Publications by authors named "Ian Chow"

22 Publications

  • Page 1 of 1

Opioid-Prescribing Practices in Plastic Surgery: A Juxtaposition of Attendings and Trainees.

Aesthetic Plast Surg 2020 04 6;44(2):595-603. Epub 2020 Jan 6.

Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, PA, 15261, USA.

Background: The rates of opioid abuse and overdose in America have risen in parallel with the rates of opioid prescribing by physicians. As such, we sought to examine the prescribing practices among plastic surgery attendings and trainees to determine the need for more thorough education.

Methods: A survey was distributed to all ACGME-accredited plastic surgery residency programs and included questions regarding opioid-prescribing practices and self-rated ability pertaining to opioid management. Trends in prescribing practices based on prescriber position were analyzed using cumulative odds ordinal logistic regression with proportional odds and Chi-squared tests for ordinal and nominal variables, respectively.

Results: We received 78 responses with a wide geographical representation from plastic surgery residency programs: 59% of respondents were male and 39.7% female, 29.5% were attendings, 26.9% senior residents, 29.5% junior residents, and 14.1% interns. Compared with attendings, interns prescribe fewer pills (p < 0.05) and were significantly more likely to prescribe oxycodone (p < 0.03). Junior residents were 4.49 times more likely (p = 0.012) and senior residents 3.65 times more likely (p = 0.029) to prescribe additional opioids to avoid phone calls and follow-up visits. Interns and senior residents were significantly less comfortable than attendings in managing patients requesting additional opioids (p < 0.02).

Conclusions: The results of this survey demonstrate that knowledge deficits do exist among trainees, and that trainees are significantly less comfortable than their attending counterparts with opioid prescribing and patient management. Therefore, the implementation of a thorough postoperative pain management education in residency may be a cogent strategy in mitigating the opioid crisis.

Level Of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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http://dx.doi.org/10.1007/s00266-019-01588-yDOI Listing
April 2020

Wound Complications, Additional Ventilation Requirement, Prolonged Stay, and Readmission in Primary Palatoplasty: A Risk Factor Analysis of 3616 Patients.

Plast Reconstr Surg 2019 11;144(5):1150-1157

From the Division of Plastic Surgery, Baylor Scott & White Health; the Division of Pediatric Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine; and the Department of Plastic Surgery, University of Pittsburgh.

Background: The present study examined risk factors associated with 30-day palatoplasty complications based on analysis of national data.

Methods: Primary palatoplasties were identified in the 2012 to 2015 Pediatric National Surgical Quality Improvement Program database. Cases were analyzed with multivariate regression to investigate predictors for wound healing complications, additional ventilation requirement, prolonged stay (>3 days), and readmission.

Results: In 3616 operations, mean age was 12.2 months and operative time was 135.4 minutes. The 30-day complication rate was 7.6 percent overall, including wound dehiscence/infection (3.4 percent), additional ventilation requirement (2.0 percent), and readmission (2.4 percent); 5.1 percent of patients required prolonged stays. Wound healing complications were not predicted by comorbidities. American Society of Anesthesiologists class 3 or greater (OR, 2.8; p = 0.033), neuromuscular disorder (OR, 3.5; p = 0.029), and nutritional support (OR, 2.9; p = 0.035) predicted additional ventilation requirement. Prolonged stays were predicted by requiring additional ventilation (OR, 14.7; p < 0.001) or American Society of Anesthesiologists class 3 or greater (OR, 1.8; p = 0.047), but preoperative ventilator dependence was protective (OR, 0.1; p = 0.012). Mean hospital stay was 1.6 days without an airway complication versus 5.0 days with. Readmissions were increased for patients requiring nutritional support (OR, 2.6; p = 0.025).

Conclusions: This study represents one of the largest cohorts of palatoplasty patients analyzed to date. It identifies what can be learned from a nonspecific 30-day registry regarding cleft outcomes and, from its limitations, discusses what the future of cleft outcomes research might entail.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000006163DOI Listing
November 2019

The Impact of Massive Weight Loss on Psychological Comorbidities: A Large, Retrospective Database Review.

Aesthetic Plast Surg 2019 12 9;43(6):1570-1574. Epub 2019 Oct 9.

University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, USA.

Background: The obese population has a higher incidence of mood disorders compared to individuals with normal body mass index (BMI). A better understanding of the unique psychosocial challenges faced by this patient population will allow physicians to better optimize patient psychosocial support systems perioperatively, as well as help the patient to maintain appropriate expectations.

Methods: A large, retrospective database of 1135 patients with greater than 50 pounds of weight loss was reviewed. Data were analyzed using a multinomial regression model to determine the influence of psychosocial factors on the incidence of depression and anxiety.

Results: Prior to massive weight loss, patients reported an overall incidence of depression and anxiety of 42.5% and 26.3%, respectively. Following massive weight loss, the incidence of depression decreased to 32.3% and the incidence of anxiety decreased to 22.0%. Patients with spousal support and with positive self-image were more likely to experience resolution of depression. Patients with positive self-image were likely to experience resolution of anxiety. Resolution of medical comorbidities correlated with a decrease in the rate of depression.

Conclusion: Depression and anxiety are prevalent in the massive weight loss patient population undergoing body contouring surgery. Support systems are a vital resource for patients with psychological comorbidities undergoing massive weight loss. Patients who have a positive self-image of themselves are more likely to experience resolution of psychological comorbidities. Physicians should consider recommending support groups and/or counseling in patients who have poor support and negative self-image.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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http://dx.doi.org/10.1007/s00266-019-01444-zDOI Listing
December 2019

Milestones in Plastic Surgery: Attending Assessment versus Resident Assessment.

Plast Reconstr Surg 2019 02;143(2):425e-432e

From the Department of Plastic Surgery, University of Pittsburgh; and the University of Pittsburgh School of Medicine.

Background: The Plastic Surgery Milestones Project was jointly conceived by the Accreditation Council for Graduate Medical Education and the American Board of Plastic Surgery as a tool to improve granularity in resident feedback. Resident self-evaluations were compared to attending clinical competency committee evaluations to gauge resident self-perceptions and understanding of the milestones framework.

Methods: Semiannual evaluations from June of 2014 to 2017 were analyzed and compared with corresponding resident self-evaluations from the 2015 to 2017 academic year at the University of Pittsburgh Medical Center. Evaluations were analyzed for overall trends in performance. The presence of systemic differences between each type of evaluation were determined using Student's t tests. Subgroup analysis using the chi-square test was performed to determine factors that may contribute to major assessment disparity (≥1).

Results: Six thousand two hundred seven milestones across 187 faculty evaluations and 3139 milestones across 106 resident self-evaluations were available for review. With the exception of postgraduate year-2 residents, residents rated themselves at a significantly lower level in the competencies of medical education and patient care. Postgraduate year, academic year timing, and Accreditation Council for Graduate Medical Education competency were associated with major assessment discrepancies.

Conclusions: Overall, resident and faculty evaluations at the authors' program were concordant, which demonstrates that residents are capable of accurately assessing their own abilities and understanding the milestones framework. Areas of discordance between resident and faculty evaluations fostered discussion between residents and faculty and have led to multiple changes in the authors' program. The introduction of self-evaluation tools at other programs may provide them with similar benefits.
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http://dx.doi.org/10.1097/PRS.0000000000005214DOI Listing
February 2019

Amputation-Site Soft-Tissue Restoration Using Adipose Stem Cell Therapy.

Plast Reconstr Surg 2018 11;142(5):1349-1352

From the Departments of Plastic Surgery, Psychiatry, Radiology, Rehabilitation Science and Technology, and Bioengineering, University of Pittsburgh; the VA Pittsburgh Healthcare System; the University of Pittsburgh McGowan Institute of Regenerative Medicine; the Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center; and New York University Langone Medical Center.

Soft-tissue deficits in amputation stumps can lead to significant pain and disability. An emerging treatment option is stem cell-enriched fat grafting. This is the first study assessing the potential for this treatment modality in lower extremity amputation sites. In this prospective cohort study, five injured military personnel suffering from pain and limited function at amputation sites were recruited. Fat grafting enriched with stromal vascular fraction was performed at amputation sites to provide additional subcutaneous tissue padding over bony structures. Outcomes measures included complications, demographic data, physical examination, cellular subpopulations, cell viability, graft volume retention, pain, Lower Extremity Functional Scale, Functional Mobility Assessment, 36-Item Short-Form Health Survey, and rates of depression. Follow-up was 2 years. There were no significant complications. Volume retention was 61.5 ± 24.0 percent. Overall cell viability of the stromal vascular fraction was significantly correlated with volume retention (p = 0.016). There was no significant correlation between percentage of adipose-derived stem cells or number of cells in the stromal vascular fraction and volume retention. There was a nonsignificant trend toward improvement in pain scores (3.0 ± 2.5 to 1.2 ± 1.6; p = 0.180 at 2 years). There were no significant changes in disability indexes. Results from this pilot study demonstrate that stromal vascular fraction-enriched fat grafting is a safe, novel modality for the treatment of symptomatic soft-tissue defects in traumatic lower extremity amputations. Volume retention can be anticipated at slightly over 60 percent. Further studies are needed to assess efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000004889DOI Listing
November 2018

Weather Patterns in the Prediction of Pediatric Dog Bites.

Clin Pediatr (Phila) 2019 Mar 29;58(3):354-357. Epub 2018 Oct 29.

Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine; Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.

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http://dx.doi.org/10.1177/0009922818809518DOI Listing
March 2019

Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty.

Plast Reconstr Surg 2018 04;141(4):892-901

Chicago, Ill.; and Baltimore, Md.

Background: Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications.

Methods: Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications.

Results: Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication.

Conclusions: When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004212DOI Listing
April 2018

Vasopressin stimulates the proliferation and differentiation of red blood cell precursors and improves recovery from anemia.

Sci Transl Med 2017 Nov;9(418)

Adult Stem Cell Section, Craniofacial and Skeletal Diseases Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health (NIH), Bethesda, MD 20892, USA.

Arginine vasopressin (AVP) made by hypothalamic neurons is released into the circulation to stimulate water resorption by the kidneys and restore water balance after blood loss. Patients who lack this antidiuretic hormone suffer from central diabetes insipidus. We observed that many of these patients were anemic and asked whether AVP might play a role in red blood cell (RBC) production. We found that all three AVP receptors are expressed in human and mouse hematopoietic stem and progenitor cells. The AVPR1B appears to play the most important role in regulating erythropoiesis in both human and mouse cells. AVP increases phosphorylation of signal transducer and activator of transcription 5, as erythropoietin (EPO) does. After sublethal irradiation, AVP-deficient Brattleboro rats showed delayed recovery of RBC numbers compared to control rats. In mouse models of anemia (induced by bleeding, irradiation, or increased destruction of circulating RBCs), AVP increased the number of circulating RBCs independently of EPO. In these models, AVP appears to jump-start peripheral blood cell replenishment until EPO can take over. We suggest that specific AVPR1B agonists might be used to induce fast RBC production after bleeding, drug toxicity, or chemotherapy.
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http://dx.doi.org/10.1126/scitranslmed.aao1632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309406PMC
November 2017

Evaluating the Rule of 10s in Cleft Lip Repair: Do Data Support Dogma?

Plast Reconstr Surg 2016 Sep;138(3):670-679

Chicago, Ill.; and Baltimore, Md.

Background: Cleft lip represents one of the most common birth defects in the world. Although the timing of cleft lip repair is contingent on a number of factors, the "rule of 10s" remains a frequently quoted safety benchmark. Initially reported by Wilhelmsen and Musgrave in 1966 and modified by Millard in 1976, this rule referred to performing surgery once patients had reached cutoffs in weight, hemoglobin, and age/leukocyte count. Despite significant advances in both surgical and anesthetic technique, the oft-quoted "rule of 10s" has not been systematically investigated since its inception.

Methods: Patients who underwent primary cleft lip repair were identified from the National Surgical Quality Improvement Program Pediatric database. Multivariate logistic regression models were used to determine the independent effect of each rule of 10 metric or violation of the rule of 10s as a whole on postoperative complications, and to determine independent risk factors for complications in cleft lip surgery.

Results: One thousand three hundred thirteen patients met inclusion criteria, with a 3.6 percent complication rate. Of the included patients, 151 (11.5 percent) violated at least one facet of the rule of 10s. Other than patient weight, neither the rule of 10s nor any individual metric was significantly predictive of postoperative complications.

Conclusions: Since its introduction nearly a half century ago, the risks associated with performing surgery in patients who violate the rule of 10s has undergone dramatic reductions. This analysis highlights the need to continually validate and evaluate dogma as the field continues to advance.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000002476DOI Listing
September 2016

Reply: Is There a Safe Lipoaspirate Volume? A Risk Assessment Model of Liposuction Volume as a Function of Body Mass Index.

Plast Reconstr Surg 2016 Apr;137(4):756e-758e

Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill.

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http://dx.doi.org/10.1097/01.prs.0000480035.97330.6bDOI Listing
April 2016

Predictors of 30-day readmission after mastectomy: A multi-institutional analysis of 21,271 patients.

Breast Dis 2015 ;35(4):221-31

Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Background: Recent healthcare legislation has made unplanned hospital readmission an important metric of health care quality, and current efforts center on reducing this complication in order to avoid fiduciary penalties.

Objective: There is currently a paucity of data delineating risk factors for readmission following mastectomy. To this end, we sought to develop a predictive model of unplanned readmissions following mastectomy.

Methods: The 2011 and 2012 National Surgical Quality Improvement Program (NSQIP) datasets were retrospectively queried to identify patients who underwent mastectomy. Multivariate logistic regression modeling was used to identify risk factors for readmission.

Results: Of 21,271 patients meeting inclusion criteria, 1,190 (5.59%) were readmitted. The most commonly cited reasons for readmission included surgical site complications (32.85%), infection not localized to the surgical site (2.72%), and venous thromboembolism (4.39%). Independent predictors of readmission included BMI, active smoking status, and skin-sparing mastectomy. Significantly, concurrent breast reconstruction and bilateral mastectomy were not independent predictors of readmission.

Conclusions: This is the first study of readmission rates after mastectomy. Awareness of specific risk factors for readmission, particularly those that are modifiable, may serve to identify and manage high risk patients, aid in the development of pre- and postoperative clinical care guidelines, and ultimately improve patient care.
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http://dx.doi.org/10.3233/BD-150412DOI Listing
September 2016

Is There a Safe Lipoaspirate Volume? A Risk Assessment Model of Liposuction Volume as a Function of Body Mass Index.

Plast Reconstr Surg 2015 Sep;136(3):474-483

Chicago, Ill.; and Allentown, Pa. From the Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine; the American Society of Plastic Surgeons; Cosmetic & Reconstructive Specialists of the Lehigh Valley, Lehigh Valley Health Network; and the Division of Plastic Surgery, University of Illinois.

Background: No concrete data exist to support a specific volume at which liposuction becomes unsafe; surgeons rely on their own estimates, professional organization advisories, or institutional or government-imposed restrictions. This study represents the first attempt to quantify the comprehensive risk associated with varying liposuction volumes and its interaction with body mass index.

Methods: Suction-assisted lipectomies were identified from the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models incorporating the interaction between liposuction volume and body mass index were used to assess the influence of liposuction volume on complications and to develop a tool that returns a single adjusted odds ratio for any combination of body mass index and liposuction volume. Recursive partitioning was used to determine whether exceeding a threshold in liposuction volume per body mass index unit significantly increased complications.

Results: Sixty-nine of 4534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Liposuction volume and body mass index were significant independent risk factors for complications. With progressively higher volumes, increasing body mass index reduced risk (OR, 0.99; 95 percent CI, 0.98 to 0.99; p = 0.007). Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (OR, 4.58; 95 percent CI, 2.60 to 8.05; p < 0.001).

Conclusions: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors' risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index confer an increased risk of complications.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000001498DOI Listing
September 2015

Assessing the Impact of Blood Loss in Cranial Vault Remodeling: A Risk Assessment Model Using the 2012 to 2013 Pediatric National Surgical Quality Improvement Program Data Sets.

Plast Reconstr Surg 2015 Dec;136(6):1249-1260

Chicago, Ill. From the Division of Pediatric Plastic Surgery, Lurie Children's Hospital of Northwestern Feinberg School of Medicine.

Background: Most cranial vault remodeling for craniosynostosis is associated with substantial blood loss necessitating transfusion. The transfusion of over 25 ml/kg of red blood cells has long been considered an important safety threshold and has been proposed as a potential marker of health care quality, despite a lack of evidence. The authors sought to ascertain risk factors for transfusion in cranial vault remodeling and to quantify the effect of transfusion volume on postoperative complications.

Methods: Patients who underwent complex cranial vault remodeling for craniosynostosis were identified from the Pediatric National Surgical Quality Improvement Program database. Multivariate regression models were used to identify independent risk factors for transfusion and to assess its impact on subsequent outcomes.

Results: One thousand fifty-nine patients met inclusion criteria. Seven hundred seventy-seven patients (73.4 percent) required a transfusion and 520 patients (49.1 percent) required a transfusion in excess of 25 ml/kg. Neither transfusion nor transfusion volume in excess of 25 ml/kg had a significant effect on postoperative outcomes. Therefore, the authors sought to determine a more meaningful threshold. The top 20 percent of transfusion volumes were greater than or equal to 45.28 ml/kg. Recursive partitioning generated a threshold of 62.52 ml/kg, which independently predicted a greater number of complications and was associated with higher odds ratios than the quintile method. A threshold of 60 ml/kg was chosen for simplicity and was independently predictive of overall complications, medical complications, and increased length of stay.

Conclusions: Transfusion is common in complex cranial vault remodeling. Currently described occurrence thresholds do not accurately convey postoperative risk. Transfusion in excess of 60 ml/kg significantly increases risk for complications and length of stay in cranial vault remodeling.
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http://dx.doi.org/10.1097/PRS.0000000000001783DOI Listing
December 2015

Assessing the Rates, Predictors, and Complications of Blood Transfusion Volume in Posterior Arthrodesis for Adolescent Idiopathic Scoliosis.

Spine (Phila Pa 1976) 2015 Sep;40(18):1422-30

*Center for Children, NYU Hospital for Joint Diseases, New York, NY; and †Northwestern University Feinberg School of Medicine, Chicago, IL.

Study Design: Retrospective cohort study.

Objective: To determine predictors of and 30-day complications associated with blood transfusion volume after posterior spinal fusion for adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume.

Methods: Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program pediatric database from 2012 to 2013. Patients were stratified on the basis of blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates.

Results: A total of 1691 patients were included. Male sex (P = 0.010), esophageal or gastrointestinal disease (P = 0.016), cardiac risk factors (P = 0.037), preoperative inotrope requirement (P = 0.031), total operative time of 300 minutes or more (P < 0.001), and posterior arthrodesis of 13 or more vertebral segments (P < 0.001) were independent risk factors for requiring blood transfusion. Total transfusion volume of 20 mL/kg or more was the minimum volume independently associated with increased rates of total complications (P = 0.018), with a complication rate of 5.9%.

Conclusion: We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications after posterior arthrodesis for AIS. Although transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000001019DOI Listing
September 2015

The Effect of Body Mass Index on Postoperative Morbidity After Orthopaedic Surgery in Children With Cerebral Palsy.

J Pediatr Orthop 2016 Jul-Aug;36(5):505-10

*Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL †Center for Children, NYU Hospital for Joint Diseases, New York, NY.

Background: Although a plethora of literature exists on the impact of body mass index (BMI) in orthopaedic surgery, few have examined its implications in the pediatric cerebral palsy (CP) population. The aim of this study is to evaluate the effect of BMI class on 30-day complications after orthopaedic surgery on children with CP.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric participant use files from 2012 to 2013 was conducted. Patients with a diagnosis of CP undergoing any orthopaedic procedure were included and subclassified according to BMI classes: underweight, normal weight, overweight, and obese. Multivariate logistic regressions were performed to evaluate the independent effect of BMI class on total, surgical site, and medical complications as well as unplanned reoperations.

Results: A total of 1746 patients were included in our study. These included 345 (19.8%) underweight, 952 (54.5%) normal weight, 209 (12.8%) overweight, and 240 (13.7%) obese children and adolescents. In hip and lower extremity osteotomies, underweight class was an independent risk factor for total complications (P=0.037) and medical complications (P=0.031). Similarly, underweight class was a risk factor for total complications (P=0.022) and medical complications (P=0.019) in spine procedures. Weight class was not independently associated with complications in tendon procedures. Overweight and obesity classes were not associated with any independent increased risk for complications.

Conclusions: With respect to the pediatric CP population, underweight status was deemed an independent predictor of increased complications in osteotomies and spine surgery with no independent increased risk in the overweight or obese cohorts. This information can greatly aid providers with risk stratification, preoperative counseling, and postoperative monitoring as it relates to orthopaedic surgery.

Level Of Evidence: Level III-Prognostic.
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http://dx.doi.org/10.1097/BPO.0000000000000475DOI Listing
April 2017

A Predictive Risk Index for 30-day Readmissions Following Surgical Treatment of Pediatric Scoliosis.

J Pediatr Orthop 2016 Mar;36(2):187-92

*Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, IL †Center for Children, NYU Hospital for Joint Diseases, New York, NY.

Background: Pediatric scoliosis often requires operative treatment, yet few studies have examined readmission rates in this patient population. The purpose of this study is to examine the incidence, reasons, and independent risk factors for 30-day unplanned readmissions following scoliosis surgery.

Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric database from 2012 to 2013 was performed. Patients undergoing spinal arthrodesis for progressive infantile scoliosis, idiopathic scoliosis, or scoliosis due to other medical conditions were identified and divided between 2 groups: patients with unplanned 30-day readmissions (Readmitted) and patients with no unplanned readmissions (Non-Readmitted). Multivariate logistic regression models were created to determine independent risk factors for readmissions.

Results: A total of 3482 children were identified, of which 120 (3.4%) had an unplanned readmission. A majority of patients had a readmission due to a surgical site complication regardless of scoliosis etiology. Risk factors for readmission included obesity (P<0.001) and posterior fusion of 13 or more vertebrae (P=0.029) for idiopathic scoliosis, impaired cognition (P=0.009) for progressive infantile scoliosis, and pelvic fixation (P=0.025) and American Society of Anesthesiologist ≥3 (P=0.048) for scoliosis due to other conditions.

Conclusions: We present 30-day readmissions risk factors based on independent patient and procedural risk factors. This may be useful in the clinical management of patients following scoliosis surgery, specifically for the role of preoperative and predischarge risk stratification.
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http://dx.doi.org/10.1097/BPO.0000000000000423DOI Listing
March 2016

Short stem metaphyseal-engaging femoral implants: a case-controlled radiographic and clinical evaluation with eight year follow-up.

J Arthroplasty 2015 Apr 10;30(4):600-6. Epub 2014 Jan 10.

Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

A prospective comparison of 148 hips in 139 consecutive patients treated with an off-the-shelf uncemented metaphyseal engaging (91-105 mm) stem and 69 hips in 61 patients treated with a custom uncemented metaphyseal engaging short stem was conducted to evaluate the mid-term clinical and radiographic results of an off-the-shelf metaphyseal-engaging short stem implant. All implants were radiographically stable with proximal bony in-growth. There was no significant difference in post-operative HHS (P <. 001) or WOMAC scores (P < .001) between cohorts. An off-the-shelf short femoral stem designed to fit and fill the metaphysis provides reliable fixation up to eight years with equivalent clinical and radiographic results to a customized implant.
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http://dx.doi.org/10.1016/j.arth.2014.01.003DOI Listing
April 2015

Pre-existing lumbar spine diagnosis as a predictor of outcomes in National Football League athletes.

Am J Sports Med 2015 Apr 23;43(4):972-8. Epub 2015 Jan 23.

Department of Orthopaedic Surgery, NorthShore University, Chicago, Illinois, USA.

Background: It is currently unknown how pre-existing lumbar spine conditions may affect the medical evaluation, draft status, and subsequent career performance of National Football League (NFL) players.

Purpose: To determine if a pre-existing lumbar diagnosis affects a player's draft status or his performance and longevity in the NFL.

Study Design: Cohort study; Level 3.

Methods: The investigators evaluated the written medical evaluations and imaging reports of prospective NFL players from a single franchise during the NFL Scouting Combine from 2003 to 2011. Players with a reported lumbar spine diagnosis and with appropriate imaging were included in this study. Athletes were then matched to control draftees without a lumbar spine diagnosis by age, position, year, and round drafted. Career statistics and performance scores were calculated.

Results: Of a total of 2965 athletes evaluated, 414 were identified as having a pre-existing lumbar spine diagnosis. Players without a lumbar spine diagnosis were more likely to be drafted than were those with a diagnosis (80.2% vs. 61.1%, respectively, P < .001). Drafted athletes with pre-existing lumbar spine injuries had a decrease in the number of years played compared with the matched control group (4.0 vs. 4.3 years, respectively, P = .001), games played (46.5 vs. 50.8, respectively, P = .0001), and games started (28.1 vs. 30.6, respectively, P = .02) but not performance score (1.4 vs. 1.8, respectively, P = .13). Compared with controls, players were less likely to be drafted if they had been diagnosed with spondylosis (62.37% vs. 78.55%), a lumbar herniated disc (60.27% vs. 78.43%), or spondylolysis with or without spondylolisthesis (64.44% vs. 78.15%) (P < .001 for all), but there was no appreciable effect on career performance; however, the diagnosis of spondylolysis was associated with a decrease in career longevity (P < .05). Notably, 2 athletes who had undergone posterior lateral lumbar fusion were drafted. One played in 125 games, and the other is still active and has played in 108 games.

Conclusion: The data in this study suggest that athletes with pre-existing lumbar spine conditions were less likely to be drafted and that the diagnosis is associated with a decrease in career longevity but not performance. Players with lumbar fusion have achieved successful careers in the NFL.
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http://dx.doi.org/10.1177/0363546514562548DOI Listing
April 2015

Preoperative predictors of increased hospital costs in elective anterior cervical fusions: a single-institution analysis of 1,082 patients.

Spine J 2015 May 20;15(5):841-8. Epub 2015 Jan 20.

Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, 676 North Saint Clair St, NMH/Arkes Family Pavilion Suite 1350, Chicago, IL 60611, USA. Electronic address:

Background Context: The frequency of anterior cervical fusion (ACF) surgery and total hospital costs in spine surgery have substantially increased in the last several years.

Purpose: To determine which patient comorbidities are associated with increased total hospital costs after elective one- or two-level ACFs.

Study Design/setting: Retrospective cohort analysis.

Patient Sample: Individuals who have undergone elective one- or two-level ACFs at our single institution. The total number of patients amounted to 1,082.

Outcome Measures: Total hospital costs during single admission.

Methods: Multivariate linear regression models were used to analyze independent effects of preoperative patient characteristics on total hospital costs. Univariate analysis was used to examine association of these characteristics on operative time, length of hospital stay (LOS), and complications.

Results: Age, obesity, and diabetes were independently associated with increased average hospital costs of $1,404 (95% confidence interval [CI], $857-$1,951; p<.001), $681 (95% CI, $285-$1,076; p=.001), and $1,877 (95% CI, $726-$3,072; p=.001), respectively. Age was associated with increased LOS (p<.001) and complications (p<.001) but not operative time (p=.431). Diabetes was associated with increased LOS (p<.001) and complications (p=.042) but not operative time (p=.234). Obesity was not associated with increased LOS (p=.164), complications (p=.890), or operative time (p=.067).

Conclusions: This study highlights the patient comorbidities associated with increased hospital costs after one- or two-level ACFs and the potential drivers of these costs.
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http://dx.doi.org/10.1016/j.spinee.2015.01.022DOI Listing
May 2015

Surgeon specialty differences in single-level anterior cervical discectomy and fusion.

Spine (Phila Pa 1976) 2014 Sep;39(20):1648-55

From the Departments of *Orthopaedic Surgery and †Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Study Design: Retrospective cohort study.

Objective: To determine the impact of spine surgeon specialty on 30-day postoperative complication rates of single-level anterior cervical discectomy and fusions (ACDFs).

Summary Of Background Data: ACDFs are performed by both neurological and orthopedic surgeons. Although previous studies have examined preoperative risk factors for postoperative complications in ACDFs, no studies have shown the impact of surgical specialty on these variables.

Methods: All patients who underwent any single-level ACDF between 2006 and 2012 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity-score matching was used to reduce confounding preoperative differences. Baseline demographics, comorbidities, and complications were compared between the 2 surgical specialties using univariate analyses. Multivariate logistic regression models were created to isolate independent effects of surgeon specialty on complications.

Results: A total of 1944 patients undergoing single-level ACDFs were included in our analysis. Orthopedic surgeons and neurosurgeons performed 19.9% and 80.1% of ACDFs, respectively. Patients who underwent surgery by neurosurgeons had a higher number of comorbidities. After propensity matching, however, not all preoperative variables vary significantly between the specialty cohorts. Multivariate analysis of the propensity-matched groups revealed that for single-level ACDFs, treating physician cohort (orthopedic surgeons vs. neurosurgeons) was not associated with higher odds for overall complications (OR, 1.708; 95% CI, 0.849-3.436; P = 0.133), surgical site complications (OR, 0.869; 95% CI, 0.233-3.247; P = 0.835), or medical complications (OR, 1.863; 95% CI, 0.805-4.311; P = 0.146).

Conclusion: Spine surgeon specialty is not a risk factor for any reported postoperative complication in patients undergoing single-level ACDFs.

Level Of Evidence: 4.
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September 2014

The impact of a cervical spine diagnosis on the careers of National Football League athletes.

Spine (Phila Pa 1976) 2014 May;39(12):947-52

*Department of Orthopaedic Surgery, Northwestern University, Evanston, IL †Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH; and ‡Department of Orthopaedic Surgery, NorthShore University, Evanston, IL.

Study Design: Cohort study.

Objective: To determine the effect of cervical spine pathology on athletes entering the National Football League.

Summary Of Background Data: The association of symptomatic cervical spine pathology with American football athletes has been described; however, it is unknown how preexisting cervical spine pathology affects career performance of a National Football League player.

Methods: The medical evaluations and imaging reports of American football athletes from 2003 to 2011 during the combine were evaluated. Athletes with a cervical spine diagnosis were matched to controls and career statistics were compiled.

Results: Of a total of 2965 evaluated athletes, 143 players met the inclusion criteria. Athletes who attended the National Football League combine without a cervical spine diagnosis were more likely to be drafted than those with a diagnosis (P = 0.001). Players with a cervical spine diagnosis had a decreased total games played (P = 0.01). There was no difference in the number of games started (P = 0.08) or performance score (P = 0.38). In 10 athletes with a sagittal canal diameter of less than 10 mm, there was no difference in years, games played, games started, or performance score (P > 0.24). No neurological injury occurred during their careers. In 7 players who were drafted with a history of cervical spine surgery (4 anterior cervical discectomy and fusion, 2 foraminotomy, and 1 suboccipital craniectomy with a C1 laminectomy), there was no difference in career longevity or performance when compared with matched controls.

Conclusion: This study suggests that athletes with preexisting cervical spine pathology were less likely to be drafted than controls. Players with preexisting cervical spine pathology demonstrated a shorter career than those without; however, statistically based performance and numbers of games started were not different. Players with cervical spinal stenosis and those with a history of previous surgery demonstrated no difference in performance-based outcomes and no reports of neurological injury during their careers.
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May 2014