PURPOSE:Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. METHODS:Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. RESULTS:In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). CONCLUSION:While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.

Background: Multilevel cervical pathology can often be addressed via anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes. The purpose was to compare perioperative adverse events and long-term cervical reoperation rates of four-level ACDF and PCF. Methods: The 2010 to Q1 2020 PearlDiver MSpine database was queried. Patients undergoing isolated elective four-level ACDF or PCF were identified (excluding cases performed for trauma, neoplasm, and/or infections) and 1:1 matched based on age, sex, and comorbidities. Ninety-day adverse events were compared with univariate and multivariate analyses. Five-year incidences of subsequent cervical reoperations were also compared. Results: A total of 3,714 patients 1:1 matched for four-level ACDF and PCF performed for degenerative pathologies were identified (1,857 for each of the study groups). On multivariate analysis controlling for age, sex, and comorbidities, PCF was found to have significantly greater odds ratios (OR) for any (OR 2.12), serious (OR 2.31), and minor (OR 1.95) adverse events, as well as for length of stay ≥3 days (OR 1.76), p<0.001 for each. However, PCF had nearly three times lower odds of dysphagia compared to ACDF (OR 0.36, p<0.001). At five years, four-level ACDF cases were found to have significantly higher reoperation rates compared to four-level PCF cases (26.3% vs 18.3%, p<0.001). Conclusion: In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.

The original article can be found online.

Background: Proximal interphalangeal arthroplasty (PIPA) has been indicated for patients suffering from osteoarthritis (OA) or rheumatoid arthritis of the hand. Although there is extensive literature showing the outcomes of PIPA, there is paucity in the literature regarding trends of PIPA in patients with OA of the hand. The purpose of this study was to determine annual primary utilization and revision PIPA trends within the Medicare population with the use of an administrative database. Methods: A retrospective query was performed using the Medicare Standard Analytical Files from the PearlDiver database. Patients undergoing primary and revision PIPA with hand OA were queried using International Classification of Disease, Ninth Revision, and Current Procedural Terminology coding. Primary outcomes analyzed included annual and revision utilization of PIPA and demographic comparison of age, gender, and geographic location. Statistical analysis was primarily descriptive. An α value less than 0.05 was considered statistically significant. Results: The query returned 10 191 patients who underwent primary and revision PIPA between 2005 and 2013. Calculated annual growth rate for primary and revision PIPA was 2.40% and −0.03%, respectively (P < .001). Patients between the ages of 70 and 74 years represented most of the patients undergoing a primary PIPA, whereas patients between 65 and 69 years most commonly underwent a revision procedure. Regionally, primary and revision PIPA were most commonly performed in the South. Conclusion: The data demonstrate an increased use of primary PIPA utilization for patients with OA, whereas revision PIPA decreased. The increased use indicates the increasing demand for PIPA in the United States.

A literature review of minimally invasive treatment options for lumbar spinal stenosis was conducted to determine the efficacy and outcomes of existing and evolving techniques. This study focuses on minimally invasive interlaminar decompression, unilateral laminectomy for bilateral decompression, and internal indirect decompression devices/interlaminar stabilization. We found that both minimally invasive interlaminar decompression and unilateral laminectomy for bilateral decompression can lead to acceptable and effective outcomes for patients with lumbar spinal stenosis. Indirect decompression via devices that provide interlaminar stabilization, including the Superion, X-STOP, and Coflex implants, has led to mixed results, but further research is still required.

BACKGROUND The first-generation, lateral-center-of-rotation reverse shoulder arthroplasty (RSA) modular design has demonstrated durable early-, mid-, and long-term outcomes. The second-generation monoblock implant shares a similar design but eliminates the modular junction and facilitates inset placement within the metaphysis to avoid humeral-sided junctional failures and facilitate metaphyseal press-fit. However, no paper has specifically examined the radiographic findings and improvements in pain and function after the use of this next generation design. QUESTIONS/PURPOSES (1) After second-generation, lateral-center-of-rotation monoblock RSA, what are the improvements in shoulder scores, general health scores, and ROM at a minimum of 2 years of followup? (2) Are the differences in shoulder scores, health scores, and ROM associated with fixation (cemented versus cementless components)? (3) How frequently do complications occur (defined as humeral loosening, dislocation, baseplate failure, scapular notching, acromial fractures, and revision surgery) after inset monoblock RSA? METHODS We retrospectively studied patients undergoing primary RSA between 2010 and 2015 with preoperative data and a minimum of 2 years of clinical followup. Of the 329 primary RSA performed during this period, 125 were excluded based on the use of a different generation humeral stem of the same design, three based on need for a nickel-free implant, and 39 due to a lack of preoperative shoulder scores. Of the remaining 162 patients, 137 patients (85%) met the inclusion criteria with a mean age of 74 years (range, 46-90 years). The predominant indications were osteoarthritis with a massive rotator cuff tear (74%) and fracture sequelae (16%). During the study, humeral implants were typically inserted using an uncemented press-fit technique (85%), with only 21 patients requiring a cemented humeral stem. The mean clinical and radiographic followup period was 37 months (range, 24-82 months). Patient-reported outcome measures (PROMs) including the Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, VAS for pain, SF-12, Single Assessment Numeric Evaluation, and measured active motion (forward elevation and external and internal rotation) were recorded at pre- and postoperative intervals. Postoperative radiographs were evaluated for baseplate failure, glenoid and humeral loosening, scapular notching, and acromion fractures. Complications were recorded in the longitudinally maintained institutional repository. RESULTS At the most recent followup examination, there were improvements in measured motion, general health outcomes, and all PROMs. There were no differences between the cemented and press-fit techniques. Complications observed included 17 of 137 patients (12%) with scapular notching, six postoperative acromion fractures (4%), and two revision procedures (1%). No patients experienced gross humeral loosening or baseplate failure. CONCLUSIONS Primary RSA using a second-generation monoblock inset humeral component resulted in improvements in pain and functional outcomes as well as low rates of acromion fractures, humeral radiolucency, and complications. Future studies are needed to provide a more definitive analysis on the use of an uncemented technique for humeral stem fixation and the effect of an inset stem on postoperative acromion fractures. LEVEL OF EVIDENCE Level IV, therapeutic study.

Background: Medical comorbidities have been shown to impact outcomes in patients with carpal tunnel syndrome (CTS) undergoing primary open carpal tunnel release (CTR). There is paucity in the literature comparing reimbursement rates of patients with medical comorbidities undergoing CTR compared to the general population. The study analyzed and compared reimbursements of medical comorbidities in patients undergoing open CTR. Methods: A retrospective review was performed using the PearlDiver supercomputer (PearlDiver Technologies, Fort Wayne, IN, USA). Patients were queried using International Classification of Disease, ninth revision (ICD-9) and Current Procedural Terminology (CPT) coding. Comorbidities analyzed included: obesity, chronic kidney disease (CKD), cirrhosis, chronic obstructive pulmonary disease (COPD), depression, diabetes mellitus, hypertension, hyperlipidemia, and smoking. Analysis of variance (ANOVA) was used to compare 90-day mean reimbursement rates. Tukey's post-hoc testing was used to determine significance between the comorbidities and the general population. An alpha value less than 0.05 was considered statistically significant. Results: The query returned 76,996 patients who underwent primary CTR from 2007-2015. Mean total global 90-day episode of care reimbursement was $5,274 (range: $5,520-$ 7,193; SD: $663). ANOVA demonstrated statistical difference between comorbidities and the general population. Reimbursement rates were highest in patients with cirrhosis ($7,045) and lowest in patients with hyperlipidemia ($5,520). Reimbursement rates in the general population were $5,274. Conclusions: Comorbidities increase the total global 90-day episode of care costs amongst patients undergoing open CTR compared to the general population. Appropriate presurgical optimization could potentially minimize the costs associated with these conditions.

BACKGROUND:Anterior cervical discectomy and fusion (ACDF) is indicated for patients suffering from cervical radiculopathy, myelopathy, and degenerative disc disease, among other diseases. There is paucity in the literature regarding postoperative complications in patients undergoing primary ACDF with a diagnosis of hypothyroidism. The purpose of this study is to compare 90-day postoperative complications in patients with and without hypothyroidism undergoing primary ACDF.METHODS:A retrospective analysis was completed using a national administrative database known as Pearl Diver (Pearl Diver Technologies, Fort Wayne, Indiana) using the International Classification of Disease, ninth revision (ICD-9) codes. The study group consisted of patients having undergone ACDF with an active diagnosis of hypothyroidism 90 days prior to and on the day of surgery. Patients undergoing primary ACDF without hypothyroidism served as the control group. Patients in both groups were randomly matched according to age, gender, and Charlson-Comorbidity Index (CCI). The 90-day postoperative medical complications were assessed along with readmission rates and total cost of care.RESULTS:There were a total of 107,066 patients equally divided between the 2 cohorts. Patients with hypothyroidism had greater odds of developing complications such as non-healing surgical wound (OR: 2.27; P<0.001), pulmonary embolus (OR: 2.16; P<0.001), myocardial infarction (OR: 2.10; P<0.001), compared to patients in the control group after undergoing primary ACDF. Readmission rates were also higher in patients with hypothyroidism (OR: 1.45; P<0.001). Total cost of care was also greater in patients with hypothyroidism compared to patients without hypothyroidism undergoing primary ACDF.CONCLUSIONS:Hypothyroidism is a risk factor for worse postoperative outcomes in patients undergoing primary ACDF. Appropriate preoperative optimization with thyroid hormone supplementation could potentially minimize the incidence of developing numerous medical complications, in addition to potentially lowering readmission rates and the total cost of care.

Background Due to increased postoperative complications with anterior cervical discectomy and fusion (ACDF), there has been an increasing interest in the use of cervical disc arthroplasty (CDA). Advancements in prosthetic designs and techniques have improved patient reported outcome measurements and minimized revision rates. There is a paucity in the literature regarding recent trends in CDA utilization and revision rates. The purpose of this study was to determine annual primary and revision CDA trends with the use of an administrative database. Methods A retrospective review from 2005-2014 was performed using the Medicare Standard Analytical Files from the PearlDiver supercomputer (PearlDiver Technologies, Fort Wayne, IN, USA). Patients who underwent primary CDA were queried using International Classification of Disease, ninth revision (ICD-9) and current procedural terminology (CPT) code 84.62 and 22856, respectively. Revision CDAs were queried using ICD-9 procedure code 84.66. Primary outcomes of this study included annual primary procedures, annual revision incidence (RI), and additional demographic data such as age, gender, geographic location, Charlson-Comorbidity Index (CCI); in addition to length of stay (LOS), cost, and reimbursement. Results The query returned 2,016 and 517 primary CDA and revision CDA procedures were performed in the Medicare database, respectively. The data showed that the CAGR of primary and revision CDA procedures to be 20.54% and 5.84% (P<0.001), respectively. RI and RB demonstrated a CAGR of -12.22% and -9.61%, respectively. Patients younger than the age of 65 represented the majority of the patients undergoing this procedure. Demographically, primary and revision CDAs were found highest in the South. Conclusions The data demonstrates a high rate of annual growth in CDA utilization (20.54%) and revision CDA (5.84%), indicating there is an increase demand for CDA in the United States. Compared to ACDF, patients who undergo CDA have improved patient reported outcome measurements and lower rates of postoperative complications.