Anaesthetists' risk assessment of placebo nerve block studies using the SHAM (Serious Harm and Morbidity) scale

The SHAM (Serious Harm and Morbidity) scale was developed to categorise the severity of potential complications of placebo control interventions in the context of local anaesthesia research. A convenience sample of 43 anaesthetists used the SHAM scale to grade ten published randomised controlled trials investigating local anaesthesia nerve blocks. The Fleiss κ statistic assessed agreement between these anaesthetists and probability of random agreement (Pr(e)) when using the SHAM scale; a κ > 0 shows concordance between assessors above random agreement. Overall κ was 0.50 (95% CI 0.49-0.51, p < 0.001), Pr(e) = 0.21. There was moderate agreement between assessors in determining whether studies were low-risk (SHAM score 0-2) or high-risk (SHAM score 3-4) (κ 0.60 (95% CI 0.58-0.62), Pr(e) = 0.51). Compared with anaesthetists given clinical examples of interventions when applying the SHAM score, anaesthetists who were not given examples showed significantly less inter-individual agreement (κ 0.76 (95% CI 0.72-0.81), Pr(e) = 0.5 vs 0.45 (95% CI 0.41-0.49), Pr(e) = 0.52, p < 0.0001). These results suggest that the SHAM score can be successfully used to grade the severity of potential complications of placebo-controlled interventions in local anaesthesia research and represent a first step towards the score's validation.     

Antithrombotic treatment and risk of complications after head and neck full thickness skin graft surgery

Abstract

Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013–2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7–10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (n?=?125 patients) was not associated with higher adjusted risk of total complications in multivariate analysis (OR 0.70; 95% CI: 0.34–1.46). In subgroup analyses, the total risk was not increased in patients on aspirin (OR 0.76; 95% CI: 0.39–1.48) or warfarin (OR 1.20; 95% CI: 0.47–3.10). In the warfarin subgroup (N?=?26), there was a statistically non-significant trend towards increased risk of graft necrosis. This study supports that aspirin and warfarin should not be discontinued prior to head and neck full thickness skin graft surgery.     

The association of preoperative TNF-alpha inhibitor use and reoperation rates in spinal fusion surgery

BACKGROUND CONTEXTPreoperative TNF-AI use has been associated with increased rate of postoperative infections and complications in a variety of orthopedic procedures. However, the association between TNF-AI use and complications following spine surgery has not yet been studied.PURPOSEThe purpose of the present study was to assess the risk of reoperation in patients prescribed TNF-AI undergoing spinal fusion surgery.STUDY DESIGNThis is a retrospective review.PATIENT SAMPLEA total of 427 patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018.OUTCOME MEASUREReoperation within 1 year.METHODSWe retrospectively reviewed the records of patients who underwent spinal fusion surgery at a large healthcare system from 1/1/2009 to 12/31/2018. There were three distinct cohorts of spine surgery patients under study: patients with TNF-AI use in 90 days before surgery, patients with non-TNF-AI DMARD medications use in the 90 days before surgery, and patients taking neither TNF-AI nor other DMARD medications in 90 days before surgery. The primary outcome of interest was reoperation for any reason within 1 year following surgery.RESULTSOur study included 90 TNF-AI, 90 DMARD, and 123 control patients. Reoperation up to 1-year postsurgery occurred in 19% (n=17) of the TNF-AI group, 11% (n=10) of the DMARD group, and 6% (n=7) of the control group. The reasons for reoperation for TNF-AI group were 47% (n=8) infection and 53% (n=9) other causes which included failure to fuse and adjacent segment disease. Reasons for reoperation at 1 year were 40% (n=4) infection and 60% (n=6) other causes for DMARD patients and 14% (n=1) infection with 86% (n=6) other causes for control patients. The cox-proportional hazard model of reoperation within 1 year indicated that the odds of reoperation were 3.1 (95% CI:1.4–7.0) and 2.2 (95% CI 0.96–5.3) times higher in the TNF-AI and DMARD groups, respectively, compared to the control group.CONCLUSIONSPatients taking TNF-AIs before surgery were found to have a significantly higher rate of reoperation in the 1 year following surgery compared to controls. The higher rate of reoperation associated with TNF-AI use before spinal fusion surgery represents the potential for higher morbidity and costs for patient which is important to consider for both surgeon and patient in preoperative decision making.     

Complications and reoperations after surgery for 647 patients with spine metastatic disease

Background Context

Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival.

Osteoporotic Vertebral Fracture Prevalence Varies Widely Between Qualitative and Quantitative Radiological Assessment Methods: The Rotterdam Study

Accurate diagnosis of vertebral osteoporotic fractures is crucial for the identification of individuals at high risk of future fractures. Different methods for radiological assessment of vertebral fractures exist, but a gold standard is lacking. The aim of our study was to estimate statistical measures of agreement and prevalence of osteoporotic vertebral fractures in the population‐based Rotterdam Study, across two assessment methods. The quantitative morphometry assisted by SpineAnalyzer® (QM SA) method evaluates vertebral height loss that affects vertebral shape whereas the algorithm‐based qualitative (ABQ) method judges endplate integrity and includes guidelines for the differentiation of vertebral fracture and nonfracture deformities. Cross‐sectional radiographs were assessed for 7582 participants aged 45 to 95 years. With QM SA, the prevalence was 14.2% (95% CI, 13.4% to 15.0%), compared to 4.0% (95% CI, 3.6% to 4.5%) with ABQ. Inter‐method agreement according to kappa (κ) was 0.24. The highest agreement between methods was among females (κ = 0.31), participants age >80 years (κ = 0.40), and at the L₁ level (κ = 0.40). With ABQ, most fractures were found at the thoracolumbar junction (T₁₂–L₁) followed by the T₇–T₈ level, whereas with QM SA, most deformities were in the mid thoracic (T₇–T₈) and lower thoracic spine (T₁₁–T₁₂), with similar number of fractures in both peaks. Excluding mild QM SA deformities (grade 1 with QM) from the analysis increased, the agreement between the methods from κ = 0.24 to 0.40, whereas reexamining mild deformities based on endplate depression increased agreement from κ = 0.24 to 0.50 (p <0.001). Vertebral fracture prevalence differs significantly between QM SA and ABQ; reexamining QM mild deformities based on endplate depression would increase the agreement between methods. More widespread and consistent application of an optimal method may improve clinical care. © 2017 American Society for Bone and Mineral Research.     

Roux-en-Y gastric bypass versus sleeve gastrectomy: nationwide data from the Danish quality registry for treatment of severe obesity

BackgroundBariatric surgery as treatment of obesity is increasing worldwide. No guidelines exist on which type of bariatric procedure to choose for the individual patient.ObjectivesThis study aims to compare Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) with respect to weight loss, complications, comorbidities, and quality of life.SettingA nationwide multi-center register-based cohort study.MethodsWe identified 16,053 patients treated by bariatric surgery from 2008 to 2021 (RYGB, n = 13,075; SG, n = 2978) from the Danish quality registry for treatment of severe obesity (DBSO). We calculated risk ratios (RRs) and prevalence ratios (PRs) comparing surgical complications, weight loss, and medical comorbidities by type of procedure up to 2 years after surgery.ResultsPatients treated with RYGB experienced a greater weight loss than patients treated by SG both after 1 year (PR, .53; 95% confidence interval [CI], .48–.58) and 2 years (PR, .46; 95% CI, .39–.54). Compared with RYGB, SG yielded a lower risk of readmission (RR, .71; 95% CI, .60–.85). Likewise, the risk of reoperation between 30 days and 1 year (RR, .40; 95% CI, .30–.53) and 1 and 5 years (RR, .15; 95% CI, .12–.20]) were lower following SG. At 1-year follow-up, 76% of patients treated with RYGB and 63% of patients treated with SG experienced diabetes remission. Ten percent and 61% of patients were lost to follow-up after 1 and 2 years, respectively.ConclusionThe DBSO is an important resource in studying treatment of severe obesity. Weight loss is slightly greater after RYGB than after SG, but RYGB is associated with more frequent readmissions and reoperations.     

Validity of registry data: Agreement between cancer records in an end‐stage kidney disease registry (voluntary reporting) and a cancer register (statutory reporting)

Aims: End‐stage kidney disease registries inform outcomes and policy. Data quality is crucial but difficult to measure objectively. We assessed agreement between incident cancer reported to the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) and to the Central Cancer Registry (CCR) in New South Wales. Methods: ANZDATA records were linked to CCR using probabilistic matching. We calculated agreement between registries for patients with ≥1 cancers, all cancers and site‐specific cancer using the kappa statistic (κ). We investigated cases where records disagreed and compared estimates of cancer risk based either on ANZDATA or on CCR using standardized incidence ratios (indirect standardization by age, sex and calendar year). Results: From 1980 to 2001, 9453 residents had dialysis or transplantation. ANZDATA recorded 867 cancers in 779 (8.2%) registrants; CCR 867 cancers in 788 (8.3%). ANZDATA recorded 170 patients with cancer that CCR did not, CCR recorded 179 patients that ANZDATA did not (κ = 0.76). ANZDATA had sensitivity 77.3% (confidence interval (CI) 74.2–80.2), specificity 98.1% (CI 97.7–98.3) if CCR records were regarded as the reference standard. Agreement was similar for diagnoses while receiving dialysis (κ = 0.78) or after transplantation (κ = 0.79), but varied by cancer type. Agreement was poorest for melanoma (κ = 0.61) and myeloma (κ = 0.47) and highest for lymphoma (κ = 0.80), leukaemia (κ = 0.86) and breast cancer (κ = 0.85). Artefact accounted for 20.8% of the non‐concordance but error and misclassification did occur in both registries. Estimates of cancer risk based on ANZDATA or CCR records did not differ in any important way. Conclusion: Agreement of cancer records between both registries was high and differences largely explicable. It is likely that both ANZDATA and CCR have some inaccuracies, for reasons that are now more explicit, with themes similar to those likely to be experienced by other registries.     

Assessment of medical student clinical reasoning by "lay" vs physician raters: inter-rater reliability using a scoring guide in a multidisciplinary objective structured clinical examination

BackgroundTo determine whether a “lay” rater could assess clinical reasoning, interrater reliability was measured between physician and lay raters of patient notes written by medical students as part of an 8-station objective structured clinical examination.MethodsSeventy-five notes were rated on core elements of clinical reasoning by physician and lay raters independently, using a scoring guide developed by physician consensus. Twenty-five notes were rerated by a 2nd physician rater as an expert control. Kappa statistics and simple percentage agreement were calculated in 3 areas: evidence for and against each diagnosis and diagnostic workup.ResultsAgreement between physician and lay raters for the top diagnosis was as follows: supporting evidence, 89% (κ = .72); evidence against, 89% (κ = .81); and diagnostic workup, 79% (κ = .58). Physician rater agreement was 83% (κ = .59), 92% (κ = .87), and 96% (κ = .87), respectively.ConclusionsUsing a comprehensive scoring guide, interrater reliability for physician and lay raters was comparable with reliability between 2 expert physician raters.     

The effects of acute kidney injury in a multicenter cohort of high-risk surgical patients

Background and objectivesPatients who develop post-operative acute kidney injury (AKI) have a poor prognosis, especially when undergoing high-risk surgery. Therefore, the objective of this study was to evaluate the outcome of patients with AKI acquired after non-cardiac surgery and the possible risk factors for this complication.MethodsA multicenter, prospective cohort study with patients admitted to intensive care units (ICUs) after non-cardiac surgery was conducted to assess whether they developed AKI. The patients who developed AKI were then compared to non-AKI patients.ResultsA total of 29 ICUs participated, of which 904 high-risk surgical patients were involved in the study. The occurrence of AKI in the post-operative period was 15.8%, and the mortality rate of post-operative AKI patients at 28 days was 27.6%. AKI was strongly associated with 28-day mortality (OR = 2.91; 95% CI 1.51–5.62; p = 0.001), and a higher length of ICU and hospital stay (p < 0.001). Independent factors for the risk of developing AKI were pre-operative anemia (OR = 7.01; 95% CI 1.69–29.07), elective surgery (OR = 0.45; 95% CI 0.21–0.97), SAPS 3 (OR = 1.04; 95% CI 1.02–1.06), post-operative vasopressor use (OR = 2.47; 95% CI 1.34–4.55), post-operative infection (OR = 8.82; 95% CI 2.43–32.05) and the need for reoperation (OR= 7.15; 95% CI 2.58–19.79).ConclusionAKI was associated with the risk of death in surgical patients and those with anemia before surgery, who had a higher SAPS 3, needed a post-operative vasopressor, or had a post-operative infection or needed reoperation were more likely to develop AKI post-operatively.     

Exploring perioperative complications of anterior lumber interbody fusion in patients with a history of prior abdominal surgery: A retrospective cohort study

BACKGROUND CONTEXTAnterior lumbar interbody fusion (ALIF) exposes the anterior aspect of the spine through a retroperitoneal approach. Access to the anterior spine requires mobilization of intra-abdominal viscera/vasculature, which can become complicated as scarring and/or adhesions develop from prior abdominal surgical interventions, increasing risk of intraoperative complications. The literature suggests that “significant prior abdominal surgery” is a relative contraindication of ALIF surgery; however, there is no consensus within the literature as to what defines “major/significant” abdominal surgeries. Additionally, the association between the number of prior abdominal surgeries and perioperative complications in ALIF surgery has not been explored within the literature.PURPOSEThis study seeks to explore the association between perioperative complications of ALIF surgery and the type (major and/or minor) and number of prior abdominal surgeries.DESIGNA retrospective cohort study was performed to examine perioperative complications in ALIF patients with or without prior history of abdominal surgery.PATIENT SAMPLEAll consecutive patients undergoing ALIF with or without a history of prior abdominal surgery from 2008 to 2018 at a single tertiary center were evaluated. Patients under the age of 18, patients with spinal malignancy, or patients who had ALIF above L3 were excluded.OUTCOME MEASURESPerioperative complications included intraoperative complications during ALIF surgery and postoperative complications within 90 days of ALIF surgery. Intraoperative complications include vascular injury, ureter injury, retroperitoneal hematoma, etc. Postoperative complications include urinary tract infection, revision of abdominal scar, ileus, deep vein thrombosis, pulmonary embolism, etc. Other outcome measures include readmission within 90 days, length of ALIF surgery, and length of hospital stay.METHODSElectronic medical records of 660 patients who underwent ALIF between 2008 and 2018 were retrospectively reviewed. Patient demographics, Charleston Comorbidity Index (CCI), level of fusion, past abdominal surgical history, use of access surgeon during exposure, intraoperative, and postoperative complications were collected. Predictors of intraoperative and postoperative complications were analyzed using simple and multivariable logistic regression. Statistical analysis was performed using JMP 14.0 (SAS, Cary, NC, USA) software.RESULTSAfter controlling for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon, there was no significant association between the type of prior abdominal surgery (major and/or minor) and intraoperative complications on multivariable logistic regression analysis (Minor: odds ratio [OR]=1.68; 95% confidence interval [CI]: 0.58–4.86 & Major: OR=1.99; 95% CI: 0.80–4.91). On multivariable logistic regression, the odds of developing an intraoperative complication increases by 52% for each additional prior abdominal surgery after adjusting for age, length of ALIF, gender, multilevel ALIF, and the use of an access surgeon (OR=1.52, 95% CI: 1.10–2.11). Iliac vein laceration was the most common intraoperative complication (n=27, 4%). Neither the type (major and/or minor) nor the number of prior abdominal surgeries were significant predictors of postoperative complications (Minor: OR=1.29; 95% CI: .72–2.31, Major: OR=1.24; 95% CI: 0.77–2.00, & Number: OR=1.03; 95% CI: .84–1.26).CONCLUSIONWith each additional prior abdominal surgery, accumulation of scarring and adhesions can likely obscure anatomical landmarks and increase the risk of developing an intraoperative complication. Therefore, the number of prior abdominal surgeries should be taken into consideration during planning and operative exposure of the anterior spine via a retroperitoneal approach.     

Bariatric surgery in patients with obesity and end-stage renal disease

BackgroundBariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.ObjectivesTo compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.SettingMeta-analysis.MethodsA comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.ResultsOf 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66–4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99–3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55–3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80–9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32–2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomesConclusionsBariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.     

Safety of same-day discharge after laparoscopic sleeve gastrectomy: propensity score–matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Registry

BackgroundInformation on the safety of outpatient sleeve gastrectomy is sparse.ObjectiveThis study aimed to assess the safety of sleeve gastrectomy as a day case surgery.SettingUniversity health network, United States.MethodsPatients who underwent primary sleeve gastrectomy were identified in the 2015–2017 MBSAQIP database. Day case surgery procedure was defined as having a hospital length of stay of 0 days. Day case surgery patients were matched with inpatient controls using propensity score matching. The primary outcome was 30-day mortality.ResultsA total of 271,658 sleeve gastrectomy patients met the inclusion criteria. Of these, only 7825 (2.88 %) were day case surgery procedures. There was no mortality in the group. Day case surgery, compared with inpatient sleeve gastrectomy, was associated with a similar risk of a leak (.56% versus .40%; relative risk [RR], 1.419; 95% CI, .896–2.245; P = .133), bleeding (.38% versus .31%; RR, 1.250; 95% CI, .731–2.138; P = .414), 30-day reoperation (.81% versus .56%; RR, 1.432; 95% CI, .975–2.104; P = .066), and 30-day morbidity (1.15% versus 1.01%; RR, 1.139; 95% CI, .842–1.541; P = .397). Outpatients’ SG increased the risk for 30-day readmission (3.35% versus 2.79%; RR, 1.202; 95% CI, 1.009–1.432; P = .039).ConclusionsSleeve gastrectomy in the outpatient setting as a day case surgery was associated with no mortality and no statistically significant risk of reoperation, leakage, or bleeding compared with patients admitted to inpatient units. The readmission rate was higher in the day case surgery group.     

Bariatric surgery outcomes in geriatric patients: a contemporary,nationwide analysis

ObjectiveThis retrospective study sought to characterize the incidence of mortality in elderly patients following bariatric surgery and assessed the association of geriatric status with postoperative outcomes and resource use.BackgroundBariatric surgery is a safe and efficacious intervention for obesity and related diseases. The clinical and economic impact of geriatric status on bariatric surgery is largely unexplored.SettingAcademic, university-affiliated hospital; US.MethodsAdults (≥45 yr) undergoing elective laparoscopic gastric bypass or sleeve gastrectomy were identified in the 2016–2019 Nationwide Readmissions Database. Patients ≥65 years were categorized into the geriatric cohort. Multivariable linear and logistic models were developed to evaluate the independent association of geriatric status with outcomes of interest.ResultsOf an estimated number of 351,292 patients meeting inclusion criteria, 44,183 (12.6%) comprised the geriatric cohort. Of these patients, .3% died during the index hospitalization. Geriatric status was associated with significantly increased odds of in-hospital mortality (adjusted odds ratio [AOR] = 2.39, 95% confidence interval [CI]: 1.33–4.30), respiratory (AOR = 1.34, 95% CI: 1.13–1.59), infectious (AOR = 1.65, 95% CI: 1.25–2.17), and renal complications (AOR = 1.27, 95% CI: 1.12–1.46), and prolonged hospitalization (AOR = 1.35, 95% CI: 1.24–1.48). Elderly patients experienced a .19-day increment in the length of stay (95% CI: .11–.27) and $620 in attributable hospitalization costs (95% CI: 310–930).ConclusionsWhile overall rates of postoperative death and complications are low, geriatric patients experience significantly increased mortality, morbidity, and resource use following bariatric operations relative to younger adults. These findings may aid in shared decision-making for obesity management in geriatric patients.     

Algorithm‐Based Qualitative and Semiquantitative Identification of Prevalent Vertebral Fracture: Agreement Between Different Readers,Imaging Modalities,and Diagnostic Approaches

We compared SQ and ABQ diagnosis of VF imaged by radiography and X‐ray absorptiometry. Mild ABQ VF had stronger associations with osteoporosis than mild SQ VF. Interobserver agreement (radiographic diagnosis) was better for ABQ. Introduction: Vertebral fracture (VF) assessment from images acquired by X‐ray absorptiometry (VFA) is often based on a semiquantitative approach (SQ); prevalent VF is identified if vertebral height appears reduced by >20%. Algorithm‐based qualitative definition of osteoporotic VF (ABQ) requires evidence of endplate depression, and there is no threshold for reduction in vertebral height. The aims of this study were to (1) compare the prevalence of VFs; (2) compare the characteristics of women with and without VFs; (3) compare interobserver agreement; and (4) compare agreement between methods and imaging modalities for ABQ and SQ definitions of VFs. Materials and Methods: Spine radiographs and absorptiometry images for 203 elderly women were assessed using ABQ (readers ABQ‐1 and ABQ‐2). These readings were compared with SQ assessments (readers SQ‐1 and SQ‐2) of the same images performed in a previous study. Agreement between readers and methods was assessed by kappa (κ) statistics. Results: The prevalence of VF was 15–18% (radiography) and 12–24% (VFA) for ABQ and SQ, respectively. Women with ABQ or SQ fractures were older and had lower BMD than those without fracture (p < 0.01). Mild ABQ (but not SQ) VF was associated with low BMD. κ scores for interobserver agreement for radiography and VFA, respectively, were as follows: ABQ, κ = 0.74 (95% CI, 0.60, 0.87) and 0.65 (95% CI, 0.48, 0.81); SQ, κ = 0.53 (95% CI, 0.46, 0.60) and 0.51 (95% CI, 0.44, 0.58). For agreement between ABQ‐1 and SQ‐1, κ = 0.55 (95% CI, 0.39, 0.72) for radiography and 0.41 (95% CI, 0.25, 0.58 for VFA. Conclusions: The prevalence of radiographic VF identified by ABQ and SQ was similar, but on VFA was 50% higher for SQ. Mild ABQ VF was associated with low BMD. Interobserver agreement for radiographic diagnosis was significantly better for ABQ than for SQ. Agreement between ABQ and SQ was moderate.     

Is Reoperation Higher Than Expected after Below-the-knee Amputation? A Single-center Evaluation of Factors Associated with Reoperation at 1 Year

BackgroundBelow-the-knee amputation (BKA) is relatively common among patients with vascular disease, infection, trauma, or neoplastic disease. Many BKAs are performed in patients with incompletely treated medical comorbidities, and some are performed in patients with acute high-energy trauma or crush injuries, malignant neoplasm undergoing time-sensitive limb removal, and diabetes with active infection or sepsis. Consequently, revision is common. Prior studies of outcomes after BKA, including several based on the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database, have follow-up periods that do not cover the entire at-risk period.Questions/purposes(1) What is the survivorship free from unplanned reoperation within 1 year of BKA? (2) What patient characteristics are associated with reoperation within 1 year of BKA?MethodsWe retrospectively studied all BKAs performed by the orthopaedic surgery service at a Level 1 trauma center from 2008 to 2018, as identified by Current Procedural Terminology (CPT) codes. Twenty-eight percent (38 of 138) underwent amputation as treatment for traumatic injury, 57% (79 of 138) for infection, and 15% (21 of 138) for malignancy. A total of 17% (23 of 138) had a final follow-up encounter before the 1-year study minimum, without differential loss to follow-up by surgical indication (p = 0.43) or hemoglobin A1c (p = 0.71). Median (range) follow-up was 570 days (6 to 3375). The primary outcome was survivorship from unplanned reoperation within 1 year of BKA index surgery or last planned reoperation, as determined by Kaplan-Meier estimation. Secondarily, we identified patient characteristics independently associated with reoperation within 1 year of BKA. Collected data included age, indication, BMI, diabetes, hemoglobin A1c level, closure method, and substance use. Unplanned reoperation was defined as irrigation and débridement, stump revision, or revision to a higher-level amputation; this did not include planned reoperations for BKAs closed in a staged manner. Factors associated with reoperation were determined using multivariate logistic regression analyses. All endpoints and variables related to patients and their surgical procedures were extracted from electronic medical records by someone other than the operating surgeon.ResultsUsing Kaplan-Meier estimation, 38% of patients (95% confidence interval 29 to 46) who underwent BKA had an unplanned reoperation within 1 year of their index surgery. Twelve percent of patients (95% CI 7 to 17) who underwent BKA did not reach 30 days with the limb survivorship free from unplanned reoperation. The median (range) time between the initial surgery and reoperation was 54 days (6 to 315). After controlling for potential confounding variables like age, gender, platelet count, albumin, and the reason for undergoing amputation, a hemoglobin A1c level greater than 8.1% (relative to A1c ≤ 8.1%) was the only variable independently associated with increased odds of reoperation (odds ratio 4.6 [95% CI 1.3 to 18.1]; p = 0.02).ConclusionBKA carries a higher risk for reoperation than currently reported in studies that use 30-day postoperative follow-up periods. Clinicians should critically assess whether BKA is necessary, especially in patients with uncontrolled diabetes assessed by hyperglycemia. Before planned BKA, patients should have documented glycemic control to minimize the odds of reoperation. Because many of this study’s limitations were due to its retrospective single center design, we recommend that future work cover a clinically appropriate surveillance period using a larger cohort such as a national database and/or employ a prospective design.Level of EvidenceLevel III, therapeutic study.     

Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures

Background and purpose Hip arthroplasty is an option for elderly patients with osteoporosis for the treatment of failure after fixation of trochanteric and subtrochanteric fractures, either as a total hip arthroplasty (THA) or as a hemiarthroplasty (HA). We analyzed the reoperation rate and risk factors for reoperation in a consecutive series of patients.

Methods All patients (n = 88) operated from 1999 to 2006 with a THA (n = 63) or an HA (n = 25) due to failure of fixation of a trochanteric fracture (n = 63) or subtrochanteric fracture (n = 25) were included. Background data were collected from the patient records. A search was performed in the national registry of the Swedish National Board of Health and Welfare in order to find information on all reoperations. The follow-up time was 5–11 years.

Results The reoperation rate was 16% (14/88 hips). A periprosthetic fracture occurred in 6 patients, a deep prosthetic infection in 5 patients, and a dislocation of the prosthesis in 3 patients. Standard-length femoral stems had an increased risk of reoperation (11/47) compared to long stems (3/41) (HR = 4, 95% CI: 1.0–13; p = 0.06).

Interpretation The high reoperation rate reflects the complexity of the surgery. Using long femoral stems that bridge previous holes and defects may be one way to reduce the risk for reoperation.     

Repeat surgery after lumbar decompression for herniated disc: the quality implications of hospital and surgeon variation

Background contextRepeat lumbar spine surgery is generally an undesirable outcome. Variation in repeat surgery rates may be because of patient characteristics, disease severity, or hospital- and surgeon-related factors. However, little is known about population-level variation in reoperation rates.PurposeTo examine hospital- and surgeon-level variation in reoperation rates after lumbar herniated disc surgery and to relate these to published benchmarks.Study design/settingRetrospective analysis of a discharge registry including all nonfederal hospitals in Washington State.MethodsWe identified adults who underwent an initial inpatient lumbar decompression for herniated disc from 1997 to 2007. We then performed generalized linear mixed-effect logistic regressions, controlling for patient characteristics and comorbidity, to examine the variation in reoperation rates within 90 days, 1 year, and 4 years.ResultsOur cohort included 29,529 patients with a mean age of 47.5 years, 61% privately insured, and 15% having any comorbidity. The age-, sex-, insurance-, and comorbidity-adjusted mean rate of reoperation among hospitals was 1.9% at 90 days (95% confidence interval [CI], 1.2–3.1), with a range from 1.1% to 3.4%; 6.4% at 1 year (95% CI, 3.9–10.6), with a range from 2.8% to 12.5%; and 13.8% at 4 years (95% CI, 8.8–19.8), with a range from 8.1% to 24.5%. The adjusted mean reoperation rates of surgeons were 1.9% at 90 days (95% CI, 1.4–2.4) with a range from 1.2% to 4.6%, 6.1% at 1 year (95% CI, 4.8–7.7) with a range from 4.3% to 10.5%, and 13.2% at 4 years (95% CI, 11.3–15.5) with a range from 10.0% to 19.3%. Multilevel random-effect models suggested that variation across surgeons was greater than that of hospitals and that this effect increased with long-term outcomes.ConclusionsEven after adjusting for patient demographics and comorbidity, we observed a large variation in reoperation rates across hospitals and surgeons after lumbar discectomy, a relatively simple spinal procedure. These findings suggest uncertainty about indications for repeat surgery, variations in perioperative care, or variations in quality of care.     

Mortalité périopératoire précoce dans un hôpital pluridisciplinaire

ObjectivesTo evaluate the incidence and the causes of early intra- and postoperative deaths in a multidisciplinary hospital.Study designRetrospective survey.PatientsAll patients receiving an anaesthetic between 1992 and 1995.MethodsAnalysis of all deaths occurring during anaesthesia and in the subsequent 24 hours. Demographic data (age, gender) and medical data (ASA physical class, type of surgery and degree of emergency) were recorded. The contribution of anaesthesia, surgery or patient disease to fatal outcome was analysed.ResultsThe analysis included 52,654 patients who underwent either general anaesthesia or epidural analgesia. Perioperative mortality (n = 170) was 1/310 patients (0.32%). The risk factors for mortality (multivariate analysis) were: age > 64 years (odds-ratio [OR] 4.8), ASA class ≥ 3 (OR 16.6), emergency surgery (OR 3.6), duration of surgery > 115 minutes (OR 3.4) or occurrence of a perioperative complication (OR 37.4). Fifty percent of deaths (95% confidence interval [CI] = 42–58) were related to patient's underlying diseases and 29% to surgery (CI 95% = 22–36). The percentage of deaths linked to anaesthesia was 17.6% (CI 95% = 11.9–23.3, 1/1,755), consisting of 8.2% (CI 95% = 4.1–9.3, 1/3,761) totally due to anaesthesia and 9.4% (CI 95% = 5–13.8, 1/3,291) only partially. The main aetiologies of the deaths linked to anaesthesia were a mismanagement of severe haemorrhages (30%), respiratory complications (23%) or cardiac complications (23%). The mismanagement of an intraoperative critical situation (46%) and a mistake in the postoperative care (33%) were the main causes.DiscussionIn this survey, mortality due to anaesthesia was higher than the rates reported in other studies. Human error remained the main cause.