The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

Outpatient Simultaneous Bilateral Total Knee Arthroplasty: Is It Safe?

BackgroundIt is currently unknown if simultaneous bilateral total knee arthroplasty (si-BTKA) can also be safely performed in the outpatient setting. The primary aim of this study was to compare 30-day postoperative complication rates between outpatient and inpatient si-BTKA.MethodsAdults undergoing simultaneous bilateral total knee arthroplasty (si-BTKA) from 2015-2019 were queried using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Our primary analysis compared the rates of complications between outpatient si-BTKA and inpatient si-BTKA using bivariate comparisons and multivariable logistic regression of outpatient and inpatient cases controlling for differences in baseline demographics and comorbidities.ResultsFrom 2015 to 2019, the utilization of outpatient si-BTKA increased from 0.6% to 10.5%. Outpatient si-BTKA were found to have significantly lower odds of any complication (OR = 0.49), minor complication (OR = 0.50), and postoperative transfusion (OR = 0.66) compared to inpatient cases. Outpatient si-BTKA also had a significantly shorter operative time.ConclusionCompared to inpatient si-BTKA, patients who undergo outpatient si-BTKA do not demonstrate increased rates of any complication, severe complications, and minor complications within 30-days postoperatively. Further insight is needed on the effect of outpatient si-BTKA on long-term outcomes.     

Complications after spinal fixation surgery for osteoporotic vertebral collapse with neurological deficits: Japan Association of Spine Surgeons with ambition multicenter study

BackgroundThere have been few reports on the incidence and risk factors of the complications after spinal fixation surgery for osteoporotic vertebral collapse (OVC) with neurological deficits. This study aimed to identify the incidence and risk factors of the complications after OVC surgery.MethodsIn this retrospective multicenter study, a total of 403 patients (314 women and 89 men; mean age 73.8 years) who underwent spinal fixation surgery for OVC with neurological deficits between 2005 and 2014 were enrolled. Data on patient demographics were collected, including age, sex, body mass index, smoking, steroid use, medical comorbidities, and surgical procedures. All postoperative complications that occurred within 6 weeks were recorded. Patients were classified into two groups, namely, complication group and no complication group, and risk factors for postoperative complications were investigated by univariate and multivariate analyses.ResultsPostoperative complications occurred in 57 patients (14.1%), and the most common complication was delirium (5.7%). In the univariate analysis, the complication group was found to be older (p = 0.039) and predominantly male (p = 0.049), with higher occurrence rate of liver disease (p = 0.001) and Parkinson's disease (p = 0.039) compared with the no-complication group. In the multivariate analysis, the significant independent risk factors were age (p = 0.021; odds ratio [OR] 1.051, 95% confidence interval [CI] 1.007–1.097), liver disease (p < 0.001; OR 8.993, 95% CI 2.882–28.065), and Parkinson's disease (p = 0.009; OR 3.636, 95% CI 1.378–9.599).ConclusionsComplications after spinal fixation surgery for OVC with neurological deficits occurred in 14.1%. Age, liver disease, and Parkinson's disease were demonstrated to be independent risk factors for postoperative complications.     

Patients with radiculopathy have worse baseline disability and greater improvements following anterior cervical discectomy and fusion compared to patients with myelopathy

BACKGROUND CONTEXTAnterior cervical discectomy and fusion (ACDF) is commonly performed in patients with radiculopathy and myelopathy. Although the goal of surgery in patients with radiculopathy is to improve function and reduce pain, patients with myelopathy undergo surgery to halt disease progression. Although the expectations between these preoperative diagnoses are generally understood to be disparate by spine surgeons, there is limited literature demonstrating their discordant outcomes.PURPOSETo compare improvements in patient reported outcome measures (PROMs) for patients undergoing ACDF for myelopathy or radiculopathy. Secondarily, we analyzed the proportion of patients who attain the minimum clinically important difference (MCID) postoperatively using thresholds derived from radiculopathy, myelopathy, and mixed cohort studies.STUDY DESIGN/SETTINGSingle institution retrospective cohort studyPATIENT SAMPLEPatients undergoing primary, elective ACDF with a preoperative diagnosis of radiculopathy or myelopathy and a complete set of preoperative and one-year postoperative PROMs.OUTCOME MEASURESOutcome measures included the following PROMs: Short-Form 12 Physical Component (PCS-12) and Mental Component (MCS-12) scores, the Visual Analog Scale (VAS) Arm score, and the Neck Disability Index (NDI). Hospital readmissions and revision surgery were also collected and evaluated.METHODSPatients undergoing an ACDF from 2014 to 2020 were identified and grouped based on preoperative diagnosis (radiculopathy or myelopathy). We utilized “general MCID” thresholds from a cohort of patients with degenerative spine conditions, and “specific MCID” thresholds generated from cohorts of patients with myelopathy or radiculopathy, respectively. Multivariate linear regressions were performed for delta (?) PROMs and multivariate logistic regressions were performed for both general and specific MCID improvements.RESULTSA total of 798 patients met inclusion criteria. Patients with myelopathy had better baseline function and arm pain (MCS-12: 49.6 vs 47.6, p=.018; VAS Arm: 3.94 vs 6.02, p<.001; and NDI: 34.1 vs 41.9, p<.001), were older (p<.001), had more comorbidities (p=.014), more levels fused (p<.001), and had decreased improvement in PROMs following surgery compared to patients with radiculopathy (?PCS-12: 4.76 vs 7.21, p=.006; ?VAS Arm: -1.69 vs -3.70, p<.001; and ?NDI: -11.94 vs -18.61, p<.001). On multivariate analysis, radiculopathy was an independent predictor of increased improvement in PCS-12 (β=2.10, p=.019), ?NDI (β=-5.36, p<.001), and ?VAS Arm (β=-1.93, p<.001). Radiculopathy patients were more likely to achieve general MCID improvements following surgery (NDI: Odds ratio (OR): 1.42, p=.035 and VAS Arm: OR: 2.98, p<.001), but there was no difference between patients with radiculopathy or myelopathy when using radiculopathy and myelopathy specific MCID thresholds (MCS-12: p=.113, PCS-12: p=.675, NDI: p=.108, and VAS Arm: p=.314).CONCLUSIONSPatients undergoing ACDF with myelopathy or radiculopathy represent two distinct patient populations with differing treatment indications and clinical outcomes. Compared to radiculopathy, patients with myelopathy have better baseline function, decreased improvement in PROMs, and are less likely to reach MCID using general threshold values, but there is no difference in the proportion reaching MCID when using specific threshold values.LEVEL OF EVIDENCEIRB     

The effect of continuous popliteal sciatic nerve block on unplanned postoperative visits and readmissions after foot surgery – a randomised,controlled study comparing day‐care and inpatient management

Regional anaesthesia has been shown to have several advantages over general anaesthesia in reducing the need for, and hence cost of, unscheduled outpatient visits or readmission to hospital. However, the benefit has not been evaluated in a direct comparison between day‐care patients and inpatients. We randomly allocated 120 patients undergoing unilateral foot surgery to either inpatient (two‐day postoperative stay) or day‐care management under continuous regional anaesthesia, and compared the impact on unscheduled postoperative outpatient visits, readmissions to hospital and the associated costs. The operations were performed under popliteal sciatic nerve block. A perineural catheter was inserted before surgery and removed from all patients on the third postoperative day. We found no significant difference in the incidence of outpatient visits (3.3% day‐care vs 5.0% inpatient, p = 0.640), readmissions (6.7% day‐care vs 3.3% inpatient, p = 0.395) or complications between the two groups. Costs were also significantly lower in the day‐care group (net difference €8011 (£6684; $10 986) per patient, p < 0.001). We conclude that continuous regional anaesthesia allows foot surgery to be performed as a day‐care procedure more cheaply than in inpatients, without an increase in clinical complications.     

Reduction mammaplasty in patients with history of breast cancer: The incidence of occult cancer and high-risk lesions

IntroductionContralateral reduction mammaplasty is regularly included in the treatment of breast cancer patients. We analyzed the incidence of occult breast cancer and high-risk lesions in reduction mammaplasty specimens of women with previous breast cancer. We also analyzed if timing of reduction mammaplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics.Materials and methodsThe study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammaplasty between 1/2007 and 12/2011. The data was retrospectively analyzed for demographics, operative and histopathology reports, oncological treatment, and postoperative follow-up.ResultsReduction mammaplasty specimens revealed abnormal findings in 68 (21.5%) patients. High-risk lesions (ADH, ALH, and LCIS) were revealed in 37 (11.7%), and cancer in six (1.9%) patients. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Abnormal histopathological findings were more frequent in patients with reduction mammaplasty performed prior to oncological treatment (p < 0.001), and in patients with immediate reconstruction (p = 0.0064).ConclusionThe incidences of malignant and high-risk lesions are doubled compared to patients without prior breast cancer. Patients with abnormal histopathology cannot be preoperatively identified based on demographics. If reduction mammaplasty is performed before oncological treatment, the incidence of abnormal findings is higher. In the light of our results, contralateral reduction mammaplasty with histopathological evaluation in breast cancer patients offers a sophisticated tool to catch those patients whose contralateral breast needs increased attention.     

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

IntroductionPatients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.MethodsAdults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.ResultsAfter propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.ConclusionCirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.Level of EvidencePrognostic Level III.     

IMPACT-Global Hip Fracture Audit: Nosocomial infection,risk prediction and prognostication,minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

AimsThis international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.MethodsA multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.ResultsA total of 7090 patients were included, with a mean age of 82.2 (range 50–104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.ConclusionThe prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.     

Are outpatient three- and four-level anterior cervical discectomies and fusion safe?

BACKGROUND CONTEXTThe safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management.PURPOSEThe present study aimed to investigate the safety of outpatient three- and four-level ACDF.STUDY DESIGNRetrospective cohort studyPATIENT SAMPLEThe National Surgical Quality Improvement Program – a large, prospectively-collected registry – was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting.OUTCOME MEASURESThe rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status.METHODSBaseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF.RESULTSIn total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not.CONCLUSIONSThis present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.     

Extended length of stay and postoperative complications in octogenarians with hypertension following revision total knee arthroplasty

BackgroundPrior studies have shown hypertensive patients to be at an increased risk of postoperative complications following various surgeries, including revision total knee arthroplasty (rTKA). However, whether these risks are compounded in octogenarian patients has not yet been well explored. The purpose of this study was to analyze whether hypertensive octogenarians, aged 80 to 89, undergoing rTKA are at an increased risk of postoperative complications relative to the younger hypertensive geriatric population aged 65 to 79.MethodsA national database was used to collect data for all hypertensive patients who underwent rTKA from 2006 to 2018. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, medical comorbidities, and postoperative complications were compared between the two cohorts. Bivariate and multivariate analyses were performed.ResultsOf the 6,599 hypertensive patients who underwent rTKA, 5,477 (83.0%) patients were in the aged 65 to 79 group and 1,122 (17.0%) patients were in the aged 80 to 89 group. Following adjustment to control for demographic and comorbidity data, relative to patients in the 65 to 79 age group, hypertensive patients who were 80–89 years old had an increased risk of unplanned reintubation (OR 3.52; p = 0.008), urinary tract infection (OR 2.08; p = 0.011), postoperative transfusion (OR 1.90; p < 0.001), myocardial infarction (OR 2.55; p = 0.017), and extended length of hospital stay (OR 1.77; p < 0.001).ConclusionHypertensive octogenarian patients undergoing rTKA have an increased risk of an extended length of stay and other postoperative complications relative to their younger hypertensive geriatric counterparts. Orthopaedic surgeons should consider a multi-disciplinary approach to managing hypertension in these octogenarian patients prior to surgery to minimize this risk. However, even with this risk, an octogenarian age should not be used independently in evaluating if a hypertensive geriatric patient is a safe rTKA candidate.     

Impact of comorbidities on oncological outcomes of Japanese patients with high grade soft tissue sarcomas

BackgroundConsidering the invasiveness of standard multidisciplinary approaches used for the treatment of soft tissue sarcoma, including surgery with wide margins, intensive chemotherapy, and radiotherapy, evaluation of comorbidities in high-grade soft tissue sarcoma patients is essential. Several previous studies have reported the impact of comorbidities on the survival of soft tissue sarcoma patients. Patient health status differs between nationalities or ethnic groups and only limited data has been reported with respect to the impact of comorbidities on Japanese soft tissue sarcoma patients.MethodsThe incidence of each comorbidity, relationship between comorbidities and underlying clinicopathological factors, relationship between treatment status and comorbidities, and impact of comorbidities on disease-specific death in 136 patients with high-grade soft tissue sarcoma at the authors' institution were analyzed. For the evaluation of comorbidities, the updated Charlson comorbidity index was applied.ResultsOf the patients, 25% presented with more than one comorbidity. Elderly patients showed a significantly higher incidence of comorbidities (p < 0.0001). Patients with congestive heart failure (p = 0.004), dementia (p < 0.0001), hemiplegia/paraplegia (p < 0.0001), and renal disease (p < 0.0001) showed worse prognosis. Tumor grade (p = 0.01) and updated Charlson comorbidity index (p < 0.0001) were independent risk factors for disease-specific death.ConclusionsComorbidity status was a significant risk factor for disease-specific death in Japanese patients with high-grade soft tissue sarcoma. Innovations in comorbidity management may be a means for the improvement of oncological outcomes in soft tissue sarcoma. Given the difficulties in conducting standard randomized control studies in this field, data accumulation from real-world cases appears to be the most practical approach in establishing and applying strategies for the treatment of patients with comorbidities or elderly patients.     

Association of pre-admission opioid abuse and/or dependence on major complications in traumatic brain injury (TBI) patients

SettingIn the last few decades, an opioid related health crisis has been a challenging problem in many countries around the world, especially the United States. Better understanding of the association of pre-admission opioid abuse and/or dependence (POAD) on specific major complications in traumatic brain injury (TBI) patients can aid the medical team in improving patient care management and outcomes.Study objectiveOur goal is to assess and quantify the risk of POAD on in-hospital mortality and major complications in TBI patients.DesignWe conducted a retrospective study and used the National Inpatient Sample (NIS) database from 2004 to 2015 to investigate the impact of POAD on in-hospital mortality and major complications in TBI patients. We utilized propensity score matching and conditional logistic regression models, adjusted with injury severity score (ISS) and comorbidities, to obtain the adjusted odds ratios (OR).Main resultsPOAD TBI patients had lower risks of in-hospital mortality (OR 0.58; p < 0.001) and acute myocardial infarction (OR 0.53; p = 0.045), while a higher risk of respiratory (OR 1.59; p < 0.001) and neurologic complications (OR 2.54; p < 0.001), compared to non-POAD TBI patients. Additionally, POAD patients were significantly more likely to have sepsis (OR 2.16, p < 0.001), malnutrition (OR 1.56, p < 0.001), delirium (OR 2.81, p < 0.001), respiratory failure (OR 1.79, p < 0.001), and acute renal failure (OR 1.83, p < 0.001). POAD TBI patients had shorter length of hospital stay compared to non-POAD TBI patients (mean 8.0 vs 9.2 days, p < 0.001).ConclusionsPOAD TBI patients have a lower in-hospital mortality, shorter duration of hospitalization and a lower risk of acute myocardial infarction, while they are more likely to have respiratory failure, delirium, sepsis, malnutrition, and acute renal failure compared to TBI patients without POAD. Prospective study is warranted to further confirm these findings.     

Over Half of All Medicare Total Knee Arthroplasty Patients Are Now Classified as an Outpatient–Three-Year Impact of the Removal From the Inpatient-Only List

BackgroundIn 2018, Centers for Medicare & Medicaid Services removed total knee arthroplasty (TKA) from its inpatient-only list, triggering many unintended consequences. The purpose of this study was to determine how the impact of TKA removal affected the number of outpatient TKA patients, which patients were being labeled outpatient, and how outpatient classification affected discharge location and readmission rates.MethodsUsing a large administrative claims database, we reviewed a consecutive series of 216,365 primary TKA Medicare patients from 2015 to 2020. Patients who had an inpatient status (n = 63,356) were compared to patients who had an outpatient status (n = 38,510) from 2018 to 2020 based on demographics, comorbidities, discharge dispositions, and readmissions.ResultsIn 2015, only 1.8% of TKA patients were designated as outpatients, but by 2020, 57.2% of Medicare TKA patients were classified as outpatients. A majority of patients (72%) who had an outpatient designation remained in the hospital for >24 hours (average length of stay was 2.7 days). Patients who had an outpatient status were discharged to skilled nursing facilities more frequently than patients who had an inpatient status (3.1 versus 2.0%, P < .001) with increased emergency visits (5.1 versus 3.9%, P < .001) and 90-day readmissions (2.2 versus 0.9%, P < .001).ConclusionOver half of all Medicare TKA patients are being classified as outpatients 3 years following the policy to remove TKA from the inpatient-only list. Patients designated as outpatients had higher readmissions than those designated as inpatients. This policy should be re-evaluated in the context of failure to demonstrate safer discharge of Medicare patients who undergo TKA.     

Major National Shifts to Outpatient Total Knee Arthroplasties in the United States: A 10-Year Trends Analysis of Procedure Volumes,Complications, and Healthcare Utilizations (2010 to 2020)

BackgroundThe removal of total knee arthroplasty (TKA) from inpatient-only lists accelerated changes in orthopaedic surgical practices across the United States. This study aimed to (1) quantify the annual volume of inpatient/outpatient primary TKAs; (2) compare patient characteristics before/after the year 2018; and (3) compare annual trends in 30-day readmissions, 30-day complications, and healthcare utilization parameters for inpatient/outpatient TKAs.MethodsThe National Surgical Quality Improvement Program was reviewed (January 2010 to December 2020) for patients who underwent primary TKA (n = 470,456). The primary outcome was annual volumes of inpatient/outpatient TKA. Secondary outcomes included 30-day readmissions, 30-day reoperations, and 30-day major/minor complications. Demographic characteristics and healthcare utilization parameters (hospital lengths of stay and discharge dispositions) were compared between cohorts via Chi-square goodness-of-fit tests.ResultsOverall, 89% had inpatient TKA (n = 416,972) and 11% had outpatient TKA (n = 53,854). Between 2017 and 2020, annual volumes of outpatient TKA increased by 1,925 (1,019 to 20,633), while inpatient TKA decreased by 53% (61,874 to 29,280). Patients who had outpatient TKA after 2018 were older (P < .001), predominantly males (P < .001), more commonly White (P < .001), and had a greater proportion of American Society of Anesthesiologists class III (P < .001). The inpatient cohort had higher rates of 30-day readmissions, reoperations, and complications. Average length of stay and nonhome discharges decreased for both cohorts.ConclusionOutpatient TKA increased 20-fold at NSQIP hospitals. The changes in comorbidity profiles and the increase in volumes of outpatient TKA were not associated with a rise in cumulative 30-day readmissions and complications. Further research and policy endeavors should focus on identifying patients who still require or benefit from inpatient TKA.     

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BackgroundThe Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.MethodsThis is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.ResultsControlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.ConclusionFor patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.     

Predictive factors for developing acute cholangitis and/or cholecystitis in patients undergoing delayed cholecystectomy: A retrospective study

Background/Objective: We evaluated the risk of acute cholangitis and/or cholecystitis while waiting for cholecystectomy for gallstones.MethodsWe retrospectively enrolled 168 patients who underwent cholecystectomy for gallstones after conservative therapy. We compared clinical data of 20 patients who developed acute cholangitis and/or cholecystitis while waiting for cholecystectomy (group A) with 148 patients who did not develop (group B). We investigated surgical outcomes and risk factors for developing acute cholangitis and/or cholecystitis.ResultsPreoperatively, significant numbers of patients with previous history of acute grade II or III cholecystitis (55.0% vs 10.8%; p < 0.001) and biliary drainage (20.0% vs 2.0%; p = 0.004) were observed between groups A and B. White blood cell counts (13500/μL vs 8155/μL; p < 0.001) and C-reactive protein levels (12.6 vs 5.1 mg/dL; p < 0.001) were significantly higher in group A than in group B; albumin levels (3.2 vs 4.0 g/dL; p < 0.001) were significantly lower in group A. Gallbladder wall thickening (≥5 mm) (45.0% vs 18.9%; p = 0.018), incarcerated gallbladder neck stones (55.0% vs 22.3%; p = 0.005), and peri-gallbladder abscess (20.0% vs 1.4%; p = 0.002) were significantly more frequent in group A than in group B. A higher conversion rate to open surgery (20.0% vs 2.0%; p = 0.004), longer operation time (137 vs 102 min; p < 0.001), and higher incidence of intraoperative complications (10.0% vs 0%; p = 0.014) were observed in group A, compared with group B.ConclusionA history of severe cholecystitis may be a risk factor for acute cholangitis and/or cholecystitis in patients waiting for surgery; it may also contribute to increased surgical difficulty.     

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

BackgroundThe purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis.MethodsA retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.ResultsThe DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892).ConclusionsIn our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.     

Thoracic sarcopenia predicts clinical outcomes in patients undergoing coronary artery bypass grafting: A 6-year cohort study

BackgroundThe relationship between thoracic sarcopenia and clinical outcomes in patients underwent coronary artery bypass grafting (CABG) is unclear. This study aims to evaluate whether thoracic sarcopenia has a satisfactory prognostic effect on adverse outcomes after CABG.MethodsFrom December 2015 to May 2021, 338 patients who underwent isolated CABG at our institution were recruited in this study. Skeletal muscle area at T12 level acquired by chest computed tomography (CT) was normalized to assess thoracic sarcopenia. Univariate and multivariate analyses were performed to evaluate the risk factors of postoperative complications and overall survival (OS).ResultsThe prevalence of thoracic sarcopenia in patients underwent CABG was 13.02%. The incidence of total major complication was significantly higher in thoracic sarcopenia group (81.8% vs 61.9%, p = 0.010). Thoracic sarcopenic patients also had longer postoperative hospital stays (p = 0.047), intensive care unit (ICU) stays (p = 0.001), higher costs (p = 0.001) and readmission rates within 30 days of discharge (18.2% vs 4.4%, p = 0.001). Patients without thoracic sarcopenia showed significantly higher OS at the 2-year follow-up period (93.9% vs 72.7%, p<0.001). Multivariate analyses demonstrated that thoracic sarcopenia was significantly and independently associated with postoperative complications and long-term OS after CABG.ConclusionThoracic sarcopenia is an effective clinical predictor of adverse postoperative complications and long-term OS in patients underwent CABG. Thoracic sarcopenia based on chest CT should be included in preoperative risk assessment of CABG.     

Pediatric instant noodle burns: A ten-year single center retrospective study

IntroductionChildren are particularly vulnerable to scald injuries, and hot beverages/foods are often implicated in this subset of pediatric burns. Burns from instant noodles are common and thus an attractive target for burn prevention. The purpose of this study is to characterize the frequency, demographics, outcomes, and circumstances of pediatric instant noodle burns to guide future educational and prevention efforts.MethodsThis is a retrospective review of all pediatric patients (<18 years) admitted to the University of Chicago Burn Center with a diagnosis of scald injury between 2010 and 2020. Burns caused by instant noodles were identified and compared to all other scald burns over this period.ResultsAmong 790 pediatric scald burns, 245 (31.0 %) were attributed to instant noodles. Compared to other scalds, patients with instant noodle burns were older (5.4 vs. 3.8 years, p < 0.001), equally likely to be male (51 % vs. 54 %, p = 0.488), and more likely to be Black/African American (90.6 % vs. 75.2 %, p < 0.001). Patients with instant noodle burns lived in zip codes with a lower average childhood opportunity index score (9.9 vs. 14.6, p < 0.001). In terms of circumstances, children with instant noodle burns were more likely to be unsupervised at the time of injury (37 % vs 21 %, p < 0.001). Instant noodle burns were smaller (3.6 % total body surface area (TBSA) vs. 5.8 % TBSA, p < 0.001) and less likely to require operative intervention (29 % vs. 41 %, p < 0.001). Instant noodle burns had a shorter length of stay (4.2 days vs. 6.4 days, p < 0.001), but similar adjusted length of stay (1.7 days/%TBSA vs. 1.5 days/%TBSA, p = 0.18) and experienced similar complication rates (10 % vs. 15 %, p = 0.06).ConclusionInstant noodle burns comprised nearly one-third of all pediatric scald burn admissions at our institution, a higher proportion than previously reported. While less severe than other scald burns in this series, instant noodles injuries still demonstrated a need for hospitalization and operative intervention. Instant noodle burns disproportionately affected Black/African American patients, as well as from neighborhoods with lower socioeconomic status. These findings suggest that focused burn prevention efforts may be successful at reducing the incidence of these common, but serious injuries.