The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty

The Effect of Preoperative Medications on Length of Stay, Inpatient Pain, and Narcotics Consumption After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

To determine the association between preoperative medications and length of stay, inpatient pain, and narcotics consumption after a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Previous studies have identified risk factors for increased length of hospital stay, inpatient pain, and narcotics consumption. However, little is known regarding the effects of preoperative medications on outcomes after spine surgery.

METHODS

A prospectively maintained surgical database of patients undergoing primary, single-level MIS TLIF was retrospectively reviewed. Preoperative medications taken within 30 days before surgery were recorded for each patient and categorized by medication type. Poisson regression with robust error variance was used to determine the association between preoperative medications and length of stay, pain scores, and narcotics consumption. Multivariate analysis was performed using a backwards, stepwise regression to identify independent risk factors.

RESULTS

In total, 138 patients were included in this analysis. On bivariate analysis, benzodiazepines were associated with longer hospital stays [relative risk (RR)=2.03; P=0.031]. Benzodiazepines (RR=3.71; P<0.001) and preoperative narcotics (RR=2.60; P=0.012) were risk factors for pain ≥7 on postoperative day 0. On multivariate analysis, benzodiazepines were an independent risk factor for prolonged stay. Benzodiazepines, narcotics, and nonsteroidal anti-inflammatories were identified as independent risk factors for increased postoperative pain.

CONCLUSIONS

These results suggest that benzodiazepines are a risk factor for increased length of stay and postoperative pain after MIS TLIF. Preoperative narcotics and nonsteroidal anti-inflammatories were also identified as risk factors for postoperative pain though this did not lead to increases in narcotics consumption. Patients taking these medications should undergo more vigilant perioperative monitoring for adequate pain management. More work must be done to further elucidate the association between preoperative medications and postoperative outcomes after MIS TLIF.

Facing the faceless patients - the emerging challenges of identity fraud in general surgery: A case series

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Identity fraud is becoming a more recognizable challenge, particularly with the introduction of electronic medical records.

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Particularly in surgery, identity fraud can result in significant harm to patients and burden to the health care system.

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Clinical vigilance and implementation of strategies to reduce system error can reduce the negative impact of identity fraud.

Introduction

This case series highlights the challenges faced in general surgery when encountering patients who use multiple false identities and provide unreliable histories.

Presentation of cases

We present two patients both with a background of mental health disorders and previous abdominal surgeries. After extensive workup with one patient almost proceeding to surgery, it was noted that these patients have had multiple presentations under different aliases to multiple different hospitals and had given inconsistent medical and surgical histories.

Discussion

In such patients, history and clinical examinations are unreliable. Medical records are also not helpful given the patients’ multiple aliases. Particularly in surgery, inaccurate knowledge of the patients’ previous operative details can lead to significant harms. Extensive investigations are usually performed in assessing these patients, resulting in excessive radiation exposure and incurring significant costs to the health system. It is also important to recognise the potential legal repercussions and harms to the patients who have had their identities stolen.

Conclusion

Identity fraud poses significant challenges to patient care, vigilance from clinicians and implementing strategies to reduce system error can help to limit harms to the patient and the health care system.

Mental health, preoperative disability, and postoperative outcomes in patients undergoing shoulder arthroplasty

BACKGROUND

Mental health conditions are associated with poor outcomes in patients with chronic disease as well as various orthopedic conditions. The purpose of this study was to describe the relationship between mental health, preoperative disability, and postoperative outcomes in patients undergoing shoulder arthroplasty.

METHODS

Data, including mental health diagnoses, were prospectively collected from patients undergoing total shoulder arthroplasty or reverse total shoulder arthroplasty from 2009 to 2015 at a single academic institution. Shoulder range of motion, visual analog scale, 12-Item Short Form Health Survey, and American Shoulder and Elbow Surgeons scores were collected preoperatively and at 1 and 2 years postoperatively. Data were analyzed using multivariate mixed-effect regression analysis.

RESULTS

The study included 280 patients, 105 (37.5%) of whom had a mental health diagnosis of depression, anxiety, schizophrenia, or bipolar disorder. Both groups of patients had similar shoulder range of motion, pain, and function before shoulder arthroplasty. Hospital length of stay, discharge destination, and readmissions were similar for both groups. There were similar improvements in pain, function, and range of motion after shoulder arthroplasty in patients with and without diagnosed mental health conditions.

CONCLUSIONS

Overall, the presence of a psychiatric diagnosis was not predictive of outcomes. Although psychiatric conditions are often considered surgical comorbidities, mental health diagnoses should not be a barrier to performing clinically indicated shoulder arthroplasty, because both groups of patients appear to benefit from pain relief and improved shoulder function.

Shoulder arthroplasty. Comorbidity as prognostic factor

Introduction

Preoperative comorbidity seems to be an important factor for the functional recovery of patients after shoulder replacement, but few studies support this correlation.The purpose of this study was to clinically evaluate the influence of comorbidity in restoring function after shoulder replacement.

Methods

We performed a retrospective analysis of shoulder replacement accomplished at our institution from 2005 to 2016 (n = 70). Demographic data, number of comorbidities, preoperative drugs, type of arthroplasty, and postoperative complications were collected. Functional results were evaluated according to the QuickDASH questionnaire.

Results

QuickDASH as continuous data was directly correlated with number of drugs prior to the surgical intervention (R = 0.270, p = 0.024) and number of comorbidities (R = 0.280, p = 0,016); especially neurological disorders (R = 0.338, p = 0.004) and osteoporosis (R = 0.0242, p = 0.043). The QuickDASH score is inversely correlated with patient satisfaction (R = -0.621, p < 0.01) and with gender (male) (R = -0.469, p < 0.001).When the patients were divided into 2 equally sized groups according to the QuickDASH score, statistical significance was found between the group with the worst outcome and female sex (91.2%) (p < 0.001), neurological disorders (p = 0.004), alcohol consumption (p = 0.028) and when shoulder arthroplasty is due to proximal humeral fracture (p = 0.002).

Conclusion

Better functional results are obtained in patients with less comorbidities.Worse functional results are obtained in patients taking more drugs, in women, alcohol consumers and those after proximal humeral fractures. Preoperative clinical status must be optimized and the patients' comorbidities should be carefully taken into accounting order to ascertain the correct shoulder arthroplasty.

Psychosocial Factors and Surgical Outcomes in Adult Spinal Deformity: Do Dementia Patients Have More Complications?

STUDY DESIGN

Retrospective analysis of a prospectively collected, national inpatient hospital database.

OBJECTIVE

We aimed to investigate comorbid psychiatric disorders in the adult spinal deformity (ASD) population. We hypothesized that a high incidence of comorbid psychiatric disorders in ASD would negatively impact perioperative outcomes.

SUMMARY OF BACKGROUND DATA

Patients with adult spinal fusion (ASF) suffer from severe back pain and often depression. Psychiatric comorbidities in the ASD population are not well understood, despite the apparent psychological effects of spinal deformity-related self-image.

METHODS

The Nationwide Inpatient Sample databases from 2001 to 2009 were queried for patients ages 18 years or older with in-hospital stays including a spine arthrodesis. Patients were divided into two groups: ASD (diagnosis of scoliosis, excluding neuromuscular and congenital) and all other ASF. Subjects were further stratified by presence of a comorbid psychiatric diagnosis. Differences between each surgical group in psychiatric frequency and complications were calculated using analysis of variance, adjusted for operative complexity. A binary logistic regression analyzed the association between psychiatric diagnoses and likelihood of complications.

RESULTS

A total of 3,366,352 ASF and 219,975 ASD patients were identified. The rate of comorbid psychiatric diagnoses in ASD was significantly higher (23.5%) compared to ASF patients (19.4%, P < 0.001). Complication rates were higher for ASD compared to ASF; patients without a psychiatric diagnosis had lower (or comparable) complication rates than psychiatric patients, across all disorder categories. Patients with psychotic disorders and dementia showed more complications than controls; patients with mood, anxiety and alcohol disorders showed fewer.

CONCLUSION

Psychiatric comorbidities are more common in the ASD population than in adult fusion patients. ASD and ASF patients with the most common psychiatric disorders (mood, anxiety, and alcohol abuse) are not at increased risk for complications compared to controls. Those patients with psychotic disorders and dementia are at a significant risk for increased complications and surgeons should be aware of these specific risks.

LEVEL OF EVIDENCE

2.

Impact of Psychiatric Illness on Outcomes After Operatively Managed Tibial Plateau Fractures (OTA-41)

OBJECTIVES

To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PATIENTS

Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis.

INTERVENTION

Surgical repair of tibial plateau fractures.

MAIN OUTCOME MEASURE

Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations).

RESULTS

Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041].

CONCLUSIONS

Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for failing to achieve improvement after anatomic total shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND

Although anatomic total shoulder arthroplasty (TSA) successfully improves pain and function, not all patients improve clinically. This study was conducted to determine patient-related factors for failure to achieve improvement after primary TSA for osteoarthritis at 2 years postoperatively.

METHODS

This prospective study reviewed an institutional shoulder registry for consecutive patients who underwent primary TSA for osteoarthritis from 2007 to 2013 with baseline and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form scores. A failed outcome was defined as (1) a failure to reach the ASES minimal clinically important difference of 16.1 points or (2) revision surgery within 2 years of the index procedure, or both. Univariate and multivariable analyses of clinical and demographic patient factors were performed using logistic regression.

RESULTS

Of 459 arthroplasties that met inclusion criteria, 411 were deemed successful by the aforementioned criteria, and 48 (10.5%) failed to achieve a desirable outcome. Clinical risk factors associated with failure included previous surgery to the shoulder (P = .047), presence of a torn rotator cuff (P = .025), and presence of diabetes (P = .036), after adjusting for age, sex, race, and body mass index. A higher preoperative ASES score at baseline was associated with failure (P < .001).

CONCLUSION

Previous shoulder surgery, a rotator cuff tear requiring repair during TSA, presence of diabetes, surgery on the nondominant arm, and a higher baseline ASES score were associated with a higher risk of failing to achieve improvement after anatomic TSA.

Impact of serious mental illness on surgical patient outcomes

BACKGROUND

People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system.

METHODS

Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined.

RESULTS

Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%).

CONCLUSION

Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.

Increased Complications for Schizophrenia and Bipolar Disorder Patients Undergoing Total Joint Arthroplasty

BACKGROUND

Although it has been shown that anxiety and depression are associated with increased complications after total joint arthroplasty (TJA), the outcomes of TJA in patients with a history of psychosis are unknown. This study evaluated the influence of bipolar and schizophrenic disorders on complications after TJA, particularly aseptic and septic revisions.

METHODS

A retrospective review of 156 TJAs (125 primaries and 31 revisions) was performed at a single institution from 2000 to 2015. Bipolar and schizophrenic patients were identified based on International Classification of Diseases, Ninth Revision codes or by those actively taking anti-psychotic medications, followed by manual chart review to confirm diagnoses. The psychosis patient cohort was matched 3:1 for a variety of factors. Revisions and readmissions were evaluated. Survivorship curves were generated.

RESULTS

Patients with schizophrenia or bipolar disorder had an increased odds of developing peri-prosthetic joint infection at 90 days (odds ratio [OR] 3.34, P = .049), 2 years (OR 3.94, P = .004), and at any time point (OR 4.32, P = .002). Psychosis patients had increased odds of aseptic and mechanical revisions at all endpoints, particularly from dislocation. Psychosis patients had a higher number of post-operative emergency department visits (P < .001), and were more likely to be discharged to a rehabilitation facility (P < .001).

CONCLUSIONS

Patients with bipolar affective disorder or schizophrenia may have multiple barriers to self-care after TJA, and are at an increased risk for undergoing revision TJA for prosthetic joint infection and mechanical causes. Increased pre-operative education and screening of this patient population may be necessary prior to performing TJA.

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

BACKGROUND

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

METHODS

The Medicare standard analytical files were queried using International Classification of Disease codes between 2005 and 2014 to identify patients undergoing primary TKA. Patients with a diagnosis of hypothyroidism were matched by age and gender on a 1:1 ratio. Ninety-day postoperative complication rates, day of surgery, and 90-day global period charges and reimbursements were compared between matched cohorts.

RESULTS

A total of 2,369,594 primary TKAs were identified between 2005 and 2014. After age and gender matching, each cohort consisted of 98,555 patients. Hypothyroidism was associated with greater odds of postoperative complications compared to matched controls (odds ratio 1.367, 95% confidence interval 1.322-1.413). The 90-day incidence of multiple postoperative medical and surgical complications, including periprosthetic joint infection, was higher among patients with hypothyroidism. Day of surgery and 90-day episode of care costs were significantly higher in the hypothyroidism cohort.

CONCLUSION

This study demonstrated an increased risk of multiple postoperative complications and higher costs among patients with hypothyroidism following primary TKA. Surgeons should counsel patients on these findings and seek preoperative optimization strategies to reduce these risks and lower costs in this patient population.

Psychological Factors Affecting Outcomes After Elective Shoulder Surgery

To optimize outcomes following elective shoulder surgery, it is important to address not only the injury or pathology itself, but also the cognitive and emotional factors that may influence a patient's recovery. Depression, anxiety, catastrophic thinking, distress, somatization, and decreased self-efficacy are among the most common psychological factors associated with adverse perioperative events and poor postoperative outcomes. Such factors may manifest at any point during recovery. Validated questionnaires can be used to measure psychological factors preoperatively, thereby enabling earlier intervention that may mitigate any potential negative effect of these factors on the patient's overall outcome. Orthopaedic surgeons must be sensitive to the influence of stress, distress, and limited coping strategies on patients and should learn how best to mitigate the detrimental effects of these factors on outcomes after elective shoulder surgery.

Safety of service users with severe mental illness receiving inpatient care on medical and surgical wards: A systematic review

This review aimed to synthesize the evidence on the likelihood of harm and mortality on medical and surgical inpatient wards for people with severe mental illness (SMI). From 937 results identified through database searching, and a further 10 papers identified through citation searching and hand searching, 11 papers met the criteria for inclusion in the final review. This review did not find strong evidence for higher in-hospital mortality in people with SMI. There was evidence that adverse events are higher in people with SMI. A higher likelihood of emergency instead of planned care, and poorer access to treatment were identified as potential contributing factors to these adverse events. In addition, service users with SMI were more likely to have a longer length of stay, associated with a higher cost of care. The severity of the mental illness increased the likelihood of harm or death, and people with schizophrenia were more likely than people with other mental illnesses to experience these adverse outcomes. There is evidence that people with SMI are provided with lower-quality health care, whereas higher-quality, better-planned care is required to overcome the inequalities in access faced by this vulnerable population.

Total Knee Arthroplasty: Does Day of Surgery Matter?

Introduction

There has been an influx of research studies aimed at identifying all factors that contribute to minimizing cost and maximizing postoperative care after total knee arthroplasty (TKA). Length of stay (LOS) has been defined as a significant factor that contributes to increased burden. We aimed at looking whether day of surgery has any significant effect on the LOS and postoperative complications following total knee arthroplasty (TKA).

Materials and methods

Retrospective cohort study done at the Aga Khan University Hospital, Pakistan, from January 2007 to December 2015. A total of 611 patients who underwent a unilateral or bilateral total knee arthroplasty (TKA) were included in study: 269 (44.0%) patients underwent unilateral TKA and 342 (56.0%) underwent a bilateral TKA.

Results

Kruskal-Wallis test and post hoc pairwise comparisons showed that unilateral TKAs performed on Tuesday, Saturday, and Sunday resulted in a lower median LOS (P < .05). No significant association was seen in bilateral TKA group. Day of surgery was not associated with postoperative complications.

Conclusions

Unilateral TKAs performed earlier during the week and later on the weekend are associated with a significantly lower LOS. It is highly probable that patch ancillary services during the latter part of the week and a higher workload for the staff are important reasons for this phenomenon.

The Role of Psychiatric Diagnoses for Outcome After Hip and Knee Arthroplasty

BACKGROUND

Surgical patients receiving psychopharmacologic treatment have been associated with adverse outcomes in total hip and knee arthroplasty (THA and TKA). The purpose of this study was to investigate whether a specific high-risk group of patients receiving psychopharmacologic treatment could be identified based upon a nationwide psychiatric diagnosis register.

METHODS

From 7 different orthopedic centers, 8288 THA and TKA patients were included from January 2010 to November 2012 of which 943 (11.4%) received psychopharmacologic treatment. Patients receiving preoperative psychopharmacologic treatment were divided into 2 groups based on the presence or absence of a psychiatric diagnosis in a nationwide administrative database and analyzed with respect to length of hospital stay (LOS >4 days) and 30- and 90-day readmissions using multivariable logistic regression models.

RESULTS

A total of 191 patients receiving psychopharmacologic treatment were registered with a psychiatric diagnosis while 752 patients received psychopharmacologic treatment without a registered psychiatric diagnosis. No significantly increased risk was found in patients with a preoperative registered psychiatric diagnosis compared to patients without, with regard to LOS >4 days (odds ratio [OR], 1.19; P = .51), 30-day readmission (OR, 0.56; P = .086), or 90-day readmission (OR, 0.81; P = .446), respectively. However, both groups had an increased risk of LOS >4 days and readmissions compared to a control population without psychopharmacologic treatment or any registered psychiatric diagnoses.

CONCLUSION

No further risk was found for psychopharmacologically treated THA/TKA patients with an additional hospital-related psychiatric diagnosis compared to patients without, suggesting that the psychopharmacologic treatment per se is an outcome risk factor independent of severity of the psychiatric disorder.

Determinants of patient satisfaction following reconstructive shoulder surgery

Background

Obtaining patient satisfaction is a key goal of surgical treatment. It was the purpose of this study to identify pre-, peri- and postoperative factors determining patient satisfaction after shoulder surgery, quantify their relative importance and thereby allow the surgeon to focus on parameters, which will influence patient satisfaction.

Methods

We retrospectively reviewed 505 patients, who underwent either rotator cuff repair (n = 216) or total shoulder arthroplasty (n = 289). We examined 21 patient-specific and socio-demographic parameters as well as 31 values of the Constant-Score with regard to their impact on patient satisfaction.

Results

In the univariable analysis higher patient satisfaction was correlated with higher age, private health insurance, light physical work, retirement, primary surgery, non-smoking, absence of chronic alcohol abuse, absence of peri- or postoperative complications, operation performed by the medical director as well as various Constant Score sub-values (p < 0.05). In the multivariable analysis absence of peri- or postoperative complications (p = 0.008), little postoperative pain (p = 0.0001), a large range of postoperative active abduction (p = 0.05) and a high postoperative subjective shoulder value (p = 0.0001) were identified as independent prognostic factors for high satisfaction.

Conclusion

After reconstructive shoulder surgery particular attention should be paid to prevention of complications, excellent perioperative pain control and restoration of abduction during rehabilitation. This study is first step towards a preoperative prediction model of a subjectively successful surgery as well as a tool to exclude irrelevant parameters in clinical routine.

Outcomes after traumatic injury in patients with preexisting psychiatric illness

BACKGROUND

Patients with psychiatric illness have been shown to experience higher rates of traumatic injury. Injury patterns, treatment decisions, and outcomes have not been well characterized in patients with psychiatric illness after injury, in particular those who undergo acute surgical intervention. The purpose of this analysis was to determine mortality, complications, and surgical intervention rates in patients with psychiatric illness after traumatic injury.

METHODS

This is a retrospective study of trauma patients ≥18 years old admitted to LAC + USC Medical Center between January 2008 and March 2015. Patients with psychiatric diagnoses were identified using ICD-9 diagnosis codes. Multivariate logistic regression analyses taking into account demographic and injury characteristics were used to identify associations between psychiatric comorbidity, injury mechanism, surgical interventions, and outcomes in patients after injury.

RESULTS

A total of 26,502 patients were analyzed. Of these, 3,040 (11.5%) had a documented psychiatric comorbidity (2.0% depressive disorder, 0.8% bipolar disorder, 1.3% schizophrenia, 0.5% anxiety disorder, 3.2% substance use disorder). Patients with psychiatric illness were significantly older (49.6 years vs. 42.0 years, p < 0.001), had a lower proportion of penetrating injuries (13.8% vs. 18.1%, p < 0.001), and had a higher incidence of self-inflicted injuries (11.6% vs. 0.72%, p < 0.001). No difference in gender distribution was observed (74.2% men vs. 74.4% men, p = 0.80). Overall mortality was similar in both groups (adjusted odds ratio [aOR], 0.73; p = 0.07). Patients with psychiatric illness were significantly less likely to undergo acute surgical intervention within 6 hours of emergency department admission (aOR, 0.64; p < 0.001). Time from ED arrival to consent for acute surgical intervention was similar in both groups (94.8 min vs. 93.0 min, p = 0.84). No significant difference in mortality after acute surgical intervention was observed (aOR, 0.26; p = 0.10). Psychiatric illness was associated with a significantly higher likelihood of developing complications (aOR, 1.90; p < 0.001) and longer hospital lengths of stay (10.6 days vs. 6.2 days, p < 0.001).

CONCLUSIONS

Trauma patients with comorbid psychiatric illness were observed to have lower rates of acute surgical interventions, higher complication rates, and longer hospital lengths of stay. Further studies are needed to better characterize the causative factors underlying these associations.

LEVEL OF EVIDENCE

Epidemiological, level III.

Related Research and Arthroscopy: Increasing the Breadth of Arthroscopy and Arthroscopy Techniques

An editorial goal is to increase the breadth of Arthroscopy and Arthroscopy Techniques. Our readers are more than arthroscopic surgeons and scientists. Rather, the health care providers and scientists who read our journals are, first and foremost, physicians, allied health practitioners, and academic intellectuals whose interests include improving individual and public health and welfare across a wide spectrum of scholarly topics. By reaching a broader audience, we hope to expand our contribution to arthroscopic and related surgery and continue to develop the potential of our subspecialty.

Humeral shaft fractures: union outcomes in a large cohort

BACKGROUND

Humeral shaft fractures can be managed conservatively or operatively. Fracture characteristics were analyzed to identify patients who would benefit from early operative fixation.

METHODS

We performed a retrospective cohort study of 126 consecutive humeral shaft fractures (2008-2015). Fractures were classified according to fracture type, location, separation, and comminution.

RESULTS

Of 126 patients, 96 were managed conservatively. In 54%, union occurred before 26 weeks, and 13% had delayed union after 26 weeks, whereas 33% did not achieve union. Of 30 patients managed surgically, 63% had union before 26 weeks, 33% had delayed union, and 4% did not achieve union. A statistically significant difference favored operative management. This difference was maintained in specific fracture patterns (simple and spiral fractures) and locations (proximal- or distal-third humeral fractures). Early surgery had a significantly higher union rate than delayed surgery. No difference was present between plate and nail fixation regarding union or neurologic injury. Separation of fragments, open injury, and comminution were not associated with nonunion. A psychiatric history (including psychotic disorders, bipolar disorder, multiple involuntary psychiatric admissions, or dementia) was significantly associated with nonunion after conservative management (P = .016). Two patients with dementia died after their conservatively managed fractures progressed to open injuries.

CONCLUSION

This study found high rates of delayed union and nonunion with conservative management. Patients with a significant psychiatric history may benefit from consideration of operative intervention.

Changes in Psychological Status and Health-Related Quality of Life Following Total Shoulder Arthroplasty

BACKGROUND

There has been little documentation of the effects of total shoulder arthroplasty (TSA) on psychological status and health-related quality of life (HRQoL). We investigated changes in psychological status (depression and anxiety) and HRQoL following TSA and assessed the effect of preoperative psychological status on postoperative clinical and functional outcome. We hypothesized that TSA would improve both psychological status and HRQoL.

METHODS

We prospectively enrolled 46 patients undergoing TSA for osteoarthritis. Preoperatively and at 3, 6, and 12 months postoperatively, all of the subjects completed the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons Scale (ASES), the Subjective Shoulder Value (SSV) measure, the Hospital Anxiety and Depression Scale (HADS), and the World Health Organization Quality of Life Scale Abbreviated Version (WHOQOL-BREF).

RESULTS

From 3 months after surgery, significant improvement in HADS-depression, HADS-anxiety, and WHOQOL-BREF scores as well as in the other outcome measures of VAS pain score, ASES score, and SSV were observed. The prevalence of depression and anxiety decreased from a rate of 15.2% and 19.5%, respectively, preoperatively to a rate of 6.5% for each at 12 months postoperatively. Preoperative HADS-depression and HADS-anxiety scores did not correlate with any of the clinical and functional outcome measures at 12 months after surgery.

CONCLUSIONS

This study showed significant improvement in psychological status and HRQoL as well as in pain and functional ability from 3 months after TSA in patients with osteoarthritis. Preoperative depression and anxiety did not predict poor postoperative outcome. Our findings suggest that TSA offers an excellent chance of improving psychological status and HRQoL.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Resilience correlates with outcomes after total shoulder arthroplasty

BACKGROUND

Resilience, characterized by an ability to bounce back or recover from stress, is increasingly recognized as a psychometric property affecting many outcomes' domains including quality of life, suicide risk in active-duty military personnel, and recovery in cancer patients. This study examines the correlation between resilience, as measured by the Brief Resilience Scale (BRS), and traditional outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn scores in patients undergoing total shoulder arthroplasty (TSA).

METHODS

Seventy patients undergoing primary anatomic TSA were followed up for a minimum of 2 years (mean, 30 ± 3 months). Patients were stratified into groups a priori, based on deviation from the mean of the BRS score, into low-resilience (LR), normal-resilience (NR), and high-resilience (HR) patients, and outcome scores were calculated for each group.

RESULTS

Postoperative BRS scores significantly correlated with ASES, Penn, and SANE scores (r = 0.41-0.44, P < .004 for all scores). When we evaluated patients based on resilience group, the LR group had a Penn score that was 34 points lower than that in the HR group. Likewise, the LR group had a SANE score that averaged 40 points lower than that in the HR group (SANE score of 53 points in LR group and 92 points in HR group, P = .05). When we evaluated ASES subscores, it appeared that the pain subscale was responsible for most of the difference between the LR and HR groups (29 points and 48 points [out of 50 points], respectively; P = .03).

CONCLUSIONS

Resilience is a major predictor of postoperative outcomes after TSA. Patients who are classified as having LR have outcome scores that are 30 to 40 points lower on traditional outcome scales than patients with HR.

Depression and Patient-Reported Outcomes Following Total Shoulder Arthroplasty

BACKGROUND

Recent studies have found that depression is associated with increased pain and impairment following lower-extremity arthroplasty; however, this association has not been investigated for total shoulder arthroplasty. The objective of this study was to investigate the association between depression and patient-reported outcomes following total shoulder arthroplasty.

METHODS

A prospectively collected institutional registry was queried for consecutive patients who underwent total shoulder arthroplasty for osteoarthritis from 2007 to 2013 with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores. Revision procedures and total shoulder arthroplasty for diagnoses other than osteoarthritis were excluded. Patients with a preoperative diagnosis of depression (n = 88) formed the study cohort; control patients without a diagnosis of depression were matched to the study patients by age and sex in a 2:1 ratio (n = 176). Baseline characteristics and patient-reported outcome measures were compared between groups, as were minimum 2-year patient-reported outcomes and change in patient-reported outcomes. A multivariable regression was performed to investigate the independent effect of depression on improvement in ASES scores.

RESULTS

Except for the Short Form-12 Mental Component Summary (SF-12 MCS) scores, there were no significant differences (p > 0.05) in baseline characteristics between study patients and controls. There was a significant improvement in the ASES score for patients with depression (p < 0.0001) and controls (p < 0.0001). Patients with depression had significantly lower final ASES scores (p = 0.001) and less improvement in ASES scores (p = 0.001) and SF-12 Physical Component Summary scores (p = 0.006) as well as lower satisfaction levels at 2 years; however, the latter difference did not reach clinical importance. Depression (p = 0.018) was an independent predictor of less improvement in ASES scores.

CONCLUSIONS

Patients with a diagnosis of depression should be counseled that they will experience a significant clinical improvement from baseline after total shoulder arthroplasty. A preoperative diagnosis of depression is an independent predictor of significantly less improvement in ASES scores following total shoulder arthroplasty; however, this difference does not reach clinical importance and should not discourage patients with a clinical diagnosis of depression from undergoing total shoulder arthroplasty.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intermediate-term outcome of hemiarthroplasty for comminuted proximal humerus fractures

BACKGROUND

The purpose of this study was to evaluate the outcome of hemiarthroplasty for comminuted proximal humerus fractures and to verify the risk factors for functional and radiologic outcomes.

MATERIALS AND METHODS

We treated 29 comminuted proximal humerus fractures by hemiarthroplasty with a low-profile prosthesis and a bone block graft, with an average follow-up period of 53.9 (24-119) months. The patients' mean age at surgery was 71.7 (52-85) years. We evaluated visual analog scale (VAS) scores for pain and satisfaction, active range of motion, modified University of California-Los Angeles (UCLA) score, and shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographs were checked for stem position, loosening, and tuberosity union. The statistical evaluation was conducted to compare 2 demographics.

RESULTS

The mean VAS score was 2.1 (0-5) for pain and 8.0 (4-10) for satisfaction. Mean active forward flexion was 125° (90°-170°); external rotation, 42° (25°-70°); and internal rotation, at T11 (T7-L2). The mean modified UCLA score was 20 (12-30), and the mean QuickDASH score was 25 (12-38). All stems were stable without any loosening. All tuberosities were united except 2 tuberosity absorptions.

DISCUSSION

Patients older than 70 years and patients with chronic debilitating disease, >5-mm displacement of the prosthetic head from the glenoid, and a critical shoulder angle of >38° showed significantly poorer clinical outcome.

CONCLUSION

Low-profile hemiarthroplasty with bone block graft had unique advantages for tuberosity union. During surgery, good prosthetic positioning with respect to the anatomic axis of the glenoid and critical shoulder angle (>38°) were essential. However, age (>70 years) and systemic comorbidity showed poor clinical outcome. These factors should be considered in standardizing the clinical results.

Early Postoperative Complications After Shoulder Arthroplasty in Patients With Epilepsy

Epilepsy is the most common serious neurological disorder in the United States, but little is known about its effect in the perioperative shoulder surgery setting. The authors sought to determine whether patients with epilepsy undergoing shoulder arthroplasty would be at increased risk for in-hospital adverse events, prolonged length of stay, and nonroutine disposition. Using the National Inpatient Sample (2002-2011), 422,371 adults undergoing shoulder arthroplasty were identified, 3714 (0.9%) of whom had epilepsy. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling. The authors found that patients with epilepsy were more likely to experience postoperative adverse events (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.54-1.84), including mechanical ventilation (OR, 3.91; 95% CI, 2.81-5.44), gastrointestinal complication (OR, 3.86; 95% CI, 2.78-5.37), deep venous thrombosis (OR, 3.23; 95% CI, 2.22-4.69), pneumonia (OR, 1.66; 95% CI, 1.35-2.04), posthemorrhagic anemia (OR, 1.57; 95% CI, 1.42-1.73), transfusion (OR, 1.56; 95% CI, 1.41-1.72), and acute renal failure (OR, 1.34; 95% CI, 1.04-1.74). An epilepsy diagnosis was also associated with increased odds for prolonged hospital stay (OR, 1.39; 95% CI, 1.28-1.52) and nonroutine discharge (OR, 1.80; 95% CI, 1.67-1.94). This study concludes that patients with epilepsy are at higher risk for early postoperative complications and resource use following shoulder arthroplasty surgery. Awareness of these risks may allow more targeted perioperative management of these patients to optimize postoperative outcomes and limit complications. [Orthopedics. 2016; 39(6):e1075-e1079.].

Psychiatric disorders increase complication rate after primary total knee arthroplasty

BACKGROUND

Psychiatric disease is difficult to screen preoperatively and the incidence of mental health disorders in patients undergoing total knee arthroplasty (TKA) may be underappreciated. The purpose of this study is to evaluate the perioperative complication profile in patients with psychiatric disorders.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed to identify patients who underwent primary TKA with bipolar disorder (20,972), depression (187,448), and schizophrenia (7607). A cohort of 1,271,464 patients as controls with minimum 2.5-year follow-up. Medial and surgical complications at 30-days, 90-days, and overall were compared between the two cohorts.

RESULTS

Patients with any psychiatric disease were more likely to be younger (age<65 OR 5.5, p<0.001), female (OR 2.61, p<0.001), and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, p<0.05). There was a significant increase (p<0.001) in 11/14 (78.5%) of recorded postoperative medical complication rates at 90-days. There was a statistically significant increase in periprosthetic infection (OR 2.17 p<0.001), periprosthetic fracture (OR 2.40, p<0.001), revision TKA (OR 2.06, p<0.001), and extensor mechanism rupture (OR 2.41, p<0.001) at 90day and overall time points.

CONCLUSIONS

Patients with psychiatric disorders who undergo elective primary TKA have significantly increased medical and surgical complication rates in the global period and short term follow-up. An ideal screening tool is yet to be determined and these patients need to be counseled appropriately regarding the increased complication rates before proceeding with TKA.

Psychiatric disease as a risk factor in fast-track hip and knee replacement

Recent studies suggest that patients with psychiatric disorders tend to do worse than patients without a psychiatric diagnosis when undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Whether this is due to their psychiatric condition, pharmacological treatment, a combination of the two, or something else has not been thoroughly analyzed-and there are no internationally accepted guidelines for perioperative management of psychiatric patients. This overview summarizes our current knowledge on perioperative risks in patients with preoperative psychiatric disorders and the possible role of psychotropic drugs in the perioperative course. This will be useful when planning future strategies for improvement of surgical outcome following hip and knee arthroplasty.

Should We Think Twice About Psychiatric Disease in Total Hip Arthroplasty?

BACKGROUND

Psychiatric disease (PD) is common, and the effect on complications in total hip arthroplasty (THA) is poorly understood. The purpose of this study was to evaluate the medical and surgical postoperative complication profile in patients with PD, and we hypothesize that they will be significantly increased compared with control group.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease version 9 codes to identify 86,976 patients who underwent primary THA with PD including bipolar (5626), depression (82,557), and schizophrenia (3776). A cohort of 590,689 served as a control with minimum 2-year follow-up. Medical and surgical complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts.

RESULTS

Patients with PD were more likely to be younger (age < 65 years; odds ratio [OR] = 4.51, P < .001), female (OR = 2.02, P < .001) and more medically complex (significant increase in 28/28 Elixhauser medical comorbidities, P < .001). There was a significant increase (P < .001) in 13/14 (92.8%) recorded postoperative medical complications rates at the 90-day time point. In addition, there was a statistically significant increase in periprosthetic infection (OR = 2.26, P < .001), periprosthetic fracture (OR = 2.09, P < .001), dislocation (OR = 2.30, P < .001), and THA revision (OR = 1.93, P < .001) at overall follow-up.

CONCLUSION

Patients with PD who undergo elective primary THA have significantly increased medical and surgical complication rates in the global period and short-term follow-up, and these patients need to be counseled accordingly.

Causes of poor postoperative improvement after reverse total shoulder arthroplasty

BACKGROUND

Although reverse total shoulder arthroplasty (RTSA) has been successful in improving pain and function in most patients, some patients fail to improve clinically. The present study used a large registry of RTSA patients to evaluate associations between patient-related factors and poor postoperative improvement after RTSA.

MATERIALS AND METHODS

A prospectively collected shoulder arthroplasty registry was queried for consecutive patients who underwent RTSA from 2007 to 2013. Patients with baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. Poor postoperative improvement was defined as a change in the ASES of less than 12 points. Multivariate logistic regression analysis was used to identify independent risk factors.

RESULTS

A total of 150 patients met inclusion and exclusion criteria. Logistic regression revealed that male sex (adjusted odds ratio [OR], 7.9; P = .004), presence of an intact rotator cuff at the time of surgery (adjusted OR, 4.8; P = .025), depression (adjusted OR, 11.2; P = .005), a higher baseline ASES score (P < .001), and higher total number of medical comorbidities (P = .035) were associated with poor postoperative improvement after RTSA.

CONCLUSIONS

Surrogates for better preoperative function after RTSA, such as a higher baseline ASES score and intact rotator cuff at the time of surgery, correlated with poor postoperative improvement. In addition, male sex, depression, and total number of medical comorbidities also correlated with poor postoperative improvement. Interestingly, factors such as patient age and indication for surgery were not found to correlate with poor improvement after RTSA.

Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty

BACKGROUND

With an increasingly large number of patients undergoing total shoulder arthroplasty (TSA) combined with increased requirements for public reporting of patient outcomes, there is a greater need to better understand the underlying factors related to patient satisfaction. The purpose of this study was to compare patient demographics, nonorthopedic comorbidities, patient-reported outcome scores, and range of motion of patients who reported being either satisfied or dissatisfied with their procedure at midterm follow-up.

METHODS

We identified 234 primary TSAs performed by a single surgeon for glenohumeral osteoarthritis with a minimum 2-year follow-up in a prospective shoulder arthroplasty registry. American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction, and active forward flexion, abduction, and external rotation at 0° of flexion-abduction were assessed before and after TSA.

RESULTS

Of the 234 patients, 207 (88.5%) were satisfied with their procedure. Dissatisfied patients had significantly lower ASES scores both before and after surgery (P < .001) as well as a significantly lower preoperative to postoperative change in ASES score (P < .001). Similarly, dissatisfied patients demonstrated significantly lower changes in active forward flexion (P = .004), abduction (P = .02), and external rotation (P = .03). Patients with ASES score changes <12 points were 19 times more likely to be dissatisfied after TSA (95% confidence interval, 4.4-81.4; P = .0001).

CONCLUSION

Dissatisfied patients had significantly lower improvements in pain, function, and range of motion. Furthermore, a change in ASES score <12 points was associated with a 19-fold increase in the risk of being dissatisfied after TSA.

Disorder-related risk factors for revision total hip arthroplasty after hip hemiarthroplasty in displaced femoral neck fracture patients: a nationwide population-based cohort study

Background

The choice of primary hip hemiarthroplasty or total hip arthroplasty for displaced femoral neck fracture is still controversial. Revision hip arthroplasty not only increases risk and cost but also could result in worse outcome. Determining the risk factors for revision can help inform medical decision-making and aid in risk stratification of publicly reported outcomes. Therefore, we conducted a nationwide population-based study to identify the disease-related risk factors and construct a risk score nomogram to predict revision surgery.

Methods

Records of all 68,030 femoral neck fracture patients receiving partial hemiarthroplasty (HA) in 2000–2010, with no total hip arthroplasty (THA) or revision HA history, were collected from the National Health Insurance Research Database. Cox proportional hazard regression was used to estimate the risk of revision hip replacement (RHA). The score of each risk factor was the quotient of the regression coefficient of the variable by the regression coefficient for a 10-year increase in age. The predictive accuracy was tested using the area under the receiver operating characteristic curve (AUROC).

Results

The revision risk for hemiarthroplasty increased in male, those with schizophrenia and end-stage renal disease patients had 1.58-, 1.88-, and 1.74-fold revision HA risk (95 % confidence interval (CI) = 1.40–1.78, 1.26–2.79, and 1.29–2.34, respectively). In a predictive model, the cumulative risk score ranged from 0 to 13 with a 5.08 to 91.82 % 10-year predicted RHA risk. The percentage of AUROC for 10-year RHA risk in nomogram was 61.9 (95 % CI = 60.0–63.4).

Conclusions

Males, schizophrenia and end-stage renal disease patients have higher risk of revision surgery after hemiarthroplasty for femoral neck fracture.

The Influence of Psychiatric Comorbidity on Inpatient Outcomes following Distal Humerus Fractures

Background. The influence of psychiatric comorbidity on outcomes following inpatient management of upper extremity fractures is poorly understood. Methods. The National Hospital Discharge Survey was queried to identify patients admitted to US hospitals with distal humerus fractures between 1990 and 2007. Patients were subdivided into 5 groups: depression, anxiety, schizophrenia, dementia, and no psychiatric comorbidity. Multivariable logistic regression analysis identified independent risk factors for adverse events, requirement of blood transfusion, and discharge to another inpatient facility. Results. A cohort representative of 526,185 patients was identified as having a distal humerus fracture. Depression, anxiety, and dementia were independently associated with higher odds of in-hospital adverse events (P<0.001). Depression was associated with higher odds of inpatient blood transfusion (P<0.001). Depression, schizophrenia, and dementia were associated with higher odds of nonroutine discharge to another inpatient facility (P<0.001). Patients with a diagnosis of schizophrenia had a mean of 12 (P<0.001) more days of care than patients with no psychiatric comorbidity. Discussion. Patients with comorbid psychiatric illness who are admitted to hospitals with distal humerus fractures are at increased risk of inpatient adverse events and posthospitalization care.

Psychiatric Disorders and Psychopharmacologic Treatment as Risk Factors in Elective Fast-track Total Hip and Knee Arthroplasty

BACKGROUND

Psychiatric disorder (PsD) is rarely considered when evaluating perioperative risk factors. Studies on PsD are often limited by use of administrative coding, incomplete follow-up, and lack of preoperative data on psychopharmacological treatment.

METHODS

A multicenter study with prospective registration on preoperative comorbidity, complete 90-day follow-up, and information on dispensed prescriptions on psychopharmacological treatment (excluding benzodiazepines). All departments used similar fast-track approaches and discharge to home. Evaluation of postoperative morbidity was based on discharge records. Odds ratios for length of stay (LOS) more than 4 days and surgery-related readmissions were calculated using multiple logistic regression adjusting for potential confounders.

RESULTS

Of 8,757 procedures, 1,001 (11.4%) were in PsD patients. Of these, 43.4% used selective serotonin inhibitors (SSRIs), 31.6% used other antidepressants, 8.5% used a combination, and 16.5% used antipsychotics. PsD was associated with increased risk of LOS more than 4 days (16.5 vs. 7.3%; odds ratio, 1.90; 95% CI, 1.52 to 2.37), regardless of treatment with SSRIs (2.19; 1.62 to 2.97), other antidepressants (1.81; 1.25 to 2.61), or antipsychotics (1.90; 1.62 to 3.16). PsD was associated with increased 30- (9.9 vs. 5.1%; 1.93; 1.49 to 2.49) and 90-day surgery-related readmissions (12.8 vs. 7.4%; 1.68; 1.34 to 2.10), significant for SSRIs (1.97; 1.38 to 2.82 and 1.77; 1.29 to 2.43), other antidepressants (2.24; 1.51 to 3.32 and 1.82; 1.27 to 2.61), and antipsychotics (1.85; 1.03 to 3.31, 30 days only). In PsD patients, pain (1.4%), postoperative anemia (1.1%), and pulmonary complications (1.1%) were the most frequent causes of LOS more than 4 days. Hip displacements (2.8%) and falls (1.9%) were the most frequent readmissions, and 90-day surgery-related mortality was 0.7% with and 0.2% without PsD.

CONCLUSIONS

Psychopharmacologically treated PsD is a risk factor for postoperative morbidity after fast-track arthroplasty, regardless of treatment type. This may be due to PsD per se and/or drug-related side effects.

Validation of the four-dimensional symptom questionnaire (4DSQ) and prevalence of psychological symptoms in orthopedic shoulder patients

Psychological problems are common in shoulder patients. A validated psychological questionnaire measuring clinically relevant psychological symptoms (including distress, depression, anxiety, and somatization) in shoulder patients is lacking. The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report questionnaire to identify distress, depression, anxiety, and somatization which has been validated in primary care populations. The aim of this study was to validate the 4DSQ in orthopedic shoulder patients. We assessed whether the 4DSQ measures these four constructs the same way in an orthopedic population with shoulder problems compared to a general practice population. We also investigated the prevalence of psychological symptoms in shoulder patients. The shoulder group consisted of 200 consecutive patients and the general practice group comprised 368 patients, matched for gender and age. Differential item functioning analysis showed that the 4DSQ measures the different psychological symptoms in orthopedic shoulder patients the same way as in general practice patients. The shoulder patients tended to score higher on the somatization scale, resulting in a new cut-off point for somatization. The prevalence of distress, somatization, anxiety, and depression in the shoulder group was 23%, 14%, 10%, and 8%, respectively. It can be concluded from this study that the 4DSQ in orthopedic shoulder patients measures the same constructs as in general practice patients and can therefore be used in orthopedic practice to measure psychological symptoms in patients with shoulder complaints.

A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality

BACKGROUND

Previous studies evaluating the epidemiology of pelvic ring fractures and predictors of mortality are largely based upon non-US populations, potentially limiting their generalizability. This study sought to analyze trends of pelvic ring fractures and associated complications in the United States using the largest and most recent national data set available. The specific aims of this study were to determine whether the incidence of pelvic ring fractures changed over time, whether in-hospital mortality following pelvic ring fracture changed over time, whether hospital length of stay following pelvic ring fracture changed over time, and whether there are independent predictors of in-hospital mortality, adverse events, or nonroutine discharge following pelvic fracture.

METHODS

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with pelvic ring fractures between 1990 and 2007. A cohort representative of 1 464 458 patients was identified, and multivariable logistic regression was used to find independent predictors of mortality, adverse events, and nonroutine discharge to another inpatient facility.

RESULTS

Between 1990 and 2007, the population-adjusted incidence of pelvic ring fractures increased from 27.24 to 34.30 per 100 000 capita (P < .001). Mortality declined from 4.2% to 2.8% (P < .001) paralleling an increase in the proportion of patients treated with surgical fixation (7.22%-10.36%). All forms of internal fixation were associated with decreased odds of mortality, while external fixation was associated with increased odds of mortality. Internal fixation was also associated with lower odds of adverse events and nonroutine discharge to inpatient facilities. The average in-hospital length of stay decreased from 11.2 days to 6.5 days (P < .001).

CONCLUSION

This study provides the largest and most comprehensive epidemiologic analysis of pelvic ring fractures in the United States. Knowledge of the increasing incidence of pelvic fractures and prognostic factors associated with poor outcomes may improve outcomes.

Prevalence of and Factors Associated With Major Depression in Patients With Upper Extremity Conditions

PURPOSE

To determine the prevalence of an estimated diagnosis of major depression in patients with upper extremity conditions and factors that help identify patients who might benefit from psychological treatment.

METHODS

In this observational cross-sectional study, 190 patients completed questionnaires measuring symptoms of depression with the Patient Health Questionnaire, upper extremity disability with the Patient-Reported Outcomes Measurement Information System Upper Extremity, pain interference with the Patient-Reported Outcomes Measurement Information System Pain Interference, and health anxiety with the Short Health Anxiety Inventory.

RESULTS

The estimated prevalence of an estimated diagnosis of major depression (Patient Health Questionnaire 9 ≥ 10) among this group of patients was 12%. Having multiple pain conditions, a history of depression, and greater limitation from pain for daily activities were independently associated with an estimated diagnosis of major depression.

CONCLUSIONS

The finding that 1 in 8 patients presenting to a hand surgeon have untreated or undertreated symptoms of depression sufficient to qualify for an estimated diagnosis of major depression emphasizes the importance of assessing for depression at all levels of care.

Anxiety's Impact on Length of Stay Following Lumbar Spinal Surgery

INTRODUCTION

Despite some evidence that anxiety may affect length of stay (LOS), relatively little inquiry exists regarding this in neurosurgical literature.

OBJECTIVE

To determine the influence of anxiety on LOS after elective lumbar decompression and fusion (LDF) surgery.

METHODS

The medical records of 307 patients who consecutively underwent elective LDF surgery from October 1, 2010, through September 30, 2013, were retrospectively reviewed. Each patient's medications and comorbidities were determined using the medical history. The impact of their medications on LOS was studied using multivariate analysis. Linear regression was also used to assess the relationship between anxiolytic use and LOS. An independent sample t test was used to compare the mean LOS of the group of patients receiving muscle relaxants with that of the group who were not.

RESULTS

Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.8 days longer than those with no diagnosis of anxiety and who were not taking anxiolytics (n = 224) after LDF surgery (p = 0.003). Those with a diagnosis of anxiety who were taking anxiolytics (n = 32) stayed 1.9 days longer than those with no diagnosis of anxiety and who were taking anxiolytics (n = 24) after LDF surgery (p = 0.003).

CONCLUSION

Our study suggests that those with a diagnosis of anxiety who take medications for that condition have a longer LOS than those with no diagnosis of anxiety and who are not medicated for the condition. This could be because these patients are more vulnerable to states of anxiety when required to be nil per os for 12 hours before surgery.

Factors associated with in-hospital pulmonary embolism after shoulder arthroplasty

BACKGROUND

Despite that pulmonary embolism (PE) is a feared complication after shoulder arthroplasty, little is known about its perioperative associated factors.

MATERIALS AND METHODS

We used the Nationwide Inpatient Sample to gather a sample of 422,372 patients who underwent shoulder arthroplasty between 2002 and 2011. This population was divided into 2 cohorts on the basis of those who experienced perioperative PE (0.25%) and those who did not. Demographics were compiled for both cohorts. Multivariable logistic regression analysis was used to account for confounding variables and to determine significant predictors of perioperative PE.

RESULTS

After adjusting for patient demographic and clinical variables in multivariable regression modeling, the top 4 independent predictors for PE were primary diagnosis of proximal humerus fracture, deficiency anemia, congestive heart failure, and chronic lung disease. Other pertinent risk factors included increasing age, obesity, fluid and electrolyte abnormalities, undergoing total shoulder arthroplasty rather than hemiarthroplasty, and subsequent days of postoperative care.

CONCLUSIONS

Knowledge of these factors might help in preoperative counseling and prove useful for implementation of quality improvement strategies to reduce the occurrence of PE. Surgeons may consider initiating thromboprophylaxis in patients with any of the aforementioned comorbidities.

Alcohol Misuse is an Independent Risk Factor for Poorer Postoperative Outcomes Following Primary Total Hip and Total Knee Arthroplasty

The influence of alcohol misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. Using the National Hospital Discharge Survey, a cohort representative of 8,372,232 patients (without cirrhosis) who underwent THA or TKA between 1990 and 2007 was identified and divided into two groups: (1) those who misused alcohol (n=50,861) and (2) those who did not (n=8,321,371). Differences in discharge status, comorbidities and perioperative complications were analyzed. Compared to patients with no diagnosis of alcohol misuse, alcohol misusers were nine times more likely to leave against medical advice and had longer hospital stays (P<0.001). Alcohol misuse was independently associated with higher odds of in hospital complications (OR: 1.334, range: 1.307-1.361), surgery related complications (OR: 1.293, range: 1.218-1.373) and general medical complications (OR: 1.300, range: 1.273-1.327).

Outcomes Following Primary Total Hip or Knee Arthroplasty in Substance Misusers

The influence of drug misuse on outcomes following primary total hip (THA) or knee (TKA) arthroplasty is poorly understood. The National Hospital Discharge Survey was used to identify patients who underwent primary THA or TKA between 1990 and 2007. Patients were divided into two groups: 1) those with a diagnosis of drug misuse (cannabis, opioids, cocaine, amphetamines, sedatives, inhalants or mixed combinations) (n=13,163) and 2) those with no diagnosis of misuse (n=8,366,327). Patients with a diagnosis of drug misuse had longer hospital stays (P<0.001), nearly eight times the odds of leaving against medical advice (P<0.001) and five times the mortality rate (P<0.001). Drug misuse was associated with higher odds (P<0.001) of complications including postoperative infection, anemia, convulsions, osteomyelitis, and blood transfusion.

Increase in perioperative complications following primary total hip and knee arthroplasty in patients with hepatitis C without cirrhosis

The effects of hepatitis C on primary total hip (THA) and knee (TKA) arthroplasties are poorly understood. The National Hospital Discharge Survey was used to identify patients who underwent THA or TKA between 1990 and 2007 without a diagnosis of cirrhosis, HIV, or hepatitis A, B, D or E virus infection. Patients were split into two groups: 1) hepatitis C (n=26,444) and 2) non-hepatitis C (n=8,336,882) and analyzed for differences in length of hospital stay, discharge status and perioperative complications. Those with hepatitis C had shorter hospital stays, higher rates of nonroutine discharge and higher odds of in-hospital complications (OR: 1.686, range: 1.645-1.727), surgery related complications (OR: 1.559, range: 1.516-1.603) and general medical complications (OR: 2.012, range: 1.961-2.064) (P<0.001).

Comparative analysis of anatomic and reverse total shoulder arthroplasty: in-hospital outcomes and costs

BACKGROUND

The rate of shoulder arthroplasty has continued to increase at an exponential rate during the past decade in large part owing to approval by the Food and Drug Administration of reverse shoulder arthroplasty. Whereas reverse shoulder arthroplasty has resulted in expanded surgical indications, there are numerous reports of relatively high complication rates. The increased prevalence of both anatomic and reverse shoulder arthroplasty underscores the need to elucidate whether perioperative outcomes are influenced by type of total shoulder arthroplasty. The purpose of this study was to determine the impact of shoulder arthroplasty type, anatomic or reverse, with respect to perioperative adverse events, in-hospital death, prolonged hospital stay, nonroutine disposition, and hospital charges in a nationally representative sample.

METHODS

By use of the Nationwide Inpatient Sample database from 2011, the first year that reverse total shoulder arthroplasty received a unique International Classification of Diseases, Ninth Revision procedure code, an estimated 51,052 patients undergoing total shoulder arthroplasty were separated into anatomic total shoulder arthroplasty (58%) and reverse total shoulder arthroplasty (43%). Comparisons of early outcome measures between anatomic and reverse total shoulder cohorts were performed by bivariate and multivariable analyses with logistic regression modeling.

RESULTS

Compared with anatomic shoulder arthroplasty recipients, patients undergoing reverse shoulder replacement were at higher risk for in-hospital death, multiple perioperative complications, prolonged hospital stay, increased hospital cost, and nonroutine discharge.

CONCLUSION

Despite the expanding indications for reverse shoulder arthroplasty, it is an independent risk factor for inpatient morbidity, mortality, and hospital costs and should perhaps be offered more judiciously and performed in the hands of appropriately trained shoulder specialists.

The influence of psychiatric comorbidity on perioperative outcomes following primary total hip and knee arthroplasty; a 17-year analysis of the National Hospital Discharge Survey database

Studies conflict regarding the impact of psychiatric illnesses including depression, anxiety, dementia and schizophrenia on perioperative outcomes following total hip (THA) and knee arthroplasty (TKA). Psychiatric comorbidity incidence, in-hospital adverse events, discharge disposition, and mortality were assessed for THA or TKA patients between 1990 and 2007 using the US National Hospital Discharge Survey. A cohort representative of 8,379,490 patients was identified and analyzed using multivariable regression analysis. Diagnoses of depression, dementia and schizophrenia were associated with increased odds of adverse events (P<0.001). Schizophrenia and depression were associated with higher odds of perioperative blood transfusion (P<0.001). All psychiatric comorbidities were associated with higher odds of non-routine discharge (P<0.001). Diagnosis of dementia was associated with higher in-hospital mortality (P<0.001).