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Competing Interests: Disclosures None.

Objectives: To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk., Design: Retrospective database review., Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database., Patients: Patients in the NSQIP database with fractures involving the upper extremity., Intervention: Surgical management of upper extremity fracture, including operative debridement for open injuries., Main Outcome Measurements: Surgical site infection, including both superficial and deep infections., Results: A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431)., Conclusions: Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To empirically define a "delay" for hip fracture surgery based on clinical outcomes, and to identify patient demographics and hospital factors contributing to surgical delay., Design: Retrospective database analysis., Setting: Hospital discharge data., Patients/participants: A total of 2,121,215 patients undergoing surgical repair of hip fracture in the National Inpatient Sample between 2000 and 2009., Intervention: Internal fixation or partial/total hip replacement., Main Outcome Measurements: Logistic regressions were performed to assess the effect of surgical timing on in-hospital complication and mortality rates, controlling for patient characteristics and hospital attributes. Subsequent regressions were performed to analyze which patient characteristics (age, gender, race, comorbidity burden, insurance status, and day of admission) and hospital factors (size, teaching status, and region) independently contributed to the likelihood of surgical delay., Results: Compared to same-day surgery, each additional day of delay was associated with a significantly higher overall complication rate. However, next-day surgery was not associated with an increased risk of in-hospital mortality. Surgery 2 calendar days (odds ratio: 1.13) and 3+ days (odds ratio: 1.33) after admission was associated with higher mortality rates. Based on these findings, "delay" was defined as surgery performed 2 or more days after admission. Significant factors related to surgical delay included comorbidity score, race, insurance status, hospital region, and day of admission., Conclusions: Surgical delay in hip fracture care contributes to patient morbidity and mortality. A variety of patient and hospital characteristics seem to contribute to surgical delay and point to important health care disparities., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Study Design: Retrospective review of a multicenter database of consecutive patients undergoing 3-column osteotomy for treatment of adult spinal deformity (ASD)., Objective: To rigorously develop a T1 pelvic angle (TPA) categorization paradigm and use it to assess the surgical management of patients with ASD., Summary of Background Data: TPA, the angle between the hips-T1 line and hips-S1 endplate line, is a novel spinopelvic parameter that assesses the combined effect of a loss of lordosis on trunk inclination and pelvic retroversion., Methods: A prospective, multicenter database of consecutive patients with ASD was queried to identify the severe deformity threshold and meaningful change values for TPA by correlation with Oswestry Disability Index. A separate multicenter, consecutive, retrospective database of patients with ASD treated with single lumbar 3-column osteotomy was then analyzed at baseline, 3-month, and 1-year follow-up. Subjects were classified into well-aligned or poorly aligned groups at 3 months on the basis of TPA. Patients "deteriorated" if they lost more than 1 meaningful change in TPA between 3 months and 1 year and had TPA more than deformity threshold at 1 year., Results: The severe deformity threshold for TPA was 20° (Oswestry Disability Index > 40) and the meaningful change was 4.1° (Oswestry Disability Index change = 15). Review of the 3-column osteotomy database identified 179 patients with preoperative severe deformity; 63 were well-aligned (TPA < 15.9°) and 73 were poorly aligned (TPA > 20°) at 3-month follow-up. This newly developed TPA categorization mechanism grouped patients in a manner comparable with the Scoliosis Research Society-Schwab Classification. Subjects who were well-aligned at 3 months had less severe baseline deformity, but received more correction, than poorly aligned subjects. Four well-aligned patients and 13 poorly aligned patients deteriorated between 3 months and 1 year after surgery., Conclusion: TPA accounts for sagittal vertical axis and pelvic tilt and shows great promise as a classification tool. Longitudinal analysis demonstrated undercorrection among patients with more severe preoperative deformity. We propose a surgical target of 10° for TPA., Level of Evidence: 4.

Study Design: Post hoc analysis of prospectively collected data., Objective: Development of methods to determine in vivo spinal cord dimensions and application to correlate preoperative alignment, myelopathy, and health-related quality-of-life scores in patients with cervical spondylotic myelopathy (CSM)., Summary of Background Data: CSM is the leading cause of spinal cord dysfunction. The association between cervical alignment, sagittal balance, and myelopathy has not been well characterized., Methods: This was a post hoc analysis of the prospective, multicenter AOSpine North America CSM study. Inclusion criteria for this study required preoperative cervical magnetic resonance imaging (MRI) and neutral sagittal cervical radiography. Techniques for MRI assessment of spinal cord dimensions were developed. Correlations between imaging and health-related quality-of-life scores were assessed., Results: Fifty-six patients met inclusion criteria (mean age = 55.4 yr). The modified Japanese Orthopedic Association (mJOA) scores correlated with C2-C7 sagittal vertical axis (SVA) (r = -0.282, P = 0.035). Spinal cord volume correlated with cord length (r = 0.472, P < 0.001) and cord average cross-sectional area (r = 0.957, P < 0.001). For all patients, no correlations were found between MRI measurements of spinal cord length, volume, mean cross-sectional area or surface area, and outcomes. For patients with cervical lordosis, mJOA scores correlated positively with cord volume (r = 0.366, P = 0.022), external cord area (r = 0.399, P = 0.012), and mean cross-sectional cord area (r = 0.345, P = 0.031). In contrast, for patients with cervical kyphosis, mJOA scores correlated negatively with cord volume (r = -0.496, P = 0.043) and mean cross-sectional cord area (r = -0.535, P = 0.027)., Conclusion: This study is the first to correlate cervical sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment. It is interesting to note that sagittal balance but not kyphosis is tied to myelopathy score. Future work will correlate alignment changes to cord morphology changes and myelopathy outcomes. SUMMARY STATEMENTS: This is the first study to correlate sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment.