Association Between Diabetes Mellitus and Total Hip Arthroplasty Outcomes: An Observational Study Using the US National Inpatient Sample

OBJECTIVES: To investigate the association of diabetes with postoperative outcomes in patients undergoing primary total hip arthroplasty (THA). DESIGN: Retrospective cohort study using data from the US National Inpatient Sample (NIS). SETTING: Study cohort was hospitalisations for primary THA in the USA, identified from the 2016-2020 NIS. PARTICIPANTS: We identified 2 467 215 adults in the 2016-2020 NIS who underwent primary THA using International Classification of Diseases, 10th Revision codes. Primary THA hospitlizations were analysed as the overall group and also stratified by the underlying primary diagnosis for THA. OUTCOME MEASURES: Outcome measures of interest were the length of hospital stay\u3ethe median, total hospital charges\u3ethe median, inpatient mortality, non-routine discharge, need for blood transfusion, prosthetic fracture, prosthetic dislocation and postprocedural infection, including periprosthetic joint infection, deep surgical site infection and postprocedural sepsis. RESULTS: Among 2 467 215 patients who underwent primary THA, the mean age was 68.7 years, 58.3% were female, 85.7% were white, 61.7% had Medicare payer and 20.4% had a Deyo-Charlson index (adjusted to exclude diabetes mellitus) of 2 or higher. 416 850 (17%) patients had diabetes. In multivariable-adjusted logistic regression in the overall cohort, diabetes was associated with higher odds of a longer hospital stay (adjusted OR (aOR) 1.38; 95% CI 1.35 to 1.41), higher total charges (aOR 1.11; 95% CI 1.09 to 1.13), non-routine discharge (aOR 1.18; 95% CI 1.15 to 1.20), the need for blood transfusion (aOR 1.19; 95% CI 1.15 to 1.23), postprocedural infection (aOR 1.62; 95% CI 1.10 to 2.40) and periprosthetic joint infection (aOR 1.91; 95% CI 1.12 to 3.24). We noted a lack of some associations in the avascular necrosis and inflammatory arthritis cohorts (p\u3e0.05). CONCLUSION: Diabetes was associated with increased healthcare utilisation, blood transfusion and postprocedural infection risk following primary THA. Optimisation of diabetes with preoperative medical management and/or institution of specific postoperative pathways may improve these outcomes. Larger studies are needed in avascular necrosis and inflammatory arthritis cohorts undergoing primary THA

A Predictive Model of Failure to Rescue After Thoracolumbar Fusion

Objective Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients. Methods Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011–2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR. Results The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21–25, 1.3 [0.8–2.2]; RAI 26–30, 4.0 [2.4–6.6]; RAI 31–35, 7.0 [3.8–12.7]; RAI 36–40, 10.0 [4.9–20.2]; RAI 41– 45, 21.5 [9.1–50.6]; RAI ≥ 46, 45.8 [14.8–141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89–0.95). Conclusion Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication

Endoscopic and Nonendoscopic Approaches to Single-Level Lumbar Spine Decompression: Propensity Score-Matched Comparative Analysis and Frailty-Driven Predictive Model

Objective The endoscopic spine surgery (ESS) approach is associated with high levels of patient satisfaction, shorter recovery time, and reduced complications. The present study reports multicenter, international data, comparing ESS and non-ESS approaches for single-level lumbar decompression, and proposes a frailty-driven predictive model for nonhome discharge (NHD) disposition. Methods Cases of ESS and non-ESS lumbar spine decompression were queried from the American College of Surgeons National Surgical Quality Improvement Program database (2017–2020). Propensity score matching was performed on baseline characteristics frailty score (measured by risk analysis index [RAI] and modified frailty index-5 [mFI-5]). The primary outcome of interest was NHD disposition. A predictive model was built using logistic regression with RAI as the primary driver. Results Single-level nonfusion spine lumbar decompression surgery was performed in 38,686 patients. Frailty, as measured by RAI, was a reliable predictor of NHD with excellent discriminatory accuracy in receiver operating characteristic (ROC) curve analysis: C-statistic: 0.80 (95% confidence interval [CI], 0.65–0.94) in ESS cohort, C-statistic: 0.75 (95% CI, 0.73–0.76) overall cohort. After propensity score matching, there was a reduction in total operative time (89 minutes vs. 103 minutes, p = 0.049) and hospital length of stay (LOS) (0.82 days vs. 1.37 days, p < 0.001) in patients treated endoscopically. In ROC curve analysis, the frailty-driven predictive model performed with excellent diagnostic accuracy for the primary outcome of NHD (C-statistic: 0.87; 95% CI, 0.85–0.88). Conclusion After frailty-based propensity matching, ESS is associated with reduced operative time, shorter hospital LOS, and decreased NHD. The RAI frailty-driven model predicts NHD with excellent diagnostic accuracy and may be applied to preoperative decision-making with a user-friendly calculator: nsgyfrailtyoutcomeslab.shinyapps.io/lumbar_decompression_dischargedispo

Immunoglobulin G4–related epidural inflammatory pseudotumor presenting with pulmonary complications and spinal cord compression: case report

Immunoglobulin G4–related disease (IgG4-RD) is a recently defined condition characterized by inflammatory tumefactive lesions in various organ systems. IgG4-RD is a clinical and radiological diagnosis of exclusion and requires the presence of specific histopathological criteria for diagnosis.A 50-year-old man presented to an outside hospital with a 3-month history of progressively worsening back pain and symptoms of pleurisy, nasal crusting, and hematochezia. Radiological workup revealed an epidural-paraspinal mass with displacement of the spinal cord, destruction of the T5–6 vertebrae, and extension into the right lung. Biopsy sampling and subsequent histopathological analysis revealed dense lymphoplasmacytic infiltrate with an increased number of IgG4-positive plasma cells and a storiform pattern of fibrosis. With strong histopathological evidence of IgG4-RD, the patient was started on a regimen of prednisone. Further testing ruled out malignant neoplasm, infectious etiologies, and other autoimmune diseases. Two weeks later, the patient presented with acute-onset paraplegia due to spinal cord compression. The patient underwent decompression laminectomy of T5–6, posterior instrumented fusion of T2–8, and debulking of the epidural-paraspinal mass. After the continued administration of glucocorticosteroids, the patient improved remarkably to near-normal strength in the lower extremities and sensory function 6 months after surgery.To the authors' knowledge, this is the first case of IgG4-related epidural inflammatory pseudotumor and spinal cord compression in the United States. This case highlights the importance of early administration of glucocorticosteroids, which were essential to preventing further progression and preventing relapse. IgG4-RD evaluation is important after other diseases in the differential diagnosis are ruled out.</jats:p

Abstract 137: Gastrointestinal Bleeding in Acute Ischemic Stroke: A Nationwide Inpatient Sample Study

Introduction: Gastrointestinal bleeding (GIB) has been reported as a complication in acute cerebrovascular ailments. Here, we examined the incidence, risk factors, and outcomes of GIB in acute ischemic stroke (AIS) using the largest all-payer inpatient database in the U.S. Methods: The Nationwide Inpatient Sample (2002-2011) was queried to identify all adult patients with a primary diagnosis of AIS both with and without a secondary diagnosis of GIB. We utilized multivariate analyses, adjusting for patient and hospital factors, to identify risk factors for GIB in AIS patients and to determine the effect of GIB on in-hospital complications and outcomes. Results: Of 3,988,667 patients admitted with AIS, there were 49,348 cases of GIB (1,237 per 100,000 patients) with 25.7% receiving blood transfusions. Multivariate analysis revealed several independent predictors of GIB in AIS: age 55-64 (OR: 1.39, 95% CI: 1.33-1.45), age 65-74 (OR: 1.52, 95% CI: 1.44-1.59), age 75+ (OR: 1.79, 95% CI: 1.71-1.88), alcohol use (OR: 1.23, 95% CI: 1.17-1.30), coagulopathy (OR: 1.69, 95% CI: 1.62-1.77), cancer (OR: 1.70, 95% CI: 1.60-1.80), fluid/electrolyte disturbance (OR: 1.91, 95% CI: 1.87-1.96), liver disease (OR: 2.44, 95% CI: 2.29-2.60), and history of peptic ulcer disease (OR: 2.47, 95% CI: 2.13-2.86) (all p&lt;0.0001). Administration of thrombolytic therapy decreased the likelihood of GIB by 10% (p&lt;0.0001). In further multivariate models, GIB was determined to be an independent predictor of septicemia (OR: 1.47, 95% CI: 1.39-1.55), gastrostomy (OR: 1.75, 95% CI: 1.70-1.81), pulmonary embolism (OR: 1.75, 95% CI: 1.55-2.00), intubation (OR: 2.04, 95% CI: 1.95-2.13), and blood transfusion (OR: 11.31, 95% CI: 11.00-11.63; all p&lt;0.0001). The occurrence of GIB increased hospital length of stay by an average of 5.8 days and total costs by $14,120 per patient (all p&lt;0.0001). GIB was independently associated with a 46% increased likelihood of severe disability and 82% increased likelihood of in-hospital death (all p&lt;0.0001). Conclusion: Age and several preexisting comorbidities are strong risk factors for GIB in AIS. GIB occurrence precipitates further in-hospital complications and adverse clinical outcomes in AIS, significantly increasing disability and mortality. </jats:p