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BACKGROUND Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p

In 2020, total hip arthroplasty (THA) was removed from the inpatient-only list by the Centers for Medicare and Medicaid Services. The objective was to analyze outpatient THA in the Medicare population to understand incidence of failed same-day discharge (SDD) and risk factors for complications and extended length of stay (LOS). The 2015–2019 American College of Surgeons—National Surgical Quality Improvement Program database was queried for Medicare patients (≥ 65 years) undergoing outpatient THA. Short-term complications, LOS, and discharge destination were evaluated. Multivariate logistic regression was used to evaluate risk factors for complications, failed SDD, reoperation, readmission, and non-home discharge disposition. Overall, 2,063 THAs were included. Complication rate was 7.4%. The number of patients staying in the hospital ≥ 1 day was 1,080 (52%). A total of 151 patients (7.3%) experienced a non-home discharge. Predictors for having any complication was an extended LOS ≥ 1 day (odds ratio [OR] 2.86), p II (OR 1.67), and age ≥ 71 (OR 1.31) (all p ≤ 0.004). Significant predictors for a non-home discharge were LOS ≥ 1 day (OR 13.71), American Society of Anesthesiologists Class > II (OR 2.36), age ≥ 71 (OR 2.07), operative time ≥ 82 minutes (OR 1.88), and female gender (OR 1.81), all p ≤ 0.003. The current study identifies the incidence, risk factors, and clinical impact of postoperative complications and prolonged LOS in Medicare-aged patients undergoing outpatient THA. Providers should consider preoperatively risk stratifying patients to reduce the costs associated with extended LOS, complication, and unplanned discharge destination.

Introduction The U.S. News & World Report (USNWR) hospital rankings remain the most publicly referenced system for identifying top hospitals for each specialty. The current study aims to evaluate whether there are any differences in outcomes and costs for patients undergoing anatomic TSA (ATSA) or reverse TSA (RTSA) for degenerative pathologies at ranked vs. non–ranked hospitals. Methods The 2011-2014 USNWR hospital rankings were used to identify ranked hospitals in “Orthopedics.” The 2011-2014 100% Medicare Standard Analytical Files (SAF100) were used to identify patients undergoing ATSA or RTSA for degenerative arthritis. The study cohort was divided into two groups, based on whether patients received surgery at a ranked hospital vs. a non–ranked hospital. Multi-variate logistic and linear regression analyses were used to assess for differences in 90-day outcomes and costs between ranked and non–ranked hospitals, while controlling for potential co-variates/confounders. Results A total of 82,417 TSA were included in the study – out of which 8,868 (10.8%) were performed in one of the 68 hospitals that were ranked by the USNWR between 2011 and 2014. Following adjustment for baseline demographics, and clinical characteristics, there were no statistically significant differences between ranked vs. non–ranked hospitals, with regards to rates of infectious complications (0.8% vs. 1.0%, OR 0.91 [95% CI 0.82-1.01]; P = .079), dislocations (0.8% vs. 0.9%, OR 1.07 [95% CI 0.79-1.43]; P = .658), peri-prosthetic fractures (0.3% vs. 0.3%, OR 0.77 [95% CI 0.47-1.21]; P = .269), pulmonary embolism (0.7% vs. 0.8%, OR 0.88 [95% CI 0.64-1.20]; P = .435), deep venous thrombosis (1.1% vs. 0.9%, OR 1.21 [95% CI 0.93-1.56]; P = .153), myocardial infarction (0.4% vs. 0.5%, OR 1.00 [95% CI 0.67-1.46]; P = .995), sepsis (6.0% vs. 7.3%, OR 0.95 [95% CI 0.85-1.05]; P = .314), urinary tract infections (4.8% vs. 5.6%, OR 0.99 [95% CI 0.87-1.11]; P = .831) and readmissions (7.1% vs. 8.3%, OR 0.91 [95% CI 0.82-1.01]; P = .079). Ranked hospitals, however, did have higher risk-adjusted charges (+ $6,167; P Conclusion Based on our findings, patients undergoing TSA at ranked hospitals vs. non–ranked hospitals have similar outcomes, despite the former facilities having higher costs and charges across the episode of care. Level of Evidence Level III

Background Impact of resident participation on short-term postoperative outcomes after total elbow arthroplasty has not been studied. The aim was to investigate whether resident participation affects postoperative complication rates, operative time, and length of stay. Methods The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2012 for patients undergoing total elbow arthroplasty. A 1:1 propensity score match was performed to match resident cases to attending-only cases. Comorbidities, surgical time, and short-term (30-day) postoperative complications were compared between groups. Multivariate Poisson regression was used to compare the rates of postoperative adverse events between groups. Results After propensity score match, 124 cases (50% with resident participation) were included. Adverse event rate after surgery was 18.5%. On multivariate analysis, there were no significant differences between attending-only cases and resident involved cases, with regards to short-term major complications, minor complications, or any complications (all p > 0.071). Total operative time was similar between cohorts (149.16 vs. 165.66 min; p = 0.157). No difference was observed in the length of hospital stay (2.95 vs. 2.6 days), p = 0.399. Discussion Resident participation during total elbow arthroplasty is not associated with increased risk for short-term medical or surgical postoperative complications or operative efficiency.

Objective To evaluate medical and surgical complication rates between robotic-assisted versus conventional elective posterior lumbar fusions. Methods The Symphony Integrated DataVerse was queried using International Classification of Diseases, 10th Edition, Clinical Modification procedure codes to identify patients undergoing elective posterior lumbar fusions for degenerative spine pathologies between 2015 and 2018. International Classification of Diseases, 10th Edition, Clinical Modification procedure codes (8E0W4CZ, 8E0W0CZ, 8E0W3CZ) were used to identify patients undergoing a robotic-assisted spinal fusion. Outcome measures were 90-day medical and surgical complications, 1-year pseudarthrosis, and 1-year revision surgery rates. Multivariate logistic regression analyses were used to assess whether undergoing a robotic-assisted fusion (vs. conventional fusion) was associated with differences in wound complications, medical complications, pseudarthrosis, revision surgery, and readmissions within 90 days of surgery. Results A total of 39,387 patients undergoing elective posterior lumbar fusions were included in the cohort—of whom 245 (0.62%) patients underwent a robotic-assisted fusion. Multivariate analysis showed that robotic-assisted fusion (vs. conventional fusion) was not associated with significant differences in 90-day rates of wound complications (P = 0.299), urinary tract infections (P = 0.648), acute myocardial infarctions (P = 0.209), acute renal failure (P = 0.461), pneumonia (P = 0.214), stroke (P = 0.917), deep venous thrombosis (P = 0.562), pulmonary embolism (P = 0.401), and readmissions (P = 0.985). In addition, there were no significant differences in the 1-year rates of revision fusions (P = 0.316) and pseudarthrosis (P = 0.695). Conclusions Patients who underwent a robotic-assisted fusion had similar rates of surgical and medical complications compared with those who underwent a conventional fusion. Further studies are warranted to better understand the future role of robots in spine surgery.

Objective To understand trends and variability of procedures performed by orthopedic spine surgery fellows during training. Design Cross-sectional survey. Setting Accreditation Council on Graduate Medical Education (ACGME) case logs. Participants Fellows enrolled in ACGME-accredited “Orthopaedic Surgery of the Spine” fellowships from 2010 to 2015. Results The 2010 to 2015 ACGME fellowship case logs for “Orthopaedic Surgery of the Spine” were retrieved. Spine cases in case logs are grouped into the following categories: (1) Excision, (2) Osteotomy, (3) Fracture and/or Dislocation, (4) Decompression, (5) Anterior fusion/arthrodesis, (6) Posterior fusion, (7) Deformity surgery, (8) Exploration, (9) Instrumentation, and (10) other/uncategorized. The total number of spine cases logged by each fellow increased from 821 in 2010 to 1134 in 2015 (38.2% increase). The greatest increases were noted from fracture/dislocation cases (77.9%), followed by posterior fusions (62.2%), anterior fusions (43.6%), decompressions (36.3%), and instrumentation (29.5%). The average number of deformity cases decreased from 23 in 2010 to 19 in 2016 (18.6% decrease). The average number of adult-only cases increased from 770 in 2010 to 1100 in 2015 (42.8% increase), whereas the average number of pediatric-only cases declined from 51 in 2010 to 35 in 2015 (32.1% decrease). Based on case logs from 2015, the greatest variation in case volume between the 10th centile and 90th centile of fellows was noted for deformity cases, followed by decompressions and posterior fusions. Conclusions Even though there has been a 38% increase in the overall number of spine cases performed by fellows during training, a large amount of variation in type of case exposure exists between fellowships. The findings of our study call for the establishment of minimal case volumes and/or uniformity of training spectrums across the nation to ensure appropriate surgical care is made accessible to all patients.

STUDY DESIGN Retrospective observational study. OBJECTIVE The aim of this study was to evaluate whether there are any differences in outcomes and costs for elective one- to three-level anterior cervical fusions (ACFs) performed at US News and World Report (USNWR) ranked and unranked hospitals. SUMMARY OF BACKGROUND DATA Although the USNWR rankings are advertised by media and are routinely used by patients as a guide in seeking care, evidence regarding whether these rankings are reflective of actual clinical outcome remains limited. METHODS The 2010-2014 USNWR hospital rankings were used to identify ranked hospitals in "Neurosurgery" and "Orthopedics." The 2010-2014 100% Medicare Standard Analytical Files (SAF100) were used to identify patients undergoing elective ACFs at ranked and unranked hospitals. Multivariable logistic regression and generalized linear regression analyses were used to assess for differences in 90-day outcomes and costs between ranked and unranked hospitals. RESULTS A total of 110,520 patients undergoing elective one- to three-level ACFs were included in the study, of which 10,289 (9.3%) underwent surgery in one of the 100 ranked hospitals. Following multivariate analysis, there were no significant differences between ranked versus unranked hospitals with regards to wound complications (1.2% vs. 1.1%; P = 0.907), cardiac complications (12.9% vs. 11.9%; P = 0.055), pulmonary complications (3.7% vs. 6.7%; P = 0.654), urinary tract infections (7.3% vs. 5.8%; P = 0.120), sepsis (9.3% vs. 7.9%; P = 0.847), deep venous thrombosis (1.9% vs. 1.3%; P = 0.077), revision surgery (0.3% vs. 0.3%; P = 0.617), and all-cause readmissions (4.7% vs. 4.4%; P = 0.266). Ranked hospitals, as compared to unranked hospitals, had a slightly lower odds of experiencing renal complications (7.0% vs. 4.9%; P = 0.047), but had significantly higher risk-adjusted 90-day charges (+$17,053; P

Study design This was a national database study. Objective The objective of this study was to assess the impact of prior bariatric surgery (BS) on altering 90-day postoperative outcomes following elective anterior cervical discectomy and fusions (ACDFs). Summary of background data Though obesity has previously been shown to be linked with adverse outcomes following elective spine surgical procedures, the effectiveness of weight-loss strategies such as BS has not been explored. Methods The PearlDiver program was used to query the 2007-2013 100% Medicare Standard Analytical Files (SAF100) for patients undergoing an elective ACDF. The study cohort was divided into 2 groups-(1) obese ACDF patients (body mass index ≥35 kg/m) receiving a BS procedure within 2 years before an ACDF and (2) obese ACDF patients (body mass index ≥35 kg/m) without a known history of a BS procedure within the last 2 years. Multivariate regression analyses were used to assess the impact of a BS procedure on postoperative outcomes following ACDF while adjusting for age, sex, region, and Elixhauser Comorbidity Index. Results A total of 411 ACDF patients underwent BS within the 2 years before an ACDF. Multivariate analysis showed that undergoing BS before an elective ACDF was associated with a significantly reduced risk of pulmonary complications [odds ratio (OR)=0.53; P=0.002], cardiac complications (OR=0.69; P=0.012), sepsis (OR=0.69; P=0.035), renal complications (OR=0.54; P=0.044), and 90-day readmissions (OR=0.53; P=0.015). Conclusions Surgery-induced weight loss before an ACDF in obese patients is associated with reduced 90-day complication and readmission rates. Orthopaedic and bariatric surgeons should counsel obese patients on the benefits of BS following ACDFs.

Purpose To evaluate trends in Medicare physician reimbursements for 20 common hand procedures/surgeries from 2002 to 2018. Methods The Physician Fee Schedule Look-up Tool was used to retrieve average reimbursement rates for 20 common hand surgeries/procedures from 2002 to 2018. All reimbursement data were adjusted for inflation to 2018 dollars. Results After adjusting all data for inflation, the average reimbursement for all included procedures decreased by 20.9% from 2002 to 2018, with a compound annual growth rate of –3.25%. Reimbursement percentage decreases were the greatest prior to 2010 (18.4% decrease), followed by a relative stabilization (0.94% increase) from 2010 to 2014, after which physicians experienced a decrease of 3.9% in reimbursements between 2014 and 2018, following implementation of the Medicare Access and Children’s Health Insurance Program Reauthorization Act in 2015. The most significant decreases in reimbursements over time were noted for primary tendon/muscle repair (–49.6%), wrist arthroscopy for triangular fibrocartilage repair/debridement (–44.0%), trigger finger release in facility (–40.1%), excision of extensor tendon sheath (–38.2%), ganglion cyst excision (–36.7%), wrist arthroscopy for diagnostic/synovial biopsy (–35.7%), wrist arthroscopy for drainage/infection/lavage (–35.1%), wrist arthrodesis (–30.6%), endoscopic carpal tunnel release (–27.2%), total wrist arthroplasty (–26.6%), carpometacarpal/basal joint arthroplasty (–25.1%), and open carpal tunnel release (–22.3%). The only procedures with a significant increase in reimbursement over time were trigger finger release in office (+4.2%), open reduction internal fixation distal radius fracture (+2.5%), and cubital tunnel release (+1.5%). Conclusions After adjusting for inflation, Medicare physician reimbursements for a major proportion of hand surgical procedures have decreased over time. Clinical relevance Health-policy makers need to understand the impact of decreasing reimbursements to develop policies of reimbursements that will not only ensure provider satisfaction but also maintain access to care for patients.

Background Context Due to financial pressures associated with healthcare reforms, an increasing number of hospitals are now merging (or consolidating) into networks (or systems). However, it remains unclear how these mergers or network participations affect quality of care and/or costs. Purpose The current study aims to evaluate the impact of hospital network participation on 90-day complications, charges and costs following elective posterior lumbar fusions (PLFs). Study Design Retrospective review of a 100% national sample of Medicare claims from 2010-2014 (SAF100). Study Sample All Medicare-eligible patients undergoing elective 1-to-3 level posterior lumbar fusions for degenerative lumbar pathology from 2010 to 2014. Outcome measures Ninety-day complications, charges and costs. Methods The 2010-2014 100% Medicare Standard Analytical Files (SAF100) was used to identify patients undergoing elective 1-to-3 level posterior lumbar fusions for degenerative lumbar pathology. The Dartmouth Atlas for Healthcare hospital-level data, which uses a combination of American Hospital Association and additional source data, was used to identify hospitals that were part of a network (or system) between 2010 and 2014. The study sample was divided into two cohorts (network hospitals and non-network hospitals) for analyses. Multi-variate logistic regression models were used to compare differences in 90-day complications between network and non-network hospitals, while controlling for baseline demographics (age, gender, region, year of surgery, median household income, co-morbidity burden) and hospital-level characteristics (case volume, teaching status, urban/rural location and hospital ownership). Generalized linear regression modeling was used to assess for differences in 90-day charges and costs. Results A total of 145,141 patients undergoing surgery in 2,186 hospitals were included in the study, out of which 107,919 (74.4%) underwent surgery in a network hospital (N=1,526). Network hospitals were more prevalent in the South or West regions of the United States. Patients in network hospitals had a median household income less than the 5th quintile. Network hospitals were also more likely to have a higher annual case volume of elective 1- to 3-level PLFs, greater number of beds, be located in an urban location, and have a voluntary/non-profit or proprietary/profit ownership model. Multi-variate analyses showed that even though patients undergoing surgery at network hospitals (vs. non-network hospitals) had a slightly increased odds of 90-day cardiac complications (7.9% vs. 7.4%, OR 1.07 [95% CI 1.02-1.12]; p=0.010), thromboembolic complications (2.4% vs. 2.2%, OR 1.12 [95% CI 1.01-1.20]; p=0.025) and emergency department visits (16.4% vs. 16.0%, OR 1.06 [95% CI 1.02-1.09]; p=0.002), the differences would not be considered clinically significant. Despite a slight decrease in risk-adjusted 90-day reimbursements (-$272), the risk-adjusted 90-day charges were actually significantly higher (+ $9,959; p Conclusions Even though hospitals that are part of a network do not appear to have significantly different complication rates following elective PLFs, they do have significantly higher risk-adjusted charges as compared to non-network hospitals. Further research is required to understand market-level changes induced by hospital mergers into networks.

Introduction: With limited evidence on national incidences of hip arthroscopy in the elderly population, the current study aims to investigate trends of primary hip arthroscopies being performed in the elderly population, using the US Medicare database, and determine risk factors for conversion to total hip arthroplasty (THA). Methods: Medicare Standard Analytic Files were queried using CPT codes to retrieve records of primary hip arthroscopies done for degenerative pathology during 2005–2014. Overall and age-stratified trends in the incidence of hip arthroscopy over time were analysed. Kaplan Meier survival curves were used to assess the overall 2-year conversion rate to a THA. Cox regression analysis was implemented to study risk factors for conversion. Results: 8100 primary hip arthroscopies for degenerative pathology were performed during 2005–2014. There was a 280% increase in overall incidence of arthroscopy. The most commonly performed arthroscopic procedure was for chondroplasty and/or resection of labrum, with 4712 (58.1%) procedures. Around 18.5% patients underwent arthroplasty within 2 years after primary arthroscopy. Following Cox regression an existing diagnosis of osteoarthritis, ages 65–69, ages 70–74, and arthroscopies done in the West were associated with higher risk of conversion to THA within 2 years. Undergoing a repeat arthroscopy was not significantly associated with a higher risk of conversion. Conclusions: Despite inconclusive clinical evidence, hip arthroscopies are being increasingly used in patients older than 65 in the Medicare population. We conclude that patients in the age bracket of 65–74 years and with a pre-existing diagnosis of osteoarthritis, arthroscopy should be approached with caution.

BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.

BACKGROUND Treatment of bone and soft-tissue sarcomas can be costly, and therefore, it is not surprising that insurance status of patients is a prognostic factor in determining overall survival. Furthermore, uninsured individuals with suspected bone and/or soft-tissue masses routinely encounter difficulty in obtaining access to basic healthcare (such as office visits, radiology scans), and therefore are more likely to be diagnosed with later stages at presentation. The Patient Protection and Affordable Care Act (ACA) mandate of 2010 aimed to increase access to care for uninsured individuals by launching initiatives, such as expanding Medicaid eligibility, subsidizing private insurance, and developing statewide mandates requiring individuals to have a prescribed minimum level of health insurance. Although prior reports have demonstrated that the ACA increased both coverage and the proportion of early-stage diagnoses among patients with common cancers (including breast, colon, prostate, and lung), it is unknown whether similar improvements have occurred for patients with bone and soft-tissue sarcomas. Understanding changes in insurance coverages and stage at diagnosis of patients with bone and soft-tissue sarcomas would be paramount in establishing policies that will ensure orthopaedic cancer care is made equitable and accessible to all. QUESTIONS/PURPOSES (1) Has the introduction of the ACA been associated with changes in insurance coverage for adult patients with newly diagnosed bone and soft-tissue sarcomas? (2) Did the introduction of health reforms under the ACA lead to an increased proportion of sarcoma diagnoses occurring at earlier disease stages? METHODS The 2007 to 2015 Surveillance, Epidemiology and End Results database was queried using International Classification of Diseases for Oncology codes for primary malignant bone tumors of the upper and lower extremity (C40.0 to C40.3), unspecified or other overlapping bone, articular cartilage, and joint and/or ribs, sternum, or clavicle (C40.8 to C40.9, C41.3, and C41.8 to C41.9), vertebral column (C41.2), pelvis (C41.4, C41.8, and C41.9), and soft-tissue sarcomas of the upper or lower extremity and/or pelvis (C49.1, C49.2, and C49.5). A total of 15,287 patients with newly diagnosed cancers were included, of which 3647 (24%) were malignant bone tumors and 11,640 (76%) were soft-tissue sarcomas. The study sample was divided into three cohorts according to specified time periods: pre-ACA from 2007 to 2010 (6537 patients), pre-Medicaid expansion from 2011 to 2013 (5076 patients), and post-Medicaid expansion from 2014 to 2015 (3674 patients). The Pearson chi square tests were used to assess for changes in the proportion of Medicaid and uninsured patients across the specified time periods: pre-ACA, pre-expansion and post-expansion. A differences-in-differences analysis was also performed to assess changes in insurance coverage for Medicaid and uninsured patients among states that chose to expand Medicaid coverage in 2014 under the ACA's provision versus those who opted out of Medicaid expansion. Since the database switched to using the American Joint Commission on Cancer (AJCC) 7th edition staging system in 2010, linear regression using data only from 2010 to 2015 was performed that assessed changes in cancer stage at diagnosis from 2010 to 2015 alone. After stratifying by cancer type (bone or soft-tissue sarcoma), Pearson chi square tests were used to assess for changes in the proportion of patients who were diagnosed with early, late, and unknown stage at presentation before Medicaid expansion (2011-2013) and after Medicaid expansion (2014-2015) among states that chose to expand versus those who did not. RESULTS After stratifying by time cohorts: pre-ACA (2007 to 2010), pre-expansion (2011 to 2013) and post-expansion (2014 to 2015), we observed that the most dramatic changes occurred after Medicaid eligibility was expanded (2014 onwards), with Medicaid proportions increasing from 12% (pre-expansion, 2011 to 2013) to 14% (post-expansion, 2014 to 2015) (p < 0.001) and uninsured proportions decreasing from 5% (pre-expansion, 2011 to 2013) to 3% (post-expansion, 2014 to 2015) (p < 0.001). A differences-in-differences analysis that assessed the effect of Medicaid expansion showed that expanded states had an increase in the proportion of Medicaid patients compared with non-expanded states, (3.6% [95% confidence interval 0.4 to 6.8]; p = 0.03) from 2014 onwards. For the entire study sample, the proportion of early-stage diagnoses (I/II) increased from 56% (939 of 1667) in 2010 to 62% (1137 of 1840) in 2015 (p = 0.003). Similarly, the proportion of unknown stage diagnoses decreased from 11% (188 of 1667) in 2010 to 7% (128 of 1840) in 2015 (p = 0.002). There was no change in proportion of late-stage diagnoses (III/IV) from 32% (540 of 1667) in 2010 to 31% (575 of 1840) in 2015 (p = 0.13). CONCLUSION Access to cancer care for patients with primary bone or soft-tissue sarcomas improved after the ACA was introduced, as evidenced by a decrease in the proportion of uninsured patients and corresponding increase in Medicaid coverage. Improvements in coverage were most significant among states that adopted the Medicaid expansion of 2014. Furthermore, we observed an increasing proportion of early-stage diagnoses after the ACA was implemented. The findings support the preservation of the ACA to ensure cancer care is equitable and accessible to all vulnerable patient populations. LEVEL OF EVIDENCE Level III, therapeutic study.

Background The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). Methods The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. Results Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (–$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. Conclusions Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

Background There has been a considerable rise in the number of musculoskeletal/orthopaedic oncology fellowships and subsequently, orthopaedic oncologists, in the nation. National societies have been concerned that the increasing number of orthopaedic oncologists, coupled with a limited number of patients with bone and soft-tissue sarcomas in the country, may have led to an unintended impact on the training spectrum and/or exposure of orthopaedic oncology fellows-in-training over time. Fellows who are unable to gain exposure by operating on varied cancer presentations during training may be less confident in dealing with a wide array of patients in their practice. Despite these concerns, the volume and variability of procedures performed by fellows-in-training remains unknown. Understanding these parameters will be helpful in establishing policies for standardizing training of prospective fellows to ensure they are well-equipped to care for patients with bone and/or soft-tissue sarcomas in the beginning of their career. Questions/purposes (1) Has the median surgical procedure volume per fellow changed over time? (2) How much variability in procedural volume exists between fellows, based on the most recent (2017) Accreditation Council on Graduate Medical Education (ACGME) procedure log data? (3) What proportion of fellows are meeting the minimum procedure volume thresholds, as recommended by the Musculoskeletal Tumor Society (MSTS)? Methods The 2010 to 2017 ACGME fellowship procedure logs for musculoskeletal oncology fellowships were retrieved from the council's official website. All fellows enrolled in ACGME-accredited fellowships are mandated to complete case logs before graduation. This study did not include operative procedures performed by fellows in nonACGME-approved fellowship programs. The 2010 to 2016 anatomic site-based procedure log data were used to evaluate fellows' overall and location-specific median operative or patient volume, using descriptive statistics. Linear regression analyses were used to assess changes in the median procedure volume over time. The 2017 categorized procedure log data were used to assess variability in procedure volume between the lowest (10th percentile) and highest (90th percentile) of all fellows. Using 2017 procedure logs, we compared the minimum procedure volume standards, as defined by the MSTS, against the number of procedures performed by fellows across the 10th, 30th, 50th (median), 70th, and 90th percentiles. Results There was no change in the median (range) procedural volume per fellow from 2010 (292 procedures [131 to 634]) to 2017 (312 procedures [174 to 479]; p = 0.58). Based on 2017 categorized procedure log data, there was considerable variability in procedural volume between the lowest (10) percentile and highest (90) percentile of fellows across programs: pediatric oncologic procedures (10-fold difference), surgical management of complications from limb-salvage surgery (sevenfold difference), soft-tissue resections or reconstructions (fourfold difference), bone sarcoma resections or limb-salvage surgery (fourfold difference), and spine, sacrum, and pelvis procedures (threefold difference). A fair proportion of fellows did not meet the minimum procedure volume standards, as recommended by the MSTS across certain categories. For the spine and pelvis (minimum = 10 procedures), fellows in the lowest 10th percentile performed only six procedures. For patients with bone sarcomas or limb salvage (minimum = 20 procedures), fellows in the lowest 10th percentile performed only 14 procedures. For pediatric patients with oncologic conditions (minimum = 15 procedures), fellows in the 50th percentile (13 procedures) and below failed to meet the thresholds. For surgical management of complications from limb-salvage procedures (minimum = five procedures), fellows in the lowest 10th percentile performed only three procedures. Conclusions Although we were encouraged to observe that the median number of procedures performed by musculoskeletal oncology fellows over this time has not changed, we observed wide variability in the procedure volume among fellows for pediatric sarcomas, soft-tissue resection and reconstruction, limb salvage procedures, and spine procedures. We do not know how this compares with fellows trained in nonaccredited fellowship programs. Clinical relevance Although we recognize that the education of fellows entails much more than performing operations, national societies have recognized a need to bring about more uniformity or standardization of training in musculoskeletal oncology. Limiting the number of orthopaedic oncology fellowships to high-volume institutions, expanding the training time period, and/or introducing subspecialty certification may be possible avenues through which standardization of training can be defined.

BACKGROUND The management of primary malignant bone tumors in patients with metastatic disease at presentation remains a challenge. Although surgical resection has been a mainstay in the management of nonmetastatic malignant bone tumors, there is a lack of large-scale evidence-based guidance on whether surgery of the primary site/tumor improves overall survival in malignant bone tumors with metastatic disease at presentation. QUESTIONS/PURPOSES (1) Is surgical resection of the primary tumor associated with improved overall survival in patients with primary malignant bone tumors who have metastatic disease at presentation? (2) What other factors are associated with improved and/or poor overall survival? METHODS The 2004 to 2016 National Cancer Database (NCDB), a national registry containing data from more than 34 million cancer patients in the United States, was queried using International Classification of Diseases, 3rd Edition, topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8, and C40.9) and/or pelvis (C41.4). The NCDB was preferred over other national cancer registries (that is, the Surveillance, Epidemiology, and End Results database) because it includes a specific variable that codes for patients who received additional surgeries at metastatic sites. Patients with malignant bone tumors of the head or skull, trunk, and spinal column were excluded because these patients are not routinely encountered and treated by orthopaedic oncologists. Histologic codes were used to categorize the tumors into the following groups: osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients whose tumors were classified as Stage 1, 2, or 3 based on American Joint Commission of Cancer guidelines were excluded. Only patients who presented with metastatic disease were included in the final study sample. The study sample was divided into two distinct groups: those who underwent surgical resection of the primary tumor and those who did not receive any operation for the primary tumor. A total of 2288 patients with primary malignant bone tumors (1121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included, of whom 46% (1053 of 2288) underwent surgical resection of the primary site. Thirty-three percent (348 of 1053) of patients undergoing surgical resection of the primary site also underwent additional resection of metastases. Patients undergoing surgical resection of the primary site typically were younger than 18 years, lived further from a facility, had tumors involving the upper or lower extremity, had a diagnosis of osteosarcoma or chondrosarcoma, and had a greater tumor size and higher tumor grade at presentation. To account for baseline differences within the patient population and to adjust for additional confounding variables, multivariate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histologic type, and tumor size), and treatment patterns (resection of distant or regional metastatic sites, positive or negative surgical margins, and use of radiation therapy or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas, and Ewing sarcomas, were used to assess factors associated with overall survival for each tumor type. RESULTS After controlling for differences in baseline demographics, tumor characteristics, and treatment patterns, we found that surgical resection of the primary site was associated with reduced overall mortality compared with those who did not have a resection of the primary site (hazard ratio 0.42 [95% confidence interval 0.36 to 0.49]; p < 0.001). Among other factors, in the stratified analysis, radiation therapy was associated with improved overall survival for patients with Ewing sarcoma (HR 0.71 [95% CI 0.57 to 0.88]; p = 0.002) but not for those with osteosarcoma (HR 1.14 [95% CI 0.91 to 1.43]; p = 0.643) or chondrosarcoma (HR 1.0 [95 % CI 0.78 to 1.50]; p = 0.643). Chemotherapy was associated with improved overall survival for those with osteosarcoma (HR 0.50 [95% CI 0.39 to 0.64]; p < 0.001) and those with chondrosarcoma (HR 0.62 [95% CI 0.45 to 0.85]; p = 0.003) but not those with Ewing sarcoma (HR 0.7 [95% CI 0.46 to 1.35]; p = 0.385). CONCLUSIONS Surgical resection of the primary site was associated with an overall survival advantage in patients with primary malignant bone tumors who presented with metastatic disease. Further research, using more detailed data on metastatic sites (such as, size, location, number, and treatment), chemotherapy regimen and location of radiation (primary or metastatic site) is warranted to better understand which patients will have improved overall survival and/or a benefit in the quality of life from resecting their primary malignant tumor if they present with metastatic disease at diagnosis. LEVEL OF EVIDENCE Level III, therapeutic study.

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p.001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p.001), urinary tract infections (7.4% versus 12.3%; p.001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p.001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p.001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.

BACKGROUND Owing to concerns regarding higher cost, low quality of care and cherry-picking in physician-owned hospitals (POHs), the Affordable Care Act imposed sanctions that prevented the formation of new POHs. With an increasing utilization of total shoulder arthroplasties (TSAs), there is a need for re-evaluation and assessment of quality and cost of TSAs performed at these POHs. METHODS The 2011 to 2014 Medicare 100% Standard Analytical Files was used to identify patients undergoing a reverse TSA or anatomic TSA at POHs and non-POHs. Multivariate regression analyses were used to assess differences in 90-day and 1-year outcomes between the two groups. RESULTS A total of 1,626 (2.2%) patients received a TSA at a POH (N = 50). No notable differences were noted between POH versus non-POHs regarding 90-day surgical site infections (P = 0.645), dislocation (P = 0.068), periprosthetic fractures (P = 0.556), revision arthroplasty (P = 0.114), pulmonary embolism (P = 0.155), deep vein thrombosis (P = 0.208), acute myocardial infarction (P = 0.219), sepsis (P = 0.288), urinary tract infections (P = 0.186), all-cause readmissions (P = 0.427), 1-year dislocations (P = 0.475), 1-year periprosthetic fractures (P = 0.697), and 1-year revision arthroplasties (P = 0.225). TSAs performed at POHs had higher odds of postoperative stiffness at 90-day (odds ratio 1.39; P < 0.001) and 1-year follow-up points (odds ratio 1.51; P < 0.001). TSAs at POHs had markedly lower risk-adjusted 90-day charges (-$8,904) and 90-day costs (-$1,659). CONCLUSION Apart from slightly higher rates of stiffness and renal complications, patients undergoing TSAs at POHs seem to have similar outcomes as compared to non-POHs, while having lower costs of care. The findings suggest a need for further research, evaluating the value of care at POHs. LEVEL OF EVIDENCE Level III.

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged

Background: No study has evaluated the relationship between increasing BMI and severity/type of cervical spine injuries. Aims and Objectives: The objective of our study was to study the impact of body mass index (BMI) on severity of cervical spine fracture. Methods: We performed a retrospective cohort study of patients with traumatic cervical spine fractures at a level I trauma center over a 74-year period. CT scans of the cervical spine were blindly graded according to the AO Spine sub-axial cervical spine classification. The association between BMI and severity of cervical spine fracture was studied by multiple-variable logistic regression. Results: A total of 291 patients with an average BMI of 26.1 ± 5.4 kg/m2 were studied. Higher BMI was not associated with more severe injury (OR 1.03, 95%, CI: 0.97–1.08). For rollover motor vehicle accident (MVA), the association was trending towards significance (OR 2.55, 95%, CI: 0.98-6.66, P = 0.06). Conclusions: Patients with higher BMI may be predisposed to more severe cervical spine fracture in rollover MVA, but not non-rollover MVA or falls.

Obesity has been shown to be associated with higher rates of complications after lumbar spine surgery. However, the evidence regarding the impact of body mass index (BMI) on outcomes following posterior cervical fusions (PCFs) remains limited.The 2012-2017 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 22600 to identify PCFs. Patients undergoing anterior cervical spine surgery and surgery for deformity, malignancy, or infection were excluded. Patients with missing data with regard to weight, height, and 30-day outcomes were excluded. BMI (kg/mOf 2786 patients with PCFs, 710 (25.5%) had BMI25.0, 919 (33.0%) had BMI between 25.0 and 29.9, 655 (23.5%) had BMI between 30.0 and 34.9, and 502 (18.0%) had BMI ≥35.0. Following adjustment for baseline demographics and clinical characteristics, increased BMI was not associated with a higher risk of any adverse events, severe adverse events, minor adverse events, bleeding requiring transfusion, or readmissions within 30 days of surgery. BMI ≥35.0 versus BMI25.0 was associated only with a higher risk of deep surgical site infections (odds ratio 4.61; P = 0.009).With the exception of a higher rate of deep surgical site infections seen in obese patients, increased BMI does not seem to have a major impact on 30-day outcomes following PCFs.

BACKGROUND CONTEXT Current bundled payment programs in spine surgery, such as the Bundled Payment for Care Improvement (BPCI), rely on the use of Diagnosis Related Groups (DRGs) to define payments. However, these DRGs may not be adequate enough to appropriately capture the large amount of variation seen in spine procedures. For example, DRG 459 (spinal fusion except cervical with major co-morbidity or complication) and DRG 460 (spinal fusion except cervical without major co-morbidity or complication) do not differentiate between the type of fusion (anterior or posterior), the levels/extent of fusion, the use of interbody/graft/BMP, indication of surgery (primary vs revision) or even if the surgery was performed for a vertebral fracture. PURPOSE We carried out a comprehensive analysis to report the factors responsible for cost variation in a bundled payment model for spinal fusions. STUDY DESIGN Retrospective review of a 5% national sample of Medicare claims from 2008-2014 (SAF5). OUTCOME MEASURES To understand the independent marginal cost impact of various patient-level, geographic-level and procedure-level characteristics on 90-day costs for patients undergoing spinal fusions under DRG 459 and 460. METHODS The 2008-2014 Medicare 5% Standard Analytical Files (SAF) were used to retrieve patients undergoing spinal fusions under DRG 459 and DRG 460 only. Patients with missing gender, age and/or state-level data were excluded. Only those patients who had complete data, with regard to payments/costs/reimbursements, starting from Day 0 of surgery up to 90 days postoperatively were included to prevent erroneous collection. Multivariate linear regression models were built to assess the independent marginal cost impact (decrease/increase) of each patient-level, state-level and procedure-level characteristic on the average 90-day cost while controlling for other covariates. RESULTS A total of 21,367 patients (DRG-460=20,154; DRG-459=1,213) were included in the study. The average 90-day cost for all lumbar fusions was $31,716 ± $18,124, with the individual 90-day payments being $54,607 ± $30,643 (DRG-459) and $30,338 ± $16,074 (DRG-460). Increasing age was associated with significant marginal increases in 90-day payments (70-74y: + $2,387, 75-79y: + $3,389, 80-84y: + $2,872, ≥85: + $1,627). With regard to procedure-level factors – undergoing an anterior fusion (+ $3,118), >3 level fusion (+ $5,648) vs 1-3 level fusion, use of interbody device (+ $581), intra-operative neuro-monitoring (+ $1,413), concurrent decompression (+ $768) and undergoing surgery for thoracolumbar fracture (+ $6,169) were associated with higher 90-day costs. Most individual comorbidities were associated with higher 90-day costs, with malnutrition (+ $12,264), CVA/stroke (+ $5,886), Alzheimer's (+ $4,968), Parkinson's disease (+ $4,415) and coagulopathy (+ $3,810) having the highest marginal 90-day cost-increases. The top 5 states with the highest marginal cost-increase, in comparison to Michigan, were Maryland (+ $12,657), Alaska (+ $11,292), California (+ $10,040), Massachusetts (+ $8,800) and the District of Columbia (+ $8,315). CONCLUSIONS Under the proposed DRG-based bundled payment model, providers would be reimbursed the same amount for lumbar fusions regardless of the surgical approach (posterior vs anterior), the extent of fusion (1-3 level vs >3 level), use of adjunct procedures (decompressions) and cause/indication of surgery (fracture vs degenerative pathology), despite each of these factors having different resource utilization and associated costs. When defining and developing future bundled payments for spinal fusions, health policy makers should strive to account for the individual patient-level, state-level and procedure-level variation seen within DRGs to prevent the creation of a financial disincentive in taking care of sicker patients and/or performing more extensive complex spinal fusions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Study design This was a retrospective cohort study. Objective To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). Summary of background data No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. Methods The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. Results Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). Conclusions Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. Level of evidence Level III-retrospective.

STUDY DESIGN Retrospective. OBJECTIVE Assess the impact of varying severity of BMI on 30-day outcomes following posterior spinal fusions in neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA Obesity in the pediatric population is shown to be associated with adverse outcomes across varying specialties. The weight-outcome relationship in neuromuscular scoliosis has not been thoroughly investigated. METHODS The 2012-2016 American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) database was queried using Current Procedural Terminology codes 22800, 22802, and 22804 to identify patients undergoing posterior spinal fusion for neuromuscular scoliosis only. BMI was classified into four groups based on the Center for Disease Control (CDC) BMI-for-age percentile chart - Normal weight (BMI ≥5th to

Objective To understand cost distribution in a 90-day episode of care following posterior spinal fusions (PSFs) for adolescent idiopathic scoliosis (AIS). Methods The 2007–2016 Humana PearlDiver dataset was queried using Current Procedural Terminology codes (22800, 22802, 22804, 22842, 22843, and 22844) to identify patients with AIS, aged 10–19 years, receiving PSFs. The following categories were used to define distribution in 90-day costs: 1) facility costs, 2) surgeon costs, 3) anesthesia costs, 4) intraoperative neuromonitoring, 5) hospital services and investigations, 6) intensive care unit stay, 7) radiology, 8) physical therapy/rehabilitation, 9) office visits, and 10) readmissions. Results A total of 455 patients with AIS received PSFs, of whom 381 (83.7%) were commercial insurance beneficiaries and 74 (16.3%) were Medicaid beneficiaries. The overall average 90-day cost of surgery was $124,360 with the 90-day stipulated bundled prices being $136,302 and $62,871 for commercial and Medicaid beneficiaries, respectively. Facility costs comprised 85%−92% of the 90-day cost, followed by surgeon costs (5.2%−5.7%). Post-acute care (physical therapy/rehab and office visits) was not a major driver of the 90-day cost (0.2%−0.3%). Significant independent predictors of increased 90-day costs were—increased co-morbidity burden (+$11,284), ≥7 levels fusion (+$65,330), and length of stay (+$5298/day). Medicaid (−$81,957) payer type was associated with lower 90-day costs. Conclusions Facility costs are a major determinant of overall 90-day costs following PSFs in AIS. Providers should aim at optimizing the co-morbidity burden and constructing accelerated care-pathways to decrease the length of stay and reduce the cost of the entire episode of care.

The current Bundled Payment for Care Improvement model relies on the use of "Diagnosis Related Groups" (DRGs) to risk-adjust reimbursements associated with a 90-day episode of care. Three distinct DRG groups exist for defining payments associated with cervical fusions: (1) DRG-471 (cervical fusions with major comorbidity/complications), (2) DRG-472 (with comorbidity/complications), and (3) DRG-473 (without major comorbidity/complications). However, this DRG system may not be entirely suitable in controlling the large amounts of cost variation seen among cervical fusions. For instance, these DRGs do not account for area/location of surgery (upper cervical vs. lower cervical), type of surgery (primary vs. revision), surgical approach (anterior vs. posterior), extent of fusion (1-3 level vs.3 level), and cause/indication of surgery (fracture vs. degenerative pathology).To understand factors responsible for cost variation in a 90-day episode of care following cervical fusions.Retrospective study of a 5% national sample of Medicare claims from 2008 to 2014 5% Standard Analytical Files (SAF5).To calculate the independent marginal cost impact of various patient-level, geographic-level, and procedure-level characteristics on 90-day reimbursements for patients undergoing cervical fusions under DRG-471, DRG-472, and DRG-473.The 2008 to 2014 Medicare SAF5 was queried using DRG codes 471, 472, and 473 to identify patients receiving a cervical fusion. Patients undergoing noncervical fusions (thoracolumbar), surgery for deformity/malignancy, and/or combined anterior-posterior fusions were excluded. Patients with missing data and/or those who died within 90 days of the postoperative follow-up period were excluded. Multivariate linear regression modeling was performed to assess the independent marginal cost impact of DRG, gender, age, state, procedure-level factors (including cause/indication of surgery), and comorbidities on total 90-day reimbursement.Following application of inclusion/exclusion criteria, a total of 12,419 cervical fusions were included. The average 90-day reimbursement for each DRG group was as follows: (1) DRG-471=$54,314±$32,643, (2) DRG-472=$28,535±$17,271, and (3) DRG-473=$18,492±$10,706. The risk-adjusted 90-day reimbursement of a nongeriatric (age65) female, with no major comorbidities, undergoing a primary 1- to 3-level anterior cervical fusion for degenerative cervical spine disease was $14,924±$753. Male gender (+$922) and age 70 to 84 (+$1,007 to +$2,431) was associated with significant marginal increases in 90-day reimbursements. Undergoing upper cervical surgery (-$1,678) had a negative marginal cost impact. Among other procedure-level factors, posterior approach (+$3,164),3 level fusion (+$2,561), interbody (+$667), use of intra-operative neuromonitoring (+$1,018), concurrent decompression/laminectomy (+$1,657), and undergoing fusion for cervical fracture (+$3,530) were associated higher 90-day reimbursements. Severe individual comorbidities were associated with higher 90-day reimbursements, with malnutrition (+$15,536), CVA/stroke (+$6,982), drug abuse/dependence (+$5,059), hypercoagulopathy (+$5,436), and chronic kidney disease (+$4,925) having the highest marginal cost impacts. Significant state-level variation was noted, with Maryland (+$8,790), Alaska (+$6,410), Massachusetts (+$6,389), California (+$5,603), and New Mexico (+$5,530) having the highest reimbursements and Puerto Rico (-$7,492) and Iowa (-$3,393) having the lowest reimbursements, as compared with Michigan.The current cervical fusion bundled payment model fails to employ a robust risk adjustment of prices resulting in the large amount of cost variation seen within 90-day reimbursements. Under the proposed DRG-based risk adjustment model, providers would be reimbursed the same amount for cervical fusions regardless of the surgical approach (posterior vs. anterior), the extent of fusion, use of adjunct procedures (decompressions), and cause/indication of surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Our findings suggest that defining payments based on DRG codes only is an imperfect way of employing bundled payments for spinal fusions and will only end up creating major financial disincentives and barriers to access of care in the healthcare system.

BACKGROUND: A significant proportion of patients undergoing hip fracture surgery are transferred from other locations. With no current orthopedic literature present, we sought to study the impact of transfer location on 30-day outcomes following geriatric hip fracture surgery. MATERIALS & METHODS: The 2015–2016 ACS-NSQIP database was queried using CPT codes to retrieve records of geriatric patients undergoing hip fracture surgery (total hip arthroplasty/THA, hemiarthroplasty/HA and open reduction internal fixation/ORIF). Transfer status was defined into four groups – 1) No transfer (admitted from home), 2) From acute care hospital, 3) From nursing home/chronic care facility and 4) From outside emergency department (ED). Patients with missing data were excluded. A total of 31,218 patients were included in the final cohort. RESULTS: Out of 31,218 patients - 23,659 (75.8%) were admitted from home, 1574 (5.0%) from acute care hospitals, 3299 (10.6%) from nursing home/chronic care facilities and 2686 (8.6%) from outside EDs. Following adjusted analysis, transfer from nursing home vs. home was associated with higher odds of 30-day mortality (OR 1.57 [95% 1.36–1.80]; p

Caused by perceptions regarding unnecessary healthcare resource utilization, high costs of care, and financial incentives towards "cherry-picking" cases in physician owned hospitals, the Affordable Care Act (ACA) of 2010 imposed restrictions on existing physician-owned hospitals from expanding. Despite an increasing number of individuals requiring access to spine surgical care, no study has evaluated the surgical safety and costs of elective posterior lumbar fusions (PLFs) being performed in physician-owned vs. non-physician-owned hospitals.We assessed differences in 90-day costs and outcomes between patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals vs. nonphysician-owned hospitals.Retrospective cohort study of 2007 to 2014 100% Medicare claims database.The 2007 to 2014 Medicare 100% Standard Analytical Files (SAF100) was queried using International Classification of Diseases 9th Edition (ICD-9) procedure code for patients undergoing elective 1- to 3-level PLFs (81.07, 81.08, and 81.62). The Medicare Hospital Compare database was used to identify provider codes for physician-owned hospitals. These provider codes were cross-referenced to identify records of patients receiving elective PLFs at these hospitals from the SAF100 database.Ninety day complications, readmissions, emergency department (ED) visits, charges, and costs.Multivariate logistic and linear regression analyses were used to assess significant differences in 90-day complications, readmissions, charges and costs between the two groups.A total of 6,679 (2.9%) patients received an elective PLF at a physician-owned hospital (N=39; 2.2%) whereas 225,090 (97.1%) received surgery at nonphysician-owned hospital (N=1,774; 97.8%). After controlling for age, gender, region, hospital factors (socio-economic status area, urban vs. rural location and volume) and Elixhauser co-morbidity index, undergoing surgery at physician-owned hospital was associated with lower odds of thromboembolic complications (OR 0.66 [95% CI 0.53-0.82]; p.001), urinary tract infections (OR 0.87 [95% CI 0.79-0.95]; p=.002) and renal complications (OR 0.52 [95% CI 0.43-0.63]; p.001) within 90-days following the surgery. Patients undergoing PLFs at physician-owned hospitals vs. nonphysician-owned hospitals also had lower risk-adjusted inpatient charges (-$10,218), inpatient costs (-$2,302), 90-day charges (-$9,780) and 90-day costs (-$2,324). No significant differences were noted between physician-owned and nonphysician-owned hospitals with regards to 90-day wound complications (OR 1.08 [95% CI 0.94-1.22]; p=.279), pulmonary complications (OR 1.06 [95% CI 0.97-1.17]; p=.187), cardiac complications (OR 0.92 [95% CI 0.83-1.01]; p=.089), septic complications (OR 0.77 [95% CI 0.56-1.01]; p=.073), all-cause ED visits (OR 0.96 [95% CI 0.89-1.04]; p=.311), revision surgery (OR 1.09 [95% CI 0.72-1.59]; p=.653) and readmissions (OR 0.98 [95% CI 0.89-1.08]; p=.680).Our results suggest that patients undergoing elective 1- to 3-level PLFs at physician-owned hospitals do not experience a greater number of complications and/or readmissions while having lower risk-adjusted charges and costs over the 90-day episode of care. The findings call on the need for revaluation/reconsideration of the ACAs restriction on the expansion of these physician-owned hospitals.

Aims The aim of this study was to investigate the differences in 30-day outcomes between patients undergoing revision for an infected total hip arthroplasty (THA) compared with an aseptic revision THA. Patients and Methods This was a retrospective review of prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, between 2012 and 2017, using Current Procedural Terminology (CPT) codes for patients undergoing a revision THA (27134, 27137, 27138). International Classification of Diseases Ninth Revision/Tenth Revision (ICD-9-CM, ICD-10-CM) diagnosis codes for infection of an implant or device were used to identify patients undergoing an infected revision THA. CPT-27132 coupled with ICD-9-CM/ICD-10-CM codes for infection were used to identify patients undergoing a two-stage revision. A total of 13 556 patients were included; 1606 (11.8%) underwent a revision THA due to infection and there were 11 951 (88.2%) aseptic revisions. Results Patients undergoing an infected revision had a significantly greater length of stay of more than three days (p < 0.001), higher odds of any 30-day complication (p < 0.001), readmission within 30 days (p < 0.001), 30-day reoperations (p < 0.001), and discharge to a destination other than the patient’s home (p < 0.001). Conclusion The findings suggest the need for enhanced risk adjustment based on the indication of revision THA prior to setting prices in bundled payment models of total joint arthroplasty. This risk adjustment should be used to reduce the chance of financial disincentives in clinical practice. Cite this article: Bone Joint J 2019;101-B:547–551.

Study Design: Retrospective cohort. Objective: To understand which patient and surgical factors are predictive of an increased odds of undergoing an admission and a prolonged stay >2 days in an intensive care unit (ICU) following corrective surgery for pediatric deformity. Methods: The 2016 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric Spinal Fusion Procedure Targeted database records, merged with original 2016 ACS-NSQIP Pediatric file variables, were used for this study. Univariate and multivariate analyses were used to identify independent risk factors associated with admission, as well as a prolonged length of stay in the ICU following surgery. Results: A total of 1398 (39.5%) patients required an ICU admission following the procedure—out of whom 416 (29.8%) stayed for more than 2 days. Following adjusted analysis, patient and surgical factors independently associated with an ICU admission were black/African American versus white race, anterior fusion, combined fusion, nonidiopathic scoliosis, preoperative ventilator dependence, asthma, having structural pulmonary abnormality, developmental delay, having a neuromuscular disorder, requiring nutritional support and a total operative time >270 minutes. The only significant factors associated with a prolonged length of ICU stay >2 days were preoperative ventilator dependence, nutritional support requirement, and undergoing anterior or combined fusion. Conclusions: This study is the first of its kind to identify significant patient- and procedure-level factors associated with an ICU admission, and also explores predictors for a prolonged stay in the ICU. Surgeons can use this data to preoperatively counsel families and ensure postoperative course of care is appropriately planned ahead of time.

Relative value units (RVUs) are used for ensuring that physicians are appropriately reimbursed based on case complexity. While past research has elucidated that surgeons are reimbursed at a higher rate for primary total knee arthroplasty (TKA) versus revision TKA, no study has explored differences in reimbursements between single-component and double-component revisions, considering a double-component revision is likely to require more effort/skill as compared with single-component revision. The 2015 to 2016 American College of Surgeons National Surgical Quality Improvement Program files were queried using Current Procedural Terminology (CPT) codes for single-component revision TKA (CPT-27486) and double-component revision TKA (CPT-27487). A total of 1,962 single-component and 4,184 double component revisions were performed during this period. Total RVUs, RVU/min, and dollar amount/min were calculated for each case. The mean RVU was 21.12 and 27.11 for single-component and double-component revision TKAs, respectively. A statistically significant difference was noted in mean operative time (single component = 100.44 vs. double component = 144.29; p

Clubfoot is an important aspect of pediatric orthopedics and is a readily prevalent condition presenting to orthopedic clinics worldwide. To identify landmark articles and important contributions to this field, we sought to do a citation analysis of the top 100 most-cited articles on clubfoot. Using the Scopus database and the search strategy 'Clubfoot', 'Clubfeet' OR 'Talipes Equinovarus', we identified 5753 articles. After filtering for relevant articles, the top 100 cited articles on clubfoot were retrieved for descriptive and statistical analysis. The most cited paper was 'Long-term results of treatment of congenital clubfoot' by S.J. Laaveg and I.V. Ponseti with 358 citations. The publication years ranged from 1969 to 2011. The USA was the most productive country in terms of research output, followed by the UK. Institution-wise, the University of Iowa contributed the most in terms of number of publications. The Journal of Pediatric Orthopaedics held the most number of articles. Most publications were level IV and level V studies. Although citation analysis has it flaws, this is a comprehensive list of the top 100 articles significantly affecting literature on clubfoot. On the basis our study, we conclude that there is marked deficiency of high-level articles with respect to the number of citations, and future researches need to cater to this question to produce high-quality studies.

Background: We compiled evidence from a large national surgical database to identify the incidence, risk factors and postoperative impact of Clostridium difficile infection (CDI) in patients undergoing hip fracture repair. Methods: We identified 17,474 patients who underwent hip fracture repairs in 2015 using the ACS-NSQIP database. Interventions studied were open reduction/Internal fixation, total hip arthroplasty or hemiarthroplasty being performed for traumatic hip fractures. Outcomes studied were incidence, preoperative and postoperative risk factors for occurrence of CDI were studied using descriptive and statistical analysis. Results: A total of 92 patients (0.53%) developed CDI within 30 days of the operation. Following adjustment using multi-variate logistic regression, preoperative and hospital-associated factors associated with development of CDI were smoking (OR 1.75 [95% CI 1.03–2.99]), hypertension (OR 1.70 [95% CI 1.01–2.85]), hyponatraemia (OR 1.65 [95% CI 1.04–2.63]), prior systemic inflammatory response syndrome (SIRS) (OR 2.18 [95% CI 1.32-3.59]) and a length of stay >7 days (OR 1.98 [95% CI 1.11–3.53]. Postoperative factors associated with occurrence of CDI were occurrence of a deep surgical site infection (SSI) (OR 5.89 [95% CI 1.31–26.6]), a stay in the hospital >30 days (OR 6.56 [95% CI 2.56–16.9]) and unplanned reoperations (OR 2.78 [95% CI 1.29–5.99]). Conclusion: As we move toward an era of bundled-payment models, identification of risk factors associated with the occurrence of postoperative complications, such as CDI, will help curb excess healthcare utilisation and costs associated with the management of this complication.

Despite a significant number of patients being discharged to inpatient care facilities after anterior lumbar interbody fusion (ALIF), the current literature remains limited regarding the predictors associated with a nonhome discharge and the impact of continued inpatient care in a facility on postdischarge outcomes.The 2013-2016 American College of Surgeons National Surgical Quality Improvement Program was queried using Current Procedural Terminology (CPT) codes for ALIF (CPT-22558) and additional level fusions (CPT-22585). Discharge to inpatient care facilities included discharge to skilled care facilities and/or inpatient rehabilitation units.Independent predictors of an inpatient care facility discharge were age older than 45 years (P0.001), female sex (P0.001), more than 10% body weight loss in the last 6 months prior to surgery (P=0.012), American Society of Anesthesiologists grade greater than II (P=0.005), undergoing a 2-level (P0.001) or more than 2-level fusion (P=0.017), a length of stay greater than 3 days (P0.001), and the occurrence of any predischarge complication (P0.001). After adjustment for differences in clinical and baseline characteristics between the 2 groups, discharge to an inpatient care facility after ALIF was independently associated with higher odds of any postdischarge complication (P=0.010), postdischarge wound complication (P=0.005), and postdischarge septic complications (P=0.011). No significant impact was seen on 30-day readmissions (P=0.943), 30-day reoperations (P=0.228), and 30-day mortality (P=0.913).With an increasing focus toward minimizing costs associated with postacute care, providers should understand the need of appropriate preoperative risk stratification and construction of care pathways aimed at a home discharge to reduce the occurrence and/or risk of experiencing postdischarge complications.

Objective To assess the impact of fixation to pelvis on 30-day outcomes after posterior spinal fusions in pediatric spine deformities. Methods The 2012–2016 American College of Surgeons–National Surgical Quality Improvement Program pediatric database was queried using Current Procedural Terminology codes for patients undergoing posterior spinal fusions (22800, 22802, and 22804). Patients undergoing concurrent anterior fusion/combined fusion and anterior-only fusions were removed from the study. Patients undergoing additional fixation to pelvis were identified by code 22848. Results Of a total of 13,398 patients, 1092 (8.2%) patients underwent a fixation to the pelvis. After adjustment for differences in baseline characteristics, patients undergoing fixation to pelvis had a longer length of stay (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.04–1.48]), greater odds of any 30-day complication (OR 1.26; CI 1.03–1.55), pneumonia (OR 1.85; CI 1.26–2.70), renal insufficiency (OR 6.87; CI 2.02–23.40), acute renal failure (OR 14.23; CI 2.36–84.51), urinary tract infection (OR 1.99; CI 1.23–3.23), cardiac arrest (OR 2.98; CI 1.10–8.06), sepsis (OR 2.25; CI 1.35–3.74), bleeding (OR 1.51; CI 1.25–1.82), 30-day readmissions (OR 1.39; CI 1.07–1.81), and 30-day reoperations (OR 1.37; CI 1.06–1.76). Conclusions In contrast to adult spinal deformity literature, pediatric patients undergoing a fixation to pelvis are at a greater risk of experiencing adverse outcomes within 30 days of surgery. Providers should use these data for preoperative counseling and/or risk-stratification to improve quality-of-care in the acute postoperative period in these patients.

The purpose was to observe current incidence and trends of hand and wrist injuries presenting to U.S. emergency departments (EDs) over a decade.The National Electronic Injury Surveillance System (NEISS) was queried for hand and wrist injuries from January 2009-December 2018. Descriptive analyses were used to report injury types to the hand and wrist. Incidence, age, gender, race, injury location, and type of injury were recorded. Linear regression analyses were used to assess changes in trends over time. A p value0.05 was statistically significant.In total, 649,131 cases of hand and wrist injuries were identified in the NEISS from 2009 to 2018, correlating to 25,666,596 patients nationally. Incidence rates for finger, hand, and wrist were 450, 264, and 182 per 100,000 people. The estimated number of patients per year declined by 8.6% from 2009 to 2018. Male adults (aged 18-39) were the most frequent demographic. Total national estimates of hand (-8.2%; p = 0.001), wrist (-6.1%; p = 0.007), and finger (-9.9%; p 0.001) injuries declined over the study period. The most common injuries were lacerations (36.5%), fractures (19.9%), strains/sprains (12.3%), and contusions/abrasions (12.1%) which significantly declined over the study period. The overall admission rate was 1.8%.The estimated annual number of hand/wrist injuries presenting to US EDs was 2.6 million with gradual decline over the decade. Hand injury registries could assist in quality improvement measures targeted toward increased efficiency and resource allocation and education.

BACKGROUND: Adult cervical deformity (ACD) is a potentially debilitating condition resulting from kyphosis, scoliosis, or both, of the cervical spine. Conditions such as ankylosing spondylitis, rheumatoid arthritis, Parkinson's disease, and neuromuscular diseases are particularly known to cause severe deformities. We describe the 90-day cost and complications associated with spinal fusion for ACD using International Classification of Diseases (ICD) coding terminology and study if secondary diagnoses associated with potential for severe deformity affect the cost and complication profile of ACD surgery. METHODS: Medicare data were used to study hospital costs and complications within 90 days after primary cervical fusion for ACD in 2 cohorts matched by demographics and comorbidity burden: (1) patients with diagnoses of secondary pathology (SP) known to cause severe deformity and (2) without SP. Univariate and multiple-variable analyses to study incidence of complications, readmission, and costs within 90 days were done. RESULTS: A total of 2900 patients in matched cohorts of 1450 each were included. The mean index hospital payment ($26 545 ± $25 968 versus $22 991 ± $21 599) and length of stay (4.8 ± 5.6 versus 3.9 ± 4.5 days) was significantly (P < .01) higher in ACD patients with SP. On adjusted analysis, the risk of procedure-related complications was higher (odds ratio [OR] = 1.47, 95% confidence interval [CI], 1.18–1.83) in patients with SP than those without SP, but not readmission (OR = 1.04, 95% CI, 0.82–1.32) or refusion (OR = 0.95, 95% CI, 0.45–2.0) within 90 days. The cost profile of complications, readmission, and refusion has been given. CONCLUSIONS: ACD patients with secondary diagnosis codes such as inflammatory arthropathy or neuromuscular pathology incur higher 90-day costs due to the inherent requirement of bigger fusions and higher risk of peri-operative complications, but with similar risk of readmission and refusion as those without SP. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: With evolving health care reforms and payment models, knowledge of conditions associated with higher expenditure after elective spine surgical procedures will be beneficial to providers and payors for appropriate risk stratification.

Introduction:Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >80 years).Materials and Methods:The 2012-2017 American College of Surgeons database was queried for patients undergoing open reduction internal fixation for isolated uni-malleolar, bi-malleolar and tri-malleolar ankle fractures. The study cohort was divided into 3 comparison groups (age 80). Multi-variate regression analyzes were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for baseline clinical characteristics and co-morbidity burdens.Results:A total of 19,585 patients were included: 5.3% were >80 years, 18.1% were 65-79 years, and 76.6% were 80 years were at a significantly Abstract: higher risk of 30-day wound complications (OR 1.84; p = 0.019), pulmonary complications (OR 3.88; p < 0.001), renal complications (OR 1.96; p = 0.015), septic complications (OR 3.72; p = 0.002), urinary tract infections (OR 2.24; p < 0.001), bleeding requiring transfusion (OR 1.90; p = 0.025), mortality (or 7.44; p < 0.001), readmissions (OR 1.65; p = 0.004) and non-home discharge (OR 13.91; p < 0.001).Discussion:Octogenarians undergoing ankle fracture fixation are a high-risk population in need of significant pre-operative surgical and medical optimization. With the majority of patients undergoing non-elective ORIF procedures, it is critical to anticipate potential complications and incorporate experienced geriatric providers early in the surgical management of these patients.Conclusions:Octogenarians and nonagenarians are fundamentally distinct and vulnerable age groups with a high risk of complications, readmissions, mortality and non-home discharges compared to other geriatric (65-79 years) and non-geriatric (

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only (IO) list in January 2020. Given this recommendation, we analyzed Medicare-eligible patients undergoing outpatient THA to understand risk factors for nonroutine discharge, reoperations, and readmissions. Materials and Methods: The 2015-2018 American College of Surgeons–National Surgical Quality Improvement Program database was queried using Current Procedural Terminology code 27130 for Medicare eligible patients (≥ 65 years of age) undergoing outpatient THA. Postoperative discharge destination was categorized into home and non-home. Multivariate logistic regression models were used to evaluate risk factors associated with non-home discharge disposition. Secondarily, we evaluated rates and risk factors associated with 30-day reoperations and readmissions. Results: A total of 1095 THAs were retrieved for final analysis. A total of 108 patients (9.9%) experienced a non-home discharge postoperatively. Patients were discharged to rehab (n = 47; 4.3%), a skilled care facility (n = 47; 4.3%), a facility that was “home” (n = 8; 0.7%), a separate acute care facility (n = 5; 0.5%), or an unskilled facility (n = 1; 0.1%). Independent factors for a non-home discharge were American Society of Anesthesiologists Class >II (odds ratio [OR] 2.74), operative time >80 minutes (OR 2.42), age >70 years (OR 2.20), and female gender (OR 1.67). Eighteen patients (1.6%) required an unplanned reoperation within 30 days. A total of 40 patients (3.7%) required 30-day readmissions, with 35 readmissions related to the original THA procedure. Independent risk factors for 30-day reoperation were COPD (OR 5.85) and HTN (OR 5.24). Independent risk factors for 30-day readmission were HTN (OR 4.35) and Age >70 (OR 2.48). Discussion: The current study identifies significant predictors associated with a non-home discharge, reoperation, and readmission in Medicare-aged patients undergoing outpatient THA. Conclusion: Providers should consider preoperatively risk-stratifying patients to reduce the costs associated with unplanned discharge destination, complication or reoperation.

Objective Although studies have evaluated the economic burden to medical students desiring a neurosurgery residency broadly, a detailed breakdown of costs has not been reported. Given that the Association of American Medical Colleges and Society of Neurological Surgeons have recommended neurosurgery residency programs for the 2021 residency application cycle cancel away rotations and in-person interviews, our objective was to evaluate cost savings to medical students applying during this time and the implications. Methods Using the 2019–2020 Texas STAR Dashboard database, we queried responses from neurosurgery residency applicants. We recorded application costs, away rotation costs, interview costs, and total costs for medical school seniors applying to neurosurgery residency. Demographic information for applicants was also recorded. Mean and median costs were reported with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was used to determine differences in mean costs by medical school region. Results Our cohort included 121 U.S. allopathic applicants to neurosurgery residency. Mean application costs were $1711, away rotation costs were $3840, interview costs were $6400, and total costs were $11,882. No significant difference was observed for mean total costs for applicants from schools in the central ($10,525/applicant), northeast ($11,311/applicant), south ($12,660/applicant) and west ($12,404/applicant) regions (P = 0.181). There was no significant difference in the mean application fees, away rotation costs, or interview costs among regions. Conclusions In the COVID-19 era, neurosurgery residency applicants could save >$10,000 through the use of virtual interviews and lack of away rotations. There are potential geographic trends; however, further evaluation should be performed.

As physicians, we strive to meet the needs of our patients. In doing so, we are often exposed to hazards that have the potential to not only compromise our health, but also our ability to deliver the best possible healthcare. Occupational hazards specific to the field of orthopaedics include infectious organisms, radiation, surgical smoke, chemicals, hazardous noise, musculoskeletal injury, and psychosocial stressors. Even though orthopaedic surgeons acknowledge the risk, most lack in-depth knowledge of the associated long-term harm associated with these hazards and ways of reducing risk of exposure. Orthopaedic surgeons should increase awareness, follow established guidelines, and integrate preventative measures to create the safest possible work environment. It is our hope that by improving our own health, we will be better equipped to address the health concerns of those we serve-our patients.

Introduction: We evaluated differences in reimbursement rates between native femoral shaft fractures treated with an intramedullary nail versus those undergoing repair of nonunion of femoral shaft fractures. Methods: The 2016 to 2017 American College of Surgeons—National Surgical Quality Improvement Program database was queried using International Classification of Diseases 10th Edition diagnosis codes and Current Procedural Terminology codes to identify patients undergoing surgery for native femoral shaft fractures and/or repair of nonunion of femoral shaft fracture with/without grafts. Results: The mean total relative value unit (RVU) and surgical time for each group were as follows: (1) native (RVU = 19.70, surgical time = 97.4 minutes), (2) nonunion w/out graft (RVU = 17.23, surgical time = 135.8 minutes), (3) nonunion w/graft (RVU = 18.88, surgical time = 164.5 minutes). Reimbursement rates decreased notably as complexity of case grew (native = $8.74/min versus nonunion w/graft = $6.07/min versus nonunion w/graft = $5.27/min; P < 0.001). The average reimbursement/case was $707 for native femoral shaft fracture, $618 for repair of nonunion w/out graft, and $678 for repair of nonunion with bone graft. Discussion: The study highlights the need for a change in the RVUs assigned to nonunions of the femoral shaft to ensure that the value of physician intensity is retained in future RVU evaluations.

To utilize a national all-payer claims dataset to understand whether a history of a prior shoulder arthroscopy is associated with adverse outcomes or complications after the index shoulder arthroplasty itself.The Symphony Integrated DataVerse, an all-payer claims database, was used to identify patients undergoing primary shoulder arthroplasty (hemiarthroplasty, anatomic total shoulder arthroplasty, or reverse total shoulder arthroplasty) between 2017 to 2018. Current Procedural Terminology codes were used to identify patients who had undergone a shoulder arthroscopic procedure on the ipsilateral side within 2 years before the arthroplasty. Multivariate logistic regression analyses were used to assess whether prior shoulder arthroscopy was associated with higher risks of wound complications, postoperative stiffness, mechanical complications, prosthetic joint infection, revision surgery and readmissions within 90 days of the arthroplasty.In total, 19,429 patients were included, of which 837 (4.3%) had undergone shoulder arthroscopy within 2 years before the arthroplasty. Prior shoulder arthroscopy was associated with a significantly higher risk of prosthetic joint infection (odds ratio [OR] 2.74 [95% confidence interval {CI} 1.51-4.69]; P.001) within 90 days of the arthroplasty. The greatest risk of prosthetic joint infection was associated with arthroscopies that took place within 3 months before the arthroplasty (OR 5.32 [95% CI 1.42-15.14]; P = .005).Undergoing an arthroscopic procedure of the ipsilateral shoulder before undergoing an arthroplasty was associated with greater risk of prosthetic joint infection. Furthermore, it appears that patients who received arthroscopy within the 3 months before arthroplasty had the highest risk of prosthetic joint infections. Physicians should not only anticipate possible inferior outcomes in patients who have had prior arthroscopy, but also consider delaying the arthroplasty by at least 3 months after the arthroscopy to mitigate the risks of experiencing this costly adverse event.III.

BACKGROUND: The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases. QUESTION/PURPOSE: Is there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals? METHODS: The 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs. RESULTS: After adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001). CONCLUSION: Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease. LEVEL OF EVIDENCE: Level III, therapeutic study.

Background: Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited. Methods: The 2015–2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations. Results: A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61–2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10–2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40–14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39–3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05–56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52–3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03–1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16–1.63]; p < 0.001) following discharge. Conclusion: Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

To identify intraoperative drivers of cost associated with arthroscopic rotator cuff repairs (RCRs) through analysis of an institutional database.This was a single-institution retrospective review of arthroscopic RCRs performed at an ambulatory surgical center between November 2016 and July 2019. Patient-level factors analyzed included age, sex, insurance type (private, Medicare, Medicaid, self-pay, and other government), American Society of Anesthesiologists grade (I, II, III, and missing), and Charlson comorbidity index (0, 1, 2, and ≥3). Procedure-level factors included use of biologics (decellularized dermal allograft or bioinductive healing implant), anesthesia type (regional block, monitored anesthesia care, or general), number of anchors and sutures, additional procedures (biceps tenodesis, distal clavicle resection, subacromial decompression), and operative time. Multivariate linear regression analysis was used to identify factors significantly associated with higher or lower charges.A total of 712 arthroscopic RCRs were included. The risk-adjusted operative charges were $19,728 (95% confidence interval $16,543 to $22,913). The above factors predicted nearly 65% of the variability in operative charges. The only patient-level factor significantly associated with lower charges was female sex (- $1,339; P = .002). Procedure-level factors significantly associated with higher charges were use of biologics (+ $17,791; P.001), concurrent open biceps tenodesis (+ $4,027; P.001), distal clavicle resection (+ $2,266; P = .039), use of regional block (+ $1,256; P = .004), number of anchors (+ $2,245/anchor; P .001), and increasing operative time ($26/min). Other factors had no significant association.Procedural factors are the most significant drivers of operative cost in arthroscopic RCRs, such as quantity and type of implants; additional procedures such as biceps tenodesis and distal clavicle resection; and perioperative conditions such as type of anesthesia and total operating room time. Overall, patient-level factors were not shown to correlate well with operative costs, other than lower charges with female sex.IV, economic study.

To analyze the trends in operative experience, specifically procedures of the shoulder, hip and knee, of fellows graduating from Accreditation Council for Graduate Medical Education orthopaedic sports medicine fellowships between 2011 and 2016.The 2011-2016 Accreditation Council for Graduate Medical Education orthopaedic surgery sports medicine fellow case logs were retrieved for analysis. Trends in the mean case volume for procedures of the shoulder, hip, and knee were analyzed. Linear regression was used to identify significant changes in trends over time for each surgical case/procedure. Variation in case volume between fellows in the lowest (10th) and highest (90th) centile was assessed for first and last year of the study.The average number of total procedures per fellow minimally decreased by 3.5% from 2011 to 2016 (726 to 701 cases) (P.001). The mean total number of hip procedures significantly increased by 155% from 24.9 to 63.5 (P = .049). There were no significant differences in the mean total number of shoulder (P = .88) and knee procedures (P = .54). Arthroscopic hip procedures had the largest increase from 2011 to 2016 (14.1 to 57.8 [+310%], P = .049). There was greater than 2-fold difference in total procedural volume between fellows in the 10th and 90th percentile for 2011 and 2016, with the greatest variation (64-fold) for arthroscopic hip procedures.In this study there was a 2.6-fold increase in hip procedures, largely driven by a 310% rise in arthroscopic hip cases. The average procedural volume per fellow minimally decreased, with no change in the mean number of shoulder and knee procedures.Understanding variability in case exposure among orthopaedic sports medicine fellowships is important for programs to ensure that fellows are appropriately exposed to all facets of sports medicine procedures.

Introduction There has been a burgeoning interest for implementing bundled payments for hip fractures being treated with hemiarthroplasty, percutaneous pinning, and/or open reduction and internal fixation. Concerns exist about how hip fracture bundles may impede access to care for patients who require more resources, such as those with pathologic/neoplastic fractures. Methods The 2011 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database was queried to identify patients undergoing percutaneous pinning, hemiarthroplasty, plate/screw, and intramedullary nail for hip fractures. Multivariate regression analyses were used to identify notable differences in 30-day complications, readmissions, reoperations, mortality, length of stay, and nonhome discharges between native and pathologic/neoplastic hip fractures. Results A total of 67,548 patients were included-of which 378 (0.6%) had a pathologic/neoplastic hip fracture. Pathologic fractures (versus native hip fractures) had significantly higher odds of experiencing a prolonged length of stay >5 days (odds ratio [OR] 1.57), pulmonary embolism (OR 3.67), deep vein thrombosis (OR 2.03), 30-day readmissions (OR 1.43), and 30-day mortality (OR 2.66). Discussion Patients sustaining a pathologic/neoplastic hip fracture have a worse adverse event profile. Risk adjustment based on facture etiology will be necessary to ensure that providers taking care of pathologic/neoplastic fractures are appropriately reimbursed to minimize barriers to access of care for this vulnerable cohort.

Sex has been known to significantly affect postoperative complications and length of stay after elective anterior cervical fusions. Current evidence on lumbar spine surgery is limited.The 2012-2016 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology codes 22612, 22630, and 22633 to identify patients undergoing posterior lumbar fusions. A total of 23,615 patients were included in the final cohort.Out of 23,615 patients, 10,810 (45.8%) were men and 12,805 (54.2%) were women. After controlling for demographic, comorbidities-specific, preoperative, and operative differences between the 2 groups, female sex was found to be an independent risk factor significantly associated with a length of stay longer than 3 days (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.35-1.51; P0.001), occurrence of any complication within 30 days (OR, 1.31; 95% CI, 1.16-1.47; P0.001), wound complications (OR, 1.43; 95% CI, 1.18-1.74; P0.001), urinary tract infections (OR, 2.25; 95% CI, 1.79-2.83; P0.001), 30-day reoperations (OR, 1.19; 95% CI, 1.02-1.39; P = 0.025), 30-day readmissions (OR, 1.16; 95% CI, 1.03-1.31; P = 0.015), and nonhome discharge (OR, 1.83; 95% CI, 1.69-1.98; P0.001). Interestingly, the only adverse outcome associated with male sex was renal complication (OR, 2.28; 95% CI, 1.43-3.65; P = 0.001).Contrary to literature on cervical fusions, we found that female sex was independently tied to an increased risk of adverse outcomes after elective posterior lumbar fusion. The results from the study suggest that women may benefit from close surveillance during the postoperative period to minimize risk of complications and subsequent resource utilization in this group.