Study Design: Retrospective. Objective: Identify patient risk factors for extended length of stay (LOS) and 90-day hospital readmissions following elective anterior cervical discectomy and fusion (ACDF). Methods: Included ACDF patients from 2013 to 2017 at a single institution. Eligible patients were subset into LOS <2 and LOS ≥2 days, and no 90-day hospital readmission and yes 90-day hospital readmission. Patient and surgical factors were compared between the LOS and readmission groups. Multivariable logistic regression analysis was utilized to determine the association of independent factors with LOS and 90-day readmission rates. Results: Our sample included 1896 patients; 265 (14%) had LOS ≥2 days, and 121 (6.4%) had a readmission within 90 days of surgery. Patient and surgical factors associated with LOS included patient age ≥65 years (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.15-2.56), marriage (OR 0.57, 95% CI 0.43-0.79), private health insurance (OR 0.28, 95% CI 0.15-0.50), American Society of Anesthesiologists (ASA) score (OR 1.52, 95% CI 1.12-1.86), African American race (OR 1.95, 95% CI 1.38-2.72), and harvesting iliac crest autograft (OR 4.94, 95% CI 2.31-10.8). Patient and surgical factors associated with 90-day hospital readmission included ASA score (OR 1.81, 95% CI 1.32-2.49), length of surgery (OR 1.002, 95% CI 1.001-1.004), and radiculopathy as indication for surgery (OR 0.60, 95% CI 0.39-0.96). Conclusions: Extended LOS and 90-day hospital readmissions may lead to poorer patient outcomes and increased episode of care costs. Our study identified patient and surgical factors associated with extended LOS and 90-day readmission rates. In general, preoperative patient factors affected these outcomes more than surgical factors.

BackgroundNeurological complications are common after lung transplantation. However, no large cohort studies have examined the incidence, predictors, and clinical significance of neurological events sustained by lung transplant recipients.MethodsWe conducted a retrospective cohort analysis of a consecutive series of lung transplant recipients, transplanted at Duke University Medical Center between May 2014 and February 2017 (n = 276). Early neurological complications (ie, occurring during the first week after transplant) were documented by transplant mental health specialists and included delirium, ischemic injury, and posterior reversible encephalopathy syndrome. Analyses accounted for age, native disease, sex, type of transplant, lung allocation score, and primary graft dysfunction. The objectives of the study were to characterize the prevalence and predictors of early neurological sequelae (NSE), occurring during the first week posttransplant, and the association between NSE and subsequent clinical outcomes, including length of stay and mortality.ResultsNeurological sequelae were common, occurring in 123 (45%) patients. Fifty-seven patients died over a follow-up interval of 2.1 years. The most common NSE were postoperative delirium (n = 110 [40%]) and posterior reversible encephalopathy syndrome (n = 12 [4%]), followed by stroke/transient ischemic attack and neurotoxicity. Higher lung allocation score was the strongest predictor of delirium. The presence of a NSE was associated with longer length of hospital stay (32 days vs 17 days, P < 0.001) and greater mortality (hazard ratio, 1.90; 95% confidence interval, 1.09-3.32], P = 0.024), with the greatest mortality risk occurring approximately 2 years after transplantation.ConclusionsNeurological events are relatively common after lung transplantation and associated with adverse clinical outcomes.

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Study Design: Retrospective study. Objective: Previous studies have demonstrated that increased implant density (ID) results in improved coronal deformity correction. However, low-density constructs with strategically placed fixation points may achieve similar coronal correction. The purpose of this study was to identify key zones along the spinal fusion where high ID statistically correlated to improved coronal deformity correction. Our hypothesis was that high ID within the periapical zone would not be associated with increased percent Cobb correction. Methods: We identified patients with Lenke type 1 curves with a minimum 2-year follow up. The instrumented vertebral levels were divided into 4 zones: (1) cephalad zone, (2) caudal zone, (3) apical zone, and (4) periapical zone. High and low percent Cobb correction groups were compared, high percent Cobb group was defined as percent correction >67%. Total ID, total concave ID, total convex ID, and ID within each zone of the curve were compared between the groups. A multivariable analysis was performed to identify independent predictors for coronal correction. Subsequently increased and decreased thoracic kyphosis (TK) groups were compared, increased TK was defined as post-operative TK being larger than preoperative TK and decreased TK was defined as post-operative TK being less than preoperative TK. Results: The cohort included 68 patients. The high percent Cobb group compared with the low percent Cobb group had significantly greater ID for the entire construct, the total concave side, the total convex side, the apical convex zone, the periapical zone, and the cephalad concave zone. The high percent Cobb group had greater pedicle screw density for the total construct, total convex side, and total concave side. In the multivariate model ID and pedicle screw density remained significant for percent Cobb correction. Ability to achieve coronal balance was not statistically correlated to ID ( P = .78). Conclusions: Increased ID for the entire construct, the entire convex side, the entire concave side, and within each spinal zone was associated with improved percent Cobb correction. The ability to achieve coronal balance was not statistically influence by ID. The results of this study support that increasing ID along the entire length of the construct improves percent Cobb correction.

Study DesignRetrospective study.PurposeThe objective of this study was to compare percent correction between apical and periapical pedicle screw (PS) and sublaminar wire constructs for Cobb correction and coronal balance correction.Overview of LiteratureThe current gold standard for deformity correction in adolescent idiopathic scoliosis (AIS) are PS constructs. Sublaminar wires provide an alternative means of fixation when PS fixation cannot be safely performed. Two previous studies have compared percent curve correction between sublaminar wires and PSs, with conflicting conclusions.MethodsThe study was a retrospective review of Lenke type 1 curves with minimum follow-up of at least 1 year. Cases were divided into two groups: constructs using apical/periapical sublaminar wires (SL group) versus PS only constructs (PS group). Percent Cobb correction and coronal balance were compared between the two groups at 1 year. A multivariable regression model was used to determine the impact of apical/periapical wires on percent Cobb correction and coronal balance at 1 year when accounting for additional variables.ResultsThe cohort included 71 patients who were predominantly female (80.2%), with average age of 14.2 years. Only 21 (29.5%) of constructs utilized apical/periapical sublaminar wires. There was a significant difference in percent Cobb correction at 1 year for the PS and SL groups (70.26% vs. 60.09%, p=0.05). No difference was observed in overall coronal balance. A multivariable model revealed that apical/periapical wires were negatively associated with percent Cobb correction at 1 year (coefficient=−8.49, p=0.023), while total implant density of the construct was positively associated with correction (coefficient=24.2, p<0.001).Conclusions Use of PSs in the apical and periapical zones resulted in improved percent Cobb correction at 1 year in patients with AIS Lenke type 1 curves. Sublaminar wires remain a useful surgical option and result in equivalent coronal balance compared to PSs.

Purpose/Hypothesis: Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction in children is associated with a much higher risk (˜30%) of subsequent ACL injury than in adults. Most RTS testing protocols use Limb Symmetry Indices (LSI) on physical performance tests (PPTs). This assumes that both lower extremities should be equal. We hypothesized that in the pediatric population, baseline limb asymmetry exists, limiting the clinical utility of LSIs. Since LSI > 90% is often used as a clinical cutoff for RTS, we defined a test as valid if 80% of healthy volunteers had an LSI > 90%. Number of Subjects: 63 Materials/Methods: This study included healthy volunteers ages 6-18 [mean age = 10.7 +/- 3.2 years; 34 females (54%)]. Pubertal Maturity Observation Scores (PMOS), sex, age, height, weight, and body mass index (BMI) were collected. Subjects performed ten PPTs: lower quarter Y-balance, stork balance, stork balance on BOSU, single leg squat (SLS), SLS on BOSU, clockwise and counterclockwise quadrant single leg hop (SLH), forward SLH, timed SLH, and triple crossover SLH. Subjects performed the items in the same order, but were randomly assigned the starting test and the starting limb. We developed a composite score for each limb by averaging trials, then calculated the absolute value of the side-to-side difference, and normalized this difference to the test mean to obtain a percentage side-to-side difference (%STS). Multivariable linear regression analysis was performed to assess the effect of age on limb symmetry while correcting for BMI, PMOS and sex. Results: %STS were not normally distributed for any PPT, therefore data were reported as medians and interquartile ranges. All PPTs showed baseline limb asymmetry, and none met our definition of validity. The most symmetric PPT was the clockwise quadrant hop test (%STS in females, median = 9.85, interquartile range = 4.63 – 18.7; %STS in males, median = 6.9, interquartile range = 3.64 – 14.04). The stork balance on BOSU test had the greatest limb asymmetry (%STS in females, median 41.4, interquartile range 10.1 – 71.3; %STS in males, median 47.6, interquartile range 18.2 – 66.7). PMOS was strongly correlated with age (Pearson’s? = 0.83), and was excluded as a predictor variable. Age was an independent predictor of %STS only for the stork test (B = -1.15, 95% CI = -1.92 to -0.38, p = 0.004), with older subjects having less limb asymmetry. Conclusions: Healthy children have significant baseline limb asymmetries on PPTs that are commonly used for RTS decision making after ACL reconstruction. None of the PPTs evaluated in this study met our definition of clinical validity. Limb symmetry was typically not affected by subject age. Clinical Relevance: In light of these results, limb symmetry indices (LSI) should be utilized with caution in this population. Functional recovery may be better assessed by comparison to age and sex-specific norms. [Figure: see text]

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SUMMARY There is debate surrounding the appropriate threshold for lymph node harvest during esophagectomy in patients with esophageal cancer, specifically for those receiving preoperative radiation. The purpose of this study was to determine the impact of lymph node yield on survival in patients receiving preoperative chemoradiation for esophageal cancer. The National Cancer Database (NCDB) was utilized to identify patients with esophageal cancer that received preoperative radiation. The cohort was divided into patients undergoing minimal (&lt;9) or extensive (≥9) lymph node yield. Demographic, operative, and postoperative outcomes were compared between the groups. Kaplan–Meier analysis with the log rank test was used to compare survival between the yield groups. Cox proportional hazards model was used to determine the association between lymph node yield and survival. In total, 886 cases were included: 349 (39%) belonging to the minimal node group and 537 (61%) to the extensive group. Unadjusted 5-year survival was similar between the minimal and extensive groups, respectively (37.3% vs. 38.8%; P &gt; 0.05). After adjustment using Cox regression, extensive lymph node yield was associated with survival (hazard ratio 0.80, confidence interval 0.66–0.98, P = 0.03). This study suggests that extensive lymph node yield is advantageous for patients with esophageal cancer undergoing esophagectomy following induction therapy. This most likely reflects improved diagnosis and staging with extensive yield.