Ivan J. Golub’s research while affiliated with Maimonides Medical Center and other places

Background Despite increased legalization, little is known about the influence of cannabis use disorder (CUD) following open reduction and internal fixation (ORIF) for distal radius fractures (DRFs). The aims were to determine whether CUD patients undergoing ORIF for DRF have increased: (1) medical complications; and (2) health care utilization (emergency department [ED] visits and readmission rates). Methods Patients were identified from an insurance database from 2010 to 2020 using Current Procedural Terminology codes: 25607, 25608, and 25609. Patients with a history of CUD were 1:5 ratio matched to controls by age, sex, tobacco use, alcohol abuse, opioid dependence, and comorbidities. This yielded 13,405 patients with (n = 2,297) and without (n = 11,108) CUD. Outcomes were to compare 90-day medical complications, ED visits, and readmissions. Multivariable logistic regression models computed the odds ratios of CUD on dependent variables. P values less than .005 were significant. Results The incidence of CUD among patients aged 20 to 69 years undergoing ORIF increased from 4.0% to 8.0% from 2010 to 2020 ( P < .001). Cannabis use disorder patients incurred significantly higher rates and odds of developing 90-day medical complications (15.24% vs 5.76%), including pneumoniae (3.66% vs 1.67%), cerebrovascular accidents (1.04% vs 0.32%), pulmonary emboli (0.57% vs 0.16%), respiratory failures (1.00% vs 0.48%), and surgical site infections (1.70% vs 1.04%; all P < .004). Emergency department visits (2.53% vs 1.14%) and readmission rates (5.79% vs 4.29%) within 90 days were higher among cannabis abusers. Conclusions With a greater number of states legalizing cannabis, hand surgeons should be cognizant of the association with increased 90-day complications and health care utilization parameters.

Introduction Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. Methods A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0–100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0–94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. Results Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs.$5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs.$10,462, p < 0.0001). Conclusions Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. Level of evidence III.

Abstract Introduction The incidence of osteonecrosis of the femoral head is estimated at about 10 to 20,000 patients annually, and, when left untreated, 80% or more of cases progress to femoral head collapse. A series of joint-preserving procedures have been developed to prevent/delay the need for hip arthroplasty. The aim of this study was to provide a five-year update: (1) evaluating temporal trends of arthroplasty vs. joint-preservation techniques such as core decompression, bone grafting, osteotomies, and arthroscopy; (2) determining proportions of procedures in patients aged less than vs. over 50 years; and (3) quantifying rates of specific operative techniques. Methods A total of 10,334 patients diagnosed with osteonecrosis of the femoral head and having received hip surgery were identified from a nationwide database between 1 January 2010 and 31 December 2019, by using the International Classification of Disease, the Ninth/Tenth revision (ICD-9/10) codes. The percentage of patients managed by each operative procedure was calculated annually. To identify trends, patients were grouped by age under/over 50 years and divided into a joint-preserving and a non-joint-preserving (arthroplasty) group. Chi-squared tests were performed to compare the total number of procedures per year. Results Rates of arthroplasty far exceeded those for joint-preserving procedures. However, from 2015 to 2019, significantly more joint-preserving procedures were performed than in 2010 to 2014 (4.3% vs. 3.0%, P

Purpose Clostridium difficile colitis is a serious complication in elderly patients undergoing surgery. The objectives of this study were: (1) to use a nationwide sample of patients to report the incidence and timing of C. difficile colitis in geriatric patients who underwent surgery for hip fractures, (2) to identify preoperative factors associated with developing C. difficile colitis and mortality. Methods This was a retrospective evaluation of the 2016–2019 ACS Targeted Hip Fracture database merged with the ACS-NSQIP database. Patients undergoing surgery for hip fracture were included. Outcomes studied were incidence, preoperative, and postoperative risk factors for occurrence of C. difficile infection and mortality. Chi-squared tests were used to compare demographics between the patients infected (study) and not infected (control). Logistic regression models were utilized to compute the odds ratios (OR) testing for the association of independent factors on developing C. difficile infection postoperatively and mortality. A statistical threshold was set at p < 0.008. Results The incidence of C. difficile infection within 30 days of hip fracture surgery was 0.81%. Fifty percent of infections were diagnosed within 9 days postoperatively. Preoperative and hospital-associated factors associated with development of C. difficile infection were ≥ 2 days until operation (OR 1.88 [95% CI 1.39–2.55], p < 0.001) and dependent functional status (OR 1.43 [95% CI 1.14–1.79], p = 0.002). After adjusting for multiple comorbidities, increased age, male sex, COPD, CHF, dependent functional status, and C. difficile infection were associated with increased mortality within 30 days of surgery (all p < 0.001). Conclusion Clostridium difficile colitis is a serious infection after hip fracture surgery in geriatric patients with an incidence of about 1%. Patients at increased risk should be targeted with preventative measures to prevent the morbidity from this complication.

Study design: Retrospective cohort study. Objectives: As of 2022, the Centers for Medicare and Medicaid Services does not provide nationwide coverage for cervical disc arthroplasty (CDA). The aim was to determine whether Medicare beneficiaries have differences in: (1) lengths of stay (LOS); (2) complications; (3) readmissions; and (4) costs of care. Methods: Using the 2010 to 2020 PearlDiver database, we queried patients undergoing primary CDA for degenerative disc pathology. Study groups patients were those undergoing CDA with Medicare coverage (n = 1467); patients without Medicare coverage were the comparison cohort (n = 15,389). Endpoints were to compare demographics and comorbidities within the Elixhauser comorbidity index (ECI), LOS, 90-day complications, 90-day readmissions, and 90-day reimbursements. A multivariate logistic regression was used to calculate odds (OR) of medical complications and readmissions within 90-days. A P-value less than .003 was significant. Results: Patients with Medicare coverage undergoing CDA had higher mean ECI compared to alternative payers (5.24 vs 3.26; P < .0001). Mean LOS was significantly higher for Medicare beneficiaries (2.20 vs 1.76 days; P < .010). There was no significant differences in odds of all medical complications (OR: 1.19, 95% CI: .98-1.44; P = .069) or readmission rates (1.77% vs 1.33%, OR:0.82, 95% CI: .50-1.29; P = .417) within 90-days following the index procedure among Medicare beneficiaries vs alternative payers. Non-Medicare beneficiaries had higher 90-day reimbursements compared to Medicare beneficiaries ($6,700 vs$7,086,P < .001). Conclusions: Medicare beneficiaries despite having slightly longer lengths of stay did not have higher rates of medical complications or readmissions. Surgeons and policy makers may use this data to consider alternative treatments in Medicare patients.

Objectives Despite lack of nationwide Medicare Coverage by the Centers for Medicare and Medicaid Services, the utilization of cervical disc arthroplasty (CDA) has risen in popularity. The purpose was to compare primary and revision cervical disc arthroplasty (CDA) from 2010 to 2020 with respect to: 1) utilization trends, 2) patient demographics; and 3) healthcare reimbursements. Methods Using the PearlDiver database, we studied patients undergoing primary and revision CDA for degenerative cervical disc pathology from 2010 to 2020. Endpoints of the study were to compare patient demographics (including Elixhauser Comorbidity Index (ECI)), annual utilization trends, lengths of stay (LOS), and reimbursements. Chi-square analyses compared patient demographics. T-tests compared LOS and reimbursements. A linear regression was used to evaluate for trends in procedural volume over time. P values <0.05 were statistically significant. Results In total, 15,306 patients underwent primary (n= 14,711) or revision CDA (n= 595). Patients undergoing revisions had a greater comorbidity burden (mean ECI= 4.16 vs 2.91; p<0.0001). From 2010 to 2020, primary CDA utilization increased by 413% (447 vs 2297 procedures; p<0.001); comparatively revision CDA utilization increased by 141% (32 vs 77 procedures; p<0.001). Mean LOS were greater for revision cases (1.37 vs 3.30 days, p<0.001). Reimbursements for revisions were higher on the day of surgery ($5,585 vs$13,692) and within 90 days of surgery ($7,031 vs$19,340), all p<0.0001. Conclusions There is a high rate of annual growth in CDA utilization and revision CDA in the United States. Reimbursements for revision CDA were more than double primary cases.

Objectives Interprosthetic femur fractures (IFF) present unique challenges to orthopaedic surgeons due to the preexisting implants in place, oftentimes advanced age and poor bone quality. Through the development of specific implants and improvement of fixation principles, management of this rare—yet growing—fracture pattern has progressed in recent decades to improve patient outcomes. This study’s aim was to identify patient-related outcomes after undergoing ORIF of interprosthetic femur fractures, including time to union, change in pre-operative ambulatory status, malunion/nonunion, surgical site infections, and revisions. Data sources A systematic review of published literature was conducted on Pubmed/MEDLINE and Cochrane Library databases for English language papers published with 12 studies meeting inclusion/exclusion criteria. Study selection Studies providing quantitative data comparing time to union, change in ambulatory status, surgical site infections, malunion/nonunion, revisions, and one-year mortality were used in the analysis. Studies lacking quantitative data were excluded. Data extraction 12 studies were included in this systematic review and graded by MINOR to identify potential biases. The aforementioned patient outcomes were calculated as mean values, ranges, and percentages. Data synthesis Time to union averaged 20.2 (range 6-28) weeks with roughly 18% of patients experiencing a decline in pre-operative ambulatory status. It was found 1.3% of patients experienced surgical site infections that were treated successfully either operatively or nonoperatively. Malunions and nonunions occurred in 1.63% and 6.12% of cases, respectively. Revisions were necessary in 12.6% of cases due to malunion, nonunion, and hardware failure. The one-year mortality rate was 12.8%. Conclusion Our review demonstrates that interprosthetic femur fractures continue to pose significant challenges in their treatment to both patients and orthopaedic surgeons. With the expected continued growth in the number of primary total hip and total knee arthroplasty performed annually, the incidence of interprosthetic femur fractures will continue to rise. Full femur spanning locked plating is currently the standard of care in fracture patterns with stable prostheses. Level of Evidence Therapeutic Level III

Introduction The World Health Organization (WHO) postulates that depressive disorders (DD) will be the leading cause of morbidity and mortality by 2030. Studies evaluating the association of DD following open reduction and internal fixation (ORIF) for the treatment of acetabular fractures are limited. Therefore, the purpose of this matched-control study was to determine whether DD patients undergoing ORIF for acetabular fractures have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmissions; (3) medical complications; and (4) costs of care. Materials and methods A retrospective query from the 100% Medicare Standard Analytical Files (SAF) was performed to identify patients who underwent ORIF for acetabular fractures. The study group consisted of those patients with DD, whereas patients without the condition served as controls. Primary endpoints of the study were to compare in-hospital LOS, readmission rates, ninety-day medical complications, and costs of care. A p-value less than 0.01 was considered statistically significant. Results The query yielded 7084 patients within the study (ORIF = 1187, control = 5897). DD patients were found to have significantly longer in-hospital LOS (11 days vs. 10 days, p < 0.0001); however, odds (OR) of readmission rates were similar (23.16 vs. 18.68%; OR: 0.91, p = 0.26). Multivariate regression demonstrated DD to be associated with significantly higher (67.69 vs. 25.54%; OR: 2.64, p < 0.0001) 90-day medical complications. DD patients had significantly higher day of surgery ($30,505.93 vs.$28,424.85, p < 0.0001) and total global 90-day costs ($41,721.98 vs.$37,330.16, p < 0.0001) of care. Conclusion After adjusting for covariates, DD is associated with longer in-hospital, complications, and costs of care in patients undergoing ORIF for the treatment of acetabular fractures, whereas readmission rates are similar. The study is vital as it can be used by orthopaedists and healthcare professionals to adequately educate these patients of the potential outcomes following their surgical procedure.

Introduction Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. Methods A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch’s t-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. Results There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs$5415.79, P < .0001). Conclusion This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Level of Evidence Therapeutic, Level IV: Retrospective