Background: The comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool to reduce perioperative complications of geriatric patients, however there is no universally accepted standardization of CGA for orthopedic surgery. In this study, a novel CGA strategy was applied to evaluate the conditions of older patients undergoing orthopedic surgery from a broad view and to identify potential risk factors for postoperative complications. Methods: A prospective cohort study was conducted from March 2019 to December 2020.The study enrolled patients (age > 75 years) for elective or confined orthopedic surgery. All patients were treated by a multidisciplinary team. A structured CGA was conducted to identify high-risk older patients and to facilitate coordinated multidisciplinary team care by a geriatric team. The basic patient characteristics, CGA results, postoperative complication and mortality rates were collected. Multivariate logistic regression analysis was used to identify risk factors for postoperative complications. Results: A total of 214 patients with an age of 81.07 ± 4.78 (range, 75–100) years were prospectively enrolled in this study. In total, 66 (30.8%) complications were registered, including one death from myocardial infarction (mortality rate, 0.5%). Poor Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) were accompanied by frailty, worse perioperative risk, pain, and nutritional status. Poor ADL was also associated with higher risks of falling, polypharmacy, and cardiac and respiration complications. Poor IADL was associated with a higher risk of cardiac and respiration complications. Higher stroke risk was accompanied by higher risks of cardiac complications, delirium, and hemorrhage. Worse American Society of Anesthesiologists (ASA) score was associated with worse ADL, IADL, frailty, and higher delirium risk. Multivariate logistic regression analysis showed that spinal fusion (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.65 to 0.83; p = 0.0214), blood loss(OR, 1.68; 95% CI, 1.31 to 2.01; p = 0.0168), ADL (severe dysfunction or worse) (OR, 1.45; 95% CI, 1.16 to 1.81; p = 0.0413), IADL (serious dependence) (OR, 1.08; 95% CI, 1.33 to 1.63; p = 0.0436), renal function (chronic kidney disease (CKD) ≥ stage 3a) (OR, 2.01; 95% CI, 1.54 to 2.55; p = 0.0133), and malnutrition(OR, 2.11; 95% CI, 1.74 to 2.56; p = 0.0101) were independent risk factors for postoperative complications. Conclusion: The CGA process reduces patient mortality and increases safety in older orthopedic surgery patients. Spinal fusion, blood loss, ADL (severe dysfunction or worse), IADL (serious dependence), renal function (CKD ≥ stage 3a) and nutrition mini nutritional assessment (MNA) (malnourished) were independent risk factors of postoperative complications following orthopaedic surgery in older patients.

Background: Degenerative disorders of the lumbar spine decrease the mobility and quality of life of elderly patients. Lumbar fusion surgery is the primary method of treating degenerative lumbar spine disorders; however, the surgical stress response associated with major surgery has been linked to pathophysiological changes in the elderly, resulting in undesirable postoperative morbidity, complications, pain, fatigue, and extended convalescence. In the present study, we aimed to determine whether enhanced recovery after surgery significantly improved satisfaction and outcomes in elderly patients (> 65 years old) with short-level lumbar fusion. Methods: The study enrolled lumbar disc herniation or lumbar spinal stenosis patients if they were over the age of 65 years old underwent lumbar fusion at one or two levels. Data including demographic, comorbidity, and surgical information were collected from electronic medical records. Enhanced recovery after surgery interventions was categorized as preoperative, intraoperative, and postoperative. We also evaluated primary outcome, surgical complication, length of stay, postoperative pain scores, and 30-day readmission rates. Results: A total of 192 patients were included, 96 in the enhanced recovery after surgery group and 96 case-matched patients in the non- enhanced recovery after surgery group. There were no statistically significant intergroup differences in regards to demographics, comorbidities, American Society of Anaesthesiologists grade, or the number of fusion levels. There were also no differences between mean surgery time of intraoperative blood loss between the enhanced recovery after surgery and non- enhanced recovery after surgery groups. In addition, the mean preoperative Japanese Orthopaedic Association score, visual analog score for the back and legs, and Oswestry Disability Index score were not significantly different between the two groups. Overall, enhanced recovery after surgery pathway compliance was 92.1%. There were no significant differences in the number of complications or the mortality rates between the enhanced recovery after surgery and non-enhanced recovery after surgery groups. Furthermore, the mean postoperative Japanese Orthopaedic Association score, Visual analog score for the back and legs, Oswestry Disability Index score, and readmission rates score revealed no significant differences between the groups at 30-day follow-up point. However, we observed a statistically significant decrease in length of stay in the enhanced recovery after surgery group (12.30 ± 3.03 of enhanced recovery after surgery group versus 15.50 ± 1.88 in non- enhanced recovery after surgery group, p = 0). Multivariable linear regression showed that comorbidities (p = 0.023) and implementation of enhanced recovery after surgery program (p = 0.002) were correlated with prolonged length of stay. Multivariable logistic regression showed that no characteristics were associated with complications. Conclusions: This report describes the first enhanced recovery after surgery protocol used in elderly patients after short-level lumbar fusion surgery. Our enhanced recovery after surgery program is safe and could help decrease length of stay in elderly patients with short-level lumbar fusion.

Background: Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. Enhanced recovery after surgery (ERAS) can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains. Materials and methods: An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes, and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay after surgery. Results: A total of 245 patients (age of 79.8±3.4 year) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between nonfrail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery. Conclusion: Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.

Study design: Retrospective cohort study. Purpose: The aim of our study was to determine the rates and indications of reoperations following primary lumbar fusion, as well as the independent risk factors for early and late reoperation. Methods: We retrospectively reviewed patients who underwent lumbar fusion surgery between January 2017 and March 2020. All patients were followed up for more than 2 years. Characteristics, laboratory tests, primary diagnosis and surgery-related variables were compared among the early reoperation (< 3 months), the late reoperation (> 3 months) and the non-reoperation groups. Multivariable logistic regression analysis was used to identify independent risk factors for early and late reoperations. Results: Of 821 patients included in our studies, 34 patients underwent early reoperation, and 36 patients underwent late reoperation. The cumulative reoperation rate was about 4.1% (95% CI 3.8–4.5%) at 3 months, 6.2% (95% CI 5.9–6.5%) at 1 year and 8.2% (95% CI 8.0–8.5%) at 3 years. Multivariable analysis indicated that osteoporosis (odds ratio [OR] 3.6, 95% CI 1.2–10.5, p = 0.02) and diabetes (OR 2.1, 95% CI 1.1–4.5, p = 0.04) were independently associated with early reoperation and multilevel fusion (OR 2.4, 95% CI 1.1–5.4, p = 0.03) was independently associated with late reoperation. Conclusions: The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was independent risk factor for late reoperation. Surgeons should pay more attention to these patients, and future studies should consider the effects of follow-up periods on results.

Our previous study has reported the anti-tumor effect of oleandrin on osteosarcoma (OS) cells. In the current study, we mainly explored its potential regulation on intrinsic and extrinsic apoptotic pathway in OS cells. Cells apoptosis, reactive oxygen species (ROS) and mitochondrial membrane potential (MMP) were detected using fluorescence staining and flow cytometry. Caspase-3 activity was detected using a commercial kit. The levels of cytoplasmic cytochrome c, mitochondrial cytochrome c, bcl-2, bax, caspase-9, Fas, FasL, caspase-8 and caspase-3 were detected by Western blotting. z-VAD-fmk was applied to block both intrinsic and extrinsic apoptosis pathways, and cells apoptosis was also tested. Furthermore, we used z-LEHD-fmk and Fas blocking antibody to inhibit intrinsic and extrinsic pathways, separately, and the selectivity of oleandrin on these pathways was explored. Results showed that oleandrin induced the apoptosis of OS cells, which was accompanied by an increase in ROS and a decrease in MMP. Furthermore, cytochrome c level was reduced in mitochondria but elevated in the cytoplasm. Caspase-3 activity was enhanced by oleandrin in a concentration- and time-dependent manner. Oleandrin also down-regulated the expression of bcl-2, but up-regulated bax, caspase-9, Fas, FasL, caspase-8 and caspase-3. In addition, the suppression of both apoptotic pathways by z-VAD-fmk greatly reverted the oleandrin-induced apoptosis. Moreover, the suppression of one pathway by a corresponding inhibitor did not affect the regulation of oleandrin on another pathway. Taken together, we concluded that oleandrin induced apoptosis of OS cells via activating both intrinsic and extrinsic apoptotic pathways.

Background: Wound complications are associated with worse satisfaction and additional costs in patients undergoing posterior lumbar fusion (PLF) surgery, and the relationship between enhanced recovery after surgery (ERAS) pathway and wound complications remains poorly characterized. Methods: In this retrospective single-center study, we compared 530 patients receiving ERAS pathway care with previous 530 patients in non-ERAS group. The primary aim of our study was to identify the relationship between the ERAS program and the incidence of postoperative wound-related complications and other complications following PLF surgery; other outcomes included the length of stay (LOS), 90-day hospital and rehabilitation center readmission. Results: The average patient age was 65 yr. More patients with old cerebral infarction were in ERAS group (p < 0.01), and other demographics and comorbidities were similar between groups. Patients in the ERAS group had a lower incidence of postoperative wound-related complications than the non-ERAS group (12.4 vs. 17.8%, p = 0.02). The non-ERAS group had a significantly higher rate of wound dehiscence or poor wound healing (6% vs. 3%, p = 0.02). ERAS group had a lower incidence of severe postoperative hypoalbuminemia (serum albumin less than 30 g/L) (15.8% vs. 9.0% p < 0.01). Additionally, ERAS patients had shorter postoperative LOS (8.0 ± 1.5 vs. 9.5 ± 1.7, p < 0.01), lower rate of readmission within 90 days (1.9% vs. 6.4%, p < 0.01) and discharge to rehabilitation center (4.2% vs. 1.0%, p < 0.01). Conclusion: ERAS pathway might help decrease the rates of postoperative wound complications and severe hypoalbuminemia following PLF surgery; additionally, it demonstrated that ERAS pathway was also associated with shorter LOS and lower rate of readmissions within 90 days.