Background: Total joint arthroplasty continues to burden the United States healthcare system as the population ages. Efforts to reduce costs have focused on quality measures following joint arthroplasty procedures. The purpose of this study was to investigate the effect of the Charlson Comorbidity Index (CCI) and modified Frailty Index (mFI) on length of stay (LOS), 90-day return to the operating room, 30-day readmission rates, and emergency department (ED) visits within 30 days of a joint arthroplasty procedure at a Veterans Affairs (VA) Hospital. Methods: A retrospective chart review was conducted of patients undergoing total hip or knee arthroplasty between January 2, 2013 and March 1, 2018 (n=451). Postoperative outcomes were evaluated and compared to preoperative calculated CCI and mFI values. Binomial logistic regression was used to determine the effects of CCI and mFI on each of these outcome measures. Odds ratios (OR) were calculated for significant effects (ie, where P≤0.05). Results: Higher CCI was associated with LOS greater than one day (odds ration [OR]=1.25) and greater probability of readmission within 30 days (OR=1.4). Higher mFI was related to higher probability of postoperative ED visit (OR=4.95) and readmission rate (OR=10.75). Conclusions: Presurgical evaluation utilizing CCI and MFI may better identify those at risk and encourage modified preoperative counseling for these patients. Further study is needed to determine a risk stratification scheme that allows for more accurate prediction of patients who may require more intense hospital-based postoperative care. Level of Evidence: Level IV.
Category: Hindfoot Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis is a procedure used to treat hindfoot deformity and/or arthritis. Retrograde intramedullary nails have been used as a method of fixation. The nails are either straight or have a bend to accommodate valgus alignment of the hindfoot. Studies comparing nail types or analysis of nonunions are lacking in the available literature on the subject despite a reported nonunion rate of up to 20%. The purpose of this study was to report a series of subtalar nonunions that all had an entry point that was too medial on the calcaneus resulting in inadequate purchase of the nail in the calcaneus. Methods: Six cases of subtalar nonunion were retrospectively reviewed. All were referred for second opinion. Evaluation consisted of examination, radiographs and CT scans. Patient demographics, comorbidities and findings common to all cases were recorded. Results: Presenting complaints in all cases were persistent swelling. Non-neuropathic cases all had hindfoot pain. In this series, all the implants were straight nails. Radiographs and CT scans revealed that all cases were done for severe valgus deformity with subtalar subluxation. In each of the cases, the deformity was under corrected and the nail entry point was too medial on the calcaneus which resulted in reaming out the medial wall of the calcaneus, decreasing the amount of fixation obtained with the nail. In each of the cases, the medial wall of the calcaneus was deficient and the nail had no medial containment. Conclusion: Severe valgus deformity with subtalar subluxation is a risk factor for subtalar nonunion when the deformity is under corrected and a straight nail is used. Ensuring that the tibia talus and calcaneus are collinear and that the entry point in the calcaneus is sufficiently lateral are important factors to consider when addressing this type of deformity. Accurate intraoperative imaging is essential to ensure proper positioning of the entry point to avoid reaming out the medial wall of the calcaneus and to ensure adequate purchase of the nail in the calcaneus.
Background: Despite a growing prevalence of opioid use, the impact of opioid misuse or abuse (OMA) on surgical outcomes after spinal fusion surgery is ill-defined. This study was conducted to describe the relationship between a patient’s history of OMA and postoperative outcomes. Methods: Using the 2008-2013 Florida, Nebraska, and New York state inpatient databases, the authors identified adult patients who underwent thoracolumbar spinal fusion for degenerative disc disease and postsurgical syndromes. Patients were then subgrouped according to a history of OMA. Regression models were used to describe the association between a history of OMA and in-hospital outcomes, hospital based, acute care after discharge, and subsequent encounters for OMA. Results: The final sample included 73,442 patients including 1,332 patients with a history of OMA. Patients with this history tended to be younger, have a history of smoking (63.7% vs. 30.9%) and chronic pain (20.9% vs. 2.0%), and have revision surgery (5.6% vs. 3.9%). In the adjusted analyses, patients with a history of OMA had longer lengths of stay (4.5 vs. 3.8 days), higher healthcare charges ($129,264 vs. $118,065), and were more likely be readmitted within 1 yr (adjusted odds ratio=2.88), including hospital encounters which were OMA-specific 16.3% vs. 0.8). Conclusions: Patients with a history of OMA consume greater healthcare resources following spinal fusion surgery. It is important to identify these at-risk patients prior to surgery so their care can be tailored appropriately. Level of Evidence: Level III.
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