Hustedt, Joshua W.

Introduction: More than 90% of orthopaedic surgery residents in the United States complete a fellowship program. While there is significant oversight of the educational process and rights of residents during residency, there is little standardization in fellowships in the United States. Applicants to fellowship need to be aware that they may be required to sign restrictive covenants (“non-competes”) as part of the fellowship application or acceptance process. These restrictive covenants may be designed to protect the business interests of the host institution but may affect the fellow's ability to obtain employment in a geographic region. Methods: A review of society websites designed to education fellowship applicants was reviewed. Information was gathered on whether the society provided information on restrictive covenants in fellowship programs. Results: There is little standardization of restrictive covenants in orthopedic fellowships in the United States. Only accredited fellowships prohibit restrictive covenants in orthopedic fellowships. Pediatrics is the only sub-specialty society that provides information to applicants on restrictive covenants for fellowship applicants. Conclusion: The current lack of standardization in the fellowship process means applicants need to be well versed in these restrictive covenants before applying. In turn, fellowships themselves, as well as subspecialty societies, should seek to be transparent in providing information on restrictive covenant requirements of their respective fellowships.

Objectives: Low serum albumin levels (hypoalbuminemia) have classically been used to identify malnutrition. The effect of increasing severity of malnutrition on postoperative outcomes in patients undergoing hip fracture surgery has not been well delineated on a large scale. Design: Retrospective. Setting: Multicenter. Patient/Participants: A total of 12,373 patients undergoing hip fracture surgery from 2006 to 2013 National Surgery Quality Improvement Project data were identified. Intervention: Patient demographic, comorbidity, and preoperative laboratory data and complication, reoperation, and readmission data were collected. Main Outcome Measurements: Multivariate logistic regression was used to determine the effect of increasing severity of malnutrition on rates of 30-day postoperative complications, readmissions, and reoperations. Results: A total of 12,373 hip fractures met inclusion criteria. A total of 6506 (52.6%) patients had normal albumin levels (albumin ≥3.5 g/dL), 3205 (25.9%) patients were mildly malnourished (albumin 3.1–3.49 g/dL), 2265 (18.3%) were moderately malnourished (albumin 2.4–3.1 g/dL), and 397 (3.2%) patients were severely malnourished (albumin <2.4 g/dL). Mean age was similar between the 4 cohorts (P < 0.001). Severe malnutrition was associated with a 2-fold increase in the odds of postoperative complications and mortality when compared with mild malnutrition (P < 0.001). Increasing severity of malnutrition was associated with significantly longer lengths of stay and higher odds of experiencing a related readmission (P < 0.001). Conclusions: Increasing severity of hypoalbuminemia is independently associated with poorer outcomes in the 30 days after hip fracture surgery. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Study Design: Retrospective cohort study. Objectives: Epidemiologic studies suggest that the prevalence of moderate to severe obstructive sleep apnea (OSA) is increasing. OSA has been linked to increased rates of postoperative complications following surgery. Large studies, however, regarding surgical outcomes in this patient population, particularly in the spine literature, are limited. Consequently, the purpose of this study was to assess the prevalence of and postoperative risks conferred by OSA in the elective spine population. Methods: Using data from the National Inpatient Sample from 2008 to 2012, an estimated 56 372 (5.1%) patients with OSA undergoing elective cervical and thoracolumbar spine surgery were selected and compared to 1 052 837 patients without OSA undergoing the same procedures. Our primary outcome measures included postoperative complication rates, inpatient mortality, length of stay, and total hospital charges. Results: Patients with OSA were, on average 2.6 years older than those without OSA ( P < .001) and had a higher comorbidity burden. The prevalence of OSA increased between 2008 and 2012 from 3.5% to 6.8%; P < .001. OSA was associated with a 3-fold increase in major complications ( P < .001) and was confirmed as an independent risk factor for major complications based on multivariate analysis (odds ratio [OR] = 2.82; 95% CI = 2.59-2.79; P < .001). Rates of deep venous thrombosis were doubled in patients with OSA. OSA was determined to be an independent predictor of pulmonary complications (OR = 2.69; 95% CI = 2.59-2.79; P < .001). OSA did not increase the risk of postoperative mortality. Conclusions: Patients with OSA often have multiple concomitant comorbidities and consequently are at increased risk of experiencing a more difficult postoperative course following elective spine surgery. Specifically, increased risks of pulmonary complications and deep venous thrombosis should be anticipated.