Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI. METHODS: The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05. RESULTS: Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003). CONCLUSIONS: Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Trends for Diversity in Orthopedic Sports Medicine.

Despite the increasingly diverse population of the United States, orthopedic surgery continues to lag other medical specialties in terms of diversity. It remains the specialty with the lowest percentage of women, and White physicians dominate the field, especially in leadership positions. Although the trends are slowly moving in the right direction, additional efforts must be taken to further diversify the field. A targeted, multifaceted approach is required to enhance awareness, educate, mentor, and develop future leaders. Such an approach has recently been established by the American Orthopaedic Society for Sports Medicine, which will hopefully improve future minority and female representation.

Prediction of 5-year survival in soft tissue leiomyosarcoma using a machine learning model algorithm.

BACKGROUND AND OBJECTIVES: Leiomyosarcoma (LMS) is associated with one of the poorest overall survivals among soft tissue sarcomas. We sought to develop and externally validate a model for 5-year survival prediction in patients with appendicular or truncal LMS using machine learning algorithms. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used for development and internal validation of the models; external validation was assessed using our institutional database. Five machine learning algorithms were developed and then tested on our institutional database. Area under the receiver operating characteristic curve (AUC) and Brier score were used to assess model performance. RESULTS: A total of 2209 patients from the SEER database and 81 patients from our tertiary institution were included. All models had excellent calibration with AUC 0.84-0.85 and Brier score 0.15-0.16. After assessing the performance indicators according to the TRIPOD model, we found that the Elastic-Net Penalized Logistic Regression outperformed other models. The AUCs of the institutional data were 0.83 (imputed) and 0.85 (complete-case analysis) with a Brier score of 0.16. CONCLUSION: Our study successfully developed five machine learning algorithms to assess 5-year survival in patients with LMS. The Elastic-Net Penalized Logistic Regression retained performance upon external validation with an AUC of 0.85 and Brier score of 0.15.

Risk of spinal surgery among individuals who have been re-vascularized for coronary artery disease.

HYPOTHESIS: Revascularization is a more effective intervention to reduce future postop complications. METHODS: Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05. RESULTS: 731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53-2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26-3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53-2.71, p < 0.001). CONCLUSION: With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG.

A Comparison of Complications and Survivorship after Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture compared with Cuff Tear Arthropathy.

Objectives: Traditionally used to treat rotator cuff tear arthropathy (CTA), reverse total shoulder arthroplasty (RTSA) is becoming increasingly utilized for the treatment of proximal humeral fractures (PHF). The purpose of this study was to use a matched cohort analysis to assess differences in 90-day complications as well as 2-year and 5-year implant survival between patients undergoing RTSA for CTA and patients undergoing RTSA for PHF. Methods: Patients with at least a 5-year follow-up who underwent primary RTSA for either PHF or CTA were identified in a national database (PearlDiver Technologies) using current procedural terminology (CPT) and international classification of diseases (ICD) 9 and 10 codes. Patients with a surgical indication of PHF were matched with patients with a surgical indication of CTA based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index (BMI)>30). All-cause revision at the 2-year and 5-year postoperative time intervals were assessed. Reimbursements for the surgical care episode up to the 30-day, 90-day, and 1-year postoperative intervals were also assessed. Bivariate analysis was performed with a significance set at P<0.05. Results: In total, 802 PHF patients were matched with 802 CTA patients. Compared to CTA patients, PHF patients undergoing RTSA were significantly at increased risk of atrial fibrillation, anemia, and heart failure within 90 days of surgery. Notably, there was no significant difference in all-cause revision surgery at 2-year and 5-year postoperative intervals or hospital reimbursements at the 30-day, 90-day, and 1-year postoperative intervals. Conclusion: Preoperative indication appears to be an important driver of healthcare utilization for RTSA, as PHF patients undergoing RTSA have a higher risk of short-term postoperative complications compared to CTA patients. However, there is no difference in hospital reimbursement for the two indications of RTSA, suggesting that current payment modalities may not appropriately adjust for risk based on the surgical indication.

Social Determinants of Health Disparities Are Associated With Increased Costs, Revisions, and Infection in Patients Undergoing Arthroscopic Rotator Cuff Repair.

PURPOSE: The purpose of this study was to use a national claims database to assess the impact of pre-existing social determinants of health disparities (SDHD) on postoperative outcomes following rotator cuff repair (RCR). METHODS: A retrospective review of the Mariner Claims Database was used to capture patients undergoing primary RCR with at least 1 year of follow-up. These patients were divided into two cohorts based on the presence of a current or previous history of SDHD, encompassing educational, environmental, social, or economic disparities. Records were queried for 90-day postoperative complications, consisting of minor and major medical complications, emergency department (ED) visits, readmission, stiffness, and 1-year ipsilateral revision surgery. Multivariate logistic regression was employed to assess the impact of SDHD on the assessed postoperative outcomes following RCR. RESULTS: 58,748 patients undergoing primary RCR with a SDHD diagnosis and 58,748 patients in the matched control group were included. A previous diagnosis of SDHD was associated with an increased risk of ED visits (OR 1.22, 95% CI 1.18-1.27; P < .001), postoperative stiffness (OR 2.53, 95% CI 2.42-2.64; P < .001), and revision surgery (OR 2.35, 95% CI 2.13-2.59; P < .001) compared to the matched control group. Subgroup analysis revealed educational disparities had the greatest risk for 1-year revision (OR 3.13, 95% CI 2.53-4.05; P < .001). CONCLUSIONS: The presence of a SDHD was associated with an increased risk of revision surgery, postoperative stiffness, emergency room visits, medical complications, and surgical costs following arthroscopic RCR. Overall, economic and educational SDHD were associated with the greatest risk of 1-year revision surgery. LEVEL OF EVIDENCE: III, retrospective cohort study.

Increased Dislocation Rates After Total Hip Arthroplasty in Patients With Prior Isolated Sacroiliac Joint Arthrodesis.

BACKGROUND: While stiffness of the lumbosacral spine is a known predictor of instability following total hip arthroplasty (THA), little is known about the medical- and surgical-related outcomes following THA in patients who have prior isolated sacroiliac (SI) joint arthrodesis. METHODS: 197 patients who had a history of isolated SI joint arthrodesis who subsequently underwent elective primary THA for a diagnosis of osteoarthritis (THA-SI) from 2015 to 2021 were identified in a national administrative database. Using propensity score matching and logistic regression analyses, this cohort was compared to two groups of patients: patients who did not have any history of lumbar or SI arthrodesis and patients undergoing primary THA who had a history of lumbar arthrodesis without extension into the SI joint (THA-LF). RESULTS: The THA-SI group had a significantly higher incidence of dislocation (odds ratio 2.06, 95% confidence interval 1.04-4.04, P = .037) with no increased incidence of medical complications or other surgical complications when compared to patients without a history of SI or lumbar arthrodesis. There were no significant differences in any complications in THA-SI patients when compared to THA-LF patients. CONCLUSION: Patients who had prior isolated SI joint arthrodesis undergoing primary THA demonstrated a two-fold increased incidence of dislocation when compared to those who did not have prior SI arthrodesis, although the risk of complications in this population was similar to that observed in patients who had prior isolated lumbar spine arthrodesis.

Failure to Normalize Risk Profile of Spine Fusion Patients With Coronary Artery Disease Previously Treated With Percutaneous Stent Revascularization.

BACKGROUND: The impact of an initially less invasive cardiac intervention on outcomes of future surgical spine procedures has been understudied; therefore, we sought to investigate the effect of coronary stents on postoperative outcomes in an elective spine fusion cohort. METHODS: Elective spine fusion patients were isolated with International Classification of Diseases-Ninth Edition and current procedural terminology procedure codes in the PearlDiver database. Patients were stratified by number of coronary stents: (1) 1 to 2 stents (ST12); (2) 3 to 4 stents (ST34); (3) no stents. Mean comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day and 90-day complication outcomes. Logistic regression assessed the odds of complications associated with coronary stents, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was P < 0.05. RESULTS: A total of 726,061 elective spine fusion patients were isolated. Of those patients, 707,396 patients had no stent, 17,087 ST12, and 1578 ST34. At baseline (BL), ST12 patients had higher rates of morbid obesity, chronic kidney disease, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus compared with no stent and ST34 patients (all P < 0.001). Relative to no stent patients, ST12 patients had a longer length of stay and, at 30 days, significantly higher complication rates, including pneumonia, myocardial infarction (MI), sepsis, acute kidney injury, urinary tract infection (UTI), wound complications, transfusions, and 30-day readmissions (P < 0.05). Controlling for age, sex, comorbidities, and levels fused, ST12 was a significant predictor of MI within 30 days (OR 2.15 [95% CI 1.7-2.7], P < 0.001) and 90 days postoperatively (OR 1.87 [95% CI 1.6-2.2], P < 0.001). ST34 patients compared with no stent patients at 30 days presented with increased rates of complication, including pneumonia, MI, sepsis, UTI, wound complications, and 30-day readmissions. Regression analysis showed no significant differences in complications between ST12 vs ST34 at 30 days, but at 90 days, ST34 was associated with significantly increased rate and odds of death (1.1% vs 0.3%, P = 0.021; OR 1.94 [95% CI 1.13-3.13], P = 0.01). CONCLUSION: Cardiac stents failed to normalize risk profile of patients with coronary artery disease. Postoperatively at 90 days, elective spine fusion patients with 3 or more stents were significantly at risk of mortality compared with patients with fewer or no stents.

Orthopedic Surgery Fellowship Directors: Trends in Demographics, Education, Employment, and Institutional Familiarity.

Background: Fellowship directors are assumed to be distinguished in orthopedics, but the traits and training that have enabled them to achieve their leadership positions have not been assessed. Purpose: We sought to identify common demographics, research output, and educational trends of fellowship directors in orthopedics, with an emphasis on racial, ethnic, and gender diversity. Methods: We conducted a literature review to identify published studies on fellowship directors in orthopedic surgery and found 4 cross-sectional studies of fellowship directors in spine, arthroplasty, pediatrics, and sports medicine subspecialties. Another 4 accredited orthopedic subspecialties and their fellowship directors were identified using the American College of Graduate Medical Education Public Accreditation Data System for 2020-2021 and national fellowship directories. Data endpoints included race/ethnicity, age, sex, residency and fellowship training institutions, year of fellowship completion, year of hire at current institution, year of fellowship directors appointment, and h-index. The demographics and educational backgrounds for listed fellowship directors were collected from curricula vitae (CVs). Results: Of the 537 fellowship directors identified among 8 orthopedic subspecialties, the average age was 52.9 ± 2.2 years, 5.6% (N = 30) were women, 79.1% (N = 406) were white, 12.5% (N = 64) were Asian American, 3.7% (N = 19) were African American, 2.9% (N = 15) were Middle Eastern, and 1.7% (N = 9) were Hispanic/Latino. Oncology 20% (N = 4) had the highest percentage of female fellowship directors; 37.6% (N = 202) of fellowship directors were at the same institution they trained at for residency or fellowship. Their average h-index was 18.6 ± 3.7. Conclusion: This study of fellowship directors in orthopedics found that they have a high research output and a high level of institutional familiarity. We identified a need for greater diversity in these leadership positions in both gender and race/ethnicity.

Surgical Site Infection After Primary Spinal Fusion Surgery for Adolescent Idiopathic Scoliosis: An Analysis of Risk Factors From a Nationwide Insurance Database.

STUDY DESIGN: Retrospective review. OBJECTIVE: The purpose of this study was to quantify the incidence and factors associated with surgical site infection (SSI) in pediatric patients undergoing spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Infection is a morbid complication after spinal fusion. The incidence of SSI after pediatric spinal fusion is likely underestimated; the use of a national database allows for a comprehensive assessment of this rare outcome. MATERIALS AND METHODS: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2019 and relevant patient records were queried to identify infections within 7, 30, and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors associated with postoperative infection. RESULTS: Out of 9801 patients who underwent primary fusion for AIS, 44 patients (0.4%) developed an infection within 7 postoperative days. The 30 days and 90 days incidences were 1.9% and 2.7%, respectively. Within 90 days, 154 (57.7%) of the patients with infection had undergone reoperation, of whom 72 underwent multiple reoperations. Obesity and male sex ( P < 0.05) were significantly associated with postoperative infection. The length of fusion was not a significant factor in the development of SSI ( P > 0.05). Eleven patients underwent an operation requiring hardware removal within 90 days. There were no significant factors associated with those undergoing hardware removal compared with those undergoing surgical debridement. CONCLUSIONS: The study identified a 2.7% 90 days incidence of SSI after posterior spinal fusion for AIS, with 57.7% of all infections requiring a return to the operating room. Preoperative patient-related characteristics associated with increased risk of postoperative SSI were male sex and obesity. The current study can be used to provide preoperative counseling regarding the risk of this postoperative complication. LEVEL OF EVIDENCE: Level III.

Predictors of Symptomatic Venous Thromboembolism in Patients with Soft Tissue Sarcoma in the Lower Extremity.

Orthopedic surgery and soft-tissue sarcoma (STS) both independently increase the risk of developing symptomatic venous thromboembolic events (SVTE), but there are no established risk factors or guidelines for how to prophylactically treat patients with STS undergoing surgery. The objectives of this study were to (1) identify the prevalence of SVTE in patients undergoing STS surgery, (2) identify risk factors for SVTE, and (3) determine the risk of wound complications associated with VTE prophylaxis. This retrospective study was conducted in a tertiary level, academic hospital. A total of 642 patients were treated for soft-tissue sarcoma in the lower extremity with follow up for at least 90 days for the development of SVTE such as deep venous thrombosis and pulmonary embolism. Multivariate logistic regression was used to identify predictors for these events by controlling for patient characteristics, surgical characteristics, and treatment variables, with significance held at p < 0.05. Twenty eight patients (4.36%) were diagnosed with SVTE. Multivariate analysis found six significant predictors ordered based on standardized coefficients: pre-operative (PTT) partial thromboplastin time (p < 0.001), post-operative PTT (p = 0.010), post-op chemotherapy (p = 0.013), metastasis at diagnosis (p = 0.025), additional surgery for metastasis or local recurrence (p = 0.004), and tumor size larger than 10 cm (p < 0.001). The risk of wound complications (p = 0.04) and infection (p = 0.017) increased significantly in patients who received chemical prophylaxis. Our study identifies risk factors for patients at increased risk of developing VTE. Further prospective research is necessary to identify which protocols would be beneficial in preventing SVTE in high-risk patients with a low profile of wound complications.

Improvement of postural stability and gait velocity after cervical decompression surgery in patients with cervical spondylotic myelopathy.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a progressive degenerative condition that can lead to significant neurological deficits, including gait instability. Biomechanical alterations of gait and its various components are poorly understood. The goal of the current study was to determine how spatiotemporal gait parameters, as well as postural and dynamic stability, change after surgery in CSM patients. METHODS: A total of 47 subjects were included, with 23 test subjects and 24 controls. Baseline measurements were made for both cohorts. In the CSM cohort, repeat measurements were made at 3 and 6 months postoperatively. To record spatiotemporal and dynamic stability parameters, subjects performed walking trials over force plates on a 15-m runway. To assess postural stability, standing balance trials were conducted on a floor-mounted force plate. Three-dimensional motion analysis cameras and gait modeling software were used to quantify and visually represent results. Statistical analysis was completed using repeated-measures ANOVA and paired t-tests. Significance was set at p < 0.05. RESULTS: CSM patients had significantly increased gait velocity at the 6-month follow-up (mean 0.948 ± 0.248 m/sec/leg length) versus baseline (mean 0.852 ± 0.257 m/sec/leg length) (p = 0.039). The tilted ellipse area was significantly decreased at the 6-month follow-up compared with baseline (mean 979.8 ± 856.7 mm2 vs 598.0 ± 391.1 mm2, p = 0.018). Angular momentum excursion was not significantly different between baseline and the 3- and 6-month follow-ups. CONCLUSIONS: CSM patients displayed significant improvement in gait velocity and postural stability parameters after decompressive surgery. Dynamic stability parameters did not change significantly during the study period.

Presence and Severity of Mental Illness Is Associated With Increased Risk of Postoperative Emergency Visits, Readmission, and Reoperation Following Outpatient ACDF: A National Database Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). METHODS: A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. RESULTS: Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). CONCLUSION: Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Venous Thromboembolic Events are Exceedingly Rare in Spinal Fusion for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Review of health care record database and determination of population statistics. OBJECTIVE: The purpose of this study was to quantify the incidence of clinically significant venous thromboembolic (VTE) events in patients undergoing spinal fusion surgery for adolescent idiopathic scoliosis (AIS) and to identify risk factors for VTE. SUMMARY OF BACKGROUND DATA: VTE is a serious complication that can cause disability and even death following surgery. Incidence of VTE following AIS surgery has not been well studied; the use of a national database allows the assessment of rare, yet important complications. MATERIALS AND METHODS: The PearlDiver Database was used to identify AIS patients who underwent primary instrumented spinal fusion between 2010 and 2020. Patient records were cross-referenced for documented VTEs within 30 and 90 postoperative days. Patients with nonidiopathic scoliosis were excluded. Logistic regression was used to evaluate risk factors for correlation with VTE events. RESULTS: Thirty-eight of 11,775 (0.323%) patients undergoing surgery for AIS developed a VTE complication within 90 postoperative days. Hypercoagulability [odds ratio (OR)=13.50, P <0.0001], spinal fusion involving 13+ vertebral levels (OR=2.61, P <0.0001), obesity (OR=1.30, P <0.005), and older (15-18 y) compared with younger adolescence (10-14 y) (OR=2.12, P <0.0001) were associated with VTE. Seven of 38 (18.4%) patients with a diagnosed thrombophilia experienced VTE. CONCLUSIONS: The incidence of clinically significant VTEs in pediatric patients following spinal fusion surgery for AIS is low with an incidence of 0.323%. Postoperative chemoprophylaxis in the general pediatric population is not indicated. Patients with obesity, those undergoing spinal fusion of 13 or more vertebrae, and adolescents 15-18 years old were found to have higher but still small risk of VTE following surgery. Further prospective studies are needed to validate the risk profile of patients with hypercoagulability and establish clinical guidelines for use of postoperative chemoprophylaxis in this cohort. LEVEL OF EVIDENCE: Level III.

Preoperative Substance Use Disorder Is Associated With an Increase in 90-Day Postoperative Complications, 1-Year Revisions and Conversion to Arthroplasty Following Arthroscopic Rotator Cuff Repair: Substance Use Disorder on the Rise.

PURPOSE: The purpose of the current study was to use a nationwide administrative-claims database to characterize the substance use disorder trends of patients undergoing arthroscopic rotator cuff repair (RCR). Additionally, we sought to evaluate the influence of preoperative substance use disorder on postoperative outcomes following arthroscopic RCR. METHODS: The Mariner database was used to identify patients undergoing RCR using CPT codes, ages 18-84 years old, from 2010 to 2019. Patients were stratified by substance use, including cannabis, cocaine, nicotine, alcohol, opioids, stimulants, or sedative, as defined by International Classification of Diseases (ICD) codes. Substance use disorders trends were reported. Postoperative outcomes assessed consisted of major complications, minor complications, infections, readmissions, and Emergency Department visits within 90 days of surgery. Additionally, postoperative stiffness, revision surgery, and conversion to arthroplasty within 1 year were evaluated. Multivariate logistic regressions were used to control for demographic and comorbid factors. RESULTS: Substance use trends from 2010 to 2019 show an increase in documentation of substance use in patients undergoing RCR. Individuals with a history of substance use disorder had an increased risk of adverse outcomes, most notably major medical complications (odds ratio [OR]: 1.63; 95% confidence interval [CI]: 1.44-1.86; P < .001), revision surgery (OR: 1.43; 95% CI: 1.30-1.56; P < .001), and conversion to arthroplasty (OR: 1.40; 95% CI: 1.08-1.80; P = .009). Subgroup analysis demonstrated that cannabis users were at higher risk for major medical complications (OR: 1.75; 95% CI: 1.15-2.56; P < .001), conversion to arthroplasty (OR: 3.54; 95% CI: 1.77-6.4; P < .001), and revision (OR: 1.53; 95% CI: 1.12-2.04; P < .05) compared to controls. Additionally, substance use was associated with higher medical costs in terms of procedural cost (ß; $3634: $3,490-3,777) and 90-day postoperative costs (ß: $436; $375-$498). CONCLUSION: Documentation of substance use disorder is increasing in individuals undergoing arthroscopic rotator cuff repair. Substance use is associated with higher rates of postoperative complications, overall costs, and revision surgery following arthroscopic RCR. Nicotine and cannabis use were most commonly associated with increased rates of postoperative complications and treatment failure. LEVEL OF EVIDENCE: IV, retrospective therapeutic case series.

Treatment of Hepatitis C Virus Prior to Posterior Lumbar Fusion: No Difference in Medical Outcomes or Reoperation.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To analyze and confirm the rates of postoperative complications of patients with hepatitis C virus (HCV) undergoing primary posterior lumbar fusion (PLF) and assess whether treatment of HCV before surgery reduces complications. BACKGROUND CONTEXT: HCV causes chronic disease, leading to increased risk of cirrhosis and chronic illness. Currently, there is a lack of research regarding whether the patient's HCV is a modifiable risk factor for postoperative complications after spinal procedures. METHODS: The Mariner database was utilized to find patients from 2010 to 2018 undergoing PLF with active follow-up for a year. Cases involving same-day revision procedures and patients with a history of spine, infection, trauma, human immunodeficiency virus, hepatitis B, or neoplasm were excluded. Patients with a history of HCV diagnosis were identified and further stratified whether they had prior treatment using the national drug codes for antiviral, interferons, or ribavirin. Patients with HCV were matched with those without respect to age, sex, and comorbidity of burden. Outcome measured included 90-day medical complications, infection, readmission, and 1-year reoperation. RESULTS: There were 2,129 patients with HCV and 10,544 patients in the matched control group who underwent primary PLF. Out of the 2,129 patients, 469 (22.0.%) were treated with HCV medications before surgery. Patients with prior history of HCV had a significantly increased risk of wound complications (4.4% vs. 3.2%, odds ratio 1.56, 95% confidence interval 1.24-1.96, P =0.009), and infection (7.7% vs. 5.7%, odds ratio 1.26, 95% confidence interval 1.07-1.53, P =0.009) within 90 days of surgery. Patients treated before surgery did not have a difference in major ( P =0.205) or minor medical complications ( P =0.681) after surgery. CONCLUSIONS: Patients with prior history of HCV are at increased risk for many complications after surgery; however, this risk factor does not seem to be modifiable as the treatment group did not experience any improvement in postoperative outcomes. LEVEL OF EVIDENCE: Level III.

Staging Bilateral Hip Arthroscopies Less Than 1 Year Apart May Reduce the Risk of Revision Surgery.

PURPOSE: To identify the influence of timing between staged bilateral hip arthroscopy on 90-day postoperative medical complications and 2-year surgical complications including revision, conversion to total hip arthroplasty (THA), and infection. METHODS: The Mariner data set of the PearlDiver all-payer claims database was queried for patients undergoing staged bilateral hip arthroscopy. Patients were stratified into cohorts based on time between arthroscopies: (1) ≤3 months, (2) 3 to ≤6 months, (3) 6 to ≤12 months, and (4) >1 year. Multivariate logistic regression was utilized to control for any confounding variables. RESULTS: In total, 998 patients underwent staged bilateral hip arthroscopy out of 38,080 patients who underwent primary hip arthroscopy. The 2-year revision rate was 7.6% for all patients undergoing bilateral hip arthroscopy, while 1.9% of patients underwent conversion to THA. Patients with arthroscopy procedures staged less than 1 year apart (cohorts 1, 2, and 3) had significantly decreased risk of revision compared to the greater than 1 year cohort (P = .008, .025, and .044, respectively). There were no differences in rates of major medical, minor medical, or remaining surgical complications between the cohorts. Direct comparisons between the cohorts staged ≤1 year apart showed no significant differences in medical or surgical complications (P > .05). CONCLUSIONS: The revision rate in all patients undergoing staged bilateral hip arthroscopy was 7.6%. Staging hip arthroscopy ≤1 year apart was associated with a decreased risk of revision when compared to the staged cohort >1 year. Among those staged less than 1 year, the timing of staging had no association with rates of medical or surgical complications. Patients who are indicated for bilateral hip arthroscopy may benefit from staging under 1 year apart to reduce the risk of revision surgery. Optimal timing decisions may be patient specific and rely on the duration of symptoms, severity of pathology, or progression of rehabilitation after the index procedure. LEVEL OF EVIDENCE: III, retrospective comparative study.

Economic and educational disparities are associated with an increased risk of revision surgery following shoulder arthroplasty.

BACKGROUND: There is limited literature exploring how nonmedical factors such as social determinants of health (SDOHs) are associated with postoperative outcomes following shoulder arthroplasty. METHODS: A retrospective cohort review of the Pearl Diver Database was used to capture patients undergoing either primary anatomic total or reverse shoulder arthroplasty from the fourth quarter of 2015 to the third quarter of 2019 with at least 1 year of active longitudinal follow-up. Patients with proximal humeral fractures, stress fractures, or septic arthritis were excluded. The included patients were then divided into 2 cohorts based on the presence of current SDOHs or a history of SDOHs. The SDOH cohort comprised 4 non-mutually exclusive categories: economic, educational, social, and environmental disparities. Subsequently, a control cohort was matched at a 1:1 ratio to the SDOH cohort. Primary outcome measures were assessed using a logistic regression and consisted of the following 90-day postoperative complications: minor and major medical complications and infection. Emergency department (ED) visits and readmissions for any cause were also assessed. Additionally, the following 1-year outcomes were assessed: aseptic loosening, instability, and revision arthroplasty. Surgical costs and 90-day postoperative costs were collected using averaged insurance reimbursements for both the control and SDOH cohorts. RESULTS: There were 5190 patients in each cohort. Economic disparities made up the largest portion of the SDOH cohort (n = 4631, 89.2%), followed by social (n = 741, 14.3%), environmental (n = 417, 8.0%), and educational (n = 99, 1.9%) disparities. Compared with the control cohort, SDOHs were associated with an increased risk of major complications (2.3% vs. 1.4%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.29-1.87; P < .001), minor complications (5.7% vs. 3.8%; OR, 1.62; 95% CI, 1.21-1.95; P = .001), readmissions (4.3% vs. 2.8%; OR, 1.56; 95% CI, 1.26-1.84; P < .001), and ED visits (15.2% vs. 11.0%; OR, 1.45; 95% CI, 1.29-1.63; P < .001) within 90 days following surgery. Additionally, SDOHs were associated with an increased risk of aseptic loosening (1.1% vs. 0.6%; OR, 1.85; 95% CI, 1.20-2.65; P = .006), instability (4.0% vs. 2.2%; OR, 1.80; 95% CI, 1.43-2.28; P < .001), and ipsilateral revision (9.2% vs. 7.6%; OR, 1.24; 95% CI, 1.08-1.43; P < .001) at 1 year postoperatively compared with the control cohort. CONCLUSION: SDOHs are associated with increased rates of adverse outcomes following shoulder arthroplasty including revision surgery, ED visits, length of stay, and overall cost compared with matched controls without SDOHs. Specifically, economic and educational disparities are associated with increased rates of adverse outcomes following surgery including revision surgery, ED visits, length of stay, and overall cost.

Prognostic Factors Impacting Surgical Outcomes in Patients With Cervical Spondylotic Myelopathy.

The purpose of surgical decompression in patients who have CSM is to stop the progression of symptoms and hopefully improve function. It is critical to understand prognostic factors that affect the outcome. Factors intrinsic to the patient that can adversely affect outcomes include diabetes, older age, tobacco use, the presence of mental health disease, and obesity. MRI imaging findings of T2 hyperintensity and clinical duration and severity of symptoms is also associated with poorer outcomes. Patients should be counseled regarding the efficacy of decompressive procedures for CSM and given realistic expectations based on their unique biophysical profiles.