Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods.

INTRODUCTION: Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically. METHODS: A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded. RESULTS: The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively. CONCLUSION: The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

Extracorporeal Shockwave Therapy for Foot and Ankle Disorders: A Systematic Review and Meta-Analysis.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) was first introduced into clinical practice in 1982 and has been a beneficial inclusion to the noninvasive treatment option of numerous orthopaedic pathologies. However, clinical evidence of the use of ESWT for various foot and ankle disorders has been limited with a consensus on its efficacy yet available. Therefore, the purpose of this study is to systematically review the literature, to provide a critical evaluation and meta-analysis for the use of ESWT in foot and ankle disorders. METHODS: The PubMed and Embase databases were systematically reviewed and clinical studies that reported ESWT use for various foot and ankle disorders included. RESULTS: A total of 24 clinical studies that included 12 randomized controlled trials and 12 case series were identified. Analysis of the evidence has indicated that ESWT can help manage plantar fasciitis, calcaneal spur, Achilles tendinopathy and Morton's neuroma. Meta-analysis of the change in pre- to post-VAS overall scores for plantar fasciitis significantly favored ESWT compared to placebo/conservative treatment with a MD -3.10 (95% CI, -4.36 to -1.83; I2 = 68%; P < 0.00001). CONCLUSIONS: The current evidence has suggested that ESWT can provide symptomatic benefit to plantar fasciitis treatment, with minimal and unremarkable side effects. Overall, ESWT has been demonstrated to be a safe treatment option with a favorable complication profile. Further well-designed studies of ESWT for the treatment of calcaneal spurs, Achilles tendinopathy and Morton's neuroma are warranted to more soundly and safely support its current use. Future studies are suggested to investigate the optimization of ESWT treatment protocols.

Patient Positioning for Proximal Femur Fracture Fixation: a Review of Best Practices.

PURPOSE OF REVIEW: Proximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury. RECENT FINDINGS: Strategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation. Positioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries.

Trends in Periprosthetic Knee Infection and Associated Costs: A Population-Based Study Using National Data.

Given increasing demand for primary knee arthroplasties, revision surgery is also expected to increase, with periprosthetic joint infection (PJI) a main driver of costs. Recent data on national trends is lacking. We aimed to assess trends in PJI in total knee arthroplasty revisions and hospitalization costs. From the National Inpatient Sample (2003-2016), we extracted data on total knee arthroplasty revisions (n = 782,449). We assessed trends in PJI prevalence and (inflation-adjusted) hospitalization costs (total as well as per-day costs) for all revisions and stratified by hospital teaching status (rural/urban by teaching status), hospital bed size (≤299, 300-499, and ≥500 beds), and hospital region (Northeast, Midwest, South, and West). The Cochran-Armitage trend test (PJI prevalence) and linear regression determined significance of trends. PJI prevalence overall was 25.5% (n = 199,818) with a minor increasing trend: 25.3% (n = 7,828) in 2003 to 28.9% (n = 19,275) in 2016; p < 0.0001. Median total hospitalization costs for PJI decreased slightly ($23,247 in 2003-$20,273 in 2016; p < 0.0001) while median per-day costs slightly increased ($3,452 in 2003-$3,727 in 2016; p < 0.0001), likely as a function of decreasing length of stay. With small differences between hospitals, the lowest and highest PJI prevalences were seen in small (≤299 beds; 22.9%) and urban teaching hospitals (27.3%), respectively. In stratification analyses, an increasing trend in PJI prevalence was particularly seen in larger (≥500 beds) hospitals (24.4% in 2003-30.7% in 2016; p < 0.0001), while a decreasing trend was seen in small-sized hospitals. Overall, PJI in knee arthroplasty revisions appears to be slightly increasing. Moreover, increasing trends in large hospitals and decreasing trends in small-sized hospitals suggest a shift in patients from small to large volume hospitals. Decreasing trends in total costs, alongside increasing trends in per-day costs, suggest a strong impact of length of stay trends and a more efficient approach to PJI over the years (in terms of shorter length of stay).

Pediatric Group A streptococcal spinal epidural abscess presenting with recurrent symptoms of viral illness: An operative case report.

BACKGROUND: Spinal epidural abscess (SEA) in children is a rare condition with dangerous sequelae, and with only 22 other cases reported in the literature, treatment algorithms are poorly understood. Quick identification of the classic tried of sepsis, back pain and neurological deficit is critical. Source identification difficult and often cannot be identified. Reported pathogens include varicella-zoster virus, S. aureus, and S pyogenes. CASE DESCRIPTION: We report a case of spontaneous pediatric SEA in a 22-month old female without obvious neurologic deficit, who underwent a T10-11 decompressive laminotomy and evacuation of abscess and subsequent 3-week course of intravenous ceftriaxone for culture positive S. pyogenes. OUTCOME: The patient showed marked improvement in symptoms after decompression. 5 weeks postoperatively after transitioning from intravenous ceftriaxone to oral ceftin, the patient redeveloped a deep space infection and was taken back for a repeat debridement. The cultures from this procedure were negative and the patient was discharged on oral clindamycin. CONCLUSIONS: Pediatric spontaneous SEA is a rare condition and early diagnosis and surgical intervention if indicated can prevent dangerous sequelae. Further studies into the surgical indications for decompression will aid in algorithmic decision making.

Progressive double major scoliotic curve with concurrent lumbosacral spondylolisthesis in a skeletally immature patient with Marfan syndrome treated with anterior scoliosis correction.

STUDY DESIGN: Case report (review of patient records, imaging, and pulmonary function tests) and literature review. OBJECTIVES: To describe the case of a skeletally immature patient with Marfan syndrome who underwent anterior scoliosis correction (ASC) and muscle-sparing posterior far lateral interbody fusion (FLIF) in a two-stage procedure to correct progressive severe double major scoliosis and spondylolisthesis. Patients with Marfan syndrome suffer from rapidly progressive scoliosis and spondylolisthesis. Operative treatment has typically been limited to PSF, but newer techniques may be less invasive and provide more spine motion. METHODS: A 12-year-old girl with Marfan syndrome, spondylolisthesis, and severe progressive scoliosis underwent a two-stage procedure to achieve correction. Muscle-sparing posterior FLIF of the spondylolisthesis from L4-S1 was initially performed, followed 1 week later by ASC from right T4-T11 and left T11-L3 using an anterior screw/cord construct. RESULTS: Follow-up from the index procedures for the spondylolisthesis and scoliosis is 35 months. No significant complications occurred in perioperative and postoperative follow-up periods. At the 13-month follow-up, the double major scoliosis showed continued curve correction via growth modulation and overcorrection of the lumbar to - 13°. A revision lengthening procedure of the anterior cord from T11-L3 was performed. An asymptomatic elevated hemidiaphragm was discovered at 6 weeks postoperation, which was believed to be secondary to retraction neuropraxia and subsequently improved. At 21 months postlengthening and 35 months postindex procedure, she is skeletally mature and the curves have maintained correction in both the coronal and sagittal planes without any further complications. CONCLUSIONS: Anterior scoliosis correction of both a thoracic and lumbar curve combined with an L4-S1 PSF was effective for this patient and may be promising for patients with Marfan syndrome, progressive scoliosis, and spondylolisthesis. Overcorrection can be planned for and easily corrected by inserting a new cord of a different length.

Body Image Disturbance Improvement After Operative Correction of Adolescent Idiopathic Scoliosis.

HYPOTHESIS: Body Image Disturbance Questionnaire-Scoliosis version (BIDQ-S) is a sensitive outcomes instrument to evaluate improvements in body image-related psychosocial effects with surgical correction. DESIGN: Prospective observational study. INTRODUCTION: The BIDQ-S was previously validated (convergent validity, internal consistency) as a tool to assess body image-related distress and psychosocial impairment in adolescent idiopathic scoliosis (AIS). This study was conducted to evaluate responsiveness to change in the BIDQ-S associated with surgical treatment of AIS two years postoperatively to complete the validation of this questionnaire. METHODS: Seventy-five consecutive operative AIS patients were enrolled and completed BIDQ-S and Scoliosis Research Society-22 (SRS-22) at preoperative and two-year postoperative visits. Demographic and radiographic data were collected. Preoperative and two-year postoperative BIDQ-S (1 = best, 5 = worst) and SRS-22 scores (1 = worst, 5 = best) were compared using paired t test. Correlations between BIDQ-S and SRS-22 scores were evaluated by linear regression. RESULTS: Eighty-four percent of the subjects were females, with average age at surgery of 14.4 ± 1.6 years. The mean follow-up was 2.26 years (range 2.0-4.5). The major Cobb was corrected from 50.0° ± 7.2° to 14.2° ± 5.8° (Δ = 71.3% ± 12.1%; p < .0001). There was a significant improvement in BIDQ-S scores after surgery (1.64 ± 0.51 to 1.21 ± 0.38, p < .0001). BIDQ-S improvements were correlated with change in SRS self-image (p = .0055), activity (p = .0057), mental (p = .0018), and overall mean (p = .0007) domains. Preoperative, two-year postoperative, and Δ BIDQ-S score were not associated with major Cobb magnitude, truncal rotation, or Lenke curve type. Patients who reached SRS-22r minimal clinically important difference (MCID) in activity and self-image domains had worse preoperative BIDQ scores than those who did not reach MCID (activity 1.91 vs. 1.54 [1 = best, 5 = worst], p = .0099; self-image 2.08 vs. 1.51, p < .0001). Greater improvement in BIDQ-S was noted in patients who reached MCID in SRS-22 self-image than those who did not (Δ = 0.77 vs. 0.38, p = .0052). CONCLUSION: BIDQ-S is responsive to surgical correction of AIS. The BIDQ-S is a valuable clinical outcome tool to assess the psychosocial effects of scoliosis in adolescents augmenting existing outcome instruments.

Impact of Obesity on Surgical Outcomes Following Laminectomy for Spinal Metastases.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To determine the effect of obesity (body mass index >30 kg/m2) on perioperative morbidity and mortality after surgical decompression of spinal metastases. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database is a large multicenter clinical registry that collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent decompression with laminectomy for treatment of metastatic spinal lesions between 2010 and 2014. Patients were separated into 2 cohorts based on the presence of absence of obesity. Univariate analysis and multivariate logistic regression analysis were used to analyze the effect of obesity on perioperative morbidity and mortality. RESULTS: There was a significantly higher rate of venous thromboembolism (VTE; obese 6.6% vs nonobese 4.2%; P = .01) and pulmonary complications (obese 2.6% vs nonobese 2.2%; P = .046) in the obese group compared with the nonobese group. The nonobese group had prolonged hospitalization (obese 62.0% vs nonobese 69.0%; P = .001) and a higher incidence of blood transfusions (obese 26.8% vs nonobese 34.2%; P < .001). On multivariate analysis, obesity was found to be an independent risk factor for VTE (odds ratio = 1.75, confidence interval = 1.17-2.63, P = .007). CONCLUSIONS: Obese patients were predisposed to an elevated risk of VTE following laminectomy for spinal metastases. Early postoperative mobilization and a low threshold to evaluate for perioperative VTE are important in these patients in order to appropriately diagnose and treat these complications and minimize morbidity.

Hypoalbuminemia as an Independent Risk Factor for Perioperative Complications Following Surgical Decompression of Spinal Metastases.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Malnutrition has been shown to be a risk factor for poor perioperative outcomes in multiple surgical subspecialties, but few studies have specifically investigated the effect of hypoalbuminemia in patients undergoing operative treatment of metastatic spinal tumors. The aim of this study was to assess the role of hypoalbuminemia as an independent risk factor for 30-day perioperative mortality and morbidity after surgical decompression of metastatic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014. METHODS: We identified 1498 adult patients in the ACS-NSQIP database who underwent laminectomy and excision of metastatic extradural spinal tumors. Patients were categorized into normoalbuminemic and hypoalbuminemic (ie, albumin level <3.5 g/dL) groups. Univariate and multivariate regression analyses were performed to examine the association between preoperative hypoalbuminemia and 30-day perioperative mortality and morbidity. Subgroup analysis was performed in the hypoalbuminemic group to assess the dose-dependent effect of albumin depletion. RESULTS: Hypoalbuminemia was associated with increased risk of perioperative mortality, any complication, sepsis, intra- or postoperative transfusion, prolonged hospitalization, and non-home discharge. However, albumin depletion was also associated with decreased risk of readmission. There was an albumin level-dependent effect of increasing mortality and complication rates with worsening albumin depletion. CONCLUSIONS: Hypoalbuminemia is an independent risk factor for perioperative mortality and morbidity following surgical decompression of metastatic spinal tumors with a dose-dependent effect on mortality and complication rates. Therefore, it is important to address malnutrition and optimize nutritional status prior to surgery.

Progressive Neuromuscular Scoliosis Secondary to Spinal Cord Injury in a Young Patient Treated With Nonfusion Anterior Scoliosis Correction.

Ninety-eight percent of skeletally immature patients with spinal cord injury (SCI) suffer from progressive neuromuscular scoliosis (NMS). Operative treatment has typically been limited to posterior spinal fusion (PSF), but a newer technique as described may be less invasive and preserve more function. A PSF of the entire spine to the pelvis is standard of care. However, maintenance of spinal flexibility, motion, and potential growth is desirable. We present a case for proof-of-concept of utilizing a surgical motion-preserving technique to treat progressive NMS in an 11year-old girl with T10 level (AIS B) paraplegia with a progressive 60° NMS of the lumbar spine. She had anterior scoliosis correction (ASC) from T11-L5 without fusion. Over 24 months, the curve growth-modulated to a residual of 12° with continued modulation to 7° at 3-year follow-up (skeletal maturity).

Age Is a Risk Factor for Postoperative Complications Following Excisional Laminectomy for Intradural Extramedullary Spinal Tumors.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: The incidence of intradural extramedullary (IDEM) spinal tumors is increasing. Excisional laminectomy for removal and decompression is the standard of care, but complications associated with patient age are unreported in the literature. Our objective is to identify if age is a risk factor for postoperative complications after excisional laminectomy of IDEM spinal tumors. METHODS: A retrospective analysis was performed on the 2011 to 2014 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database for patients undergoing excisional laminectomy of IDEM spinal tumors. Age groups were determined by interquartile analysis. Chi-squared tests, t tests, and multivariate logistic regression models were employed to identify independent risk factors. Institutional review board approval was not needed. RESULTS: A total of 1368 patients met the inclusion criteria for the study. Group 1 (age ≤ 44) contained 372 patients, group 2 (age 45-54) contained 314 patients, group 3 (age 55-66) contained 364 patients, and group 4 (age > 66) contained 318 patients. The univariate analysis showed that mortality and unplanned readmission were highest among patients in group 4 (1.26%, P = .011, and 10.00%, P = .039, respectively). Postoperative wound complications were highest among patients in group 1 (2.15%, P = .009), and postoperative venous thromboembolism and cardiac complications were highest among patients in group 3 (4.4%, P = .007, and 1.10%, P = .032, respectively). Multivariate logistic regression revealed that elderly age was an independent risk factor for postoperative venous thromboembolism (group 3 vs group 1; odds ratio = 6.739, confidence interval = 1.522-29.831, P = .012). CONCLUSIONS: This analysis revealed that increased age is an independent risk factor for postoperative venous thromboembolism in patients undergoing excisional laminectomy for IDEM spinal tumors.

Risk Factors for Perioperative Complications in Morbidly Obese Patients Undergoing Elective Posterior Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The prevalence of obesity-related low back pain and degenerative disc disease is on the rise. Past studies have demonstrated that obesity is associated with higher perioperative complication rates, but there remains a gap in the literature regarding additional risk factors that further predispose this already high-risk patient population to poor surgical outcomes following elective posterior lumbar fusion (PLF). The aim of the study is to identify independent risk factors for poor 30-day perioperative outcomes in morbidly obese patients undergoing elective PLF. METHODS: We identified 22 909 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent elective PLF. There were 1861 morbidly obese patients. Baseline patient demographics and medical comorbidities were collected. Univariate analysis was performed to compare perioperative complication rates between non-morbidly obese and morbidly obese patients. The 5 most common complications in the morbidly obese group were then selected for multivariate regression analysis to identify independent risk factors for poor 30-day outcomes. RESULTS: Morbidly obese patients had a higher perioperative complication rate. The 5 most common complications were prolonged hospitalization, blood transfusion, readmission, wound complications, and reoperation. Independent risk factors for these complications were age ≥65 years, super obesity (ie, BMI > 48.6), chronic steroid use, American Society of Anesthesiology classification ≥3, poor functional status, long length of fusion ≥4 levels, and extended operative time (ie, operative time ≥318 minutes). CONCLUSIONS: Morbidly obese patients are at higher risk of perioperative complications following elective PLF. Modifiable risk factors for the most common complications are obesity and preoperative steroid use.

Preoperative Nutritional Status as a Risk Factor for Major Postoperative Complications Following Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine rates of medical and surgical postoperative complications in adults with hypoalbuminemia undergoing anterior lumbar interbody fusion (ALIF). METHODS: This was a retrospective analysis of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database of patients (≥18 years old) undergoing ALIF procedures, identified by CPT (Current Procedural Terminology) code from 2011 to 2014. Poor nutritional status was defined by a preoperative serum albumin level <3.5 g/dL, and albumin levels above this were considered normal. Multivariate logistic regression models were utilized to assess preoperative risk factors including nutritional status as predictors of specific postoperative complications. Significance was defined as P < .05 and odds ratios (ORs) were calculated with a 95% confidence interval (CI). This model was used to determine the strength of nutritional status as an adjusted predictor of adverse postoperative events. RESULTS: There were 3184 ALIF cases, including 1,275 (40%) of which had preoperative serum albumin levels. 53 (4.15%) patients were classified as having poor nutrition status. Poor preoperative nutritional status was shown to be a strong independent predictor of length of stay ≥5 days (OR = 2.56, 95% CI 1.43-4.59, P = .002), urinary tract infection (OR = 5.93, 95% CI 2.11-16.68, P = .001), and sepsis (OR = 5.35, 95% CI 1.13-25.42, P = .035) compared to patients with normal preoperative serum albumin levels. CONCLUSIONS: Our analysis shows that patients with poor nutritional status before ALIF are independently at risk for sepsis as well as increased length of stay and urinary tract infection.

Diabetes Mellitus as a Risk Factor for Acute Postoperative Complications Following Elective Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: Diabetes mellitus is a highly prevalent disease in the United States. Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. Considering utilization of spinal surgery will continue to increase, this study investigates the influence of diabetes mellitus on acute postoperative outcomes following elective ASD surgery. METHODS: The 2010-2014 American College of Surgeon's National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases (9th Revision) diagnosis codes relevant to ASD surgery. Patients were divided into cohorts based on their diabetic status. Bivariate and multivariate logistic regression analyses were employed to identify which 30-day postoperative outcomes patients are at risk for. RESULTS: A total of 5809 patients met the inclusion criteria for the study of which 4553 (84.2%) patients were nondiabetic, 578 (10.7%) patients had non-insulin-dependent diabetes mellitus (NIDDM), and 275 (5.1%) patients had insulin-dependent diabetes mellitus (IDDM). Diabetes status was significantly associated with length of stay ≥5 days (NIDDM: odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.02-1.58, P = .034; IDDM: OR = 1.55, 95% CI = 1.15-2.09, P = .004), any complication (NIDDM: OR = 1.26, 95% CI = 1.01-1.58, P = .037), urinary tract infection (NIDDM: OR = 1.87, 95% CI = 1.14-3.05, P = .012), and cardiac complications (IDDM: OR = 4.05, 95% CI = 1.72-9.51, P = .001). CONCLUSIONS: Given the prevalence of diabetes, surgeons will invariably encounter these patients for ASD surgery. The present study identifies the increased risk NIDDM and IDDM patients experience following ASD surgery. Quantification of this increased risk may improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety.

Age Stratification of 30-Day Postoperative Outcomes Following Excisional Laminectomy for Extradural Cervical and Thoracic Tumors.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To evaluate age as an independent predictive factor for perioperative morbidity and mortality in patients undergoing surgical decompression for metastatic cervical and thoracic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014. METHODS: We identified 1673 adult patients undergoing excisional laminectomy of cervical and thoracic extradural tumors. Patients were stratified into quartiles based on age, with Q1 including patients aged 18 to 49 years, Q2 including patients aged 50 to 60 years, Q3 including patients aged 61 to 69 years, and Q4 including patients ≥70 years. Univariate and multivariate regression analyses were performed to examine the association between age and 30-day perioperative morbidity and mortality. RESULTS: Age was an independent risk factor for 30-day venous thromboembolism (VTE) and reoperation. Patients in Q3 for age had nearly a 4 times increased risk of VTE than patients in Q1 (odds ratio [OR] 3.97; 95% CI 1.91-8.25; P < .001). However, there was no significant difference in VTE between patients in Q4 and Q1 (P = .069). Patients in Q2 (OR 1.99; 95% CI 1.06-3.74; P = .032) and Q4 (OR 2.18; 95% CI 1.06-4.52; P = .036) for age had a 2 times increased risk of reoperation compared with patients in Q1. CONCLUSIONS: Age was an independent predictive factor for perioperative VTE and reoperation, but there was no clear age-dependent relationship between increasing age and the risk of these perioperative complications.

Outcomes and Complications Following Laminectomy Alone for Thoracic Myelopathy due to Ossified Ligamentum Flavum: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: Examine the functional outcomes and complications following laminectomy for thoracic myelopathy due to ossification of the ligamentum flavum (OLF). SUMMARY OF BACKGROUND DATA: OLF is a rare condition that can cause thoracic myelopathy. Laminectomy is a procedure that can be performed to decompress the spinal cord in patients with thoracic myelopathy due to OLF. Few studies have examined postoperative outcomes and complications following laminectomy for thoracic myelopathy secondary to OLF. METHODS: A systematic review and meta-analysis was performed. Literature search yielded six studies that met our selection criteria. Study characteristics and baseline patient demographics were extracted from each study. Primary outcomes included pre- and postoperative Japanese Orthopedic Association (JOA) scores and perioperative complications including dural tears, cerebrospinal fluid (CSF) leaks, neurological deficits, surgical site infections, and other complications. We calculated pooled proportion estimates for JOA scores and complications using a random effects model. RESULTS: A total of 137 patients were included. The pooled pre- and postoperative JOA scores were 5.08 (95% confidence interval [CI], 2.70-7.47; I = 98%) and 8.29 (95% CI, 7.73-8.85; I = 18%), respectively, with a mean improvement of +3.03 points (95% CI, 1.08-4.98; I = 88%). Pooled proportion estimates for dural tears, CSF leaks, infections, and early neurological deficits were 18.4% (95% CI, 12.6-26.1; I = 0%), 12.1% (95% CI, 6.6-21.2; I = 0%), 5.8% (95% CI, 2.1-15.4; I = 0%), and 5.7% (95% CI, 2.2-14.3; I = 0%), respectively. CONCLUSION: Thoracic myelopathy secondary to OLF can be treated with laminectomy. However, despite some improvement in JOA score, functional status remains poor postoperatively. Perioperative complications are common, with dural tears and CSF leaks occurring most frequently. OLF is an uncommon condition and more research is needed to better understand how we can improve the outcomes of laminectomy alone for the treatment of thoracic myelopathy due to OLF. LEVEL OF EVIDENCE: 3.

Nutritional Insufficiency as a Predictor for Adverse Outcomes in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: The effect of malnutrition on outcomes after general surgery has been well reported in the literature. However, there is a paucity of data on the effect of malnutrition on postoperative complications during adult deformity surgery. The study attempts to explore and quantify the association between hypoalbuminemia and postoperative complications. METHODS: A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing adult deformity surgery were separated into cohorts based serum albumin (<3.5 or >3.5 g/dL). Chi-square and multivariate logistic regression models were used to identify independent risk factors. RESULTS: A total of 2236 patients met the inclusion criteria for the study, of which 2044 (91.4%) patients were nutritionally sufficient while 192 (8.6%) patients were nutritionally insufficient. Multivariate logistic regressions revealed nutritional insufficiency as a risk factors for mortality (odds ratio [OR] = 15.67, 95% confidence interval [CI] = 6.01-40.84, P < .0001), length of stay ≥5 days (OR = 2.22, 95% CI = 1.61-3.06, P < .0001), any complications (OR = 1.82, 95% CI = 1.31-2.51, P < .0001), pulmonary complications (OR = 2.29, 95% CI = 1.29-4.06, P = .005), renal complications (OR = 2.71, 95% CI = 1.05-7.00, P = .039), and intra-/postoperative red blood cell transfusion (OR = 1.52, 95% CI = 1.08-2.12, P = .015). CONCLUSIONS: This study demonstrates that preoperative hypoalbuminemia is a significant and independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital in patients undergoing adult deformity surgery surgery. Nutritional status is a modifiable risk factor that can potentially improve surgical outcomes after adult deformity surgery.

Incidence of reoperation and wound dehiscence in patients treated for peroneal tendon dislocations: comparison between osteotomy versus soft tissue procedures.

PURPOSES: There is a lack of substantial clinical evidence endorsing the clinical outcomes of osteotomy for peroneal tendon dislocations. The aim of this study was to compare the post-operative reoperation rates following osteotomy techniques and soft tissues procedures using large database in order to investigate the efficacy of bony techniques. METHODS: Patients who underwent osteotomy and soft tissue procedures for peroneal tendon dislocations were identified and subsequently analysed using the United Healthcare Orthopedic and the Medicare datasets (PearlDiver Patient Record Database, PearlDiver Technologies Inc., Fort Wayne, IN). The investigated period was from 2005 to 2012. The annual incidence, gender distribution, and incidences of reoperation and wound dehiscence following primary operative procedures were determined in these cohorts. RESULTS: Of 6122 patients who received operative treatment for peroneal tendon dislocations, 1416 patients (23.1%) received the osteotomy technique, while 4706 (76.9%) were treated with the soft tissue techniques. The incidence of these operative procedures did not change significantly over the time periods of each database. In both databases, reoperation rates were 2.8% (40/1416) for osteotomy patients and 3.4% (158/4706) for soft tissue repair patients, with no statistical difference (2.8 vs. 3.4%. odds ratio 0.8, 95% confidence interval [CI] 0.6-1.2, [n.s.]) between them. Based on both databases, wound dehiscence occurred in 2.6% (37/1416) of the osteotomy patients and 2.3% (110/4706) of soft tissue repair patients with no statistical difference (2.6 vs. 2.3%, odds ratio 1.1, 95% CI 0.8-1.6, [n.s.]) between the groups. CONCLUSION: The results of this study show that osteotomy techniques were frequently performed for patients with peroneal tendon dislocations. Nevertheless, osteotomy techniques for peroneal tendon dislocations are not associated with a lower risk of reoperation. In conclusion, soft tissue procedures offer a satisfactory method of treating peroneal tendon dislocations without any additional risk of reoperation when compared to osteotomy techniques that have potentially greater complication rates. LEVEL OF EVIDENCE: III.

The Impact of Metastatic Spinal Tumor Location on 30-Day Perioperative Mortality and Morbidity After Surgical Decompression.

STUDY DESIGN: A retrospective cohort study from 2011 to 2014 was performed using the American College of Surgeons National Surgical Quality Improvement Program database. OBJECTIVE: The purpose of this study was to assess the impact of tumor location in the cervical, thoracic, or lumbosacral spine on 30-day perioperative mortality and morbidity after surgical decompression of metastatic extradural spinal tumors. SUMMARY OF BACKGROUND DATA: Operative treatment of metastatic spinal tumors involves extensive procedures that are associated with significant complication rates and healthcare costs. Past studies have examined various risk factors for poor clinical outcomes after surgical decompression procedures for spinal tumors, but few studies have specifically investigated the impact of tumor location on perioperative mortality and morbidity. METHODS: We identified 2238 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent laminectomy for excision of metastatic extradural tumors in the cervical, thoracic, or lumbosacral spine. Baseline patient characteristics were collected from the database. Univariate and multivariate regression analyses were performed to examine the association between spinal tumor location and 30-day perioperative mortality and morbidity. RESULTS: On univariate analysis, cervical spinal tumors were associated with the highest rate of pulmonary complications. Multivariate regression analysis demonstrated that cervical spinal tumors had the highest odds of multiple perioperative complications. However, thoracic spinal tumors were associated with the highest risk of intra- or postoperative blood transfusion. In contrast, patients with metastatic tumors in the lumbosacral spine had lower odds of perioperative mortality, pulmonary complications, and sepsis. CONCLUSION: Tumor location is an independent risk factor for perioperative mortality and morbidity after surgical decompression of metastatic spinal tumors. The addition of tumor location to existing prognostic scoring systems may help to improve their predictive accuracy. LEVEL OF EVIDENCE: 3.

Open Versus Arthroscopic Ankle Arthrodesis: A Comparison of Subsequent Procedures in a Large Database.

Arthroscopic and open ankle arthrodesis have been compared in very few studies, and no consensus has been reached regarding the incidence of postoperative revision surgery associated with each technique. The purpose of the present study was to compare these 2 approaches for the incidence of postsurgical operations. Patients who had undergone either arthroscopic or open ankle arthrodesis were identified between January 2005 to December 2011 in the PearlDiver(™) database using a predetermined algorithm and searched for the following postsurgical operations: revision ankle arthrodesis, midfoot arthrodesis, and hindfoot arthrodesis. In the current database, 7322 cases were performed with an open technique and 1152 arthroscopically. The incidence of revision arthrodesis was not significantly different statistically between the 2 techniques. However, the incidence of subsequent adjacent joint arthrodesis was greater for the open cohort (5.6% versus 2.6%; odds ratio 2.17, 95% confidence interval 1.49 to 3.16). In the open cohort, the incidence of hindfoot arthrodesis was greater than the incidence of midfoot arthrodesis (3.9% versus 1.6%, odds ratio 2.43, 95% confidence interval 1.95 to 3.01). The results showed that although open ankle arthrodesis is more commonly performed, it is associated with a greater incidence of subsequent adjacent joint arthrodesis specifically in the hindfoot.