for baseline characteristics, including age, obesity, cartilage damage, acetabular index, and procedure timing (early vs late practice). RESULTS: Sixty-two hips were included in this analysis (39 combined, 23 staged). The average length of follow-up was similar between the combined and staged groups (20.8 vs 19.6 months; P = .192). Both groups reported significant improvements in PROs at final follow up compared to preoperative scores (P < .05 for all). There were no significant differences in HOS-ADL, HOS-SS, NAHS, or mHHS scores between groups preoperatively or at 3, 6, or 12 months postoperatively (P > .05 for all). There was no significant difference in PROs between the combined and staged groups at the final postoperative time point: HOS-ADL (84.5 vs 84.3; P = .77), HOS-SS (76.0 vs 79.2; P = .68), NAHS (82.2 vs 84.5; P = .79), and mHHS (71.0 vs 71.0, P = .75), respectively. CONCLUSIONS: Staged hip arthroscopy and PAO for hip dysplasia leads to similar PROs at 12-24 months compared to combined procedures. This suggests that with careful and informed patient selection, staging these procedures is an acceptable option for these patients and does not change early outcomes. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Early Outcomes of Proximal Humerus Fractures in Adults Treated With Locked Plate Fixation Compared with Nonoperative Treatment: An Age-, Comorbidity-, and Fracture Morphology-Matched Analysis.

OBJECTIVES: To compare patient-reported outcomes (PROs), range of motion (ROM), and complication rates for proximal humerus fractures managed nonoperatively or with open reduction internal fixation (ORIF). DESIGN: Retrospective cohort. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: Four hundred thirty-one patients older than 55 years were identified retrospectively. 122 patients were excluded. 309 patients with proximal humerus fractures met inclusion criteria (234 nonoperative and 75 ORIF). After matching, 192 patients (121 nonoperative and 71 ORIF) were included in the analysis. INTERVENTION: Nonoperative versus ORIF (locked plate) treatment of proximal humerus fracture. MAIN OUTCOME MEASUREMENTS: Early Visual Analog Score (VAS), ROM, PROs, complications, and reoperation rates between groups. RESULTS: At 2 weeks, ORIF showed lower VAS scores, better passive ROM, and patient-reported outcomes measurement information system (PROMIS) scores ( P < 0.05) compared with nonoperative treatment. At 6 weeks, open reduction internal fixation (ORIF) had lower VAS scores, better passive ROM, and PROMIS scores ( P < 0.05) compared with nonoperative treatment. At 3 months, ORIF showed similar PROMIS scores ( P > 0.05) but lower VAS scores and better passive ROM ( P < 0.05) compared with nonoperative treatment. At 6 months, ORIF showed similar VAS scores, ROM, and PROMIS scores ( P > 0.05) compared with nonoperative treatment. There was no difference in secondary operation rates between groups ( P > 0.05). ORIF patients trended toward a higher secondary reoperation rate (15.5% vs. 5.0%) than nonoperative patients ( P = 0.053). CONCLUSIONS: In an age-, comorbidity-, and fracture morphology-matched analysis of proximal humerus fractures, ORIF led to decreased pain and improved passive ROM early in recovery curve compared with nonoperative treatment that normalized after 6 months between groups. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Superior Outcomes With Reverse Shoulder Arthroplasty versus Nonoperative Management for Proximal Humerus Fractures: A Matched Cohort Analysis.

OBJECTIVE: To evaluate early outcomes (within 1 year) for geriatric proximal humerus fractures managed nonoperatively or with reverse shoulder arthroplasty (RSA). DESIGN: Retrospective cohort. SETTING: Academic level 1 trauma center, level 2 trauma/geriatric fracture center. PATIENTS/INTERVENTION: Seventy-one patients with proximal humerus fractures that underwent nonoperative management or RSA, matched by age, comorbidity burden, and fracture morphology. MAIN OUTCOME MEASUREMENTS: Patient-reported outcomes, range of motion, and complications rates within 1 year of treatment. RESULTS: RSA patients demonstrated greater active forward flexion (aFF) and external rotation compared with nonoperative patients throughout the first 6 months after treatment ( P < 0.05 for all). RSA patients achieved satisfactory ROM (>90 degrees aFF) at higher rates than nonoperative patients (96.2% vs. 62.2%, P < 0.01). RSA led to significantly lower shoulder pain and PROMIS pain interference scores throughout the first year post-treatment ( P < 0.05). PROMIS physical function scores were also higher in the RSA group at 3 months, 6 months, and 1 year compared with the nonoperative group ( P < 0.05 for all). Similar complication rates were experienced in both groups (nonoperative = 8.9%, RSA = 7.7%; P = 0.36). CONCLUSIONS: In an age, comorbidity and fracture morphology matched analysis, treatment of proximal humerus fractures with RSA is associated with greater shoulder ROM throughout the first 6 months of treatment, decreased pain, and improved physical function compared with nonoperative management, without significant differences in short-term complications. These results suggest that RSA may be superior to nonoperative management during the early recovery period for proximal humerus fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults.

PURPOSE: To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year. METHODS: Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction. RESULTS: A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3-5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0-3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1-4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2-4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs. CONCLUSIONS: Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty.

Background: This study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA). Methods: This is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables. Results: A total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05). Conclusion: The management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group.

Diagnostic intra-articular injection with provocative functional testing predicts patient-reported outcomes following hip arthroscopy: a prospective investigation.

The purpose of this study is to evaluate the predictive value of preoperative diagnostic intra-articular injections with formal provocative post-injection functional testing on patient-reported outcomes (PROs) following hip arthroscopy. Patients aged 14-40 with suspected labral pathology and/or femoroacetabular impingement were prospectively enrolled. Patients received a diagnostic intra-articular anesthetic injection then completed a battery of provocative physical function (PF) tests and were asked to rate the percentage of pain improvement. Patients completed PRO surveys preoperatively and up to 2 years postoperatively. PROs were compared between positive and negative injection response groups. Ninety-six patients received a diagnostic injection with provocative functional testing and subsequently underwent hip arthroscopy, 74 reported a positive injection response (≥75% improvement) and 22 reported a negative injection response (<75% improvement). The average postoperative follow-up was 12 months. Both groups experienced significant improvement in PROs postoperatively. A positive injection response was associated with greater improvements in hip outcome score, Non-Arthritic Hip Score, Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference and PROMIS PF at final follow-up compared to a negative injection response. Similar improvements in modified Harris Hip Score, Visual Analog Scale hip pain and PROMIS depression were experienced between groups. These results indicate that diagnostic intra-articular hip anesthetic injection with provocative functional testing may be a valuable predictor of pain and PF following hip arthroscopy. However, patients with negative injection responses still experienced significant clinical improvement in their postoperative outcomes. As such, a negative injection response should not preclude patients from being surgical candidates, but their outcomes may be less predictable.

Academic Orthopaedics As a Driver of Gender Diversity in the Orthopaedic Workforce: A Review of 4,519 Orthopaedic Faculty Members.

BACKGROUND: The purpose of this study was to perform a cross-sectional analysis on the gender composition of practicing academic orthopaedic surgeons using three databases composed of clinical orthopaedic surgeons. METHODS: A comprehensive database of 4,519 clinically active academic orthopaedic surgeons was compiled for this study after the review of publicly available data. The complied data set was evaluated alongside orthopaedic databases obtained from the 2017 Association of American Medical Colleges (AAMC) Faculty Administrative Management Online User System and the 2016 American Academy of Orthopaedic Surgery (AAOS) Orthopaedic Practice in the US census representing the entire academy membership orthopaedic workforce. Gender status was obtained and compared between the three databases. RESULTS: Of the 4,519 clinically active academic orthopaedic surgeons analyzed, 435 (10%) were female compared with 19% for the AAMC faculty database and 7% for the AAOS members. Fourteen percent of women had achieved the rank of professor compared with 25% of the men (P < 0.001). AAMC faculty had a significantly higher percentages of female representation compared with both the clinical faculty (19% versus 10%; P < 0.001) and AAOS members (19% versus 7%; P < 0.001). CONCLUSION: Despite multiple initiatives designed to increase diversity, the 7% female representation in the orthopaedic workforce identified in this study remains markedly lower than other medical and surgical specialties. A higher percentage of women were associated with the AAMC orthopaedic faculty compared with clinically active female surgeons at these institutions. Academic orthopaedic surgeons had greater female representation than the general orthopaedic workforce, highlighting the importance of training institutions at promoting gender equity.

Preliminary Evaluation of Standing Full-Length Plain Radiographs Utility in an Adult Degenerative Spine Practice.

INTRODUCTION: The role of weight-bearing full-length standing radiographs (FLSRs) of the spine in the preoperative workup of adult degenerative disease of the lumbar spine is a subject of increasing research. This investigation aims to determine whether FLSR influences preoperative planning decisions. METHODS: In this prospective study, eight spine surgeons reviewed two 30-patient case series. The first set (set A) contained a patient history, physical examination data, and preoperative images. The second set (set B) contained all information in set A in addition to preoperative FLSR AP and lateral radiographs. Within 2 weeks of evaluating set A, reviewers assessed set B. Case sets were randomized. After reviewing each set, reviewers gave surgical plans and whether they believed an FLSR was important in planning. Decisions were evaluated by subspecialty, years of practice, and postfellowship years. A McNemar test assessed differences between set viewings. A chi-square test assessed differences of preoperative decision changes between different specialties and levels of experience. A Poisson regression assessed characteristics associated with changing preoperative plans. We analyzed patients by the number of unique reviewer procedures, surgical levels, and associated pathology. RESULTS: After viewing an FLSR, 44.7% of reviewers changed procedure. Reviewer opinion of FLSR importance differed between sets (27.1% versus 35.7%, P = 0.047). Among all reviewers, FLSR presentation was associated with aligning the number of proposed procedures in 15 patients. Scoliosis and sacral dysplasia were associated with negative deltas. FLSR viewing reduced the span of operational levels considered. Along the most divided patients, those with a high magnitude (≥6 choices) of initial procedures had more negative deltas than did those with a high number (≥5 choices) of surgical level choices. CONCLUSION: FLSR remains a critical aspect of presurgical planning. Even when reviewers initially believed patients would not benefit from FLSR, we observed changes in preoperative planning after FLSR viewing.

Patient Reported Outcomes After Conversion vs. Primary Total Hip Arthroplasty: A Propensity Matched Analysis.

Background: Conversion total hip arthroplasty (cTHA) is increasingly utilized as a salvage procedure for complications associated with fracture fixation around the hip and acetabulum and for failed hip preservation surgery. While primary THA (pTHA) has a high success rate, little is known about outcomes following conversion THA. The purpose of this study is to evaluate patient reported outcomes (PROs) and complication rates following conversion THA compared to primary THA. Methods: Patients that underwent cTHA or pTHA from 2015-2020 at a large tertiary referral academic center were retrospectively identified. THA patients were propensity matched in a 1:1 fashion by age, body mass index (BMI), and sex. Pain scores and PROMIS physical function (PF), pain interference (PI), and depression (DA) scores were compared at preoperative and final postoperative follow up timepoints using independent t-tests. Differences in complication and reoperation rates between cohorts were assessed using chi square analysis. Results: A total of 118 THAs (59 cTHA, 59 pTHA) were included in this analysis with an average follow up of 21.3 months. cTHAs were most commonly performed following hip fracture fixation (50.8%). The conversion cohort had significantly longer lengths of stay (3.6 days vs 1.9 days, p<0.01) and greater use of revision-type implants (39.0% vs 0.0%, p<0.01) compared to pTHA. There was no significant difference in complication rates (cTHA = 15.3%, pTHA = 8.5%; p=0.26), with intraoperative fracture being the most common for both. Primary and conversion THA groups also experienced similar reoperation rates (cTHA = 5.1%, pTHA = 6.8%; p=0.70). No significant differences in PROs at final follow up were identified between groups. Conclusion: Patients undergoing cTHA required increased utilization of revision hip implants and had longer lengths of stay, but had comparable complication and reoperation rates, and ultimately demonstrated similar improvements in PROMIS scores compared to a matched cohort of pTHA patients. Level of Evidence: III.

Implementation and Evaluation of a Formal Virtual Medical Student Away Rotation in Orthopaedic Surgery During the COVID-19 Pandemic: A Single Institution Pilot Experience.

Away rotations are a valuable experience for medical students when applying for residency. In light of the coronavirus disease 2019 pandemic, there has been significant interest in the development of virtually based substitutes. This study evaluates the utility of a formal virtual fourth-year medical student away rotation in orthopaedic surgery by surveying participants and provides recommendations for success. METHODS: A 2-week virtual orthopaedic elective was offered to fourth-year medical students in lieu of traditional in-person away rotations. The course consisted of multiple components such as subspecialty case-based didactics, "happy hours" with residents, assigned resident mentors, student case presentations, and observation of resident lectures. After course completion, anonymous surveys were administered to participants to evaluate the rotation. RESULTS: Twenty-three of 24 participating students (96%) completed the student survey, and 22 of 24 participating faculty and residents (82%) completed the resident/faculty survey. Most students were very (87%) or somewhat (9%) satisfied with their experience and found the rotation to be a very (35%) or somewhat useful (61%) substitute for an in-person rotation. Students indicated that the rotation very (91%) or somewhat positively (9%) influenced their perception of the program. All students indicated that the rotation was very educational. Most students (91%) reported that the rotation was very useful for learning about the program and culture, with subspecialty didactics and happy hours most useful. Faculty and residents indicated that the rotation was useful for getting to know the students (17% "very useful" and 83% "somewhat useful") and for assessing student characteristics, such as knowledge base and communication skills. CONCLUSIONS: A formal virtual orthopaedic surgery away rotation can be a valuable experience for medical students which provides educational value, insight into program culture, and an opportunity to demonstrate interest in the program. The curriculum and recommendations presented in this study can be used as a preliminary template for others interested in creating successful virtual rotations.

Biomaterials for Orthopaedic Diagnostics and Theranostics.

Despite widespread use of conventional diagnostic methods in orthopaedic applications, limitations still exist in detection and diagnosing many pathologies especially at early stages when intervention is most critical. The use of biomaterials to develop diagnostics and theranostics, including nanoparticles and scaffolds for systemic or local applications, has significant promise to address these shortcomings and enable successful clinical translation. These developments in both modular and holistic design of diagnostic and theranostic biomaterials may improve patient treatments for myriad orthopaedic applications ranging from cancer to fractures to infection.

Congenital Absence of the Patellar Tendon: A Report of 2 Cases.

CASE: Isolated unilateral congenital patellar tendon absence is a rare condition that has not been well described. We report on 2 patients with congenital patellar tendon absence that underwent soft-tissue reconstruction of their patellar tendon. We present the clinical and radiographic features, surgical management with both single-stage and multistage approaches, and postoperative outcomes for the treatment of this condition. CONCLUSION: Soft-tissue reconstruction of the patellar tendon led to satisfactory outcomes, providing active knee extension and improved ambulation in both cases. In cases of significant superior migration, multiple procedures may be required to mobilize the patella to an appropriate position.

Risk Factors for Medical and Surgical Complications after 1-2-Level Anterior Cervical Discectomy and Fusion Procedures.

BACKGROUND: Postoperative complications after anterior cervical discectomy and fusion (ACDF) have a significant impact on clinical outcomes and health care resource use. Identifying predictive factors for complications after ACDF may allow for the modification of care protocols to mitigate complication risk. The purpose of this study is to determine risk factors for the incidence of medical and surgical complications up to 2 years postoperatively after ACDF procedures. METHODS: A prospectively maintained surgical registry of patients who underwent primary, 1-2-level ACDF was retrospectively reviewed. The incidence of medical and surgical complications up to 2 years postoperatively was determined. Patients were classified according to demographic, comorbidity, and procedural characteristics. Bivariate Poisson regression with robust error variance was used to determine if an association existed between the incidence of medical or surgical complications and patient characteristics. A final multivariate model including all patient and procedural characteristics as controls was created using backwards, stepwise regression until only those variables with P < .05 remained. RESULTS: A total of 310 patients were included. Upon bivariate analysis, age >50 years was identified as a risk factor for medical complications after ACDF procedures. Additionally, bivariate analysis identified ageless Charlson comorbidity index ≥2, operative duration >60 minutes, and 2-level procedures as risk factors for surgical complications after ACDF. Upon multivariate analysis, age >50 years was identified as an independent risk factor for medical complications (relative risk [RR] = 3.6, P = .005), while operative time >60 minutes was identified as an independent risk factor for surgical complications after ACDF (RR = 4.5, P = .017). CONCLUSIONS: The results of this study demonstrate that older age and longer operative time were independent risk factors for medical and surgical complications, respectively, following ACDF. Patients with these risk factors should be counseled regarding their increased risk of postoperative complications and should undergo more vigilant monitoring to aid in complication avoidance. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Surgeons should consider the elevated risk of postoperative complications in >50 years old patients and >60 min procedures.

Risk Factors for Medical and Surgical Complications After Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: The prevention of perioperative and postoperative complications is necessary to avoid poor postoperative outcomes and increased costs. Previous investigations have identified risk factors for complications after various spine procedures, but no such study exists in a population solely undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this study is to determine risk factors for the development of complications up to 2 years after MIS TLIF procedures. METHODS: Patients who underwent primary, single-level MIS TLIF from 2007 to 2016 were retrospectively reviewed. The incidence of medical and surgical complications up to 2 years postoperatively was determined. Patients were categorized according to demographic, comorbidity, and procedural characteristics. Bivariate Poisson regression with robust error variance was used to determine if an association existed between patient characteristics and complication incidence. A final multivariate model including all patient characteristics as controls was created using backwards, stepwise regression until only those variables with P < .05 remained. RESULTS: 390 patients were analyzed. Upon bivariate analysis, age >50 years (P = .025), diabetes mellitus (P = .001), and operative duration >105 minutes (P = .016) were associated with increased medical complication rates. Regarding surgical complications, age ≤50 years (P < .001), obesity (P = .012), and diabetes mellitus (P = .042) were identified as risk factors on bivariate analysis. Upon final multivariate analysis, operative time >105 minutes (P = .009) and diabetes mellitus (P = .001) were independent risk factors for medical complications. Independent risk factors for surgical complications on multivariate analysis included age ≤50 years (P < .001), diabetes mellitus (P = .002), and obesity (P = .030). CONCLUSIONS: Diabetic patients and those who underwent longer operations were at increased risk of medical complications, while younger patients, obese patients and those also with diabetes mellitus were at increased risk of surgical complications up to 2 years after MIS TLIF. Practitioners can use this information to identify patients who require preventative care before their procedure or increased postoperative vigilance and monitoring after single-level MIS TLIF. LEVEL OF EVIDENCE: 3.

Diabetes Does Not Increase Complications, Length of Stay, or Hospital Costs After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine if the presence of diabetes mellitus as comorbidity is associated with complications, inpatient length of stay, or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Very few studies have investigated the effect of diabetes on complications, length of stay, or costs in minimally invasive lumbar surgeries. METHODS: Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. Diabetic and nondiabetic patients were propensity matched in a 1:1 manner for age, sex, and comorbidity burden. An association between diabetic status and preoperative demographic or perioperative variables, including inpatient length of stay, was tested for using Student t test or χ analysis. Multivariate linear regression was used to test for an association between diabetic status and direct hospital costs. RESULTS: After 1:1 propensity matching, 100 patients were included in this analysis. There were no significant differences in age, sex, body mass index, smoking status, or Charlson Comorbidity Index between propensity-matched patients with and without diabetes. In regards to the length of stay, no significant differences existed between diabetic and nondiabetic groups (68.7 vs. 58.3 h, P=0.218). No other significant differences existed in other perioperative variables including operative time, intraoperative blood loss, or complication rate (P≥0.05 for each). Multivariate analysis indicated that diabetic status was not associated with differences in total direct hospital costs (US$20,428 vs. US$20,429, P=0.792) or cost subcategories after MIS TLIF (P≥0.05 for each). CONCLUSIONS: In this investigation, diabetes was not associated with postoperative complication rates, inpatient length of stay, or direct hospital costs after primary, single-level MIS TLIF. The reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital stay length and associated hospital costs.

American Society of Anesthesiologists Score is Not Predictive of Complication Incidence After Minimally Invasive Posterior Lumbar Spine Procedures.

BACKGROUND: Complications occurring after spinal procedures are associated with recurrent symptomatology, new-onset symptomatology, and increased health care costs. The American Society of Anesthesiologists (ASA) score is a commonly cited risk factor for complication incidence. Few investigations have been performed analyzing the relationship between ASA score and complication rate following spinal minimally invasive surgery (MIS) decompressions or fusions. Therefore, the purpose of this study is to determine whether an association exists between preoperative ASA score and the incidence of postoperative complications among patients undergoing MIS posterior lumbar decompression or fusion. METHODS: A surgical registry of patients undergoing single-level MIS posterior lumbar decompressions or fusions between 2007 and 2016 was retrospectively reviewed. Patients were stratified by preoperative ASA score (≤2, >2). The ASA score was tested for an association with preoperative demographic, comorbidity, and perioperative characteristics using the Student t test or χ2 analysis. Multivariate Poisson regression with robust error variance was used to test for an association between ASA score and the incidence of complications up to 6 months postoperatively. RESULTS: A total of 772 patients were analyzed. Of those, 86.7% had an ASA score ≤2, whereas 13.3% had an ASA score >2. An ASA score >2 was associated with older age (P < .001), higher comorbidity burden (P < .001), and higher rates of obesity (P < .001). An ASA score >2 was also associated with significantly longer operative time (P = .001) and longer length of hospital stay (P < .001). Upon multivariate analysis, ASA score category was not associated with the incidence of any complication (P = .248), medical complications (P = .227), or surgical complications (P = .816). CONCLUSIONS: The ASA score was not a predictive factor for complication incidence up to 6 months postoperatively. Thus, a higher ASA score should not preclude patients from being surgical candidates for MIS posterior lumbar decompressions or fusions. Further investigation is required to identify other predictive factors for complication incidence after minimally invasive spine surgery. LEVEL OF EVIDENCE: 3.

Patient Perceptions of Physician Ownership in Spine Care.

STUDY DESIGN: This was a prospective study. OBJECTIVE: This study aims to determine the perspectives of patients seeking spine care in regard to physician ownership of surgical facilities and to understand the importance of disclosing financial conflicts. SUMMARY OF BACKGROUND DATA: There has been limited investigation regarding patient perceptions of the proprietary structure of surgical facilities. METHODS: Patients seeking treatment for spine pathology completed an 8-item survey. The questions assessed if patients acknowledged the owners of surgical facilities, if the patient thought knowledge of ownership is important, who they perceived as most qualified to own surgical facilities, preference of communication of ownership, and impact of facility ownership on care. RESULTS: A total of 200 patients completed the survey. When patients were asked whom they thought owned the hospital, most reported private hospital corporations followed by universities/medical schools and insurance companies. With regard to whom patients thought owned an ambulatory surgical center, most reported physicians, followed by private hospital corporations and individual investors. When asked how important it is to know the financial stakeholders of a surgical facility, 73.5% of patients stated "very important" or "somewhat important." Most patients reported they were not aware of who owned the facility. Regarding how facility owners should be communicated, 31.0% answered "written document," whereas 25.0% preferred verbal communication with the staff/surgeon. When asked how much impact the owner of a surgical facility has on their care, 38.0% of patients responded, "strong impact," followed by "moderate impact," (43.0%), and "little or no impact" (19.0%). Patients thought that physicians were the most qualified to own an ambulatory surgical center, followed by universities/medical schools and private hospital corporations. CONCLUSIONS: The pretreatment perception of patients referred to a spine clinic favored the opinion that physicians were the most qualified to own and manage surgical facilities. Therefore, physicians should be encouraged to share disclosures with patients as their ownership of surgical facilities is viewed favorably.

Static Versus Expandable Devices Provide Similar Clinical Outcomes Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Few studies have analyzed differences in radiographic parameters and patient-reported outcomes (PROs) between expandable and static interbody devices in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). QUESTIONS/PURPOSES: To evaluate differences in radiographic parameters and PROs following MIS TLIF between static and expandable interbody devices. METHODS: Patients undergoing primary, single-level MIS TLIF between 2014 and 2017 were retrospectively identified. Radiographic measurements including lumbar lordosis (LL), segmental lordosis (SL), disc height (DH), and foraminal height (FH) were performed on lateral radiographs before and after MIS TLIF with a static or expandable articulating interbody device. Radiographic outcomes and PROs were compared using paired and unpaired Student's t test. RESULTS: Thirty patients received expandable interbody devices and 30 patients received static interbody devices. The expandable device cohort exhibited significantly greater improvement in DH and FH at final follow-up compared with those receiving a static device. Both device cohorts experienced significant improvements in PROs at 6 months post-operatively. CONCLUSION: MIS TLIF with an expandable interbody device led to a greater increase of DH and FH than with a static interbody device. Patients undergoing MIS TLIF can expect similar improvements in PROs whether receiving a static or an expandable interbody device. Further studies are required to better understand improvements in clinical outcomes afforded by expandable interbody devices.

Postoperative Outcomes Based on American Society of Anesthesiologists Score After Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To examine the association between the American Society of Anesthesiologists (ASA) score and patient-reported outcomes (PROs) after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA: Few studies have investigated the correlation between ASA score and PROs after MIS TLIF. METHODS: Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed and placed into 3 cohorts: ASA score ≤2 and outpatient status, ASA score ≤2 and inpatient status, and ASA score >2. Oswestry Disability Index (ODI), visual analog scale (VAS) back and leg pain, and Short Form-12 Physical Component Score (SF-12 PCS) were administered preoperatively and at 6-week, 12-week, and 6-month time points. ASA scores were tested for association with improvements in PROs using linear regression. RESULTS: A total of 187 patients had an ASA score ≤2 and 41 patients had an ASA score >2. Higher ASA scores were associated with older age, obesity, higher comorbidity burden, and an increased length of stay. ASA subgroups demonstrated a significant difference in preoperative ODI and VAS back pain scores and improvement in VAS back pain scores at the 12-week and 6-month time points; however, there was no discernible pattern of improvement amongst cohorts. No statistically significant differences were observed with improvements in PROs. CONCLUSIONS: The study suggests ASA scores are not associated with postoperative recovery in pain and disability after MIS TLIF. Our results indicate that regardless of the preoperative ASA score, patients are likely to achieve similar improvements in PROs through 6 months follow-up. Although using ASA as a risk stratification tool to predict perioperative complications, its utility in predicting improvement in PROs is still uncertain at this time.