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Background: Patients who have the autoinflammatory bowel disease ulcerative colitis (UC) may become candidates for total hip arthroplasty (THA). Having UC may predispose patients to postoperative adverse events, but it remains unclear if these events are related more to the disease process itself or perhaps related to the medications used to treat the condition., Methods: Patients undergoing THA were identified from a large administrative dataset. Those who did not have and those who had UC were matched 4:1 based on patient age, sex, and the Elixhauser Comorbidity Index (ECI). Matched THA patients who did not have UC (n = 19,482) and those who had UC (n = 4,874) were identified. The matched groups were compared regarding 90-day adverse and five-year survival. Further analyses were performed based on classes of medications., Results: Controlling for patient age, sex, and ECI, UC patients were at significantly higher odds of 90-day adverse events: any (odds ratio [OR] 1.59), severe (OR 1.72), and minor (OR 1.63) (all P < 0.001). Despite this, no differences in 5-year survival were identified. Relative to those who did not have UC, there were increasing odds of any adverse event based on the potency of related medications: no corticosteroids /immunomodulators/5-aminosalicylic acid (5-ASA) (OR 1.42), corticosteroids only (OR 1.58), 5-ASA ± corticosteroids OR (1.72), and immunomodulators ± corticosteroids (OR 1.74, all P < 0.001)., Conclusions: Total hip arthroplasty patients who have UC were at higher odds for 90-day postoperative adverse events relative to those who did not have UC, and this risk was even greater for those on defined classes of medications. Total hip arthroplasty patients who have UC bear specific considerations, and surgeons must carefully consider and manage the patient's medication regimen in the perioperative period of the THA., (Copyright © 2024. Published by Elsevier Inc.)

Study Design/setting: Retrospective cohort study., Objective: To characterize the incidence and odds of neurologic adverse events following interlaminar (IL) and transforaminal (TF) cervicothoracic epidural spinal injections (CESI)., Summary of Background Data: CESI may be considered in the management of various cervical pathology. Adverse events, although rare, can be devastating and have been reported following both IL and TF injections. The literature is mixed with regard to the risk-profile of these two types of CESI, but is largely limited to case reports, single centered studies, and literature reviews, which may incompletely characterize the relative risk of these injections at a national level., Methods: All adult patients undergoing IL and TF-CESI were identified from a large, national, multi-insurance database. The incidence of any post-injection neurologic complication was reported per 1,000 patients. The odds of specific neurologic adverse events occurring within 48-hours following TF-CESI, relative to IL-CESI, were compared by multivariable logistic regression controlling for age, sex, and Elixhauser comorbidity index (ECI)., Results: A total of 1,073,215 IL-CESI patients and 220,597 TF-CESI patients were identified. The overall incidence of any neurologic complication following IL and TF-CESI occurred at a rate of 4.15 and 4.56 per 1,000 patients, respectively (P=0.889). TF-CESI was associated with higher odds ratio (OR) of nerve root injury (OR 1.69, P<0.001), but lower odds of epidural hematoma (OR 0.60, P=0.040), relative to IL-CESI. Conversely, no other neurologic adverse events were statistically different between approaches (P>0.05 for all)., Conclusions: Following IL and TF-CESI, adverse events are relatively rare but not absent. Although the odds of the majority of individual neurologic adverse events were found to be similar, both approaches were independently associated with specific complications. Providers should therefore recognize that, at the national level, one CESI approach may not be universally associated with a lower risk of complications., Competing Interests: Financial disclosures/conflicts of interests: Jonathan N. Grauer. is the North American Spine Society Journal Editor-in-chief and member of the North American Spine Society Board, (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Behcet syndrome (BS), a multisystem autoimmune disorder, has unclear effects on outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study assessed the relative risk of perioperative adverse events in patients with BS., Methods: This retrospective cohort study used the PearlDiver M157Ortho data set, a large national administrative database. Total hip arthroplasty and TKA patients with BS were identified and matched 1:4 to those without BS based on patient age, sex, Elixhauser Comorbidity Index scores, and procedure performed (THA or TKA). The incidence of 90-day adverse events was determined and compared by multivariate analysis. 5-year survival to revision surgeries was assessed and compared with the log-rank test., Results: After matching, 282 THA/TKA patients with BS were identified and compared with 1127 without BS. On multivariate analysis, patients with BS were at independently greater risk of aggregated any (odds ratio [OR] 2.16, P < 0.0001), serious (OR 1.78, P = 0.0051), and minor (OR 2.39, P < 0.0001) adverse events compared with those without BS. No significant difference was observed in 5-year survival to revision surgery (P = 0.3)., Conclusions: Patients with BS undergoing THA or TKA experienced markedly greater 90-day postoperative adverse events. The findings underscore the need for optimized perioperative management for patients with BS undergoing arthroplasty., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Geriatric hip fractures are common and important sentinel events regarding bone health. Although dual x-ray absorptiometry (DEXA) scans are a standard method for determining bone density, differences in use among various race/ethnic groups around the time of hip fracture may reveal disparities within the healthcare system., Methods: The 2014 to 2016 Medicare Standard Analytic Files PearlDiver data set was used to identify geriatric patients sustaining hip fracture. From that cohort, those who had a DEXA scan before or after their fracture were defined. For the defined cohorts, patient age, sex, Elixhauser Comorbidity Index, race/ethnicity, and income (based on zip code) were defined and compared with univariate and multivariate analyses., Results: Of 58,099 hip fracture patients, only 19.8% had had a DEXA scan before fracture and 3.9% of the remaining group had the DEXA scan after fracture. Of the hip fracture population, 91.0% identified as White and 9.0% as non-White (Native American, Black, Hispanic, Asian, or Other). Before hip fracture, controlling for other variables and compared with White patients, all non-White categories were at lesser odds of having had the DEXA scan. After hip fracture, Black, Hispanic, and other patients were also at lesser odds of having the DEXA scan., Discussion: Using a large Medicare data set, controlling for patient age, sex, Elixhauser Comorbidity Index, and income marker, this study revealed disparities in DEXA scan utilization across race/ethnic groups before and after presenting with a hip fragility fracture. Identification of such disparities highlights the needs for improved medical access and care for this at-risk hip fracture population., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Study Design: Retrospective cohort study., Objective: To evaluate postoperative adverse events, readmissions, and five-year survival to reoperation for two-level cervical disc arthroplasty (CDA) relative to two-level anterior cervical discectomy and fusion (ACDF)., Background: CDA and ACDF are both treatment options for degenerative cervical spine pathology. Relative to ACDF, CDA is a relatively novel treatment option, and limited research exists comparing outcomes between two-level CDA and two-level ACDF., Methods: Patients undergoing two-level CDA or two-level ACDF were isolated from the PearlDiver M165Ortho database. These two cohorts were matched 1:1 based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores. The odds of 90-day postoperative adverse events were compared between the two groups by multivariable analysis. Overall cost-of-care for the first 90-days postoperatively, and five-year survival to cervical spine reoperation were then assessed., Results: Of the two-level cases identified, only 3.9% had CDA and the rest had ACDF. After matching, there were 4,224 patients in each of the study groups. With controlling for patient age, sex, and ECI on multivariable analysis, two-level CDA patients had significantly lower odds of experiencing 90-day dysphagia (OR 0.60, P<0.0001 driving aggregated any adverse event [OR 0.65, P<0.0001]) and readmission (OR 0.69, P=0.0002). Median 90-day cost of care was greater for two-level ACDF patients ($4,776.00 vs. $3,191.00, P<0.0001). No significant difference in five-year survival to cervical spine reoperation was identified (P=0.7)., Conclusions: Relative to two-level ACDF patients, two-level CDA patients were found to have significantly lower odds of 90-day readmissions and minor adverse events (dysphagia), while rates of major adverse events (pulmonary embolism, deep vein thrombosis, sepsis, etc.) were comparable between the groups. Further CDA patients had lower cost of overall care, but no difference in five-year survival to cervical spine reoperation. Thus, it may be appropriate to further consider CDA when two-level surgery is pursued., Competing Interests: Conflicts of Interest & Source of Funding: MJG: James M. Hirsch Medical Student Fellowship from Yale University School of Medicine. We have otherwise no conflicts of interest to report. No funding was received for completion of this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: To assess relative odds of perioperative complications, readmissions, and five-year survival to reoperation for three-level lumbar decompression patients who undergo three-level fusion relative to one-level fusion., Background: Patients undergoing multilevel lumbar decompression may be indicated for fusion at one or more levels. The question of fusing only one level with indications such as spondylolisthesis or fusing all levels decompressed is of clinical interest in both the short and longer term., Methods: Patients undergoing three-level lumbar decompression were extracted from the PearlDiver M165Orto database. The subset of these patients undergoing concomitant three-level and one-level lumbar fusion were identified and matched 1:1 based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores. The incidence and odds of 90-day postoperative adverse events were compared between the two groups by multivariable analysis, and comparative five-year survival to lumbar spinal reoperation was determined., Results: After matching, 28,276 patients were identified as undergoing three-level lumbar decompression with three-level fusion and the same for those undergoing three-level decompression with one-level fusion. Controlling for patient age, sex, and ECI, three-level fusion patients had significantly greater odds ratio (OR) of many 90-day adverse events and aggregated any (OR 1.42), serious (OR 1.44), and minor (OR 1.42) adverse events, as well as readmissions (OR 1.51) (P<0.0001 for all). Five-year survival to reoperation was significantly lower for those undergoing three-level decompression with three-level fusion (P<0.0001)., Conclusions: Three-level lumbar decompression patients who underwent three-level fusion were found to be at significantly greater odds of 90-day postoperative adverse events, readmissions, and five-year reoperations relative to those undergoing one-level fusion. The current data support the concept of limiting fusion to the levels with specific indications in the setting of multi-level lumbar decompressions and not needing to match the decompression and fusion levels., Competing Interests: Conflicts of Interest & Source of Funding: We have no conflicts of interest to report. No funding was received for completion of this study., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Posterior lumbar fusion (PLF) is frequently considered for various spinal pathologies. While many outcome metrics have been assessed, to our knowledge, there has yet to be literature specifically investigating inpatient falls (IPFs) and its risk factors., Methods: Adult patients who underwent single-level PLF were abstracted from the 2010-Q1 2022 M161Ortho PearlDiver Database. Patients who had an IPF were determined based on administrative coding. Various patient variables were extracted and variables independently associated with IPFs were assessed with multivariate logistic regression. Incidence of secondary injuries and cost incurred related to the IPF were determined., Results: Of the 342,890 patients who underwent PLF, IPF was identified for 4,379 (1.4%). Independent predictors of an IPF in decreasing odds ratio (OR) order were those with: active psychosis (OR=3.35), active delirium (OR=2.83), history of falling (OR=2.47), commercial insurance (OR=1.59 relative to Medicare), Medicaid insurance (OR=1.47 relative to Medicare), dementia (OR=1.17), older age (OR=1.12 per decade), alcohol use disorder (O=1.11), higher comorbidity (OR=1.08 per Elixhauser comorbidity index point) (p<.05 for each).Of patients with IPF, 44 (1.0%) sustained a head injury, and 42 (1.0%) sustained a fracture. On average, those with IPF incurred greater inpatient costs compared to patients who did not ($36,865 vs. $33,921, p<.001)., Conclusion: In this national sample of patients who underwent single-level PLF, postoperative IPFs were identified for 1.4% and were associated with defined patient variables. These findings have potential patient outcome, financial, and medicolegal implications and should help guide refinement of fall prevention programs., Competing Interests: Michael Gouzoulis received James G Hirsch Medical Student Fellowship from Yale University School of Medicine. Jonathan N Grauer is Editor-in-Chief of North American Spine Society Journal and a member of the North American Spine Society Board of Directors., (© 2024 The Authors.)

Background: This study compared trends in use, predictive factors, and reimbursement of endoscopic carpal tunnel release (ECTR) withthose of open carpal tunnel release (OCTR) from 2010 to 2021 using a national administrative database., Methods: ECTR and OCTR patients were identified in the PearlDiver M151Ortho data set. Numeric and proportional utilization of these procedures was characterized for each year of study. Multivariate analysis was conducted to identify predictive factors for having ECTR performed. The average 90-day reimbursement of ECTR and OCTR was determined., Results: From 2010 through 2021, 441,023 ECTR and 1,767,820 OCTR procedures were identified. The proportional use of ECTR compared with OCTR rose from 2010 (15.7% of procedures) to 2021 (26.1%). Independent predictors of having ECTR performed rather than OCTR included geographic variation (compared with having surgery in the Midwest, Northeast odds ratio [OR], 1.53; West OR, 1.62; and South OR, 1.66), having Medicare or commercial insurance (compared with commercial, Medicare OR, 0.94, and Medicaid OR, 0.69), female sex, and fewer comorbidities. The average 90-day reimbursement for ECTR was $3,114.82, compared with $3,087.62 for OCTR., Discussion: As of 2021, over one-fourth of carpal tunnel releases are done endoscopically. Several factors independently predict whether patients receive ECTR or OCTR., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Study Design: Descriptive epidemiologic study., Objective: To analyze trends and patient characteristics of those undergoing cervicothoracic transforaminal, interlaminar, and facet injections over time., Background: Cervicothoracic transforaminal, interlaminar, and facet injections are considered for varied spinal pathologies. Evolving literature, changing physician preferences, insurance reimbursement policies, and patient factors may influence the utilization of such injections over time., Methods: Patients undergoing cervicothoracic transforaminal, interlaminar, and facet injections 2010-2020 were identified in the M151Ortho PearlDiver database using Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index, insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, and West) were extracted and assessed over study intervals based on prevalence per 100,000 covered lives., Results: Cervicothoracic transforaminal, interlaminar, and facet injections were identified for 195,221 (11.3%), 951,191 (55.2%), and 575,228 (33.4%) patients, respectively. Patient characteristics for each injection type were defined. The annual number of injections performed per 100,000 covered lives decreased during the study period for transforaminal (17.1% decrease) and interlaminar (9.3% decrease) but increased for facet (3.7% increase) injections ( P <0.0001 for each). Stratifying by patient insurance type, administration of transforaminal, interlaminar, and facet injections per 100,000 covered lives was proportionally greatest for commercially insured patients (55%, 50%, and 45%, respectively), and proportionally smallest for Medicaid patients (10%, 13%, and 13%, respectively). Anesthesiology physicians performed the most injections, followed by physical medicine and rehabilitation physicians, with both provider types most frequently performing interlaminar injections, followed by facet and transforaminal injections., Conclusion: Annual cervicothoracic transforaminal and interlaminar injection utilization declined by 17.1% and 9.3% from 2010 to 2020, whereas facet injection administration increased by 3.7% over the same interval. Evolving practice patterns are important to consider in characterizing the overall landscape of spine care., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Total hip arthroplasty (THA) is a common procedure following which postoperative visits are important to optimize outcomes. The associated global billing period includes the 90 postoperative days (or approximately 13 weeks), during which professional billing is included with the surgery itself. The current study assessed clinical practice patterns relative to the global billing period., Methods: Using the PearlDiver M91Ortho dataset, the incidence and timing of Evaluation and Management (E&M) codes in the 26 weeks following THA were assessed. The follow-up visits within and beyond the global billing period, and those conducted by surgeons versus non-surgeon advanced practice providers (APPs) were determined., Results: 77,843 THAs were identified. Follow-up visits peaked at postoperative weeks 3, 7, and 14. The greatest week-to-week variation in the number of follow-ups was from weeks 13 to 14 immediately following the global billing period (representing a greater than 4-fold increase in visits.) During the first 13 postop weeks, 73.8% of patients were seen by orthopedic surgeons (as opposed to APPs). In the following 13 weeks, a significantly greater percentage of visits were with surgeons (86.8%, p<0.0001)., Conclusions: Following the THA global billing period, there was marked increase in the number of follow-ups and transition to a greater percentage being performed by the surgeons. These results provide interesting insight into the potential impact of the billing structure on how practice is pursued., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ratnasamy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Study Design: Retrospective cohort study., Objectives: Gabapentinoids have been increasingly studied as a non-narcotic option for neuropathic and postoperative pain. However, there is evidence suggesting that off-label use of these medications for the treatment of isolated LBP is not effective. The purpose of the current study was to evaluate prescription patterns for gabapentinoids among patients with isolated low back pain., Methods: Adult patients with LBP were abstracted from the 2019 M91Ortho PearlDiver dataset using International Classification of Diseases (ICD-10) code M54.5. Patients were excluded if they had a diagnosis of neurologic symptoms, history of spinal surgery, spinal fracture, or conditions for which gabapentinoids are FDA approved. Gabapentinoid and narcotic prescriptions within one year of LBP diagnosis were identified. Patient characteristics and prescriber specialty were extracted from the dataset and predictors of gabapentinoid prescriptions were determined using univariate and multivariate analyses., Results: Among the 1,158,875 isolated LBP patients, gabapentinoids were prescribed for 11%, narcotics for 8%, and both for 3%. The most common prescriber specialties included: primary care physicians (45%), nurse practitioners (15%), and pain management physicians (5%). Independent predictors of gabapentinoid prescriptions included: female sex, region of the country, and insurance type ( P -values <.001)., Conclusions: Of nearly 1.2 million patients with isolated LBP, 14.2% were prescribed gabapentinoids within one year of their LBP diagnosis. Patient characteristics predictive of receiving gabapentinoids were predominantly non-clinical factors., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: End-stage ankle osteoarthritis is a condition that can be treated with ankle arthrodesis (AA) or total ankle arthroplasty (TAA). The goal of this study is to estimate the 2016-2017 United States' utilization of TAA and AA in specific ambulatory settings and delineate patient and hospital factors associated with the selection of TAA vs AA for treatment of ankle osteoarthritis., Methods: TAA and AA procedures performed for ankle osteoarthritis were identified in the 2016-2017 Nationwide Ambulatory Surgery Sample (NASS) Database. Notably, the NASS database only examines instances of ambulatory surgery encounters at hospital-owned facilities. As such, instances of TAA and AA performed at privately owned or freestanding ambulatory surgical centers or those performed inpatient are excluded from this analysis. Cases were weighted using nationally representative discharge weights. Univariate analyses and a combined multiple logistic regression model were used to compare demographic, hospital-related, and socioeconomic factors associated with TAA vs AA., Results: In total, 6577 cases were identified, which represents 9072 cases after weighting. Of these, TAA was performed for 2233 (24.6%). Based on the logistic regression model, several factors were associated with increased utilization of TAA vs AA. With regard to patient factors, older patients were more likely to undergo TAA, as well as females. Conversely, patients with a higher comorbidity burden were less likely to receive TAA over AA.With regard to socioeconomic factors, urban teaching and urban nonteaching hospitals were significantly more likely to use TAA compared to rural hospitals. Similarly, privately insured patients and those with a median household income of $71 000 or more were also more likely to receive TAA over AA. Private hospitals ("not-for-profit" and "investor-owned") were significantly more likely to offer TAA over AA., Conclusion: Using a large nationally representative cohort, the current data revealed that during 2016-2017, 24.6% of operatively treated cases of end-stage ankle osteoarthritis in the ambulatory setting are treated with TAA. Associations between socioeconomic and hospital-level factors with TAA utilization suggest that nonclinical factors may influence surgical treatment choice for ankle osteoarthritis., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Background: Readmissions are a typical postoperative metric; however, postoperative emergency department (ED) utilization also negatively affects patient care. Few studies have explored this metric after patellofemoral arthroplasty (PFA); thus, we investigated the incidence, timing, predictive factors, and reasons for ED utilization within 90 days after PFA., Methods: Using the 2010 to 2021 PearlDiver M151Ortho data set, a national billing claims database containing information of over 151 million US orthopaedic patients across all payer types, the study examined weekly ED visits up to 90 days after PFA and conducted univariate and multivariate analyses to identify predictive factors., Results: Of 7765 PFA patients, 11.2% (922) had ED visits within 90 days, with 46.7% (431) occurring in the first 3 weeks. Independent predictors of ED utilization included younger age (OR 1.40 per decade decrease), higher Elixhauser Comorbidity Index (OR 1.44 per 2-point increase), surgery in the South or Midwest (OR 1.27 and 1.31), and Medicaid insurance (OR 1.74). Postoperative pain accounted for 50.6% of visits., Conclusions: 11.2% of PFA patients visited the ED within 90 days, primarily for postoperative pain. Younger, more comorbid, and Medicaid-insured patients were most likely to use the ED. This study suggests the need for targeted perioperative pain management to reduce ED utilization after PFA., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background Context: Psoriasis is a chronic, autoimmune disease of the skin that affects approximately 3% of the US adult population. Patients with psoriasis may be predisposed to spine surgical site infections (SSI) related to the condition and/or related medications following surgeries such as lumbar laminotomy/discectomy., Purpose: To assess the potential correlation of psoriasis and its related treatment medications on the risk of infection-related complications after lumbar laminotomy/discectomy., Study Design: Retrospective case control, national administrative database study., Patient Sample: Adult patients who underwent isolated single-level lumbar discectomy between 2010 and Q1 of 2021 were identified in the PearlDiver Mariner Ortho151 national administrative database (excluding those with concurrent diagnoses of fractures, neoplasms, or infections)., Outcome Measures: Ninety-day postoperative rates of surgical site infection and sepsis., Methods: Lumbar laminotomy/discectomy patients with versus without psoriasis were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index. The risk of SSI and sepsis in the 90-day postoperative window between the cohorts were compared with multivariable analyses. Five-year reoperation rates were also compared with log rank test. The matched psoriasis cohort was further subdivided by psoriasis treatment regimens - no medication treatment (NT), topical therapies only (TT), topical therapies with oral systemic treatments (TT/OS), and topical therapies with biologics (TT/B). Multivariable logistic regression was used to assess the risk of SSI and sepsis within 90 days after lumbar laminotomy/discectomy for each treatment subgroup compared to patients without psoriasis., Results: In total, 2,262 patients with psoriasis who underwent single-level lumbar laminotomy/discectomy were identified and matched by age, sex, and Elixhauser Comorbidity Index to 9,044 patients without psoriasis. Multivariable logistic regression showed that, compared to the patients without psoriasis, patients with psoriasis had a 1.795 times higher chance of developing SSI (odds ratio [OR]) (p<.001) and sepsis (OR: 1.743, p=.027) within 90 days of surgery. Having psoriasis did not significantly correlate with 5-year reoperation rates. Of those with psoriasis, NT subcohort had 1,038 patients, TT subcohort 571 patients, TT/OS subcohort 226 patients, and TT/B subcohort 140 patients. Based on multivariable analysis and compared to nonpsoriasis patients, those in the NT, TT, TT/OS were not at greater odds of postoperative SSI or sepsis. Conversely, those in the TT/B subcohort were at significantly greater odds of SSI (OR: 3.102, p=.019) and sepsis (OR: 6.367, p=.027)., Conclusions: Of single-level lumbar laminotomy/discectomy patients with psoriasis, only those on topical therapies and biologics were at greater risk of postoperative SSI and sepsis. This subcohort warrants specific attention when undergoing lumbar laminotomy/discectomy and possibly holding such medications for a period prior to surgery may be warranted if possible., Competing Interests: Declarations of competing interests One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Study Design: Descriptive epidemiologic study., Objective: To compare trends in utilization and predictive factors for single-level cervical disc arthroplasty (CDA) relative to anterior cervical discectomy and fusion (ACDF) over the years., Background: CDA is an alternative to ACDF for the treatment of cervical spine pathologies. With both procedures performed for similar indications, controversy on best practices exists., Materials and Methods: Patients who underwent single-level CDA or ACDF were identified in the 2010 through 2021 PearlDiver M151Ortho data set. The yearly number of CDAs performed and proportionality was assessed. Predictive patient factors for undergoing CDA as opposed to ACDF were determined. Kaplan Meyer survival analysis with an endpoint of cervical spine reoperation compared 5-year outcomes between CDA and ACDF., Results: From 2010 to 2021, 19,301 single-level CDAs and 181,476 single-level ACDFs were identified. The proportional utilization of CDA relative to ACDF increased from 4.00% in 2010 to 14.15% in 2018 ( P < 0.0001), after which there was a plateau between 2018 and 2021 where proportional utilization was 14.47% ( P = 0.4654). Multivariate analysis identified several predictors of undergoing CDA rather than ACDF, including: younger age [odds ratio (OR) per decade decrease: 1.72], having surgery performed in the Midwest, Northeast, or West (relative to South, OR: 1.16, 1.13, 2.26, respectively), having Commercial insurance (relative to Medicare, OR: 1.75), and having surgery performed by an orthopedic surgeon (relative to a neurological surgeon, OR: 1.54) ( P < 0.0001 for each). There was no statistically significant difference in 5-year survival to further cervical spine surgery between CDA and ACDF at 5 years (97.6% vs. 97.7%, P = 0.4249)., Conclusions: Although the use of CDA relative to ACDF rose from 2010 to 2018, its use has subsequently plateaued between 2018 and 2021 and remained a relatively low percentage of the single-level anterior cervical surgeries performed (14.47% in 2021). The causes for such changes in the trend are unclear., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background Context: Lumbar discectomy is a common procedure following which emergency department (ED) visits may occur. Although many quality improvement initiatives target reemissions, ED visits may be more common, be a marker of quality of care, affect patient satisfaction, and contribute to health-care resource utilization and costs., Purpose: To analyze the timing and risk factors predicting ED utilization following lumbar discectomy and thereby facilitate better-targeted risk reduction., Study Design/setting: Retrospective database review of the 2010 to April 30th, 2021, M157Ortho PearlDiver dataset., Patient Sample: Single-level lumbar laminotomy/discectomy between 2010 and April 30th, 2021, in the PearlDiver M157Ortho dataset., Outcome Measures: Functional measures-ED utilization in the 90 days following lumbar discectomy, patient-level predictors for ED utilization, and number and type of reoperations performed in the 90 days following lumbar discectomy., Methods: Lumbar laminotomies/discectomies were identified. Patients were excluded if additional procedures were performed or if there was not 90-day follow-up in the dataset. Patient factors were extracted, including age, sex, Elixhauser comorbidity index (ECI), region of the country in which their procedure was performed (Midwest, Northeast, South, West), and patient insurance plan (Commercial, Medicaid, Medicare). The incidence, timing, and frequency of ED utilization within 90 days of lumbar discectomy were then determined. Cohort average weekly ED utilization at 1-year postoperatively was calculated as a baseline for reference. Patient factors predictive of postoperative ED utilization were then determined with univariate and multivariate analyses. Primary diagnoses for ED visits were also categorized. Patients who underwent reoperation for complications related to lumbar discectomy following ED visits were determined, and types of reoperation procedures were characterized., Results: Of 281,103 lumbar discectomy patients identified, ED visits within 90 days of surgery were identified for 28,632 (10.2%). Of note, 40.4% of these ED visits occurred in the first 2 postoperative weeks. Multivariate analysis revealed several independent predictors of ED utilization following lumbar discectomy, including: younger age (odds ratio [OR] 1.21 per decade decrease), female sex (OR 1.12 relative to male), higher ECI (OR 1.42 per 2-point increase), having surgery performed in the Northeast, Midwest, or West United States (OR 1.05, 1.17, and 1.13, respectively, relative to South), and Medicaid coverage (OR 1.89 relative to Medicare). Forty-three percent of ED visits were surgical site related, of which surgical site pain predominated at 34.2% of overall reasons. Of patients who visited the ED, 943 (3.3%) underwent reoperation in the subsequent 2 weeks. Laminectomy with nerve root decompression was the most performed reoperation (30.9%), followed by incision and drainage (22.5%), posterior nonsegmental instrumentation (10.3%), laminectomy facetectomy and foraminotomy (9.97%), repair of dural/CSF leak or pseudomeningocele with laminectomy (9.3%), repair of dural/CSF leak not requiring laminectomy (8.9%), arthrodesis (4.3%), and posterior segmental instrumentation (3.9%)., Conclusions: Following lumbar discectomy, over 1 in 10 patients were found to visit the ED in the 90 days following their surgery, most commonly in the first 2 postoperative weeks. Specific patient characteristics were associated with such ED visits, with the most common primary diagnoses among ED visitors being surgical site pain. About 3.3% of patients who visited the ED underwent reoperation in the subsequent 2 weeks. Through identification of the timing, risk factors, primary reasons for, and risk of reoperation following ED utilization in the 90-day period after lumbar discectomy, care pathways can be modified to improve patient satisfaction, outcomes, and reduce excess health-care expenditures., Competing Interests: Declarations of Competing Interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Total ankle replacement (TAR) surgery has increased in recent decades. The aim of this study was to investigate the evolving burden of revision surgery and risk factors and timing of revision or explant., Methods: Using the 2010 to 2020 PearlDiver M151Ortho data set, this retrospective cohort study identified primary TAR, TAR revision, and TAR explant patients via Current Procedural Terminology ( CPT ) and International Classification of Disease Procedural ( ICD-P ) codes. This database contains billing claims information across all payers and sites of care in the United States. Patient factors investigated included age, sex, and Elixhauser Comorbidity Index (ECI). Annual incidence for primary TAR was normalized per 100 000 covered lives in the data set for each year of study and recorded. Annual incidence of revision TAR and explant were normalized per 100 TARs performed for each year of study. Multivariate logistic regression analyses were performed to determine independent risk factors for revision TAR or explant. For explants, the eventual intervention by 2 years was analyzed. Ten-year timing and survival to revision or explant surgery following unilateral TAR were characterized., Results: A total of 10 531 primary, 1218 revision, and 1735 explant TARs were identified. After normalization, TAR utilization increased by 284% from 2010 to 2020, annual TAR revisions rose 28%, and annual TAR explants decreased 65%. Independent predictors of revision TAR were younger age (odds ratio [OR] 1.29 per decade decrease) and higher ECI (OR 1.23 per 2-point increase). Independent predictors of explant included younger age (OR 1.80 per decade decrease), female sex (OR 1.17), and higher ECI (OR 1.35 per 2-point increase). The 10-year implant survival rate was 91.8%, of which 73% of revisions and 83% of explants occurred in the first 3 years following index TAR., Conclusion: TAR utilization has grown substantially over the past decade, with minimal increases in the annual rate of revision surgery with respect to index procedures performed., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online., (© The Author(s) 2023.)

Study Design: A retrospective cohort study using the 2010-2020 MSpine PearlDiver administrative data set., Objective: To compare perioperative adverse events and five-year revisions for single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical foraminotomy (PCF)., Summary of Background Data: Cervical disk disease can often be treated surgically using single-level ACDF or PCF. Prior studies have suggested that posterior approaches provide similar short-term outcomes as ACDF; however, posterior procedures may have an increased risk of revision surgery., Materials and Methods: The database was queried for patients undergoing elective single-level ACDF or PCF (excluding cases performed for myelopathy, trauma, neoplasm, and/or infection). Outcomes, including specific complications, readmission, and reoperations, were assessed. Multivariable logistic regression was used to ascertain odds ratios (OR) of 90-day adverse events controlling for age, sex, and comorbidities. Kaplan-Meier survival analysis was performed to determine five-year rates of cervical reoperation in the ACDF and PCF cohorts., Results: A total of 31,953 patients treated by ACDF (29,958, 93.76%) or PCF (1995, 6.24%) were identified. Multivariable analysis, controlling for age, sex, and comorbidities, demonstrated that PCF was associated with significantly greater odds of aggregated serious adverse events (OR 2.17, P <0.001), wound dehiscence (OR 5.89, P <0.001), surgical site infection (OR 3.66, P <0.001), and pulmonary embolism (OR 1.72, P =0.04). However, PCF was associated with significantly lower odds of readmission (OR 0.32, P <0.001), dysphagia (OR 0.44, P <0.001), and pneumonia (OR 0.50, P =0.004). At five years, PCF cases had a significantly higher cumulative revision rate compared with ACDF cases (19.0% vs. 14.8%, P <0.001)., Conclusions: The current study is the largest to date to compare short-term adverse events and five-year revision rates between single-level ACDF and PCF for nonmyelopathy elective cases. Perioperative adverse events differed by procedure, and it was notable that the incidence of cumulative revisions was higher for PCF. These findings can be used in decision-making when there is clinical equipoise between ACDF and PCF., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Spinal fusion is a common procedure for which bone grafting is a critical component. Although iliac crest (separate incision autograft) is typically referred to as the "gold standard" grafting material, it seems to be used less and less frequently., Methods: The 2010 to Q3 2020 MSpine PearlDiver data set was used to identify patients receiving separate incision autograft versus local autograft/allograft/graft supplement for spinal fusion. Grafting trends over the decade were determined. Patient age, sex, Elixhauser Comorbidity Index, smoking status, insurance plan, region of the country where the surgery was conducted, and surgeon specialty were characterized and compared by the type of bone graft using univariate and multivariate analyses., Results: Of 373,569 spinal bone grafting procedures, separate incision autografts were used for 32,401 (8.67%). A gradual decline was observed from 2010 (10.57% of spinal grafting procedures) to 2020 (4.69%, P -value < 0.00001). Independent predictors of having had a separate incision autograft in order of decreasing odds included surgeon specialty (relative to neurosurgery, orthopaedic odds ratio [OR], 2.45), smoking status (relative to nonsmokers, smokers OR, 1.45), region of the country (relative to Midwest, Northeast OR, 1.11; West OR, 1.42; and South OR, 1.48), insurance (relative to commercial, Medicare OR, 1.14), younger age (OR, 1.04 per decade increase), and lower Elixhauser Comorbidity Index (OR, 0.95 per two-point increase) ( P < 0.0001 for each)., Conclusion: Iliac crest autograft continues to be referred to as the gold standard grafting material for spine fusions. However, the use of this has faded over the past decade to only 4.69% of spinal fusions in 2020. While some patient factors had an effect on when separate incision autograft was used, nonsurgical factors, including surgeon specialty, geographic region where the surgery was conducted, and insurance factors, suggested that external factors/physician training influence this choice., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Background: Geriatric hip fractures are common and associated with high morbidity and mortality. This study aimed to evaluate the incidence, timing, and risk factors of contralateral hip fracture after initial hip fracture., Methods: Initial hip fractures in patients older than 65 years were abstracted from the national, administrative M91Ortho PearlDiver data set. Incidence and timing of contralateral hip fractures in the following 10 years were identified. Kaplan-Meier survival analysis until contralateral hip fracture was conducted. To account for patient mortality over the later years, 2-year univariate and multivariate analyses were used to determine factors predictive of contralateral hip fracture., Results: Of the initial 104,311 hip fractures identified, contralateral hip fracture in the 10 years that followed was identified for 7,186 (6.9%), of which 68.4% occurred in the first 2 years. Kaplan-Meier survival analysis until contralateral fracture revealed the 10-year incidence to be 12.9% when controlling for those lost from the data set during the study period. Multivariate logistic regression revealed independent predictors of contralateral hip fracture in the 2 years after index hip fracture, when the incidence was greatest, to be female sex (odds ratio [OR] 1.15), body mass index < 20 (OR 1.30), and percutaneous pinning surgery for initial hip fracture fixation (OR 1.58) (P < 0.0001 for each)., Conclusions: In a national cohort of 104,311 geriatric hip fractures, Kaplan-Meier analysis for contralateral hip fracture found the 10-year incidence to be 12.9%, of which nearly 70% were in the first 2 years, and predisposing factors were defined. As such, future research should aim to identify the cause and mitigate the risk of secondary contralateral hip fractures in geriatric patients., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background Context: Lumbar discectomy is a common procedure for which patients with rheumatoid arthritis (RA) may be considered. RA is an autoinflammatory disease that may predispose patients to postoperative adverse outcomes., Purpose: To assess the relative odds of adverse events after lumbar discectomy for those with versus without RA in a large, national, administrative dataset., Study Design/setting: Retrospective cohort study using the 2010 to 2020 MSpine PearlDiver dataset., Patient Sample: After exclusion of patients under 18 years old, those with any trauma, neoplasm, or infection diagnosis within the month before lumbar discectomy, and any patients who had any alternative lumbar spinal surgery performed on the same day as lumbar discectomy, we identified 36,479 lumbar discectomy patients. 2,937 (8.1%) of these patients had a prior diagnosis of RA. After matching 4:1 by patient age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated via ICD-9 and 10 diagnosis codes), 8,485 lumbar discectomy patients without RA and 2,149 with RA were included., Outcome Measures: Incidence of severe and minor adverse events in the 90-days following lumbar discectomy, predictive factors for adverse events within 90-days of lumbar discectomy, risk of adverse events within 90-days of lumbar discectomy stratified by patient medication regimen, 5-year survival to reoperation following lumbar discectomy., Methods: Patients undergoing lumbar discectomy were identified from the PearlDiver MSpine dataset. The subset of those with versus without RA were identified and matched 1:4 based on patient age, sex, and ECI scores. The incidence of 90-day adverse events in the two groups was determined and compared by univariate and multivariate analyses. Subgroup analysis was performed based on RA medications being taken., Results: Matched lumbar discectomy patients with RA (n=2,149) and without RA (n=8,485) were identified. Controlling for patient age, sex, and ECI, those with RA were at significantly higher odds of any (odds ratio [OR] 3.30), severe (OR 2.78), and minor (OR 3.30) adverse events (p<.0001 for all). Stratifying by medications being taken (and relative to those without RA), there was increasing odds of all adverse events (AAE) based on potency of medications (no biologic or disease modifying antirheumatic drugs [DMARDs] OR 2.33, DMARDs only OR 3.86, biologic±DMARDs OR 5.69 (p<.0001 for all). Despite this, no statistically significant difference in 5-year survival from subsequent lumbar surgery was found between those with versus without RA (p=.1000)., Conclusions: Lumbar discectomy patients with RA were found to be at significantly higher risk for 90-day adverse events following lumbar discectomy, and this was incrementally greater for those on increasingly suppressive medications. Lumbar discectomy patients with RA bear specific consideration and perioperative monitoring when considered for lumbar discectomy., Competing Interests: Declarations of Competing Interests One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Total knee arthroplasty (TKA) is a common procedure for late-stage degenerative changes, a situation for which magnetic resonance imaging (MRI) is typically not considered useful. In an era attempting to contain healthcare expenditures, the rate, timing, and predictors for MRI before TKA were assessed in a large, national, administrative data set., Methods: The 2010 to Q3 2020 MKnee PearlDiver data set was used to identify patients undergoing TKA for osteoarthritis. Those with lower extremity MRI for knee indications within 1 year before TKA were then defined. Patient age, sex, Elixhauser Comorbidity Index, region in the country, and insurance plan were characterized. Predictors of having had an MRI were assessed by univariate and multivariate analyses. The costs and timing of the obtained MRIs were also assessed., Results: Of 731,066 TKAs, MRI was obtained within 1 year prior for 56,180 (7.68%) with 28,963 (51.9%) within the 3 months of TKA. Independent predictors of having had an MRI included younger age (odds ratio [OR], 0.74 per decade increase), female sex (OR, 1.10), higher Elixhauser Comorbidity Index (OR, 1.15), region of the country (relative to South, Northeast OR, 1.08, West OR, 1.22, Midwest OR, 1.36), and insurance (relative to Medicare, Medicaid OR, 1.36 and Commercial OR, 1.35) with P < 0.0001 for each. The total cost of MRIs among patients who received a TKA is $44,686,308., Conclusion: Noting that TKA is typically done for advanced degenerative changes, MRI should rarely be indicated in the preoperative period for this procedure. Nonetheless, this study found that MRI was done within the year before TKA for 7.68% of the study cohort. In an era striving for evidence-based medicine, the almost $45 million dollars spent on MRI in the year before TKA may represent overutilization., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities., Methods: TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses., Results: Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each)., Discussion: In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately., Level of Evidence: Level III., Competing Interests: No conflicts of interest to report., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: Hip fracture surgery is associated with notable morbidity. Understanding the timing of adverse events can inform strategies for prevention and management. Owing to database limitations, many studies have limited postoperative follow-up to 30 days. However, adverse events may not have plateaued by this time. This study evaluated adverse events after hip fracture surgery out to 90 days., Methods: Hip fracture surgeries in patients 65 years or older were identified in the 2010 to 2020 Q3 M91Ortho PearlDiver data set using administrative codes. The 90-day incidence and time of diagnosis of 10 common adverse events were determined and used to calculate median, interquartile range, and middle 80% for time of diagnosis. The number of events occurring before and after 30 days was also determined., Results: A total of 258,834 hip fracture surgery patients were identified. On average, 70% of adverse events occurred in postoperative days 0 to 30 and 30% occurred in days 31 to 90. The percentage of events in days 31 to 90 ranged from 8% (transfusion) to 42% (wound dehiscence). Compared with patients with a 0- to 30-day adverse event, those with 31- to 90-day adverse events had higher average Elixhauser Comorbidity Index scores (8.6 vs. 7.8, P < 0.001) and a slightly greater proportion of men (31.5% vs. 30.2%, P < 0.001).For specific adverse events, the time of diagnosis (median; interquartile range; middle 80%) were as follows: transfusion (2 days; 1 to 4 days; 1 to 24 days), acute kidney injury (5; 2 to 26; 1 to 55), cardiac event (9; 3 to 35; 1 to 64), urinary tract infection (13; 3 to 39; 1 to 65), hematoma (14; 6 to 28; 3 to 52), pneumonia (15; 5 to 39; 2 to 66), venous thromboembolism (16; 5 to 40; 2 to 64), surgical site infection (23; 14 to 37; 7 to 56), sepsis (24; 9 to 48; 3 to 71), and wound dehiscence (26; 15 to 41; 7 to 64)., Discussion: Nearly one-third of 90-day adverse events after hip fracture surgery were found to occur after postoperative day 30. An understanding of the timing of adverse events is important for improving patient counseling and optimizing patient care., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Introduction: Emergency department (ED) visits after orthopaedic procedures such as ankle fracture open reduction and internal fixation (ORIF) have received less attention than other outcomes. This study analyzed 90-day ED visits after ankle fracture surgery in a national database to better characterize the incidence, timing, risk factors, and reasons., Methods: Ankle fractures undergoing ORIF were extracted from the PearlDiver M91Ortho 2010 to 2020Q3 data set. Patients were excluded for age younger than 18 years, presence of concomitant fractures, and <90 days of database follow-up. Patient age, sex, Elixhauser Comorbidity Index score, region of the country, and insurance plan were analyzed as predictors for 90-day ED utilization using multivariate logistic regression. Incidence of readmissions and incidence, timing, risk factors, and reasons for ED visits were determined., Results: Of 87,662 ankle fracture ORIF patients identified, ED visits were noted within 90 days of surgery for 10,087 (11.5%) while 4,030 (4.6%) were readmitted. One ED visit was noted for 6,102 patients, two visits for 2,654, three visits for 787, and more than three visits for 544. The greatest weekly incidence of ED visits was observed in weeks 1 and 2, with 2.9% and 3.1% of the entire cohort visiting in each week respectively. Factors independently associated with 90-day ED utilization included younger age (odds ratio [OR] 1.21 per decade decrease, P < 0.001), greater Elixhauser Comorbidity Index score (OR 1.40 per two-point increase, P < 0.001), and Medicaid insurance (OR 1.92, P < 0.001). In the first two postoperative weeks, 71% of ED visits were attributed to issues directly involving the surgical site while in subsequent weeks, most visits did not involve the surgical site (65%)., Discussion: Many patients visit the ED after ankle fracture surgery. The greatest ED utilization was during the first two postoperative weeks, and reasons for visits were defined. These findings have implications for optimizing care pathways and targeting resource allocation., (Copyright © 2022 by the American Academy of Orthopaedic Surgeons.)

Background: Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations., Methods: TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization., Results: Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits).Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239)., Conclusion: Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Philip P. Ratnasamy, BS, reports grants or contracts from National Institutes of Health Award 2T35HL007649-36. ICMJE forms for all authors are available online., (© The Author(s) 2022.)

Study Design: A descriptive epidemiologic study., Objective: To analyze trends and patient characteristics for lumbosacral transforaminal and interlaminar/caudal epidural injection utilization over time., Background: Lumbosacral transforaminal and interlaminar/caudal epidural injections are considered for varying lumbar pathologies. Reported studies, physician practices, insurance authorization, and other factors may influence utilization patterns over time., Methods: Patients undergoing lumbosacral transforaminal and interlaminar/caudal epidural injections between 2010 and 2019 were identified in the M91Ortho PearlDiver database based on Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index (ECI), insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, West) were assessed and tracked over the years studied based on prevalence per 100,000 covered lives., Results: Lumbosacral transforaminal and interlaminar/caudal epidural injections were identified for 426,039 and 501,228 patients, respectively. The number of injections performed per year decreased over the years studied: for transforaminal injections from 160.81 to 76.36 per 100,000 patients and for interlaminar/caudal injections from 200.53 to 77.56 per 100,000 patients. The decrease in overall injections was greatest for those with Commercial and Medicare coverage (53.40% and 66.50%, respectively), with a smaller drop amongst those with Medicaid coverage (32.39%).Over the years, the average patient undergoing injection was older and there was a relative shift toward transforaminal injections ( P <0.05 for both). In terms of specialty of those performing the injections, they were mostly performed by Anesthesiology specialists (who performed less transforaminal than interlaminar/caudal injections)., Conclusion: Lumbosacral transforaminal and interlaminar/caudal spinal epidural injections were shown to decrease by 52.37% per 100,000 patients from 2010 to 2019. Changing demographics of those undergoing such injections and practice patterns are important to consider in the picture of overall spine service utilization. Variations in injection utilization trends by patient insurance raise questions regarding disparities in care., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration., Methods: This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits., Results: Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) ( P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem., Conclusion: Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Philip P. Ratnasamy, BS, reports grants or contracts from the National Institutes of Health (Award 2T35HL007649-36). ICMJE forms for all authors are available online., (© The Author(s) 2022.)