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During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76–0.92; P P =.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [ Orthopedics . 202x;4x(x):xx–xx.]

Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts.The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI.A retrospective cohort study.Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases.Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality.Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/mIn total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI18.5 kg/mUnderweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.

Obesity and diabetes have independently been shown to predispose to adverse outcomes after total hip arthroplasty (THA). These may have a coupled effect on perioperative risks. The purpose of this study was to evaluate the effect of body mass index (BMI) on adverse outcomes in nondiabetic (ND), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients.Patients undergoing primary THA were selected from the National Surgical Quality Improvement Program Database from 2012 to 2016 and categorized as ND, NIDDM, and IDDM. BMI, demographics, and 30-day perioperative outcomes were assessed for each group. Multivariate logistic regressions controlling for demographics, functional status, and American Society of Anesthesiologists were used to determine the odds ratio of serious adverse event (SAE) in each diabetes group for patients with BMI ≥ 40 kg/m compared with a control group of ND patients with a normal BMI (18.5 to 24.9 kg/m).A total of 108,177 patients were included. The results demonstrate that ND (odds ratio 1.65; P0.001) and NIDDM (odds ratio 1.75; P = 0.007) patients have similar risks of SAE, whereas IDDM (odds ratio 2.79; P0.001) patients have a greater risk of adverse events, particularly at BMIs greater than 40 kg/m.Consistent with previous reports, ND (odds ratio 1.65; P0.001) and NIDDM (odds ratio 1.75; P = 0.007) morbidly obese patients (BMI40 kg/m) had an increased odds of SAEs after THA, but for IDDM (odds ratio 2.79; P0.001) patients this increased odds was notably higher. Although patients with IDDM have increased rates of adverse events compared with ND and NIDDM patients, these findings should not be used to establish strict BMI cutoffs in patients with IDDM. Nonetheless, the results suggest additional factors, such as patient medical history and diabetes control, should be considered when evaluating patients with IDDM for THA.Level III.

BACKGROUND CONTEXT Past studies have focused on the association of high body mass index (BMI) on spine surgery outcomes. These investigations have reported mixed conclusions, possible due to insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (e.g. underweight, overweight, and obese). Few studies have considered outcomes of patients with low BMI. PURPOSE To analyze how anterior cervical spine surgery outcomes track with World Health Organization categories of BMI to better assess where along the BMI spectrum patients are at risk for adverse perioperative outcomes. DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Patients undergoing elective anterior cervical spine surgery were abstracted from the 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program database. OUTCOME MEASURES Thirty-day adverse events, hospital readmissions, postoperative infections, and mortality. METHODS Patients undergoing anterior cervical spine procedures (anterior cervical discectomy and fusion, anterior cervical corpectomy, cervical arthroplasty) were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Patients were then aggregated into modified World Health Organization categories of BMI. Odds ratios of adverse outcomes, normalized to average risk of normal weight subjects (BMI 18.5–24.9 kg/m2), were calculated. Multivariate analyses were then performed on aggregated adverse outcome categories controlling for demographics (age, sex, functional status) and overall health as measured by the American Society of Anesthesiologists classification. RESULTS In total, 51,149 anterior cervical surgery patients met inclusion criteria. Multivariate analyses revealed the odds of any adverse event to be significantly elevated for underweight and super morbidly obese patients (Odds Ratios [OR] of 1.62 and 1.55, respectively). Additionally, underweight patients had elevated odds of serious adverse events (OR=1.74) and postoperative infections (OR=1.75) and super morbidly obese patients had elevated odds of minor adverse events (OR=1.72). Relative to normal BMI patients, there was no significant elevation for any adverse outcomes for any of the other overweight/obese categories, in fact some had reduced odds of various adverse outcomes. CONCLUSIONS Underweight and super morbidly obese patients have the greatest odds of adverse outcomes after anterior cervical spine surgery. The current study identifies underweight patients as an at-risk population that has previously not received significant focus. Physicians and healthcare systems should give additional consideration to this population, as they often already do for those at the other end of the BMI spectrum.

Background: It remains unknown whether access to elite blind sports opportunities is globally balanced or matches the prevalence of blindness/visual impairment (VI). The primary objective of this study was to determine the rate of elite blind sports participation in each world region registered in the International Blind Sports Federation’s (IBSA) and to assess its association with the global and regional prevalence of blindness/VI. The secondary objective was to determine the association between other covariates, such as age, vision class, and sex, with the number of IBSA-registered athletes from each region. Methods: A baseline estimate of blindness/VI data was established and used when comparing participation rates to blindness/VI rates. Descriptive statistics were used to describe sports participation and associated co-variates. Results: Among 123 member countries registered in IBSA, 31 did not have any completed registrations in blind sports, of which 22 had a prevalence of blindness/VI higher than the global average. During the summer season 2019, 738 (29.52%) IBSA athletes were female and 1762 (70.48%) were male. Conclusions: These results suggest elite blind/VI sport participation is limited independently from blindness/VI prevalence. Increasing blind-friendly sport resources, especially in low-and-middle-income countries (LMICs), would improve the rate of elite sport participation among athletes with blindness/VI.

Pedicle screws are commonly placed with lumbar/lumbosacral fusions. Triggered electromyography (tEMG), which employs the application of electrical current between the screw and a complementary anode to determine thresholds of conduction, may be utilized to confirm the safe placement of such implants. While previous research has established clinical thresholds associated with safe screw placement, there is variability in clinical practice of anode placement which could lead to unreliable measurements.To determine the variance in pedicle screw stimulation thresholds when using four unique anode locations (ipsilateral/contralateral and paraspinal/gluteal relative to tested pedicle screws).Prospective cohort study. Tertiary medical center.Twenty patients undergoing lumbar/lumbosacral fusion with pedicle screws using tEMG OUTCOME MEASURES: tEMG stimulation return values are used to assess varied anode locations and reproducibility based on anode placement.Measurements were assessed across node placement in ipsilateral/contralateral and paraspinal/gluteal locations relative to the screw being assessed. RA total of 94 lumbosacral pedicle screws from 20 patients were assessed. Repeatability was verified using two stimulations at each location for a subset of the screws with an RThe current study, a first-of-its-kind formal evaluation of anode location for pedicle screw tEMG testing, demonstrated very strong repeatability and strong correlation with different locations of anode placement. These results suggest that there is no need to change the side of the anode for testing of left versus right screws, further supporting that placing an anode electrode into gluteal muscle is sufficient and will avoid a sharp ground needle in the surgical field.

Historic and present-day marginalization has resulted in a high burden of disease and worse health outcomes for American Indian and Alaska Native (AI/AN) communities in the United States. Musculoskeletal disease is the leading cause of disability for the general population in the U.S. today. However, few have examined musculoskeletal disease burden and access to orthopaedic surgical care in the AI/AN communities. A high prevalence of hip dysplasia, arthritis, back pain, and diabetes, and a high incidence of trauma and road traffic-related mortality, suggest a disproportionately high burden of musculoskeletal pathology among the AI/AN communities and a substantial need for orthopaedic surgical services. Unfortunately, AI/AN patients face many barriers to receiving specialty care, including long travel distances and limited transportation to health facilities, inadequate staff and resources at Indian Health Service (IHS)-funded facilities, insufficient funding for referral to specialists outside of the IHS network, and sociocultural barriers that complicate health-system navigation and erode trust between patients and providers. For those who manage to access orthopaedic surgery, AI/AN patients face worse outcomes and more complications than White patients. There is an urgent need for orthopaedic surgeons to participate in improving the availability of quality orthopaedic services for AI/AN patients through training and support of local providers, volunteerism, advocating for a greater investment in the IHS Purchased/Referred Care program, expanding telemedicine capabilities, and supporting community-based participatory research activities.

Previous studies about osteosarcoma patient characteristics, management, and outcomes have limited patient numbers, combine varied tumor types, and/or are older studies.Patients with osteosarcoma from the 2004 to 2015 National Cancer Database data sets were separated into axial, appendicular, and other. Demographic and treatment data as well as 1-, 5-, and 10-year survival were determined for each group. A multivariate Cox analysis of patient variables with the likelihood of death was performed, and the Kaplan Meier survival curves were generated.Four thousand four hundred thirty patients with osteosarcoma (3,435 appendicular, 810 axial, and 185 other) showed survival at 1-year, 5-year, and 10-year and was highest among the appendicular cohort (91.17%, 64.43%, and 58.58%, respectively). No change in survival was seen over the periods studied. The likelihood of death was greater with increasing age category, distant metastases, and treatment with radiation alone but less with appendicular primary site, treatment with surgery alone, or surgery plus chemotherapy.Despite advances in tumor management, surgical excision remains the best predictor of survival for osteosarcomas. No difference was observed in patient survival from 2004 to 2015 and, as would be expected, distant metastases were a poor prognostic sign, as was increasing age, male sex, and axial location.

Introduction Chondrosarcoma, although relatively uncommon, represents a significant percentage of primary osseous tumors. Nonetheless, there are few large-cohort, longitudinal studies of long-term survival and treatment outcomes of chondrosarcoma patients and none using the National Cancer Database (NCDB). Methods Chondrosarcoma patients were identified from the 2004–2015 NCDB datasets and divided on three primary tumor sites: appendicular, axial, and other. Demographic, treatment, and long-term survival data were determined for each group. Multivariate Cox analysis and Kaplan-Meier survival curves were generated to assess long-term survival over time for each. Results In total, 5,329 chondrosarcoma patients were identified, of which 2,686 were appendicular and 1,616 were axial. Survival was higher among the appendicular cohort than axial at 1-year, 5-year, and 10-year (89.52%, 75.76%, and 65.24%, respectively). Multivariate Cox analysis identified patients in the appendicular cohort to have significantly greater likelihood of death with increasing age category, distant metastases at presentation, and male sex (p Conclusions For both appendicular and axial chondrosarcomas, surgical treatment remains the mainstay of treatment due to its continued superiority for the long-term survival of patients, although advancements in survival over the last decade have been insignificant. Presence of distant metastases and axial involvement are significant, poor prognostic factors perhaps because of difficulty in surgical excision or extent of disease.

Persistent global disparities in maternal and neonatal outcomes exist, in part, due to a lack of access to safe surgery. This commentary examines the relative need for increased focus on access to safe maternal and pediatric surgery globally, starting with a focus on cost-effective surgeries. There is a need to understand context-specific surgeries for regions, including understanding regional versus tertiary development. Most important is a need to understand the crucial role of supply chain management (SCM) in developing better access to maternal and pediatric surgery in limited resource settings. We evaluate the role of SCM in global surgery and global health, and the current landscape of inefficiency. We outline specific findings and takeaways from recent solutions developed in pediatric and maternal surgery to address SCM inefficiencies. We then examine the applicability to other settings and look at the future. Our goal is to summarize the challenges that exist today in a global setting to provide better access to maternal and pediatric surgery and outline solutions relying on structural, SCM-related framework. Key words: • Pediatric surgery • Neonatal outcomes • Supply-chain management • Limited resource settings Copyright © 2020 Navarro 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 work is properly cited.

With the increasing medical complexity of patients undergoing posterior lumbar surgery, more patients are pharmacologically immunosuppressed to manage chronic conditions. The effects of immunosuppression have become of greater interest across multiple surgical specialties. The goal of the current study was to investigate whether long-term corticosteroid use is independently associated with perioperative adverse outcomes among patients undergoing posterior lumbar surgery. Patients who underwent elective posterior lumbar spine surgery (decompression and/or fusion) were identified in the 2005–2016 National Surgical Quality Improvement Program (NSQIP) database. Patient factors, surgical factors, and 30-day perioperative outcomes for patients taking long-term corticosteroids were compared with those for patients who were not taking these drugs. Propensity matching and multivariate analysis were used to evaluate comparable patients while controlling for potentially confounding variables. In total, 140,519 patients undergoing posterior lumbar spine surgery were identified. Of these, 5243 (3.73%) were taking corticosteroids. After propensity matching and controlling for age, sex, body mass index, functional status, American Society of Anesthesiologists class, and surgical procedure, those taking corticosteroids were at greater risk for any adverse event (odds ratio, 1.45), a serious adverse event (odds ratio, 1.57), a minor adverse event (odds ratio, 1.47), infection (odds ratio, 1.48), reoperation (odds ratio, 1.48), and readmission (odds ratio, 1.47) ( P ≤.001 for each). The findings confirmed that long-term corticosteroid use is associated with significant increases in perioperative adverse outcomes for patients undergoing elective posterior lumbar surgery, even with matching and controlling for potentially confounding variables. These findings can guide patient counseling and preemptive interventions before surgery for this patient population. [ Orthopedics . 2021;44(3):172–179.]

Background: Body Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery. Methods: Patients undergoing elective posterior cervical spine surgery were abstracted from the 2005–2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5–24.9 kg/m2). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health. Results: A total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI 50.0 kg/m2) for post-operative infection (OR = 1.54, p = 0.041). Conclusions: The current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.

Arthroplasty procedures are commonly performed and contribute to healthcare expenditures seen in the United States. Surgical team members may make selections among implants and materials without always knowing their relative cost. The current study reports on a survey aimed to investigate the perceptions of an academic group about the relative cost and value of commonly used operating room implants and materials related to joint arthroplasty cases using 10 matched pairs of items. Of the 124 persons eligible to take the survey, 102 responded (response rate of 82.3%) including attendings, fellows, residents, physician assistants (PAs), advanced practice registered nurses (APRNs) and registered nurses (RNs). On average for the ten pairs of items, the more expensive items were correctly selected by 90.2+/-13.9% (mean+/- standard deviation) of respondents with a range from 54.9% to 100%. Of note, the cost differences were significantly overestimated for 8/10 item pairs. The majority of respondents perceived the more expensive item as the item with the higher clinical value for 9/10 item pairs. Most arthroplasty attendings (91.3%) indicated willingness to use the less expensive item of two similar items. Nonetheless, 17.9% of fellows, residents, PAs, APRNs and RNs indicated that they would not feel comfortable suggesting using the less expensive item. Although attending arthroplasty surgeons stated a desire to consider costs, a knowledge deficit with regards to identifying the extent of cost differences was identified, and a significant portion of the surgical support team reported being hesitant to suggest less expensive options.

Case We present a clinical case and technique guide demonstrating the use and effectiveness of a novel, low-cost negative pressure wound therapy (NPWT) device to achieve soft-tissue coverage in a 34-year-old patient with failed rotational flap and Masquelet technique on infected tibial nonunion. Local debridement was executed, NPWT initiated, and treatment culminated with complete wound healing. Conclusion The "Turtle VAC" offers an effective low-cost alternative to commercially vacuum-assisted closure systems for post-traumatic wounds in low-resource setting of Haiti. Its use of available equipment makes NPWT accessible and can function as a bridge to definitive closure when primary wound closure is not possible and/or between debridement procedures.

Background Preoperative laboratory studies are often obtained as part of the workup for surgeries such as total hip arthroplasty (THA). An increasing need exists to be able to identify patients at risk for adverse outcomes. Thus, metrics that correlate with postoperative adverse events and readmissions are increasingly important to optimize patient care. The implications of varying abnormal platelet counts, especially on the high end of the spectrum, have yet to be assessed in large, multicenter patient populations. This study aims to risk stratify THA patients with varying preoperative platelet counts to address these questions. The purposes of this study were to (1) evaluate cutoffs for normal versus abnormal platelet counts for patients undergoing THA by using postoperative complications data and (2) assess the correlation of such values with readmission data using the National Surgical Quality Improvement Program database. Methods Patients who underwent elective primary THA were identified in the 2011 to 2015 National Surgical Quality Improvement Program database. Risk of 30-day perioperative complications was calculated as a function of preoperative platelet counts. Based on the risk criteria, patients were categorized into the following three groups: normal platelet counts, abnormally low platelet counts, and abnormally high platelet counts. Multivariate analyses were performed to compare 30-day postoperative complications, readmissions, surgical time, and length of hospital stay between these populations. Results The current study identified 86,845 THA patients. Using the relative risk threshold of 1.5, platelets counts were divided into abnormally low (≤142,000/mL) and abnormally high (≥417,000/mL) categories. Higher rates of any, major, and minor adverse events and hospital readmission were associated with both the abnormally low and high platelet cohorts. Conclusion This study suggests that preoperative high, as well as low, platelet counts are correlated with perioperative complications after THA, including hospital readmissions. Patients with these laboratory findings warrant further attention with possible preoperative and postoperative optimization.

IntroductionPrevious studies have shown that putative pheromones 4,16-androstadien-3-one (AND) and estra-1,3,5(10),16-tetraen-3-ol (EST) cause activation in the preoptic area/anterior hypothalamus in men and women. Sex differences in neural activation patterns have been demonstrated when participants are subject to pheromone stimulation; however, whether other compounds give rise to similar neural activity has not been completely investigated.MethodsTwenty-nine young adults [16 female (21.3+/−0.54; mean yrs+/−SE), 13 male (22.85+/−0.42)] participated in a 3-block design, where participants were exposed to a scent (lavender), a synthetic male pheromone (4,16-androstadien-3b-ol; ALD), and a synthetic female pheromone (1,3,5(10),16-Estratetraen-3-ol; EST) via an automated olfactometer. Whole-brain, high-resolution (1.8mm3) functional MRI data from a Siemens Trio 3T MRI scanner were collected during all blocks. Five adults were excluded due to excessive movement. MANOVA analysis, a 2 × 3 multivariate model and analysis of 2×2 effects between sex and subsets of stimuli was done for activation over the whole brain and small volumes involved in olfaction.ResultsExploratory analysis of 2×2 effects between sex and subsets of stimuli exhibited significant interactions when assessing activations over the whole brain, and small volumes involved in olfaction. The left and right frontal poles (LFP, RFP) shows significant interaction when assessing sex with lavender and EST for whole brain analysis. For small volume analysis, the right orbitofrontal cortex (ROFC) exhibited a sex with lavender and ALD interaction, and a sex with lavender and EST interaction was observed in the left inferior frontal gyrus (LIFG). Main effects of sex, stimulus, or interaction show no differences analyzed using a 2 × 3 multivariate model.ConclusionThe study shows there is a sexually dimorphic response in the olfactory system to pheromones not previously studied. Scents like lavender do not have this same response. These distinct functional differences in activation patterns may be a result of neural development and maturation differences between sexes. Future studies should expand this pilot study and involve a younger demographic to accurately determine the age at which the olfactory response differentiates between males and females.

Purpose: Stationary training rollers enable wheelchair users to maintain physical health and train as athletes, which serves to treat and prevent immobility-associated chronic disease and improve cardiorespiratory fitness required for sports performance. However, conventional exercise equipment is largely inaccessible for persons with disabilities in low-resource areas, primarily due to cost. The aim of this study was to prototype, develop, and test a portable, cost-efficient stationary training device for wheelchair users in low-resource settings – The EasyRoller. Materials and methods: Stakeholder input from wheelchair athletes, trainers, and potential commercial manufacturers was solicited and utilized to conceptualize The EasyRoller design. The device was constructed from easily sourced, low cost components, following which it was user-tested with Para athletes. Feedback was analysed and incorporated into newer versions of the prototype. Results and conclusions: The EasyRoller creatively combines easily-sourced components to significantly cut down cost and ease both manufacture and repair for use in low-resource settings. The device is portable with a total weight of 34 pounds and total size of 42 linear inches while also affordable with a total cost of USD$199. Hereby, The EasyRoller has the potential to increase physical activity participation in populations with impairment who live in socioeconomically deprived world regions.

Purpose: Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common surgical procedure. This study assesses reasons and risk factors for readmission after DRF ORIF using the large sample size and follow-up of the American College of Surgeons National Surgical Quality Improvement Program database. Methods: Adult patients who underwent DRF ORIF were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Patient demographics, comorbidity status, hospital metrics, and 30-day perioperative outcomes were tabulated. Readmission, time to readmission, and reason for readmission were assessed. Reasons for readmission were categorized. Risk factors for readmission were assessed with multivariate analyses. Results: Of 11,124 patients who underwent DRF ORIF, 196 (1.76%) were readmitted within 30 days. Based on multivariate analysis, predictors of readmission (P < 0.05) were as follows: American Society of Anesthesiologist class > 3 (Odds ratio [OR] = 2.87), functionally dependent status (OR = 2.25), diabetes with insulin use (OR = 1.97), and staying in hospital after the index surgery (inpatient procedure, OR = 2.04). Readmissions occurred at approximately 14 days postoperatively. Of the recorded reasons for readmission after DRF ORIF, approximately one quarter were for surgical reasons, whereas over 75% of readmissions were for medical reasons unrelated to the surgery. Conclusion: This study found the rate of 30-day unplanned readmissions after DRF ORIF to be 1.76%. Demographic, comorbid, and perioperative factors predictive of readmission were defined. Most postoperative readmissions were for medical reasons unrelated to the surgical site and occurred at an average of approximately 2 weeks postoperatively. Multivariate analysis found that patients with increased American Society of Anesthesiologist class > 3, functional dependence, insulin-dependent diabetes, and those who underwent inpatient surgery for any reason were at a greater risk for readmission. Understanding these factors may aid in patient counseling and quality improvement initiatives, and this information should be used for risk stratification and risk adjustment of quality measures.

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensive interventions when possible. For wound care, an older but quite effective cleaning agent is Dakin’s solution (0.5% sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into a gallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution, placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United States is currently using Dakin’s solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, and effective treatment for post-surgical wound care for both resource-limited and non-resource strained environments. This report aims to update the current literature and encourage the consideration of Dakin’s solution for modern wound care.

Geriatric femoral neck fracture is a common injury for which hemiarthroplasty (HA) or total hip arthroplasty (THA) may be considered in select patients. As prior database studies comparing these have not used propensity matching, which is a robust statistical method of controlling for potentially confounding variables, unmatched and matched methodologies are contrasted in the present study.Patients aged ≥70 years who underwent HA or THA for hip fractures were identified from the 2012-2015 National Surgical Quality Improvement database. Propensity score 1:1 matching was performed. Differences in rates of 30-day postoperative adverse outcomes were compared using multivariate logistic regression for unmatched and matched cohorts.In total, 15,558 patients (14,403 HA and 1155 THA) were evaluated. Although multivariate outcomes for the unmatched populations were different for blood transfusion, mortality, minor adverse events, major adverse events, and reoperation, multivariate outcomes for matched populations only differed for blood transfusion (odds ratio 0.6 for HA vs THA, P.001). Of note, although readmissions were similar for the two groups, patients undergoing THA had a 5.4% greater rate of perioperative readmission due to dislocation.Geriatric patients undergoing HA and THA for hip fracture were compared with and without propensity matching. Once matching was performed, the only differences in outcomes between the two groups were a lower transfusion rate among the HA group and a greater readmission rate due to dislocation among the THA group. This suggests that either procedure can be safely considered if found to be advantageous from a longer-term outcome perspective.Level III, retrospective comparative study.

Background Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion). Methods Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts. Results In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events. Conclusion The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion. Summary Sentence Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.The present study uses a large, national sample with 30-day follow-up to investigate dialysis as risk factor for perioperative complications independent of patient demographics or comorbidities.This is a retrospective cohort study.Patients undergoing elective spine surgery with or without dialysis from the 2005-2015 National Surgical Quality Improvement Program (NSQIP) database were included in the study.Postoperative complications within 30 days and binomial reoperation, readmission, and mortality within 30 days were determined.The 2005-2015 NSQIP databases were queried for adult dialysis-dependent and dialysis-independent patients undergoing elective spinal surgery. Differences in 30-day outcomes were compared using risk-adjusted multivariate regression and coarsened exact matching analysis for adverse events, unplanned readmission, reoperation, and mortality. The percentage of complications occurring before versus after hospital discharge was also assessed. The authors have no financial disclosures related to the present study.A total of 467 dialysis and 173,311 non-dialysis patients met the inclusion criteria. Controlling for age, gender, body mass index, functional status, and American Society of Anesthesiologists (ASA) class, dialysis patients were found to be at significantly greater odds of any adverse event (odds ratio [OR]=2.52 before, 2.17 after matching, p=.001), major adverse event (OR=2.90 before, 2.52 after matching, p=.001), and minor adverse event (OR=1.50 before matching, p=.025, but not significantly different after matching). Further, dialysis patients were significantly more likely to return to the operating room (OR=2.77 before, 2.50 after matching, p=.001), have unplanned readmissions (OR=2.73 before, 2.37 after matching, p=.001), and die within 30 days (OR=3.77 before, 2.71 after matching, p=.001). Adverse events occurred after discharge for 51.78% of non-dialysis patients and for 43.80% of dialysis patients.Dialysis patients undergoing elective spine surgery are at significantly higher risk of aggregated adverse outcomes, return to the operating room, readmission, and death than non-dialysis patients, even after controlling for patient demographics and overall health (as indicated by ASA class). These differences need to be considered when determining treatment options. Additionally, with bundled payments expected in spine surgery, physicians and hospitals need to account for increased costs and liabilities when working with dialysis patients.

Background While deaths, hospitalizations, and emergency department visits for head trauma are well understood, little is known about presentations in outpatient settings. Our objective was to examine the epidemiology and extent of healthcare-seeking adult (18-64 years) head trauma patients presenting in outpatient settings compared with patients receiving nonhospitalized emergency department care. Methods We used 2004-2013 MarketScan Medicaid/commercial claims to identify head trauma patients managed in outpatient settings (primary care provider, urgent care) and the emergency department. We examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, and extent of and reasons for postindex visit ambulatory care use within 30/90/180 days by index visit location, as well as annual and monthly variations in head trauma trends. We used outpatient incidence rates to estimate the US nationwide outpatient burden. Results A total of 1.19 million index outpatient visits were included (emergency department: 348,659). Nationwide, they represented a weighted annual burden of 1.16 million index outpatient cases. These encompassed 46% of all known healthcare-seeking head trauma in 2013 (outpatient/emergency department/inpatient/fatalities) and increased in magnitude (+31%) from 2004 to 2013. One fourth (27%) of office/clinic visits led to diagnosis with concussion on index presentation (urgent care: 32%). Distributions of demographic factors varied with index visit location while injury-specific factors were largely comparable. Subsequent visits reflected high demand for follow-up treatment, increased concussive diagnoses, and sequelae-associated care. Conclusions Adult outpatient presentations of head trauma remain poorly understood. The results of this study demonstrate the extensive magnitude of their occurrence and close association with need for follow-up care.

Aims The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip. Patients and Methods Patient aged > 60 years undergoing surgery for a hip fracture were identified in the 2016 National Surgical Quality Improvement Program (NSQIP) Hip Fracture Targeted Procedure Dataset. Analysis of the effect of restricted weight-bearing on adverse events, delirium, infection, transfusion, length of stay, return to the operating theatre, readmission and mortality within 30 days postoperatively were assessed. Multivariate regression analysis was used to adjust for confounding demographic, comorbid and procedural characteristics. Results Of the 4918 patients who met inclusion criteria, 3668 (63.53%) were allowed to weight-bear as tolerated postoperatively. Controlling for patient and procedural factors, multivariate odds of any adverse event, major adverse event, delirium, infection, transfusion, length of stay ≥ 75th percentile (six days) and mortality within 30 days were all higher in patients with weight-bearing restrictions. Notably, there were no differences for thromboembolic events, return to the operating theatre or readmission within 30 days between the groups. Conclusion Elderly patients with a fracture of the hip with postoperative weight-bearing restrictions have a significantly greater risk of developing most adverse events compared with those who are encouraged to weight-bear as tolerated. These findings emphasize the importance of immediate weight-bearing as tolerated to optimize the outcome in these frail patients; however nearly 25% of surgeons fail to meet this evidence-based guideline. Cite this article: Bone Joint J 2018;100-B:1377–84.

The prevalence of dialysis-dependent patients is growing, and an increasing number of these patients are being considered for total knee arthroplasty (TKA). Studies assessing the preoperative risk associated with TKA in this population are limited to institutional cohorts with small sample sizes or national inpatient databases that lack follow-up data.The 2006-2015 National Surgical Quality Improvement Program databases were queried for adult patients undergoing elective TKA. Differences in 30-day any/severe/minor adverse event, need for reoperation, readmission, and mortality were compared for dialysis-dependent and nondialysis TKA patients using risk-adjusted logistic regression. To account for the smaller number of dialysis patients and variations in study populations, coarsened exact matching was used. The proportion of adverse events that occurred before vs after discharge was also assessed.In total, 250 dialysis-dependent patients and 163,560 nondialysis patients met inclusion criteria. After controlling for patient demographics (age, sex, body mass index, functional status) and overall health (American Society of Anesthesiologists class), matched analysis revealed dialysis-dependent patients to be significantly more likely to experience any adverse event (odds ratio = 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), severe adverse event (odds ratio = 2.49; 95% CI, 1.61-3.84; P.001), reoperation (odds ratio = 2.38; 95% CI, 1.19-4.75; P = .014), readmission (odds ratio = 2.32; 95% CI, 1.47-3.66; P = .001), and mortality (odds ratio = 6.71; 95% CI, 2.99-22.50; P = .002). The majority of adverse outcomes occurred postdischarge.Independent of patient demographics and overall health (American Society of Anesthesiologists), patients undergoing dialysis before TKA are significantly more likely to experience 30-day adverse outcomes than matched nondialysis cohorts. Preoperative evaluation of bone health status and management of medical treatment are warranted in this fragile population. Cautious surgical planning, patient counseling, and heightened surveillance are necessitated throughout their perioperative period and postoperative recovery plans may need to be different from nondialysis counterparts. Furthermore, hospitals and physicians must take these increased risks into account when working on bundle payment reimbursement strategies and resource allocation.3.

BACKGROUND: Rising healthcare costs have led to increased focus on the need to achieve a higher “value of care.” As value-maximization efforts expand to include more complex surgical patients, evidence to support meaningful implementation of complication-based initiatives is lacking. The objective of this study was to compare incremental costs of complications following major gastrointestinal (GI) resections for organ-specific malignant neoplasia using nationally-representative data. METHODS: National (Nationwide) Inpatient Sample data, 2001-2014, were queried for adult (≥18y) patients undergoing major resections for malignant neoplasia. Based on system-based complications considered relevant to the long-term treatment of GI disease, stratified differences in risk-adjusted incremental hospital costs and complication probabilities were compared. Differences in surgical outcomes and costs over time were also assessed. RESULTS: A total of 293,967 patients were included, weighted to represent 1,408,117 patients nationwide. One-fourth (26.1%, 95%CI: 25.7-26.4%) experienced ≥1 pre-discharge complication (range: 45.3% esophagectomy to 24.0% rectal resection). Resultant annual risk-adjusted incremental hospital costs totaled $540 million nationwide (19.5% of the overall cost of care and an average of $20,900 per-patient). Costs varied substantially with both cancer/resection type and complication group, ranging from $76.7 million for colectomies with infectious complications to $0.2 million for rectal resections with urinary complications. For each resection type, infectious ($154.7 million), GI ($85.5 million), and pulmonary ($77.9 million) complications were among the most significant drivers of increased hospital cost. CONCLUSIONS: Quantifying and comparing the impact of complications on an indication-specific level in more complex patients offers an important step toward allowing providers/payers to meaningfully prioritize the design of novel and adaptation of existing value-maximization approaches.

Background Context Venous thromboembolism (VTE) is a known complication after spine surgery, but prophylaxis guidelines are ambiguous for patients undergoing elective spine surgery. Purpose The objective of this study was to characterize the incidence and risk factors for VTE and the association of pharmacologic prophylaxis with VTE and bleeding complications after elective spine surgery. Study Design/Setting This is a retrospective cohort study of patients undergoing elective spine surgery in the National Surgical Quality Improvement Program (NSQIP) database and a retrospective cohort analysis at an academic medical center. Patient Sample This study included 109,609 patients in the NSQIP database from 2005 to 2014 and 2,855 patients at the authors' institution from January 2013 to March 2016 who underwent elective spine surgery. Outcome Measures The incidence and risk factors for VTE were assessed in both cohorts based on the NSQIP criteria. The incidence of bleeding complications requiring reoperation was assessed based on operative reports in the institutional cohort. Materials and Methods Associations of patient and procedure factors with VTE were characterized in the NSQIP population. In the single-institution cohort, in addition to NSQIP variables, a chart review was completed to determine the use of VTE prophylaxis, the history of prior VTE, and the incidence of hematoma requiring reoperation. The association of patient and procedure variables, including pharmacologic prophylaxis and history of prior VTE, with VTE and hematoma requiring reoperation were determined with multivariate regression. Results Among 109,609 elective spine surgery patients in NSQIP, independent risk factors for VTE were greater age, male gender, increasing body mass index, dependent functional status, lumbar spine surgery, longer operative time, perioperative blood transfusion, longer length of stay, and other postoperative complications. There were 2,855 patients included in the institutional cohort. Pharmacologic prophylaxis was performed in 56.3% of the institutional patients, of whom 97.1% received unfractionated heparin. When controlling for patient and procedural variables, pharmacologic prophylaxis did not significantly influence the rate of VTE, but was associated with a significant increase in hematoma requiring a return to the operating room (relative risk=7.37, p=.048). Conclusions Pharmacologic prophylaxis, primarily with unfractionated heparin, after elective spine surgery was not associated with a significant reduction in VTE. However, there was a significant increase in postoperative hematoma requiring reoperation among patients undergoing prophylaxis. This raises questions about the routine use of unfractionated heparin for VTE prophylaxis and supports the need for further consideration of risks and benefits of chemoprophylaxis after elective spine surgery.

Sport-related injury patterns among Para athletes have been described with increasing frequency. This review summarizes musculoskeletal injuries in Para athletes. Seated Para athletes sustain upper extremity injuries more commonly; ambulant Para athletes frequently sustain lower extremity injuries. The upper extremity is the most commonly injured anatomic area in all Para athletes, unlike able-bodied athletes. Advanced age and spinal cord injury may increase the risk of upper extremity injury. Injury data for recreational and youth Para athletes are sparse. Summarizing current injury epidemiology data may help to accelerate the development of injury prevention strategies and lifetime injury models for Para athletes.

Background The Rothman Index is a comprehensive measure of overall patient status in the inpatient setting already in use at many medical centers. It ranges from 100 (best score) to -91 (worst score) and is calculated based on 26 variables encompassing vital signs, routine laboratory values, and organ system assessments from nursing rounds from the electronic medical record. Past research has shown an association of Rothman Index with complications, readmission, and death in certain populations, but it has not been evaluated in geriatric patients with hip fractures, a potentially vulnerable patient population. Questions/purposes (1) Is there an association between Rothman Index scores and postdischarge adverse events in a population aged 65 years and older with hip fractures? (2) What is the discriminative ability of Rothman Index scores in determining which patients will or will not experience these adverse events? (3) Are there Rothman Index thresholds associated with increased incidence of postdischarge adverse outcomes? Methods One thousand two hundred fourteen patients aged 65 years and older who underwent hip fracture surgery at an academic medical center between 2013 and 2016 were identified. Demographic and comorbidity characteristics were characterized, and 30-day postdischarge adverse events were calculated. The associations between a 10-unit change in Rothman Index scores and postdischarge adverse events, mortality, and readmission were determined. American Society of Anesthesiologists (ASA) class was used as a measure of comorbidity because prior research has shown its performance to be equivalent or superior to that of calculated comorbidity measures in this data set. We assessed the ability of Rothman Index scores to determine which patients experienced adverse events. Finally, Rothman Index thresholds were assessed for an association with increased incidence of postdischarge adverse outcomes. Results We found a strong association between Rothman Index scores and postdischarge adverse events (lowest score: odds ratio [OR] = 1.29 [1.18-1.41], p < 0.001; latest score: OR = 1.37 [1.24-1.52], p < 0.001) after controlling for age, sex, body mass index, ASA class, and surgical procedure performed. The discriminative ability of lowest and latest Rothman Index scores was better than those of age, sex, and ASA class for any adverse event (lowest value: area under the curve [AUC] = 0.641; 95% confidence interval [CI], 0.601-0.681; latest value: AUC = 0.640; 95% CI, 0.600-0.680); age (0.534; 95% CI, 0.493-0.575, p < 0.001 for both), male sex (0.552; 95% CI, 0.518-0.585, p = 0.001 for both), and ASA class (0.578; 95% CI, 0.542-0.614; p = 0.004 for lowest Rothman Index, p = 0.006 for latest Rothman Index). There was never a difference when comparing lowest Rothman Index value and latest Rothman Index value for any of the outcomes (Table 5). Patients experienced increased rates of postdischarge adverse events and mortality with a lowest Rothman Index of ≤ 35 (p < 0.05) or latest Rothman Index of ≤ 55 (p < 0.05). Conclusions The Rothman Index provides an objective method of assessing perioperative risk in the setting of hip fracture surgery in patients older than age 65 years and is more accurate than demographic measures or ASA class. Furthermore, there are Rothman Index thresholds that can be used to identify patients at increased risk of complications. Physicians can use this tool to monitor the condition of patients with hip fracture, recognize patients at high risk of adverse events to consider changing their plan of care, and counsel patients and families. Further investigation is needed to determine whether interventions based on Rothman Index values contribute to improved outcomes or value of hip fracture care. Level of Evidence Level II, diagnostic study.

Introduction American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention. Methods 1999–2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications. Results Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999–2004 to 60.92% in 2011–2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16–30 cases: OR = 0.91; 95% CI: 0.85–0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61–0.76; p Discussion Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.

The number of octogenarians undergoing revision total knee arthroplasty (TKA) is increasing. However, there has been a lack of studies investigating the perioperative course and safety of revision TKA performed in this potentially vulnerable population in a large patient population. The purpose of this study is to compare complications following revision TKA between octogenarians and 2 younger patient populations (70 and 70-79 year olds).Patients who underwent revision TKA were identified in the 2005-2015 National Surgical Quality Improvement Program database and stratified into 3 age groups:70, 70-79, and ≥80 years. Baseline preoperative and intraoperative characteristics were compared between the 3 groups. Propensity score matched comparisons were then performed for 30-day perioperative complications, length of hospital stay, and readmissions.This study included 6523 (70 years), 2509 (70-79 years), and 957 octogenarian patients who underwent revision TKA. After propensity matching, statistical analysis revealed only higher rates of blood transfusion and slightly longer length of stay in octogenarians compared to70 year olds. Similarly, octogenarians had only higher rates of blood transfusion and slightly longer length of stay compared to 70-79 year olds. Notably, there were no differences in mortality or readmission between octogenarians compared to younger populations.These data suggest that revision TKA can safely be considered for octogenarians with the observation of higher rates of blood transfusion and slightly longer length of stay compared to younger populations. Octogenarian patients need not be discouraged from revision TKA solely based on their advanced age.

INTRODUCTION Existing literature investigating the correlation of body mass index (BMI) with surgical complications has focused on those with elevated BMI. These investigations have reported mixed conclusions, possible because of insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (eg, underweight, overweight, and varying classifications of obese). Few studies have considered complications of patients with low BMI. The aim of the current study was to analyze the spectrum of categories for BMI with 30-day perioperative adverse events after primary total shoulder arthroplasty (TSA) to better assess where along the BMI spectrum patients are at risk for complications. METHODS Patients undergoing elective TSA were abstracted from the National Surgical Quality Improvement Program (NSQIP) databases from 2005 to 2016. Patients were then aggregated into BMI categories, and 30-day adverse events were normalized to average risk of normal-weight subjects (BMI 18.5 to 24.9 kg/m2). Risk-adjusted multivariate regressions were performed, controlling for demographic variables and overall health. RESULTS In total, 15,717 patients met the inclusion criteria. Underweight TSA patients (BMI < 18.5 kg/m2) had the greatest odds for multiple perioperative adverse events compared with any other BMI category. By multivariate analysis, underweight patients were more likely to experience any adverse event (odds ratio [OR] = 2.22, P = 0.034), serious adverse events (OR = 3.18, P = 0.004), or have postoperative infections (OR = 2.77, P = 0.012) within 30 days when compared with normal-weight patients. No significant difference was observed in these complications for elevated BMI categories when compared with normal-weight patients. CONCLUSIONS Only underweight TSA patients were found to have higher rates of 30-day perioperative adverse events than normal BMI patients, unlike any overweight/obese category including the super morbidly obese. Underweight TSA patients were thus identified as an at-risk subpopulation of TSA patients who had not previously been described. Physicians and healthcare systems should give additional consideration to this fragile cohort because they often already do for those at the other end of the BMI spectrum. LEVEL OF EVIDENCE III.

For persons with disabilities in low-resource and tropical settings, barriers to mobility and physical activity are steep. The aim of this study was to develop and test two low-cost, durable, sustainable, purpose-built wheelchair prototypes to support wheelchair users in low-resource and tropical settings. These bamboo wheelchairs, nicknamed African Chairs by Ghanaian daily manual wheelchair users who tested the devices, adopt two designs: an urban-targeted and a rural-targeted design.The rural-targeted design incorporated stability as its key design property for the purpose of navigating variable terrain. The urban-targeted design adopted a sleeker, more portable profile for environments that require wheelchair transport in vehicles and the navigation of elevators and ramps. Both designs integrated bamboo-rod skeletons, bonded by hot-glue gun, jointed and wrapped with epoxy-soaked fibers, then upholstered by a local tailor, with basic standard wheel components. An iterative design process incorporated expert consultation as well as user feedback.The final prototypes received positive testing reviews from daily manual wheelchair users in Ghana. These locally-built, safe, economical bamboo wheelchairs have the potential to improve accessibility, provide more independence and reduce immobility-related health risks for many.Implications for rehabilitationPersons with disabilities have a right to mobility, maximum independence, and the psychological, emotional, and physical health benefits of physical activity those rights confer.For persons with disabilities in low-resource settings, barriers to mobility and physical activity are steep, due to social stigmatization and the cost and adaptability of equipment.Bamboo wheelchairs have the potential to increase access to mobility and physical activity by allowing wheelchairs to be efficiently produced at cost, according to the user's needs.The aesthetics of bamboo wheelchairs can help reduce social stigma by avoiding the "medicalization" of wheelchairs and other traditional mobility devices.

Introduction: National databases, such as the National Surgical Quality Improvement Program (NSQIP) database, are frequently used for total hip arthroplasty (THA) studies. NSQIP variables and the population included in the database have evolved over time. These changes may influence the results of studies using different periods of data. Methods: THA patients were aggregated from the 2005 to 2010 and 2011 to 2015 NSQIP data sets to define two era groups. Demographic data and 30-day perioperative outcomes were compared between the groups. As an example analysis, multivariate Poisson regression was used to determine the correlation between age and perioperative outcomes for each group. Results: Of 102,411 THA patients identified, 8098 cases were from 2005 to 2010 and 94,313 were from 2011 to 2015. A number of preoperative characteristics and perioperative outcomes were significantly different between the era groups. Multivariate analysis of the 2005 to 2010 group showed that increasing age was significantly associated with urinary tract infection and length of stay (LOS), and multivariate analysis of the 2011 to 2015 group showed that age was significantly associated with urinary tract infection, LOS, 30-day mortality, unplanned reintubation, extended LOS, pneumonia, deep vein thrombosis/thrombophlebitis, blood transfusion, and return to the operating room. Conclusion: Significantly more THA patients were enrolled in the NSQIP in the years between 2005 and 2015. Populations in 2005 to 2010 versus 2011 to 2015 were associated with differences in preoperative characteristics and perioperative outcomes. In an example analysis, it was shown that these differences together lead to different study results and conclusions. This needs to be considered when interpreting and conducting studies using earlier NSQIP data.

Introduction: Previous studies evaluating the risk of perioperative adverse events after hip fracture surgery for dialysis-dependent patients are either institutional cohort studies or limited by patient numbers. The current study uses the National Surgical Quality Improvement Program database's large national patient population and 30-day follow-up window to address these weaknesses. Methods: National Surgical Quality Improvement Program databases (2006 to 2016) were queried for patients aged 60 years or older who underwent hip fracture surgery. Differences in 30-day outcomes based on preoperative dialysis dependence were compared using risk-adjusted logistic regression and coarsened exact matching for adverse events, need for revision surgery, readmission, and mortality. The proportion of adverse events that occurred before versus after discharge was also assessed. Results: A total of 288 dialysis-dependent and 16,392 non–dialysis-dependent patients met the inclusion criteria. Matched populations controlling for demographic factors (ie, age, sex, body mass index, and functional status) and overall health (American Society of Anesthesiologists class) found dialysis-dependent patients to be associated with significantly greater odds of any adverse event (odds ratio [OR] = 1.90), major adverse event (OR = 1.77), and unplanned readmission (OR = 2.48). Increased odds of minor adverse event (OR = 1.05), return to the operating room (OR = 1.66), and death (OR = 1.42) within 30 postoperative days were also found but were not statistically significant. Discussion: Even after controlling for demographics and health status, geriatric dialysis patients undergoing surgery for hip fracture are at significantly greater odds of adverse outcomes. Because of increased risks for geriatric dialysis patients undergoing surgery for hip fracture, surgical caution, patient counseling, and heightened surveillance must be observed throughout the perioperative period for this fragile population. Furthermore, hospitals and physicians must take the increased risks associated with dialysis into account when considering bundled payment reimbursement strategies and resource allocation for hip fracture care.

ObjectivePara athletes reap significant health benefits from sport but are vulnerable to non-accidental harms. Little is known about the types and impacts of non-accidental harms Para athletes face. In this literature review, we summarise current knowledge and suggest priorities for future research related to non-accidental harms in Para athletes.DesignSix electronic databases were searched between August and September 2017. 2245 articles were identified in the initial title/abstract review, and 202 records were selected for full-text review following preliminary screening. Two independent examiners evaluated each full text, and eight citations were selected based on inclusion/exclusion criteria.Data sourcesMEDLINE, Embase, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Scopus and Academic Search Premier.Eligibility criteria for selecting studiesInclusion criteria: (A) human participants; (B) written in English; (C) descriptive, cohort and case series, case–control, qualitative, mixed methods studies and all clinical trials; and (D) data pertain to harassment/abuse of youth, recreational, collegiate, national-level and/or elite-level athletes with a physical and/or intellectual impairment.ResultsMost studies focused on young, visually impaired athletes and approximately half of all studies described high rates of bullying and its social implications. One study confirmed remarkably high rates of psychological, physical and sexual harms in Para athletes, compared with able-bodied peers.ConclusionsBullying in young, visually impaired athletes is described most commonly in the available literature. Due to the limited amount of data, the prevalence of non-accidental harms in Para athletes remains unclear and information on trends over time is similarly unavailable.

Objectives To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients. Summary of background data As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients' postacute recovery period among older adults. Methods Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models. Results A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups. Conclusion The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.

Quality metrics are the methods by which hospitals and insurers measure the quality of care at a particular institution or practice. Examples of quality metrics include structural measures, process measures, objectively assessed outcome measures, registries, patient-reported outcome measures, and patient-reported satisfaction through the hospital consumer assessment of healthcare providers and systems. Each metric provides unique insight about the care a particular institution can provide. These metrics are particularly relevant in spine care with spinal issues being such a common reason for patients to seek medical attention and mixed surgical outcomes for different surgical indications. The results are useful to patients choosing the institution at which they receive treatment, to hospitals in guiding efforts to improve their quality of care, and to insurers to rate hospitals and providers to direct policies and reimbursements. These metrics are continually evolving in order to adapt to constantly changing healthcare systems. No single metric is perfect, while each have their own unique benefits and insights about an institution; they also come with some potential downsides that must be balanced by using a varied set of measures.

Background Although interest in global surgery is increasing among medical students,1 several questions remain unanswered such as: the association of demographics with said interest, the extent that global surgical burden education has been integrated into medical education, and the availability of global surgery electives. This study aimed to assess the current state of global surgery education in the United States (U.S.) to support recommendations for future curriculum development. Materials and methods An anonymous online survey was distributed to medical students currently enrolled in the U.S. Descriptive data were compiled regarding interest in and access to global surgery programs; demographic data were analyzed using chi-squared testing for categorical variables. Results A total of 754 students from 18 medical schools throughout the U.S. responded to the survey. Only complete responses were included in final analysis (n = 658). Most of the respondents (66%) reported interest in global surgery, with a higher proportion of those interested being in their preclinical years. However, the majority (79%) reported that global surgery issues are rarely or never addressed in their required curriculum. Over half of respondents were unaware of whether their school even offers such programs. Conclusions Although interest in global surgery is on the rise among medical students, results suggest that many currently lack exposure to global surgery concepts in their medical education. To that end, early exposure may be most effective during the preclinical years, so that the next generation may align global surgery participation with clinical aspirations, with the ultimate goal of addressing global disparities.

Aims The aim of this study was to compare the rate of perioperative complications following aseptic revision total hip arthroplasty (THA) in patients aged ≥ 80 years with that in those aged < 80 years, and to identify risk factors for the incidence of serious adverse events in those aged ≥ 80 years using a large validated national database. Patients and Methods Patients who underwent aseptic revision THA were identified in the 2005 to 2015 National Surgical Quality Improvement Program (NSQIP) database and stratified into two age groups: those aged < 80 years and those aged ≥ 80 years. Preoperative and procedural characteristics were compared. Multivariate regression analysis was used to compare the risk of postoperative complications and readmission. Risk factors for the development of a serious adverse event in those aged ≥ 80 years were characterized. Results The study included 7569 patients aged < 80 years and 1419 were aged ≥ 80 years. Multivariate analysis showed a higher risk of perioperative mortality, pneumonia, urinary tract infection and the requirement for a blood transfusion and an extended length of stay in those aged ≥ 80 years compared with those aged < 80 years. Independent risk factors for the development of a serious adverse event in those aged ≥ 80 years include an American Society of Anesthesiologists score of ≥ 3 and procedures performed under general anaesthesia. Conclusion Even after controlling for patient and procedural characteristics, aseptic revision THA is associated with greater risks in patients aged ≥ 80 years compared with younger patients. This is important for counselling and highlights the need for medical optimization in these vulnerable patients. Cite this article: Bone Joint J 2018;100-B:143–51.

Background Context There has been growing interest in performing posterior lumbar fusions (PLFs) in the outpatient setting to optimize patient satisfaction and reduce cost. Although still done in only a small percentage of cases, this has been more possible because of advances in surgical techniques and anesthesia. However, data on the perioperative course of outpatient compared with inpatient PLF in a large sample size are scarce. Purpose This study aimed to compare perioperative complications between outpatient and inpatient PLF in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Study Design/Setting A retrospective cohort comparison study was carried out. Patient Sample Patients undergoing PLF with or without interbody fusion from the 2005 to 2015 NSQIP database comprised the sample. Outcome Measures Outcome measures were postoperative complications within 30 days and readmission within 30 days. Methods Patients who underwent PLF with or without interbody fusion were identified in the 2005–2015 NSQIP database. Outpatient procedures were defined as cases that had hospital length of stay (LOS)=0 days, whereas inpatient procedures were defined as LOS=1–30 days. Patient characteristics, comorbidities, and procedural variables (inclusion of interbody fusion, instrumentation, and number of levels fused) were compared between the two cohorts. Propensity score-matched comparisons were then performed for postoperative complications and 30-day readmissions between the two groups. Results The current study included 360 outpatient and 36,610 inpatient PLF cases. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in postoperative adverse events other than significantly lower blood transfusions in the outpatient group (2.78% vs. 10.83%, p Conclusions Based on the lack of differences in rates of most perioperative complications and 30-day readmissions between the outpatient and inpatient cohorts, it seems that outpatient PLF may be appropriately considered for select patients. However, extremely careful patient selection should be exercised.