The Effect of Varying Preoperative Hemoglobin Levels on the Risk of Major Complications and Surgical Site Infections After Single Level Lumbar Fusion.

INTRODUCTION: Blood transfusions are associated with an increased risk of complications after lumbar fusion, and current anemia hemoglobin thresholds are not surgery specific. We aimed to calculate single-level lumbar fusion-specific preoperative hemoglobin strata that observe the likelihood of 90-day transfusion and evaluate whether these strata are associated with increased risk of 90-day complications and 2-year infections. METHODS: A national database identified patients undergoing primary single-level lumbar fusion with preoperative hemoglobin values (g/dL). Stratum-specific likelihood ratio analysis calculated sex-based hemoglobin strata associated with the risk of 90-day transfusion. Incidence and risk of 90-day major complications and 2-year infections were observed between strata. RESULTS: Three female (hemoglobin strata, likelihood ratio [<10.9, 2.41; 11.0 to 12.4, 1.35; 12.5 to 17.0, 0.78]) and male (<11.9, 2.95; 12.0 to 13.4, 1.46; 13.5 to 13.9, 0.71) strata were associated with varying likelihood of 90-day blood transfusion. Increased 90-day complication risk was associated with two female strata (hemoglobin strata, relative risk [11.0 to 12.4, 1.52; <10.9, 3.40]) and one male stratum (<11.9, 2.02). Increased 2-year infection risk was associated with one female (<10.9, 3.67) and male stratum (<11.9, 2.11). CONCLUSION: Stratum-specific likelihood ratio analysis established sex-based single-level lumbar fusion-specific hemoglobin strata that observe the likelihood of 90-day transfusion and the risk of 90-day major complications and 2-year infections. These thresholds are a unique addition to the literature and can assist in counseling patients on their postoperative risk profile and in preoperative patient optimization. LEVEL OF EVIDENCE: Level III.

Prior Fragility Fractures are Associated With Higher Risk of Bone Health-Related Complications Within 8-Years Following Lumbar Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine the 8-year risk of revision lumbar fusion, pseudoarthrosis, mechanical failure, fragility fracture, and vertebral compression fracture in patients with a prior fragility fracture compared to those without. SUMMARY OF BACKGROUND DATA: Osteoporosis is a known modifiable risk factor for revision following lumbar fusion due to inadequate fixation. Patients with prior fragility fractures have been shown to have increased bone health-related complications following various orthopedic surgeries, however there is a paucity of literature that identifies these complications in patients undergoing lumbar fusion. METHODS: Patients aged 50 years and older who underwent elective lumbar fusion were identified in a large national database and stratified based on whether they sustained a fragility fracture within 3 years prior to fusion. These patients were propensity-score matched to a control based on age, gender, and Charlson Comorbidity Index (CCI) using a 1:1 ratio. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences and risk of complications within 8-years of index surgery. RESULTS: After matching, 8,805 patients were included in both cohorts. Patients who sustained a prior fragility fracture had a higher risk of revision (Hazard Ratio [HR]: 1.46; 95% Confidence Interval [CI]: 1.26-1.69; P<0.001), pseudoarthrosis (HR: 1.31; 95% CI: 1.17-1.48; P<0.001), mechanical failure (HR: 2.08; 95% CI: 1.78-2.45; P<0.001), secondary fragility fracture (HR: 6.36; 95% CI: 5.86-6.90; P<0.001), and vertebral compression fracture (HR: 7.47; 95% CI: 7.68-8.21; P<0.001) when compared to the control cohort. CONCLUSION: Patients who sustain a fragility fracture prior to lumbar fusion have an increased risk of revision, pseudoarthrosis, and mechanical failure within 8 years. Surgeons should be aware of this high-risk patient population and consider bone health screening and treatment to reduce these preventable complications.

The Pathologic Fracture Mortality Index: A Novel Externally Validated Tool for Predicting 30-day Postoperative Mortality.

INTRODUCTION: Current mortality predictive tools, in the setting of completed or impending pathologic fractures, are nonspecific. Clinical decision making and mortality prediction in research would benefit from creation of a high-fidelity scoring system for calculating the risk of 30-day postoperative mortality. The purpose of this study is to develop a validated research and clinical tool that is superior to existing methods in estimating postoperative mortality risk after fixation of pathologic fractures. METHODS: One thousand two hundred nineteen patients who underwent fixation for either completed or impending pathologic fractures in the National Surgical Quality Improvement Program (2012 to 2018) database were analyzed. Multivariable logistic regression with diagnostics was used to develop a predictive model in a derivation cohort and then validated in a validation cohort. Area under the curve (AUC) from receiver operator curve analysis was used to assess accuracy. A score was derived and compared with the American Society of Anesthesiologists classification and modified five-component frailty index (mF-I5). The score was validated in an exclusive cohort of patients who underwent fixation for pathologic fractures at a tertiary care center. RESULTS: Of 1,219, a total of 177 (15%) patients did not survive beyond 30 days postoperatively. AUC for our predictive model was 0.76 in the derivation and 0.75 in the validation National Surgical Quality Improvement Program cohorts. The derived Pathologic Fracture Morbidity Index included seven data points: anemia, alkaline phosphatase > 150 U/L, albumin < 3.5 mg/dL, pulmonary disease, recent weight loss, functional dependence, and white blood cell count >12,000. The PFMI (AUC = 0.75) was more accurate than ASA (AUC = 0.60) or mF-5 (AUC = 0.58) (P < 0.01). The AUC for PFMI in predicting 30-day mortality in the exclusive cohort (N = 39) was 0.74. CONCLUSION: The PFMI is a validated tool that may be used for predicting postoperative 30-day mortality after fixation of pathologic fractures, with higher level of accuracy compared with ASA or mF-I5.

Decreased rates of 30-day perioperative complications following ASD-corrective surgery: A modified Clavien analysis of 3300 patients from 2010 to 2014.

The Clavien-Dindo grading allows for broad comparison of perioperative surgical complications, and a temporal analysis of complications following ASD-corrective surgery. NSQIP database was utilized from 2010 to 2014 to isolate patients. Complications were stratified by Clavien complication (Cc) grade, and patients grouped by highest Cc grade: I, II, III, IV, V. Secondary analysis grouped by minor (I, II, III) and severe (IV, V). Comorbidity burden was assessed with a NSQIP-modified Charlson Comorbidity Index (CCI) and frailty was measured with a 5-factor modified frailty index (mFI). From 2010 to 2014, 2971 patients (57 yrs, 58% F) underwent surgery for ASD (3.4 ±â€¯4.1 levels; surgical approach: 46% anterior, 44% posterior, 10% combined), the rate of which increased 0.01% to 0.13. 32% suffered >1 complication. Patient breakdown by Cc grade: 0% I, 25% II, 3% III, 4% IV, 1% V. Severe Cc patients were more comorbid than minor Cc (CCI 2.8 vs 1.8), had longer operative times (394 min vs 251), and higher rates of osteotomy (29% vs 13%) and iliac fixation (16% vs 5%). Overall CCI (2.1-1.7) and perioperative complication rates (55-29%) decreased, despite increasing surgical invasiveness (2.8-4.5) and increasing frailty score (0.14 ±â€¯0.15 vs 0.16 ±â€¯0.16). Rates of Clavien grade II (39.80-22.20%) and IV (9.40-3.50%) complications also decreased, indicative of surgical improvements and effective preoperative patient selection. The decrease in CCI and increase in the modified frailty score may show that we are becoming more cognizant of discerning of comorbidities, but likely to not to have taken into account frailty, which may have an impact on future health socioeconomics.

A novel treatment approach to infected nonunion of long bones without systemic antibiotics.

Infected nonunion of long bones may require intravenous antibiotics over a lengthy period which may result in a high rate of complications. This study aims to assess the efficacy of local antibiotics used as a replacement to prolonged intravenous therapy. Thirteen patients with infected nonunion of long bones who failed at least one previous surgery were included. The infection was treated through extensive debridement, application of antibiotic-impregnated calcium sulphate pellets and the bone stabilized with external fixation. These patients were monitored for union and infection by clinical signs, laboratory values, and radiographs over a period of 24 months. The results support an eradication of infection and union in all patients with no antibiotic-associated complications. Local antibiotic delivery using calcium sulphate pellets provides an effective method for treatment of nonunion in long bones and is free of the complications from the intravenous route.