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Study Design Retrospective Review of a National Database. Introduction By utilizing a national database, this study aims to quantify the predictors of 30-day mortality after odontoid fixation and guide appropriate management for patients in whom the choice between operative and non-operative management is unclear. Methods The American College of Surgeons National Surgical Quality Improvement Database was queried using Current Procedural Terminology (CPT) codes and International Classification of Disease (ICD) codes to identify patients 60 or older who underwent surgical fixation of an odontoid fracture from 2005 to 2020. Risk factors for mortality significant in univariate and subsequent multivariate analysis were used to develop a scoring system to predict post-operative mortality. Results 608 patients were identified. Patients were split into a non-mortality 30 days post-op group, and into a mortality 30 days post-op group. The following risk factors were included in the scoring system: functional dependency, disseminated cancer, albumin less than 3.5, WBC count greater than 16 k, anterior surgical approach, and pre-op SIRS. Using a cutoff value of 2, the CAAD-16 score had a sensitivity and specificity of 82% and 81%, respectively. The ASA score, cutoff at 4, showed a sensitivity and specificity of 64% and 75% respectively. Conclusions This sample of 294 patients represents one of the largest samples of odontoid fracture fixation patients available in the literature and comes from a nationally representative database. We structure relevant risk factors into the CAADS-16 score, which has the potential to be a clinically relevant tool to prevent short-term postoperative mortality.

Study Design: Retrospective review. Objective: To use predictive modeling and machine learning to identify patients at risk for venous thromboembolism (VTE) following posterior lumbar fusion (PLF) for degenerative spinal pathology. Methods: Patients undergoing single-level PLF in the inpatient setting were identified in the National Surgical Quality Improvement Program database. Our outcome measure of VTE included all patients who experienced a pulmonary embolism and/or deep venous thrombosis within 30-days of surgery. Two different methodologies were used to identify VTE risk: 1) a novel predictive model derived from multivariable logistic regression of significant risk factors, and 2) a tree-based extreme gradient boosting (XGBoost) algorithm using preoperative variables. The methods were compared against legacy risk-stratification measures: ASA and Charlson Comorbidity Index (CCI) using area-under-the-curve (AUC) statistic. Results: 13, 500 patients who underwent single-level PLF met the study criteria. Of these, 0.95% had a VTE within 30-days of surgery. The 5 clinical variables found to be significant in the multivariable predictive model were: age > 65, obesity grade II or above, coronary artery disease, functional status, and prolonged operative time. The predictive model exhibited an AUC of 0.716, which was significantly higher than the AUCs of ASA and CCI (all, P < 0.001), and comparable to that of the XGBoost algorithm (P > 0.05). Conclusion: Predictive analytics and machine learning can be leveraged to aid in identification of patients at risk of VTE following PLF. Surgeons and perioperative teams may find these tools useful to augment clinical decision making risk stratification tool.

PurposeScoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease.MethodsUsing the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05.ResultsPredicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72–0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76.ConclusionsThe H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis.Level of Evidence Prognostic level III.

Objectives: The quadriceps angle (Q-angle) measures the force vector of pull of the extensor mechanism of the knee. A larger Q-angle is thought to be a predisposing factor for patellar dislocation, but previous literature has reported poor reliability and validity of clinically measured Q-Angle. In response to poor reliability, a new “Standard Q-Angle” (SQA) was developed by Merchant et al. (Merchant 2020) in an attempt to create a standardized and repeatable method of clinically measuring the Q-Angle. The SQA may be a practical, inexpensive, and valuable part of physical examinations to help clinicians decide if concomitant medializing osteotomy is indicated in patellar stabilization procedures. However, SQA has not yet been validated in patients with anatomic risk factors for recurrent patellar instability such as patella alta and trochlear dysplasia. Furthermore, while SQA has previously been demonstrated to have strong interrater reliability, it has never been shown to correlate with standardized measurements for a lateralized tibial tuberosity, such as the Tibial Tuberosity – Trochlear Grove (TT-TG) distance. Therefore, the purpose of our study was to determine the correlation between SQA and TT-TG distance in patients with recurrent patellar instability. We hypothesized that there would be a positive correlation between SQA and TT-TG distance. 1. Merchant AC, Fraiser R, Dragoo J, Fredericson M. A reliable Q angle measurement using a standardized protocol. Knee. 2020;27(3):934-939. Methods: Patients at a single institution treated by a single surgeon with recurrent patellar instability who had previously obtained a dynamic 4D CT scan were included in this study. Patients who had previous patellar stabilization procedures were excluded. The Standard Q-angle was measured as previously described by Merchant et al. (Merchant 2020). The patient was placed in the supine position with the knee extended. A long-arm goniometer was centered over the patella with the distal arm over the tibial tuberosity and the proximal arm extended up to the anterior superior iliac spine (ASIS). The examiner then centered the patella within the trochlear groove and the SQA was measured. A second examiner stood at foot of the patient’s bed to confirm positioning. Measurements were taken in the office, as well as in the operating room after the induction of general anesthesia. All measurements were performed by the senior author (***). Utilizing 4D CT scans, the TT-TG, Caton-Deschamps index (CDI), and lateral trochlear inclination (LTI) were measured as previously described. Patients whose CDIs were between 0.8 and 1.2 were considered to have normal patellar height. Patients whose LTIs were >11° were considered to have normal LTI, which has been shown to have a sensitivity of 93% and a specificity 87% for detecting trochlear dysplasia. Mean and standard deviation values were calculated for patient demographic information, and correlation coefficients were calculated to compare SQA with TT-TG distance in both awake and anesthetized patients. The statistical software Stata was utilized for all analyses (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX). Results: Fifty-seven patient knees were included in the study. The mean age was 22 years-old (±6 years). For awake patients, the correlation coefficient (R2) between SQA and TT-TG was -0.006 (Figure 1), and in anesthetized patients R2 = 0.093 (Figure 2). In the “normal patellar height” group, the R2 value was higher in the anesthetized group (R2 = 0.334) than the awake group (R2 = 0.239). In the normal lateral trochlear inclination group, there was also a greater R2 value in the anesthetized group (R2 = 0.403) than the awake group (R2 =0.093). The correlation between SQA and TT-TG was the strongest in anesthetized patients with both a CDI < 1.2 and LTI >11° (R2 = 0.635). Conclusions: There was a strong positive association between SQA and TT-TG in anesthetized patients with normal patellar height and a normal lateral trochlear inclination. However, in awake patients and patients with anatomic risk factors for recurrent patellar instability there was only a weak association between SQA and TT-TG. The SQA may be able to provide useful information, but only in selected cases. Therefore, it remains important to have objective radiographic measurements to characterize the position of the tibial tuberosity when planning patellar stabilization surgery.

Background: In response to the poor reliability of clinically measured quadriceps angle (Q angle), the standard Q angle (SQA) was developed as a standardized, repeatable measurement method. Purpose: To determine the correlation between SQA and tibial tubercle-trochlear groove (TT-TG) distance in awake and anesthetized patients with recurrent patellar instability. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We included 47 patients (94 knees; mean patient age, 23 ± 9 years) treated by 1 surgeon for recurrent patellar instability who had undergone computed tomography (CT) scans as part of their preoperative workup. SQA measurements were taken in the clinic and in the operating room after the induction of general anesthesia. Using these CT scans, we measured the TT-TG distance, Caton-Deschamps index (CDI), and lateral trochlear inclination (LTI). Results: The correlation coefficient (R2) between the SQA and the TT-TG distance was 0.03 (β = 0.18) for awake patients, and 0.15 (β = 0.39) for anesthetized patients. When the CDI was <1.2, the correlation was stronger in anesthetized patients (R2 = 0.32; β = 0.56) than in awake patients (R2 = 0.06; β = 0.24). Similarly, when the LTI was >11°, the correlation was greater in anesthetized patients (R2 = 0.27; β = 0.52) than in awake patients (R2 = 0.02; β = 0.12). The correlation between the SQA and the TT-TG distance was strongest in anesthetized patients with both a CDI of <1.2 and an LTI of >11° (R2 = 0.57; β = 0.76). Conclusion: We observed a strong positive correlation between the SQA and the TT-TG distance in anesthetized patients with normal patellar height and a normal LTI. However, in awake patients and those with anatomic risk factors for recurrent patellar instability, correlations between the SQA and the TT-TG distance were weakly positive or nonsignificant. The SQA may provide useful information, but not in patients with anatomic findings that put them at increased risk for patellofemoral instability.

Study Design: Retrospective cohort study. Objective: The purpose was to compare rates of postoperative ED visits, readmission, and reoperation between patients with and without preexisting mental illness undergoing outpatient anterior cervical discectomy and fusion (ACDF). Methods: A retrospective review of the Mariner Database was conducted on patients who underwent ACDF between 2010 and 2017. Exclusion criteria included same day revision surgery and patients with a history of spine infection, trauma, or neoplasm. Patients were grouped into 3 categories: those with existing history of anxiety and/or depression, those with severe mental illness, and those without any history of mental illness. Severe mental illness was defined as a combination of diagnosis including schizophrenia, bipolar disorder, and/or psychotic disorder. Outcome measures were analyzed by comparing groups using multivariate logistic regression. Significance was set at P < 0.05. Results: Patients with anxiety/depression and patients with severe mental illness both had significantly increased risk of ED visits and readmission at 30-day and 90-day intervals. Compared to patients without mental illness, patients with severe mental illness (OR 1.93, P < 0.001) had significantly increased rates of reoperation at 90-days and 1-years postoperatively. Patients with anxiety/depression did not have increased rates of reoperation relative to patients without anxiety/depression at any time interval (P > 0.05). Conclusion: Anxiety/depression as well as more severe psychiatric disease such as Schizophrenia and Bipolar disorder were significantly associated with increased healthcare utilization following outpatient ACDF. Patients with preexisting mental illness undergoing outpatient ACDF should be carefully evaluated preoperatively and closely followed postoperatively to reduce risk of adverse events.

Category: Other Introduction/Purpose: There is little consensus on the effects of vitamin D on fracture healing. This review aims to clarify that effect in addition to determining trends in the classification of deficiency and supplementation. Methods: This systematic review searched Pubmed, Embase, and Web of Science for manuscripts related to vitamin D status/deficiency and fracture healing. Two independent reviewers screened articles, graded evidence quality, and extracted data. A total of 38 human studies, 11 in vivo studies and 14 systematic reviews were analyzed. Results: The median vitamin D deficiency prevalence reported amongst the human studies was 41.2% which is comparable to subset of patients with deficiency defined as <20 ng/mL, 43.3%. Amongst the 9 human studies reporting vitamin D supplementation, the exact dosage varied greatly. No RCTs reported any radiographic evidence of increased fracture union with any form of supplementation. Several RCTs reported reduction in pain with smaller daily supplementation compared to placebo or single large boluses. Animal studies reported mixed results, with some showing no significant effects of vitamin D status on the biomechanical properties of bone, while others demonstrated a correlation between supplementation improved biomechanical stiffness. Furthermore, the metabolite 24,25D may be a mediator in Vitamin D's probable osteoprotective effects. Conclusion: While the role of vitamin D in fracture healing appears to be osteoprotective in animal models, the degree and significance of its effects on human fracture healing and prevention remains inconclusive. We recommend standardizing the definitions for vitamin D deficiency to be <20 ng/mL for deficiency and >30 ng/mL for sufficiency. Although there is no radiographic evidence, daily smaller doses of vitamin D supplementation seem to have a stronger impact on clinical fracture healing than large boluses.

Category: Trauma; Ankle; Hindfoot Introduction/Purpose: The standardized identification of patients who are at higher risk of early postoperative adverse events has implications for quality improvement, preoperative medical optimization, and cost reduction through bundled payments. The purpose of the present study was to develop points-based risk stratification systems for predicting 30-day adverse events (AEs) and mortality after open fixation of periarticular hip, knee, and ankle fractures. Methods: Query of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database yielded 65,529 patients who underwent periarticular hip, knee, and ankle fracture repair from 2010-2019. We collected patient demographics and preoperative risk factors. To generate our risk stratification systems, 60% of patients were randomly designated as the development cohort and analyzed with multivariable regression plus bootstrap modeling to identify independent risk factors for early AE and mortality. A nomogram analysis was then conducted to assign scores for each risk factor and generate two points-based risk stratification systems, for AE and mortality. To validate our models, the systems were applied to the remaining 40% of patients (the validation cohort) and tested for predictive ability. Results: In total, 13,212 patients (20.2%) experienced any AE and 3,613 patients (5.5%) mortality within 30 days of fracture fixation. Patients were assigned points for each of the following in both risk stratification systems: fracture type (+4 hip, +2 knee, +0 ankle), male gender (+1), age (>=80 years +5, 60-79 years +3, 40-59 years +2), functionally dependent (+2), anemia (+2 for AE, +1 for mortality), pulmonary disease (+3 for AE, +1 for mortality), congestive heart failure (+3 for AE, +2 for mortality), and end- stage renal disease (+3 for AE, +1 for mortality). Corticosteroid use (+1), hypertension (+1), and insulin-dependent diabetes (+2) were additional predictors for only AEs. The AE and mortality models had maximum scores of 27 and 17 points, and Harrell C statistics of 0.66 and 0.75, respectively. The estimated risk of developing early AE ranged from 3.4-79.5% and mortality from 0.08- 54.4%. Conclusion: Fracture type, male gender, age >=40 years, corticosteroid use, functional dependence, anemia, hypertension, insulin-dependent diabetes, pulmonary disease, congestive heart failure, and end-stage renal disease can be used in the prediction of early AE or mortality following open fixation of periarticular lower extremity fractures, with a marked disparity in estimated risks depending on the number of risk factors possessed by a patient.

Category: Trauma; Ankle; Hindfoot; Other Introduction/Purpose: Race-based differences in the surgical management of hip fractures are well-established. Studies assessing these disparities for below-knee fractures have yet to be conducted despite their high volume. Our purpose was to determine whether 1) early postoperative complications and 2) time to surgery for operative fixation of below-knee fractures differ for black versus white patients, and to assess whether disparities exist between fracture subtypes. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients (>=18 years) undergoing open fixation of below-knee fractures between 2010-2019. This yielded 9,172 patients; 1,120 (12%) were black. We collected patient demographics and preoperative risk factors. Primary outcomes were 30-day postoperative complications and time to surgical fixation. Fractures were further subclassified as tibia and/or fibula shaft, isolated malleolar, bi/trimalleolar, and pilon fractures. Nearest-neighbor propensity score matching in a 1:1 ratio was applied to compare outcomes by race. Alpha = 0.05. Results: After matching, we identified 1,120 white patients with equal propensity scores as our black patients. Black patients had 1.5 times higher odds (95% confidence interval [CI]: 1.0-2.0) of experiencing any early adverse event when compared with matched white counterparts. Blacks also had 1.9 times higher odds (95% CI: 1.2-3.0) of requiring unplanned readmission within 30 days of operative fixation. Fifty-eight black patients (5.3%) required short-term readmission, compared with 351 white patients (4.5%) - 32 (2.9%) in the matched cohort. The most common reasons for readmission were wound, gastrointestinal, thromboembolic, and recurrent musculoskeletal complications for both races. There were no significant differences by race in time to surgery. Fracture subtype was not associated with postoperative complications or time to surgery in the multivariable analysis. Conclusion: Racial disparities in the early postoperative course after open fixation of below-knee fractures exist, with significantly higher rates of early adverse events and unplanned readmission for black versus white patients that persist after propensity matching. These trends may be secondary to a host of community- and hospital-level factors, illustrating the importance of interventions that consider the differences between hip and non-hip fractures and increase resources to vulnerable areas.

Background Acute kidney injury (AKI) following total joint arthroplasty (TJA) is associated with increased morbidity and mortality. Estimated glomerular filtration rate (eGFR) is used as an indicator of renal function. The purpose of this study was (1) to assess each of the five equations that are used in calculating eGFR, and (2) to evaluate which equation may best predict AKI in patients following TJA. Methods The National Surgical Quality Improvement Program (NSQIP) was queried for all 497,261 cases of TJA performed from 2012 to 2019 with complete data. The Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Cockcroft-Gault, Mayo quadratic, and Chronic Kidney Disease Epidemiology Collaboration equations were used to calculate preoperative eGFR. Two cohorts were created based on the development of postoperative AKI and were compared based on demographic and preoperative factors. Multivariate regression analysis was used to assess for independent associations between preoperative eGFR and postoperative renal failure for each equation. The Akaike information criterion (AIC) was used to evaluate predictive ability of the five equations. Results Seven hundred seventy-seven (0.16%) patients experienced AKI after TJA. The Cockcroft-Gault equation yielded the highest mean eGFR (98.6 ± 32.7), while the Re-expressed MDRD II equation yielded the lowest mean eGFR (75.1 ± 28.8). Multivariate regression analysis demonstrated that a decrease in preoperative eGFR was independently associated with an increased risk of developing postoperative AKI in all five equations. The AIC was the lowest in the Mayo equation. Conclusions Preoperative decrease in eGFR was independently associated with increased risk of postoperative AKI in all five equations. The Mayo equation was most predictive of the development of postoperative AKI following TJA. The mayo equation best identified patients with the highest risk of postoperative AKI, which may help providers make decisions on perioperative management in these patients.