Carlos Ortiz-Babilonia

Purpose Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement. Methods Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7–12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program. Results From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, − 18.49% to − 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, − 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, − 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, − 1.83%) ≥ 13-level fusion. Fees for both 7–12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level. Conclusions Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012–2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted. Level of evidence III.

Category: Ankle Introduction/Purpose: Ankle fractures are common and can potentially lead to devastating consequences if not treated appropriately. The aim of this study was to assess trends in incidence, presentation, causes, and final disposition of emergency department visits for ankle fractures from 2019 to 2020. Methods: The National Electronic Injury Surveillance System (NEISS) database is a probability sample of hospitals in the United States. This sample was stratified and weighted based on ED size, which was used to generate national estimates (NE). The NEISS databases contains variables such as age, race, drug use, alcohol use, location, disposition, cause, body part, and injury type. The NEISS database from 2001 to 2020 was queried for patients who sustained an ankle fracture. Two cohorts: before COVID-19 (BC) (July 2019 - Dec 2019) and during COVID-19 (DC) (July 2020 - Dec 2020) were compared. Results: This study assessed 3,350 (NE: 131, 672) total patients who presented to emergency departments around the United States. 1,683 (NE: 17,936) patients presented BC and 1,667 (NE: 64,380) DC, representing a 4% decrease compared to the year before. The median age was 44 (Interquartile Range (IQR) 24-62), with 60% (NE: 79,051) females. On bivariate analysis, the rate of alcohol related ankle fractures increased (1.9% BC vs. 2.6% DC; p<0.001). Further, the number of ankle fractures at school (3% BC vs. 0.7% DC; p<0.001) and during sports (19% BC vs. 14% DC) decreased. Emergency departments visits leading to hospitalization increased (23% BC vs. 24% DC). The top three causes of ankle fracture during COVID-19 were stairs (NE 18,026, 28%), floors (NE 4,635, 7.2%), and skateboards (4.40%). The three largest increases in ankle fracture etiologies during COVID-19 were skateboards (+2.80%), floors (+1.10%), and powered scooters (+0.80%). Conclusion: There was a decrease in ankle fractures during the COVID-19 pandemic compared to the year before. Drug related fractures increased as did those resulting in hospitalization. Fractures caused by skateboards, powered scooters, and mopeds experienced an increase during COVID-19.

Background: Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. Results: We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event ( P < .001), deep surgical site infections (SSIs; P = .013), sepsis ( P = .001), 30-day readmission ( P < .001), and extended length of stay (LOS) ( P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event ( P < .001), deep SSIs ( P = .003), sepsis ( P = .001), readmission ( P < .001), and extended LOS ( P < .001). Both mild ( P = .004) and moderate to severe ( P < .001) anemia groups had higher odds of requiring a blood transfusion. Conclusion: Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes. Level of Evidence: Level III, comparative study.

Background: Randomized controlled trial (RCT) outcomes reaching statistical significance, frequently determined by P <.05, are often used to guide decision making. Noted lack of reproducibility of some RCTs has brought special attention to the limitations of this approach. In this meta-analysis, we assessed the robustness of RCTs evaluating platelet-rich plasma (PRP) for the treatment of chronic noninsertional Achilles tendinopathy (AT) by using fragility indices. Methods: The present study was a systematic review and meta-analysis of RCTs comparing outcomes after PRP injection vs alternative treatment in patients with AT. Representative data sets were generated for each reported continuous outcome event using summary statistics. Fragility indices refer to the minimal number of patients whose status would have to change from a nonevent to an event to turn a statistically significant result into a nonsignificant result, or vice versa. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively, by manipulating each data set until reversal of significance (a=0.05) was achieved. The corresponding fragility quotient (FQ) and continuous FQ (CFQ) were calculated by dividing FI/CFI by sample size. Results: Of 432 studies screened, 8 studies (52 outcome events) were included in this analysis. The 12 dichotomous outcomes had a median FI of 4.5 (FQ: 0.111), and the 40 continuous outcomes had a median CFI of 5 (CFQ: 0.154). All 52 outcome events included lost-to-follow-up data, and 12 (23.1%) indicated a greater number of patients lost to follow-up than the FI or CFI. Conclusion: Our findings suggest that RCTs evaluating PRP for AT therapy lack statistical robustness, because changing only a small number of events may alter outcome significance. Level of Evidence: Level II, therapeutic study.

Study Design: Systematic Review. Objectives: To synthesize previous studies evaluating racial disparities in spine surgery. Methods: We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay. Results: A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications. Conclusions: This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Background: There is limited research on the supply and distribution of orthopaedic surgeons in the United States. The goal of this study was to analyze the association of orthopaedic surgeon distribution in the United States with geographic and sociodemographic factors. Methods: County-level data from the US Department of Health and Human Services Area Health Resources Files were used to determine the density of orthopaedic surgeons across the United States on a county level. Data were examined from 2000 to 2019 to analyze trends over time. Bivariate and multivariable negative binomial regression models were constructed to identify county-level sociodemographic factors associated with orthopaedic surgeon density. Results: In 2019, 51% of the counties in the United States did not have an orthopaedic surgeon. Metropolitan counties had a mean of 22 orthopaedic surgeons per 100,000 persons while nonmetropolitan and rural counties had a mean of 2 and 0.1 orthopaedic surgeons per 100,000 persons, respectively. Over the past 2 decades, there was a significant increase in the percentage of orthopaedic surgeons in metropolitan counties (77% in 2000 vs 93% in 2019, P < 0.001) and in the proportion of orthopaedic surgeons 55 years and older (32% in 2000 vs 39% in 2019, P < 0.001). Orthopaedic surgeon density increased with increasing median home value (P < 0.001) and median household income (P < 0.001). Counties with a higher percentage of persons in poverty (P < 0.001) and higher unemployment rate (P < 0.001) and nonmetropolitan (P < 0.001) and rural (P < 0.001) counties had a lower density of orthopaedic surgeons. On multivariable analysis, a model consisting of median home value (P < 0.001), rural counties (P < 0.001), percentage of noninsured persons (P < 0.001), and percentage of foreign-born persons (P < 0.001) predicted orthopaedic surgeon density. Conclusion: Access to orthopaedic surgeons in the United States in rural areas is decreasing over time. County-level socioeconomic factors such as wealth and urbanization were found to be closely related with surgeon density.