Effect of Hospital Characteristics on Performance of Pediatric Digit Replantation in the United States.

Introduction Utilize a national pediatric database to assess whether hospital characteristics such as location, teaching status, ownership, or size impact the performance of pediatric digit replantation following traumatic digit amputation in the United States. Materials and Methods The Kid's Inpatient Database (KID) was used to query pediatric traumatic digit amputations between 2000 and 2012. Ownership (private and public), teaching status (teaching and non-teaching), location (urban and rural), hospital type (general and children's), and size (large and small-medium) characteristics were evaluated. Replantations were then divided into those that required subsequent revision replantation or amputation. Fisher's exact tests and multivariable logistic regressions were performed with p <0.05 considered statistically significant. Results Overall, 1,015 pediatric patients were included for the digit replantation cohort. Hospitals that were privately owned, general, large, urban, or teaching had a significantly greater number of replantations than small-medium, rural, non-teaching, public, or children's hospitals. Privately owned (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.06-3.06; p = 0.03) and urban (OR: 2.29; 95% CI: 1.41-3.73; p = 0.005) hospitals were significantly more likely to perform replantation. Urban (OR: 4.02; 95% CI: 1.90-8.47; p = 0.0003) and teaching (OR: 2.11; 95% CI: 1.17-3.83; p = 0.014) hospitals were significantly more likely to perform a revision procedure following primary replantation. Conclusion Private and urban hospitals were significantly more likely to perform replantation, but urban and teaching hospitals carried a greater number of revision procedures following replantation. Despite risk of requiring revision, the treatment of pediatric digit amputations in private, urban, and teaching centers provide the greatest likelihood for an attempt at replantation in the pediatric population. The study shows Level of Evidence III.

Unanticipated Admission Following Outpatient Ligament Reconstruction and Tendon Interposition: An Analysis of 3966 Cases.

Background: Hand surgeons in the United States commonly perform ligament reconstruction and tendon interposition (LRTI) to address debilitating thumb carpometacarpal arthritis. The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after a planned outpatient LRTI. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) datasets from years 2009 to 2016 were used to identify patients with a primary Current Procedural Terminology code for LRTI (25445, 25447). Only outpatient, nonemergent, and elective procedures were considered. Univariable and multivariable regression were used to determine risk factors and postoperative complications associated with increased likelihood of unanticipated admission, defined as length of initial hospital stay greater than 0 days. Statistical significance was set at P < .05. Results: Of 3966 patients who underwent outpatient LRTI, 134 (3.4%) had unplanned admission. On multivariable regression, age ≥ 65 years (odds ratio [OR] = 1.50), white race (OR = 4.44), and chronic steroid use (OR = 2.42) were significant predictors of unplanned admission. History of smoking, obesity, hypertension, diabetes, American Society of Anesthesiologists classification, and anesthesia method were not associated with admission. Patients who had unplanned admission had increased rate of reoperation (2.5% vs 0.3%) compared with nonadmitted patients. There was no difference in rate of postoperative infection, deep vein thrombosis, wound dehiscence, or 30-day mortality. Conclusions: Age ≥ 65 years, chronic steroid use, and white race were significant predictors of unplanned admission following LRTI. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient LRTI.

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost.

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

A Novel Machine Learning Model Developed to Assist in Patient Selection for Outpatient Total Shoulder Arthroplasty.

INTRODUCTION: Patient selection for outpatient total shoulder arthroplasty (TSA) is important to optimizing patient outcomes. This study aims to develop a machine learning tool that may aid in patient selection for outpatient total should arthroplasty based on medical comorbidities and demographic factors. METHODS: Patients undergoing elective TSA from 2011 to 2016 in the American College of Surgeons National Surgical Quality Improvement Program were queried. A random forest machine learning model was used to predict which patients had a length of stay of 1 day or less (short stay). A multivariable logistic regression was then used to identify which variables were significantly correlated with a short or long stay. RESULTS: From 2011 to 2016, 4,500 patients were identified as having undergone elective TSA and having the necessary predictive features and outcomes recorded. The machine learning model was able to successfully identify short stay patients, producing an area under the receiver operator curve of 0.77. The multivariate logistic regression identified numerous variables associated with a short stay including age less than 70 years and male sex as well as variables associated with a longer stay including diabetes, chronic obstructive pulmonary disease, and American Society of Anesthesiologists class greater than 2. CONCLUSIONS: Machine learning may be used to predict which patients are suitable candidates for short stay or outpatient TSA based on their medical comorbidities and demographic profile.

Epidemiology and Video Analysis of Achilles Tendon Ruptures in the National Basketball Association.

BACKGROUND: There is a paucity of literature regarding risk factors and mechanisms of Achilles tendon (AT) ruptures in the National Basketball Association (NBA). PURPOSE: To identify the risk factors and outcomes of AT ruptures in NBA athletes. Furthermore, using video analysis, to characterize the mechanisms of rupture by identifying the most common playing situations and lower extremity positions at the time of injury. STUDY DESIGN: Descriptive epidemiology study. METHODS: AT ruptures in the NBA that occurred between the seasons of 1969-1970 and 2017-2018 were identified. Player data collected included age, position, body mass index, total games started before and after injury, and Player Efficiency Rating. Injury-related variables collected included date of injury, laterality, minutes played before injury, operative versus nonoperative treatment, and time to return to play. Available video footage was analyzed for the mechanism and body position at the time of injury. Univariable and multivariable linear regression was used to compare changes in performance before and after AT rupture. Statistical significance was set at P < .05. RESULTS: Forty-four ruptures were identified between 1970 and 2018. The mean age was 28.3 years, with players averaging 6.8 seasons before AT rupture. AT ruptures were most prevalent during early-season game play (27.3%), followed by preseason (18.2%) and late season (18.2%). More than a third (36.8%) of players either did not return to play or started in fewer than 10 games in the remainder of their career, with 21% of ruptures leading to retirement. The mean time to return to play was 10.5 months. The Player Efficiency Rating declined by an average of 2.9 points (range, -11.5 to +2.3) (P < .001). Analysis of available injury footage (n = 12) demonstrated all ruptures to be noncontact in nature, most commonly occurring just before takeoff as the player began to push off from a stopped position, with the foot in dorsiflexion, the knee in early flexion, and the hip in extension. CONCLUSION: In the NBA, a majority of AT ruptures occur early in the season, in veteran players, with almost half not returning to play or starting fewer than 10 games in the remainder of their career. The most common mechanism of injury is taking off from a stopped position just before toe-off in a dorsiflexed foot.

Matched cohort analysis of peri-operative outcomes following total knee arthroplasty in patients with and without Parkinson's disease.

BACKGROUND: Increased complication rate has been reported in Parkinson's disease (PD) patients following total knee arthroplasty (TKA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following TKA using a national database. METHODS: The HCUP Nationwide Inpatient Sample was evaluated for the years 2000 to 2012. PD patients were matched 1:10 with non-PD control patients for age, sex, Charlson Comorbidity Index (CCI), and year of admission utilizing a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. RESULTS: Before matching, TKA patients with PD were significantly older (p < 0.0001), more frequently male (p < 0.0001), and had a greater CCI (p = 0.3058). In the matched cohort, PD was associated with significantly increased length of stay (3.92 vs 3.71 days, p < 0.0001) and total hospital charges ($41,523.52 vs $40,657.00, p = 0.0037). There was no significant difference in in-hospital complication rate (8.28% vs 8.04%, p = 0.4297) or in-hospital mortality (0.164% vs 0.150%, p = 0.8465) between PD patients and matched non-PD patients. CONCLUSIONS: Matched cohort analysis demonstrated statistically significant but clinically minor increases in length and cost of hospitalization for TKA in PD patients. Complication rate and in-hospital mortality rate was not higher in PD patients, suggesting that this group may be safely considered for TKA. LEVEL OF EVIDENCE: Prognostic - Level III.

Matched Cohort Analysis of Total Hip Arthroplasty in Patients With and Without Parkinson's Disease: Complications, Mortality, Length of Stay, and Hospital Charges.

BACKGROUND: Increased complication rate has been reported in Parkinson's disease (PD) patients following total hip arthroplasty (THA). However, this has not previously been studied on a national scale. The purpose of this study was to determine whether PD patients had increased cost, complication, mortality, and length of stay following THA using a national database. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample was evaluated for the years 2000-2014. PD patients were matched 1:3 with non-PD control patients for age, gender, Charlson Comorbidity Index, and year of admission using a propensity score matching procedure. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. RESULTS: 794,689 THAs were performed from 2000-2014. 4003 patients (0.50%) had comorbid Parkinson's disease. Before matching, arthroplasty patients with PD were significantly older (P < .001), more frequently male (P < .001), and had greater Charlson Comorbidity Index (P < .001). In the matched cohort, PD was associated with increased length of stay (3.1 vs 2.7 days, P < .001), total hospital charges ($49,061 vs $45,571, P < .001), and in-hospital complication rate (14.6% vs 11.7%, P < .001). There was no difference in-hospital mortality (0.50% vs 0.47%, P = .781). CONCLUSIONS: Matched cohort analysis demonstrated increases in complication rate, length, and cost of hospitalization for THA in patients with PD. However, in-hospital mortality rate in PD patients was not increased. Of note, the elevation in per-episode cost ($3490) may be of concern when considering PD patients for surgery within the evolving "bundled payment" model of care. LEVEL OF EVIDENCE: Prognostic- Level III.

Matched Cohort Analysis of Elective Lumbar Spinal Fusion in Patients With and Without Parkinson's Disease: In-hospital Complications, Length of Stay, and Hospital Charges.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: Parkinson's disease (PD) is a neurodegenerative condition associated with significant morbidity and mortality. PD patients often develop spinal conditions and are known to have high complication rates following surgery. This study evaluated the outcomes of lumbar fusion surgery in patients with PD using a large, public, national database. METHODS: The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) was used to identify elective lumbar spinal fusion patients with and without PD for the years 2000 to 2012. PD patients were matched with non-PD controls for comorbidity and age using propensity score matching. Univariable and multivariable logistic regression were used to determine the relationship between PD and surgical outcomes in the matched cohort. RESULTS: A total of 231 351 elective lumbar fusion patients were examined, of which 1332 had PD. Before matching, elective lumbar fusion patients with PD were significantly older (P < .001) and more likely male (P < .001) compared with non-PD patients. In the matched cohort, PD was associated with increased length of stay (6.91 vs 5.78 days) (P < .001) and total hospital charges ($129 212.40 vs $110 324.40) (P < .001). There was no significant difference in overall in-hospital complication rate between PD patients and matched non-PD patients (22.3% vs 21.4%) (P = .524). CONCLUSIONS: Analysis demonstrated significant increases in length and cost of hospitalization for elective lumbar spinal fusion in patients with PD. However, inpatient complication rates in PD patients were not significantly increased. As a growing number of PD patients undergo elective spine surgery, further studies are needed to optimize operative planning. Further study is needed to assess the long-term outcomes of lumbar spinal fusion in PD.

Trends in All-terrain Vehicle Injuries From 2000 to 2015 and the Effect of Targeted Public Safety Campaigns.

INTRODUCTION: All-terrain vehicles (ATVs) represent a notable portion of orthopaedic injuries presenting to emergency departments (EDs) in the United States. Public awareness campaigns have targeted these injuries, and this study sought to examine the effect of the 2007 American Academy of Orthopaedic Surgeons public safety campaign on ATV use. METHODS: The United States Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) was used to obtain national estimates of ATV and dirt bike injuries for the years 2000 to 2015. ED visits resulting from ATV injuries and dirt bike injuries were identified using NEISS product codes (ie, 3285-3287, 3296, and 5036). Patient demographics, injury-related data, and total annual case numbers were estimated. Chi-square tests and logistic regression were used for comparative analyses as appropriate. All statistical analyses were performed using SAS statistical software v.9.4 (SAS Institute). Statistical significance was set at P < 0.05 a priori. RESULTS: Beginning in 2000, the incidence of ATV injuries consistently increased over time and peaked in 2007 (54.1/100,000 people). Since 2007, the incidence of ATV injuries has consistently decreased (33.7/100,000 people in 2015). The frequency of ATV injuries differed significantly (P < 0.001) by age group, with children aged 14 to 17 years experiencing the highest incidence of ATV injury (2.8× national average). ATV injuries were also more common in males (2.7× national average; P < 0.001). The most common injuries were contusions and abrasions (25.3%), fractures (24.5%), and lacerations (11.4%). The decreased rate of ATV injury beginning in 2007 did not differ significantly (P = 0.81) from a comparative decrease in dirt bike-related injuries. DISCUSSION: This study provides the most current data on ATV injuries presenting to EDs in the United States. The rate of ATV-related injuries has steadily decreased since 2007, which corresponds to the American Academy of Orthopaedic Surgeons public awareness campaign. However, the reasons for this decrease are likely multifactorial. Children aged 14 to 17 years are at high risk of ATV-related injuries, with orthopaedic injuries accounting for a notable proportion.

The expanding use of total elbow arthroplasty for distal humerus fractures: a retrospective database analysis of 56,379 inpatients from 2002-2014.

OBJECTIVES: Distal humerus fractures are challenging to treat, with significant morbidity. Precontoured distal humerus locking plates and total elbow arthroplasty implants have become available in the past 15 years, potentially offering the promise of improved outcomes. However, national data regarding the usage of and in-hospital complications associated with these implants is scarce. Therefore, we aimed to determine if the incidence of inpatients with distal humerus fractures treated with arthroplasty or open reduction and internal fixation (ORIF) changed over time. Secondarily, we sought to determine what demographic factors were associated with arthroplasty versus fixation and compare inpatient outcomes. METHODS: Inpatients over 50 years old with operatively treated closed distal humerus fractures were identified between 2002 and 2014 in the Nationwide Inpatient Sample, a nationally representative, all-payer database. Patient demographic factors were associated with treatment type. Outcomes examined included complications, mortality, length-of-stay, and charges; multivariable logistic regression compared associations with treatment. RESULTS: Of 56,379 inpatients undergoing surgery, the proportion undergoing arthroplasty rose 2.3-fold from 4.8% to 10.9% from 2002 to 2014 (OR 1.039/year [95% CI [1.016-1.062]). Annual patient volume remained similar. Arthroplasty patients were older than those undergoing fixation (75.5 vs. 71.0 years, p < 0.001), more likely to be female (83.1% vs. 75.4%, p < 0.001), and less likely to be treated at a rural hospital (OR 0.601, 95% CI 0.445-0.812, p < 0.001). There was no significant difference in comorbidities. Arthroplasty patients had similar inpatient medical complication (7.1% vs. 7.8%, OR 0.998, p = 0.988) and mortality rates (0.38% vs. 0.94%, OR 0.426, p = 0.102), a decreased length of stay (by 0.3 days, p = 0.032), but increased hospital charges (by $12,033, p < 0.001). CONCLUSIONS: For inpatients over 50 years old with operatively-treated distal humerus fractures, use of elbow arthroplasty has expanded, albeit with increased cost. Further studies may help to delineate the long-term costs and benefits, as well as which patients may benefit from each type of implant. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Season-Ending Shoulder Injuries in the National Collegiate Athletic Association: Data From the NCAA Injury Surveillance Program, 2009-2010 Through 2013-2014.

BACKGROUND: Examination of the incidence of shoulder season-ending injury (SEI) in the collegiate athlete population is limited. PURPOSE: To determine the incidence of shoulder SEI in the National Collegiate Athletic Association (NCAA) and to investigate the risk factors for a shoulder injury ending an athlete's season. STUDY DESIGN: Descriptive epidemiology study. METHODS: All shoulder injuries from the NCAA Injury Surveillance Program database for the years 2009-2010 to 2013-2014 were extracted, and SEI status was noted. The incidences of SEI and non-SEI were calculated for athlete, activity, and injury characteristics and compared via univariable analysis and risk ratios to determine risk factors for an injury being season ending. RESULTS: Shoulder injuries were season ending in 4.3% of cases. The overall incidence of shoulder SEI was 0.31 per 10,000 athlete exposures (AEs), as opposed to 7.25 per 10,000 AEs for all shoulder injuries. Shoulder instability constituted 49.1% of SEI, with an incidence of 0.15 per 10,000 AEs, while fractures had the highest rate of being season ending (41.9%). Men's wrestling had the highest incidence of shoulder SEI (1.65 per 10,000 AEs), while men's soccer had the highest proportion of shoulder injuries that ended a season (14.6%). Overall, men had a 6.3-fold higher incidence of SEI than women and a 2.4-fold increased likelihood that an injury would be season ending. CONCLUSION: Injury to the shoulder of an NCAA athlete, while somewhat infrequent, can have significant implications on time lost from play. Incidence of these injuries varies widely by sport and injury, with a number of associated risk factors. Athletes sustaining potentially season-ending shoulder injuries, with their coaches and medical providers, may benefit from these data to best manage expectations and outcomes.

Inpatient orthopaedic hardware removal in children: A cross-Sectional study.

INTRODUCTION: Few data describe the specific reasons for inpatient hardware removal in the pediatric population. This study was designed to understand the conditions necessitating inpatient removal following fracture surgery. Cost data was analyzed to understand the financial implications of these procedures. METHODS: The Kids' Inpatient Database (KID) was evaluated for the year 2012. Patients undergoing open reduction internal fixation following upper and lower extremity fractures as well as those undergoing hardware removal due to hardware complications were identified using ICD-9 CM diagnosis and procedure codes. Univariable and multivariable logistic regression were used to determine predictors of surgical removal due to complications, controlling for patient demographics and comorbidities. RESULTS: The most common indication for removal was infection (1141 patients; 32%), followed by mechanical dysfunction (923; 25.4%), and pain (472; 13%). Logistic regression analysis showed that femur fractures (OR = 8.27, 95% CI: 7.63-8.96) and tibia/fibula fractures (OR = 1.24, 95% CI: 1.17-1.35) were independent predictors of infection-related hardware removal (P < 0.001). Patients who underwent removal due to infection were more likely to have asthma (OR = 1.87, 95% CI: 1.62-2.07), smoke tobacco (OR = 1.12, 95% CI: 1.05-1.23), and suffer from developmental delays (OR = 1.32, 95% CI: 1.19-1.54) (P < 0.001). Average hospital charges and costs were $36,349 and $11,792 respectively. CONCLUSION: While most commonly performed as an outpatient procedure, inpatient hardware removal occurs with relative frequency and is most often performed for infection, mechanical failure, or pain. Risk factors for infection-related removal were identified and provide a basis for further investigation.