Difference In Reoperation Research Articles

Expedited surgery in geriatric hip fracture patients taking direct oral anticoagulants is not associated with increased short-term complications or mortality rates.

Objectives:The purpose of this study was to evaluate potential differences in time to surgery, bleeding risk, wound complications, length of stay, transfusion rate, and 30-day mortality between patients anticoagulated with direct oral anticoagulants (DOACs) and those not anticoagulated at the time of evaluation for an acute hip fracture.Design:Retrospective chart review Level III Study.Setting:One university-based hospital in Rochester, NY.Patients/Intervention: Patients 65 years and older undergoing operative treatment of a hip fracture over a 5-year period. Chart review identified patients on DOAC therapy at the time of injury as well as an age and sex-matched control group not on anticoagulation.Main outcome measurements: Demographics, procedure type, admission/postoperative laboratory work, perioperative metrics, transfusion metrics, discharge course, reoperation, readmission, wound complications, and 30-day mortality were obtained for comparison.Results:Thirty-six hip fractures anticoagulated on DOACs were compared to 108 controls. The DOAC group had delays to operative treatment (27.6 h, SD 16.3 h, 95% CL [22.0–33.1]) vs the control group (19.8 h, SD 10.5 h, 95% CL [17.7–21.8], P = .01). No differences were found in estimated blood loss, procedure time, or change in hemoglobin. Transfusion rates were not significantly different between groups (58.3% DOAC vs 47.2% control, P = .25). No difference in reoperation, readmission, wound complication, deep venous thrombosis rates, or 30-day mortality rates were found.Conclusion:Patients presenting on DOAC therapy at the time of hip fracture have a delay to surgery compared with age and sex-matched controls, but no increase in short term complications or mortality rates. Expedited surgery (within 48 h) appeared to be safe and effective treatment for hip fracture patients on DOAC therapies.

206. Additional surgery after anterior cervical discectomy and fusion versus posterior foraminotomy for single- or multilevel cervical radiculopathy

BACKGROUND CONTEXT There is limited long-term comparative data for patients with cervical radiculopathy treated with either anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF) procedures. Therefore, the aim of the current study is to compare 5-year rates of reoperation after either ACDF or PCF for cervical radiculopathy in an older Medicare population. PURPOSE To determine the relative rates of reoperation after ACDF or PCF for cervical radiculopathy, stratified by single or multilevel disease. STUDY DESIGN/SETTING Retrospective cohort study PATIENT SAMPLE A total of 3,639 patients with single-level radiculopathy, 2,895 (80%) undergoing ACDF and 744 (20%) undergoing PCF. OUTCOME MEASURES Reoperations of the cervical spine METHODS A national sample of Medicare patients was reviewed for patients undergoing either single-level or multiple-level ACDF or PCF with a diagnosis of cervical disc herniation without myelopathy. All patients were followed for a minimum of 3 years postoperatively and rates of all additional cervical spine surgery were assessed for up to 5 years. Multivariate logistic regression was used to determine the relative odds of additional fusion surgery controlling for age, gender, and Charlson Comorbidity Index (CCI) RESULTS A total of 3,639 patients with single-level disease were identified, with 2,895 (80%) undergoing ACDF and 744 (20%) undergoing PCF. The rates of additional cervical spine surgery within 5 years were 1.7% and 1.5%, after ACDF and PCF respectively. A total of 2,986 patients had multilevel disease, with 2,785 (93%) undergoing multilevel ACDF and 201 (7%) undergoing multilevel PCF. The rates of additional cervical spine surgery within 5 years were 5.3% and 0.5%, after ACDF and PCF respectively. In multivariate analysis controlling for age, gender, and comorbidities, there was no significant difference in reoperations between ACDF and PCF in the single-level cohort. However, in the multilevel cohort, significantly more patients that underwent ACDF required additional cervical spine surgery within 5 years (odds ratio: 3.21, P = 0.048). CONCLUSIONS In the Medicare population for multilevel radiculopathy, PCF resulted in less reoperation compared with multilevel ACDF. However, no difference was seen for single level radiculopathy. Therefore, there may be some benefit in choosing PCF over ACDF in certain patients with multilevel disease. Choice of surgical technique ultimately depends on an individual patient's history, physical examination, and radiographic findings. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. Animmediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. Therapeutic Level III.

Comparison of outcomes following thoracoscopic versus thoracotomy closure for persistent patent ductus arteriosus.

Patent ductus arteriosus closure is traditionally performed by thoracotomy approach. Video-assisted thoracoscopic surgery is a less frequently utilised alternative. We sought to compare elective surgical outcomes between the two methods via a single-centre retrospective cohort analysis. All patients >3.2 kg undergoing surgical patent ductus arteriosus ligation at a single institution from 2000 to 2018 were retrospectively reviewed. Propensity matching for age, weight, diuretic usage, and preterm status was conducted to adjust for differences in baseline patient characteristics. Outcome measures included operative time, hospitalisation duration, post-operative complications, and re-operation. A total of 173 patients were included, 127 thoracoscopy and 46 thoracotomy. In the unmatched cohorts, no significant difference in closure success was found (94% thoracoscopy versus 100% thoracotomy, p = 0.192). Although median operative time was longer for thoracoscopy (87 versus 56 minutes, p < 0.001), hospitalisation duration was shorter (1.05 versus 2.41 days, p < 0.001), as was ICU stay (0.00 versus 0.75 days, p < 0.001). There were no significant differences in re-operation or complication rates, except chest tube placement (11% thoracoscopy versus 50% thoracotomy, p < 0.001). After matching (69 thoracoscopy versus 20 thoracotomy), these differences persisted, including median operative time (81 versus 56 minutes, p = 0.007; thoracoscopy versus thoracotomy), hospitalisation duration (1.25 versus 2.27 days, p < 0.001), and chest tube placement (17% versus 60%, p < 0.001). There remained no significant difference in complications or re-operations. Thoracoscopic ligation was associated with shorter ICU and hospital stays and less frequent chest tube placement, but longer operative times. Other risks, including bleeding, chylothorax, and recurrent laryngeal nerve injury, were similar.

Comparison of open and closed hyperthermic intraperitoneal chemotherapy: Results from the United States hyperthermic intraperitoneal chemotherapy collaborative.

BACKGROUNDCytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis can be performed in two ways: Open or closed abdominal technique.AIMTo evaluate the impact of HIPEC method on post-operative and long-term survival outcomes.METHODSPatients undergoing CRS with HIPEC from 2000-2017 were identified in the United States HIPEC collaborative database. Post-operative, recurrence, and overall survival outcomes were compared between those who received open vs closed HIPEC.RESULTSOf the 1812 patients undergoing curative-intent CRS and HIPEC, 372 (21%) patients underwent open HIPEC and 1440 (79%) underwent closed HIPEC. There was no difference in re-operation or severe complications between the two groups. Closed HIPEC had higher rates of 90-d readmission while open HIPEC had a higher rate of 90-d mortalities. On multi-variable analysis, closed HIPEC technique was not a significant predictor for overall survival (hazards ratio: 0.75, 95% confidence interval: 0.51-1.10, P = 0.14) or recurrence-free survival (hazards ratio: 1.39, 95% confidence interval: 1.00-1.93, P = 0.05) in the entire cohort. These findings remained consistent in the appendiceal and the colorectal subgroups.CONCLUSIONIn this multi-institutional analysis, the HIPEC method was not independently associated with relevant post-operative or long-term outcomes. HIPEC technique may be left to the discretion of the operating surgeon.

MRI-determined preoperative lateral meniscus degeneration is not associated with adverse mid-term clinical results after mobile-bearing unicompartmental knee arthroplasty

BackgroundOne of the conditions constituting surgical indication for medial mobile-bearing unicompartmental knee arthroplasty (UKA) is that there is full-thickness cartilage in the lateral compartment under valgus stress radiography. However, it is unclear whether medial unicompartmental knee arthroplasty should be performed if there is degeneration of the lateral meniscus on preoperative magnetic resonance imaging (MRI). MethodsThe records of 77 patients (77 knees) who underwent Oxford mobile-bearing UKA were retrospectively reviewed. Based on the status of the lateral meniscus in each knee using preoperative MRI with Stoller's classification system, the patients were divided into two groups; a normal group and a lateral meniscus degenerated group (grades 1–3). The preoperative personal data and the outcome data three years postoperatively were compared. ResultsThe normal group contained 31 knees while the lateral meniscus degenerated group comprised 46 knees. There was no difference in clinical outcome or knee function between the groups at three years after UKA. There was no difference in re-operation and revision rate between the groups with no revisions in either group. ConclusionsIt may not be necessary to exclude UKA indications for cases with degenerative findings in the lateral meniscus on preoperative MRI.

Tall-Statured Patients Have Similar Outcomes to Normal Height Patients after Primary Total Hip Arthroplasty

AbstractTotal hip arthroplasty (THA) has been proven to be a safe and efficacious operation; however, there is a paucity of literature on outcomes in patients in the 99th percentile for height. The objectives of this study were to identify differences in (1) implant selection, (2) operative times, (3) intraoperative and postoperative complications, (4) 90-day readmission, (5) all cause reoperation rates, and (6) hospital length of stay (LOS), in tall-statured patients compared with a matched control cohort. An electronic research request was used to identify 12,850 patients who underwent THA from January 2012 to December 2016 with minimum 1-year follow-up at a single health care system for retrospective chart review. Patients were identified in the 99th percentile for height (193 cm for males and 177 cm for females) and then matched to controls based on gender, race, age, body mass index, and Charlson comorbidity index. A total of 260 THA patients (2%) were identified in the 99th percentile for height. The tall-statured patients were then matched to 248 patients of normal stature. The exclusion criteria was met by 172 tall-statured patients and 165 normal-statured patients. Final analysis comprised of 86 tall-statured patients (100 THA) and 83 matched normal-statured patients (92 THA). Baseline demographics information and the outcomes of interest were then compared. The mean height of the female patients in the tall cohort was 181.01 ± 2.51 cm compared with 166.6 ± 6.98 cm for the control group (p &lt; 0.001), while it was 195.25 ± 4.03 cm for male patients in the tall cohort and 174.11 ± 4.63 cm for the control cohort (p &lt; 0.001). Tall-statured patients had larger acetabular cups (p &lt; 0.001) and femoral head (p = 0.046) components. There were no differences in reoperation (p = 0.282), 90-day readmissions (p = 0.862), intraoperative fractures (p = 0.228), postoperative complications (p = 0.678), operative times (p = 0.890), and LOS (p = 0.099) between the tall-statured and normal-statured patients. Patients that are in the 99th percentile for height have similar outcomes to patients that are of normal height. The level of evidence of this study is level 3.

Polyester mesh dressings reduce delayed wound healing rates after total hip arthroplasty compared with silver-impregnated occlusive dressings

BackgroundNew dressings purport to reduce surgical wound complications after total hip arthroplasty (THA). This study compared delayed wound healing rates and reoperations between 2 increasingly popular dressings: a silver-impregnated occlusive (standard) dressing and a 2-octyl cyanoacrylate adhesive with polyester mesh.MethodsThis retrospective cohort study reviewed 431 consecutive THAs performed by 2 surgeons between January 2017 and May 2019. One hundred and eight were excluded for not using standard or mesh dressings. A final 323 cases were separated into 2 cohorts: mesh (n = 186) and standard dressings (n = 137). Standard dressings were removed at 1 week. Mesh persisted until nonadherent, approximately 3-4 weeks. The surgeon assessed delayed wound healing at the 2-week postoperative visit. Secondary outcomes include deep infection and return to the operating room for a wound-related diagnosis. Differences were determined using the chi-square test.ResultsThere were no demographic, comorbidity, or surgical differences between groups. There were 22 total cases of delayed wound healing with 7 (3.8%) in the mesh group and 15 (10.9%) in the standard dressing group (P = .01). There were no significant differences in reoperations (2 [1.1%] vs 2 [1.5%], P = .76) or deep infections (2 [1.1%] vs 1 [0.7%], P = .75).ConclusionsMesh dressings are a safe and reliable dressing type for THA and were associated with a decrease in early wound healing complications when compared with standard, silver-impregnated occlusive dressings in this retrospective series. The mesh tension sharing properties and longer duration of occlusive protection may explain this difference.Level of EvidenceLevel III.

An Epidemiological Analysis and Comparison of Single Site and Multiple Site Fracture Repair: An NSQIP Analysis

We aimed to utilize the 2010 to 2017 National Surgical Quality Improvement Program to evaluate the epidemiology and efficacy of facial fracture repairs, specifically comparing multiple fracture site repairs (MFR) compared to single fracture site repairs (SFR). Of 4739 patients, 718 (15.2%) were found to have undergone MFR. A total of 577 (80.4%) of the MFRs involved the midface only. A total of 2114 (52.6%) of the SFRs were mid-face fractures, while 1825 (45.4%) involved the lower-face and only 82 (2.0%) involved the upper-face. The most frequent MFR was combined orbital and malar/zygoma repair (230 cases [32.0%]). When comparing MFR and SFR of the mid-face, MFR patients were more commonly male, White, operated on by plastic surgeons, presented with contaminated wounds, and active smokers. While MFRs were associated with a longer operative time (P < 0.001) and a longer postoperative hospital stay (P < 0.001), there were no differences in reoperation or readmission. Overall, complication rates were low, but slightly higher in the mid-face MFR group (1.4% in mid-face SFR and 3.0% in mid-face MFR; P = 0.019). Sub-analysis of mid-face only MFRs and middle-lower-face MFRs revealed no difference in postoperative complication rates (3.0% and 7.0%, respectively; P = 0.071). The data presented suggests that MFR are a relatively common occurrence. Although plastic surgeons perform MFRs more frequently, it is currently unclear whether the underlying reason is a product of differences in training, coding patterns, or referral patterns. Though MFRs require more hospital resources, complications rates are low. This will help manage patient expectations and guide patient counseling before surgery, as well as help to plan postoperative care.

Outcomes of Primary versus Multiple-Staged Repair in Hirschsprung's Disease in England.

The study aimed to compare 1-year outcomes for primary versus multiple-staged (three operations with colostomy) repairs in Hirschsprung's disease (HD). Retrospective analysis of a large national administrative database (Hospital Episode Statistics) including all the neonates born with HD in England between 2003 and 2015. Main outcomes were: 1-year mortality, postoperative readmissions, and reoperations. cumulative length of hospital stay (cLOS) and hospital volume-outcome relationship. A total of 1,333 neonates with HD were treated in 21 specialist pediatric surgical centers; 874 (65.5%) patients had a primary repair for HD. One-year mortality was 2.8%. The overall readmission rate was 70.2%, with a significant difference between primary and multiple-staged repair (79.9 vs. 90.1%, p < 0.01). There was no difference in reoperation. Primary pull-through was associated with a significantly lower probability of postoperative readmission (odds ratio [OR] = 0.08, 95% confidence interval [CI] = 0.06-0.11, p < 0.001) and cLOS (OR = 0.38, 95% CI = 0.28-0.52, p < 0.001) compared with multiple-staged repair. There were no significant difference in outcomes between patients treated in low-volume (<37 cases/year) and high-volume (> 55 cases/year) specialist centers. Whenever clinically indicated, primary repair should be used in HD as this is associated with fewer readmissions and shorter time spent in the hospital.

Standardization of early drain removal following pancreatic resection: proposal of the \u201cOttawa pancreatic drain algorithm\u201d

BackgroundEarly drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol.MethodsThe Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation).Results42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively).ConclusionsImplementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.

A Comparison of Revision Rates and Patient-Reported Outcomes for a 2-Level Posterolateral Fusion Augmented With Single Versus 2-Level Transforaminal Lumbar Interbody Fusion.

Study Design:Retrospective, single institution, multisurgeon case control series.Objective:To determine whether there are differences in reoperation rates or outcomes for patients undergoing 2-level posterolateral fusion (PLF) augmented by a transforaminal lumbar interbody fusion (TLIF) at only one of the levels or at both.Methods:A total of 416 patients were identified who underwent 2-level PLF with a TLIF at either one of those levels (n = 183) or at both (n = 233) with greater than 1-year follow-up. Demographic, surgical, radiographic, and clinical data was reviewed for each patient. These included age, sex, race, body mass index, smoking status, Charleston Comorbidity Index, operative time, estimated blood loss, length of stay, and patient-reported outcome measures.Results:Each cohort underwent 24 reoperations. Although the number of overall reoperations was not significantly different (P > .05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the 2-level group compared to the 1-level group (19 vs 12, P = .04). There was no difference in reoperation for pseudarthrosis between the groups (P > .05). Although both groups experienced significant improvements in Oswestry Disability Index (P < .001) and Short Form–12 health questionnaire (P < .001), there were no differences between improvements for 1- versus 2-level cohorts.Conclusions:For patients undergoing 2-level PLF in the setting of a TLIF, using a TLIF at one versus both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a 2-level PLF augmented by a 2-level TLIF.

The influence of statins on aortic aneurysm after operation: A retrospective nationwide study.

Aortic aneurysm (AA) is a disease with substantially higher health care costs and very high mortality upon rupture. Statins have a non-lipid-lowering pleiotropic mechanism that may be beneficial for AA in disease progression and improvement of AA patient outcomes. Previous studies have been conducted with some limitations and without considering immortal time bias, lag time, and adherence. The aim of our study was to analyze the effect of statin use on AA postoperation after controlling for these factors.All postoperative patients with a diagnosis of AA in Taiwan from 2004 to 2012 were included from the National Health Insurance Research Database. We excluded patients without computed tomography within 1 year after diagnosis and those who died within 30 days after the operation. We also analyzed the medication, medication possession ratio (MPR), immortal time bias, and lag time. Statin users were defined as those using statins for more than 30 days. Primary composite outcomes included mortality, reoperation for AA and rehospitalization for AA during the study period.Among the whole study population (n = 1633), 199/1633 (12.19%) patients were statin users, while the others (n = 1434) were not. Mortality was higher in statin nonusers than in statin users, with a mortality rate of 40% versus 22.61% (P < .0001). There was no significant difference in reoperation or rehospitalization for AA.Statin use may be beneficial for AA patients in our observational study. Prospective randomized controlled studies are needed to define the effect of statin therapy in this population.

Risk Factors and Outcomes in Redo Coronary Artery Bypass Grafting

Reoperative coronary artery bypass grafting (redo-CABG) has declined during the last decade, while use of percutaneous coronary intervention (PCI) has increased. The aim of this retrospective study was to evaluate risk factors, in-hospital mortality, and long-term survival between first-time CABG and redo-CABG. From January 2009 to December 2015, 2,581 patients underwent first-time CABG procedures while 132 underwent isolated redo-CABG. Logistic regression was used to identify risk factors predictive of redo-CABG and after propensity matching the in-hospital morbidity and long-term all-cause mortality were compared. Risk factors for redo-CABG were prior PCI, dyslipidaemia, diabetes and hypertension. After propensity matching there were no significant differences between the redo-CABG (n = 126) and first-time CABG groups (n = 232) in baseline characteristics. The adjusted in-hospital mortality was 3.1% for redo-CABG and 2.1% for first-time CABG (p = 0.55). Redo-CABG required significantly more intraoperative red blood cells (p = 0.03), platelets (p < 0.001), cryoprecipitate (p < 0.007) and fresh frozen plasma (p < 0.001) than first-time CABG. There was no significant difference in reoperation for bleeding (p = 0.72), prolonged ventilation (p = 0.98), postoperative stroke (p = 0.92) or dialysis (p = 0.44). The survival at 1, 3 and 5 years for redo-CABG was 93.5%, 90%, and 85% respectively, and 95.5%, 94.5%, 93% for first-time CABG, respectively (p = 0.2). Prior PCI after first time CABG and the risk factors for atherosclerotic disease are predictive for redo-CABG. An increased use of blood products is required during redo-CABG. After propensity matching, in-hospital mortality and long-term survival for redo-CABG is comparable to first-time operation. Re-sternotomy does not impact the survival in redo-CABG.

Outcomes of Primary Total Knee Arthroplasty in Patients With Ehlers-Danlos Syndromes

BackgroundEhlers-Danlos syndromes (EDS) are connective tissue disorders that cause defects in collagen synthesis or processing, resulting in joint hypermobility. Following total knee arthroplasty (TKA), concern exists that hypermobility will affect the outcome as prosthesis relies on soft tissues for stability. The purpose of this study is to investigate the outcome of TKA in the setting of EDS compared to patients undergoing TKA for osteoarthritis (OA). MethodsWe identified 16 patients (20 knees) with EDS who underwent a TKA between 2001 and 2016. Patients were matched 1:2 (n = 40) on age, gender, body mass index, and surgical date to patients undergoing TKA for OA. ResultsWe found no difference in age, body mass index, or follow-up between the cohorts (P > .05). EDS patients had significantly more surgical interventions prior to TKA (P = .03) and were more likely to require constrained components (x2 = 0.002). Following TKA, 4 patients in the EDS group and 9 patients in the matched cohort underwent a reoperation for any reason including 1 revision in the EDS cohort and 3 in the OA cohort. We found no significant difference in reoperation or revision rates between the cohorts (P > .05). There was no difference in Knee Society Scores between groups at last follow-up (P = .63) or radiographic evidence of loosening. ConclusionAlthough patients with EDS were more likely to require a constrained component, they are not at increased risk of revision or reoperation following TKA in the intermediate term.

Are clinical outcomes affected by type of plate used for management of mid-shaft clavicle fractures?

BackgroundOpen reduction and internal fixation (ORIF) using plate osteosynthesis for midshaft clavicle fractures is often complicated by the prominence of the implant due to the subcutaneous position of the clavicle. Reoperation rates for symptomatic clavicle plate removal have been reported to be as high as 53%. We sought to determine to which degree do clinical outcomes (all cause reoperation rate and rate of fracture union) differ between types of clavicle plates.Materials and methodsA retrospective chart review was performed using our hospital database for patients treated with ORIF for mid-shaft clavicle fractures (OTA/AO type 15-B). Implants included in this review were 2.7 mm reconstruction plates, 3.5 mm reconstruction plates, 3.5 mm precontoured clavicle plates and 3.5 mm locking compression plates. The primary outcome measure was the all cause reoperation rate. Secondary outcomes compared the rate fracture union, documented infection, hardware failures and clinical symptoms at the surgical site among the various plate types. Data was collected and descriptive statistics were analyzed. p values < 0.05 were considered statistically significant.ResultsA total of 102 midshaft clavicle fractures treated with ORIF were included in this study. The majority of patients were ≤ 50 years old (83.3%) and male (72.5%). The overall union rate for all plating constructs was 97.1%. We found that age, sex and smoking were not associated with the rate of re-operation. In addition, the fracture classification, type of implant used and number of screws used didn’t increase the risk of revision surgery. In addition, more than 50% of patients complaining of pain at 6 weeks post-operatively required a second surgery for removal of hardware. Moreover, there was no association between age, sex, smoking, fracture classification or plate type and the rate of union. Interestingly, clavicle fractures fixed with 3.5 mm reconstruction plates were more likely to have hardware failure due to plastic deformation, whereas 2.7 mm plates were more likely to fail by plate breakage.ConclusionAlthough different types of implants have different biomechanical properties, no difference in reoperation, union and plate removal rates were found between the various plate types. Future studies with a larger sample size are required to further examine these outcomes.Level of evidenceLevel III.

Thursday, September 27, 2018 1:05 PM–2:05 PM Lumbar Spine Surgery: What You Need to Know: 114. No difference in reoperation rates or outcomes for a two-level posterolateral fusion augmented with single- versus two-level transforaminal lumbar interbody fusion

BACKGROUND CONTEXT Interbody devices (IBD) are being increasingly utilized during lumbar fusions with reported benefits, when compared to posterolateral fusion (PLF) alone, including increased fusion rates, increased neuroforaminal height, and the potential for improved sagittal alignment. Moreover, use of IBD has been shown to reduce reoperation rates compared to PLF alone. Although excellent outcomes have been demonstrated for single level transforaminal lumbar interbody fusion (TLIF), outcomes for single level TLIF in the setting of multiple level PLF are unknown. Some have suggested that a single level TLIF in the setting of a two level PLF may lead to increased pseudarthrosis at the level without an IBD, perhaps secondary to differences in stiffness at those levels in the setting of a developing fusion. PURPOSE We aim to determine whether there are differences in reoperation rate and outcomes for patients undergoing two level PLF augmented by a TLIF at only one of the levels vs at both levels. STUDY DESIGN/SETTING Retrospective, single institution, multi-surgeon patient cohort. PATIENT SAMPLE From September 2012 through September 2017, 416 patients were identified who underwent two level PLF with a TLIF at either one of those levels (n=183) or at both (n=233) with greater than one year follow-up. The two level TLIF group was significantly younger than the single level TLIF group (60.2 vs. 63.7, p=0.001), had a significantly lower Charleston Comorbidity Index (0.32 vs. 1.21, p OUTCOME MEASURES Primary outcome was reoperation rate with secondary outcomes including surgical parameters (estimated blood loss [EBL], OR time, length of stay [LOS]) and patient reported outcome measures (ODI, SF-12). METHODS T-tests were used to compare the cohorts for continuous variables and Chi square tests were used to compare the groups on categorical variables. RESULTS The one level and two level TLIF groups underwent 24 reoperations for 25 complication types and 24 reoperations for 27 complication types, respectively. Although the number of overall reoperations was not significantly different (p>0.05), among the reoperation types, there were significantly more reoperations for adjacent segment disease in the two level group compared to the one level group (19 vs. 12, p=0.04). There was no difference in reoperation for pseudarthrosis between the groups (p>0.05). Although the two level group had a higher EBL (p=0.002), they had an overall shorter LOS (p=0.003) (likely because they were younger and healthier to start). Although both groups experienced significant improvements in ODI (p CONCLUSIONS For patients undergoing two level PLF in the setting of a TLIF, using a TLIF at one vs both levels does not seem to influence reoperation rates or outcomes. However, reoperation rates for adjacent segment disease are increased in the setting of a two level PLF augmented by two TLIFs. FDA DEVICE/DRUG STATUS All devices were FDA approved and used as instructed.

Functional outcomes of internal fixation and arthroplasty in the treatment of intertrochanteric femoral fractures: a systematic review

Background: Hip fractures are a common cause of morbidity, especially in the elderly. Treatment of extracapsular hip fractures is highly controversial. Fixation is the main treatment for this type of fracture including extramedullary and intramedullary fixation. The problem of fixation failure remains the main drawback. Many trials have shown that arthroplasty as an alternative option would have better functional results, especially in the early postoperative period. The aim of this review was to compare the functional outcomes of internal fixation versus arthroplasty in the treatment of intertrochanteric fractures. Methods: Two reviewers searched the following databases: PubMed, the Cochrane Library, Ovid, and Science Direct for randomized control trials (RCTs) and quasi-random trials comparing the outcomes of internal fixation and arthroplasty in the treatment of intertrochanteric fractures. We assessed the quality of the studies meeting the eligibility criteria by using the Cochrane assessment tool. For measuring the outcomes, we used the mean difference with 95% confidence interval for continuous data and risk difference, with 95% confidence interval for dichotomous data. Results: The electronic search revealed 3402 citations. After removing duplicate articles, 3397 citations were screened for possible inclusion in the review. Of those 3273 citations were excluded by title or abstract. One hundred and twenty-four full text articles were assessed for eligibility. Six studies compared the results of fixation versus arthroplasty. A meta-analysis of the studies showed no difference in mean Harris Hip Score between groups (mean difference −7.51 [−12.28, −2.74). There was also no difference in the independence of ambulation at 1 yr (risk difference 0.01 [−0.17, 0.19]). The cost of treatment was higher in the arthroplasty group (mean difference 5898.00 [5364.00, 6432.00]). There was no difference in reoperation (risk difference −0.09 [−0.15, −0.03]) and mortality risks (risk difference −0.10 [−0.32, 0.12]). Conclusions: Although most patients with intertrochanteric fracture are treated successfully with internal fixation, arthroplasty could be useful in certain types of fractures. However, there is a lack of high-quality evidence to assist surgeons in deciding when to use this option.

Minimally invasive repair of pectus excavatum: Analysis of the NSQIP database and the use of thoracoscopy

BackgroundThe minimally invasive repair of pectus excavatum (MIRPE) has been widely accepted and has become a viable alternative to the open Ravitch technique. MIRPE has evolved over time with some advocating that a safe repair can be accomplished without direct visualization utilizing thoracoscopy. The MIRPE with and without a thoracoscopic approach has not been previously analyzed from a nationwide database to determine differences in safety and short-term outcomes. MethodsThe American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012–2015 database was used in identifying patients that had MIRPE using Current Procedural Terminology (CPT) codes and ICD-9CM/ICD-10CM postoperative diagnosis codes. Outcomes of interest were readmissions, reoperations, complications, cardiothoracic injury, operative time, and duration of hospital stay after surgery for MIRPE with and without thoracoscopy. Descriptive statistics, simple and multivariable logistic regressions, Fisher's exact, and Wilcoxon rank sum test were used to determine any differences in 30-day postoperative outcomes. ResultsThere were 1569 MIRPE cases included. 15.9% (N=249) of MIRPE were done without thoracoscopy. There were no significant differences with the use of thoracoscopy compared to without thoracoscopy in the rate of readmissions (2.5 vs 4.8%; p=0.06), reoperations (1.4 vs 2.0%; p=0.57), postoperative complications (2.6% vs 3.2%; p=0.52), and cardiothoracic injuries (0.2% vs 0.0%; p=1.00). Unadjusted odds ratios (ORs) for readmission and reoperation comparing MIRPE with thoracoscopy to MIRPE without thoracoscopy were 0.51 (p<0.05) and 0.71 (p=0.50), respectively. Adjusted ORs were 0.49 (p=0.04) and 0.71 (p=0.50), respectively. There were no reported deaths, but two cardiothoracic injuries were recorded in the group with thoracoscopy. MIRPE with thoracoscopy was associated with longer operative time (mean 13.0min; p=0.00) and longer hospital stay (mean 0.37days; p<0.01) compared to MIRPE without thoracoscopy. No data were available for the severity of the pectus defect. ConclusionMIRPE has a low adverse event rate with no difference in reoperations, postoperative complications, and cardiothoracic injuries with or without the use of thoracoscopy. There may be a higher rate of readmissions in the nonthoracoscopic group. While the technique used remains the surgeon's decision, the use of thoracoscopy may be unnecessary and is at an added cost. Type of studyTreatment study (retrospective comparative study). Level of evidenceLevel III.

Colorectal Carcinoma in the Frail Surgical Patient. Implementation of a Work Area Focused on the Complex Surgical Patient Improves Postoperative Outcome

IntroductionAdvanced age and comorbidity impact on post-operative morbi-mortality in the frail surgical patient. The aim of this study is to assess the impact of a comprehensive, multidisciplinary and individualized care delivered to the frail patient by implementation of a Work Area focused on the Complex Surgical Patient (CSPA). MethodsRetrospective study with prospective data collection. Ninety one consecutive patients, classified as frail (ASA III or IV, Barthel<80 and/or Pfeiffer>3) underwent curative radical surgery for colorectal carcinoma between 2013 and 2015. Group I: 35 patients optimized by the CSPA during 2015. Group II: 56 No-CSPA patients, treated prior to CSPA implementation, during 2014–2015. Group homogeneity, complication rate, length of stay, reoperations, readmissions, costs and overall mortality were analyzed and adjusted by Diagnosis-Related Group (DRG). ResultsThere were no statistically significant differences in term of age, gender, ASA classification, body mass index, tumor staging and type of surgical intervention between the two groups. Major complications (Clavien-Dindo III–IV) (12.5% vs 28.5%, P=.04), hospital stay (12.6±6days vs 15.2±6days, P=.041), readmissions (12.5% vs 28.3%, P<.041), and patient episode cost weighted according to DRG (3.29±1 vs 4.3±1, P=.008) were statistically inferior in Group CSPA. There were no differences in reoperations (6.2% vs 5.3%) or mortality (6.2% vs 7.1%). 96.9% of patients of Group I manifested having received a satisfactory attention and quality of life. ConclusionsImplementation of a CSPA, delivering surgical care to frail colorectal cancer patients, involves a reduction of complications, length of stay and readmissions, and is a cost-effective arrangement.