Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair

Smokers Achieved Minimal Clinically Important Difference for Visual Analog Scale and American Shoulder and Elbow Surgeons Scores at a Lower Rate Than Nonsmokers Even When Repaired Supraspinatus Tendons Were Intact on Postoperative Magnetic Resonance Imaging

Purpose

To investigate the impact of smoking on clinical outcomes after repair of supraspinatus tendon in patients who had an intact repair found on postoperative magnetic resonance imaging.

Methods

Patients who received primary complete repair of supraspinatus tendon tear between 2014 and 2020 were retrospectively identified. Patients were excluded if a postoperative magnetic resonance imaging scan was not available or if the follow-up was less than 2 years. Visual analog score (VAS), American Shoulder and Elbow Surgeons (ASES) score, and active forward flexion were assessed at the 2-year follow-up. The percentage of patients acquiring minimal clinically important difference (MCID) was reported.

Results

One hundred primary supraspinatus tendon repairs were included. The healing rate was 77% in smokers and 90% in nonsmokers. Smoking was the independent predictor of a poorer 2-year VAS (P < .001) and ASES (P < .001) scores. Significant improvement in clinical outcomes was observed between preoperation and the 2-year follow-up, regardless of the integrity of the repair or smoking status (P < .001). When the repaired tendon was intact, nonsmokers had a greater chance of achieving MCID in 2-year VAS and ASES scores than smokers. Ninety-nine percent of nonsmokers, compared with 82% of smokers, achieved MCID in VAS at the 2-year follow-up (P = .023). The corresponding figures for ASES were 98% and 71%, respectively (P = .004).

Conclusions

In this study, smoking was associated with poorer clinical outcomes, including a greater 2-year VAS pain score and a lower 2-year ASES score, when compared with nonsmokers, even in cases in which there was no full-thickness retear of the repaired supraspinatus tendon.

Level of Evidence

Level III, retrospective cohort study.

Association of Smoking With Graft Rupture After Anterior Cruciate Ligament Reconstruction

Background

The effect of smoking on graft rupture after anterior cruciate ligament (ACL) reconstruction is not well understood.

Hypothesis

It was hypothesized that there will be no relationship between tobacco use and graft rupture after ACL reconstruction, as reflected by postoperative magnetic resonance imaging (MRI) and arthroscopic examination.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 233 patients who received primary ACL reconstruction with hamstring tendon autograft between January 1, 2013, and December 31, 2019, and who underwent MRI evaluation at 20.2 ± 1.9 months postoperatively. The patients were categorized by smoking history into 2 groups: 39 smokers and 194 nonsmokers. The 2 groups did not differ significantly in age, sex, operative technique, preinjury Tegner score, or mean time until postoperative MRI. The primary outcome was graft rupture rate, with rupture confirmed by either arthroscopic assessment or postoperative MRI diagnosis. The secondary outcome measure was degree of graft ligamentization, evaluated by measuring the signal-to-noise quotient (SNQ) of the graft.

Results

The overall ACL graft rupture rate was 6.0%. The rupture rate was significantly higher in smokers than in nonsmokers (12.8% vs 4.6%, respectively; P = .0498). Smokers also had a significantly higher whole-graft SNQ compared with nonsmokers (4.7 ± 4.4 vs 3.3 ± 3.7, respectively; P = .028), suggesting less satisfactory ligamentization in smokers.

Conclusion

Smoking was associated with a higher risk of graft rupture of ACL reconstruction and a higher SNQ of the intact graft as shown on postoperative MRI.

Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR).

METHODS

The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection.

CONCLUSIONS

In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective case series.

Impact of smoking on pain and function in rotator cuff repair: A prospective 5-year cohort follow-up of 1383 patients

BACKGROUND

This multicentre cohort study investigates the effect of smoking on the outcome of rotator cuff repair (RCR), with attention to age at presentation for surgery, pre-operative and post-operative pain and function and intra-operative findings.

METHODS

Patient information was collected pre-operatively, including Flex Shoulder Function (Flex SF) and visual analogue scale pain, then at 6 months, 1, 2 and 5 years post-operatively. Intra-operative technical data were collected by the operating surgeon. Current smokers were classified by daily cigarette consumption.

RESULTS

A total of 1383 RCRs in as many patients were included with an 84% 5-year follow-up. Smokers were on average 6.7 years younger than non-smokers (51.8 vs. 58.5, P < 0.001). There was no difference in intra-operatively assessed tear size both in anteroposterior dimension (P = 0.5) and retraction (P = 0.9). Pre-operative Flex SF score in smokers was below that of non-smokers (23.0 vs. 24.5, P = 0.002) and at 6 months (P = 0.02) but no different at 5 years (P = 0.7). Pain scores were higher in smokers than non-smokers both pre-operatively (5.34 vs. 4.67, P < 0.001) and up to 2 years (P < 0.001) but not at 5 years (P = 0.073).

CONCLUSION

Smokers undergoing RCR were younger than non-smokers, and had worse pre-operative pain scores and shoulder function. Poorer post-operative function persisted to 6 months, and with higher reported pain to 2 years in smokers. However, at 5-year follow-up, patient-reported outcomes were not affected by smoking status.

The Relationship of Staged, Bilateral Arthroscopic Primary Rotator Cuff Repair Timing and Postoperative Complications

BACKGROUND

Although previous studies have reported acceptable clinical outcomes after simultaneous, single-stage bilateral and staged bilateral rotator cuff repair (RCR), few studies have been adequately powered to compare postoperative complication rates at various time intervals between procedures.

PURPOSE

To examine the relationship between the timing of bilateral arthroscopic RCR and complications.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients from the Medicare data set within the PearlDiver database who underwent bilateral RCR between 2005 and 2014 were identified. These patients were then stratified by time between surgeries into cohorts: (1) single stage, (2) <3 months, (3) 3 to 6 months, (4) 6 to 9 months, (5) 9 months to 1 year, and (6) 1 to 2 years. Surgical and medical complications of these cohorts were compared with those of a control cohort of patients who underwent bilateral RCR >2 years apart using a regression analysis.

RESULTS

A total of 11,079 patients who underwent bilateral RCR were identified. Patients who underwent single-stage bilateral arthroscopic RCR experienced higher rates of revision RCR (odds ratio [OR], 2.1; P < .0001), reverse total shoulder arthroplasty (RTSA) (OR, 2.47; P < .0001), and postoperative infection (OR, 2.18; P = .007) in addition to higher rates of venous thromboembolism (VTE) (OR, 1.78; P = .031) and emergency department visits (OR, 1.51; P = .002) compared with the control group. Patients who underwent bilateral RCR with a <3-month interval had higher rates of revision surgery (OR, 1.56; P = .003), RTSA (OR, 1.89; P = .002), and lysis of adhesions (OR, 2.31; P < .0001) in addition to increased rates of VTE (OR, 1.92; P = .015) and emergency department visits (OR, 1.62; P < .0001) compared with the control group. There were no differences in any surgical or medical complications when surgeries were staged by ≥3 months compared with controls.

CONCLUSION

Patients with Medicare undergoing single-stage and staged bilateral RCR who had the second repair within 3 months had significantly higher rates of multiple medical and surgical complications compared with patients waiting >2 years between procedures.

Patient-Related Risk Factors for Contralateral Anterior Cruciate Ligament (ACL) Tear After ACL Reconstruction: An Analysis of 3707 Primary ACL Reconstructions

BACKGROUND

Return to play after anterior cruciate ligament (ACL) reconstruction can increase risk for both ipsilateral graft rupture and contralateral ACL rupture. The risk for injury of the contralateral knee after ACL reconstruction could be nearly double that of ipsilateral graft rupture.

QUESTIONS/PURPOSES

We sought to identify independent, patient-related risk factors for contralateral ACL rupture following primary ACL reconstruction.

METHODS

A national database was queried for patients who underwent primary ACL reconstruction from 2007 to 2015 with a minimum of 2 years of post-operative follow-up (n = 12,044). Patients who underwent subsequent primary ACL reconstruction on the contralateral extremity were then identified. A multivariate binomial logistic regression analysis was utilized to evaluate patient-related risk factors for contralateral ACL rupture, including demographic and comorbidity variables. Adjusted odds ratios and 95% confidence intervals were calculated for each risk factor.

RESULTS

Of the 3707 patients who had a minimum of 2 years of database activity and comprised the study group, 204 (5.5%) experienced a contralateral ACL rupture requiring reconstruction. Independent risk factors for contralateral ACL rupture included age less than 20 years, female gender, tobacco use, and depression. Obesity, morbid obesity, type 1 diabetes, type 2 diabetes, and a history of anxiety were not significant predictors of contralateral injury.

CONCLUSION

We were able to adequately power an analysis to identify several significant patient-related risk factors for contralateral ACL rupture after primary ACL reconstruction, including younger age, female gender, tobacco use, and depression. This information can be used to counsel patients on the risk of injury to the contralateral knee.

Management of Failed SLAP Repair: A Systematic Review

BACKGROUND

Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature.

QUESTIONS/PURPOSES

The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included.

RESULTS

A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery.

CONCLUSION

The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery

Importance

Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck.

Objective

To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck.

Design, Setting, and Participants

In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018.

Main Outcomes and Measures

Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked.

Results

Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications.

Conclusions and Relevance

Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit.

Level of Evidence

NA.

Not All SLAPs Are Created Equal: A Comparison of Patients with Planned and Incidental SLAP Repair Procedures

Background

Epidemiological studies have shown a progressive increase in the rate of superior labrum anterior-posterior (SLAP) repair surgery after the year 2000. However, it is not clear whether this is due to increased recognition of isolated SLAP tears or increased SLAP repair performed secondarily during arthroscopy for other purposes.

Hypothesis/Purpose

We hypothesized that both isolated SLAP repair and secondary SLAP repair increased with time and that patient age influenced the pathway to SLAP diagnosis and surgery—such that younger patients were more likely to have isolated SLAP repair surgery after being diagnosed in clinic.

Study Design

Descriptive epidemiology study.

Methods

Data were obtained from the MarketScan database from 2003 to 2013. CPT and ICD-9 codes were used to identify SLAP surgery patients and concomitant procedures. The timing of SLAP diagnosis relative to surgery was used to determine whether the injury was recognized preoperatively.

Results

64,497 SLAP surgery patients were included. Preoperative SLAP diagnosis increased from 17.1% in 2003 to 44.6% in 2013. Patients diagnosed preoperatively were younger and had fewer concomitant procedures. Increasing age and concomitant rotator cuff tear (RCT) repair corresponded to lower odds of preoperative SLAP diagnosis.

Discussion

Younger patients were more likely to have their SLAP tear diagnosed prior to surgery. Those diagnosed before surgery had fewer simultaneous procedures during their operations, suggesting that SLAP repair was more likely the primary operation. From 2003 to 2013, SLAP tears were increasingly recognized in the preoperative setting.

Obstructive Sleep Apnea and Arthroscopic Rotator Cuff Repair-Are Complication Rates Really Increased?

BACKGROUND

A few investigations exist which evaluate the influence of obstructive sleep apnea (OSA) on complications after arthroscopic rotator cuff repair.

METHODS

A database was queried for patients undergoing rotator cuff repair with and without OSA and further subdivided into those with and without a billing code for a continuous positive airway pressure (CPAP) device. Thirty-day and 6-month adverse events were assessed.

RESULTS

After regression analysis, patients with OSA had markedly increased emergency department visits and hospital admission (P < 0.05). This risk was mitigated by CPAP orders compared with control subjects. Patients without CPAP use had markedly increased risks of emergency department visits, hospital admission, and respiratory complications compared with control subjects (P < 0.05).

CONCLUSIONS

Patients with OSA have higher risks of emergency department visits and hospital admissions postoperatively; however, a CPAP order appears to mitigate this risk. The independent risk imparted by OSA for the studied complications was markedly lower than other comorbidities.

The importance of smoking in orthopedic surgery

INTRODUCTION

Tobacco use is related to augmented morbidity and mortality. People who smoke heavily before orthopedic surgery may have more nonmedical complications than nonsmokers. Therefore, all orthopedic surgery patients should be screened for tobacco use.

AIM

To investigate the musculoskeletal effects of perioperative smoking.

METHODS

A narrative review of the literature on the topic was performed.

RESULTS

Orthopedic perioperative complications of smoking include impaired wound healing, augmented infection, delayed and/or impaired fracture union and arthrodesis, and worst total knee and hip arthroplasty results. Orthopedic surgeons seldom postponed surgery or utilized smoking cessation methods.

CONCLUSIONS

The adoption of smoking cessation methods such as transdermal patches, chewing gum, lozenges, inhalers, sprays, bupropion, and varenicline in the perioperative period should be recommended. Perioperative smoking cessation appears to be an efficacious method to decrease postoperative complications even if it is implemented as late as 4 weeks before surgery.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears

Background

Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.

Objective

To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.

Methods

A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.

Results

Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.

Conclusion

Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

Not All Patients With Diabetes Have the Same Risks: Perioperative Glycemic Control Is Associated With Postoperative Infection Following Knee Arthroscopy

PURPOSE

To determine the association between glycemic control and infection following knee arthroscopy, and to determine the clinical utility of a threshold HbA1c level.

METHODS

A national database identified patients who underwent knee arthroscopy from 2007 to 2016. Patients with concomitant open portions, more complex knee procedures, procedures performed for infection and patients with prior septic knee arthritis were excluded. Patients with an HbA1c level checked within 3 months of surgery were compared to control groups of nondiabetics and diabetics undergoing knee arthroscopy without a perioperative HbA1c. The study group was then stratified based on their HbA1c. The incidence of deep infection within 6 months was identified and compared to those in the control groups. A subgroup analysis was performed to investigate any trend in the timing of postoperative infection. A receiver operating characteristic (ROC) analysis was performed to determine and test a threshold value of HbA1c.

RESULTS

13,470 study patients were included, with an overall rate of infection of 0.33%. The rate of infection ranged from 0.25% to 1.03%. The rate of infection in study patients was greater than the nondiabetes control group's (P < .0001) and not significantly different from that in the nonstudy diabetes control (P = .765). The inflection point of the ROC curve corresponded to an HbA1c level of 8.0 mg/dL (P = .006, specificity = 76%, sensitivity = 44%, area under curve [AUC] = 0.619).

CONCLUSIONS

The risk of infection following knee arthroscopy increases as the perioperative HbA1c increases. ROC analysis determined that an HbA1c above 8.0 mg/dL could serve as a threshold level; however, the AUC and low sensitivity reflected the poor utility of this test as an independent predictor for infection.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Patient-Related Risk Factors for Infection Following Ulnar Nerve Release at the Cubital Tunnel: An Analysis of 15,188 Cases

BACKGROUND

Although cubital tunnel release is a commonly performed orthopaedic procedure, the overall incidence of and independent risk factors for infection largely remain undefined in the current literature.

PURPOSE

To establish the rate of postoperative infection after isolated cubital tunnel release and define relevant patient-related risk factors.

STUDY DESIGN

Case-control study; Level 3.

METHODS

All Medicare-insured patients undergoing ulnar nerve decompression at the cubital tunnel from 2010 through 2012 were identified. A multivariate binomial logistic regression analysis was utilized to evaluate the impact of patient-related risk factors for postoperative infection.

RESULTS

A total of 330 (2.17%) postoperative infections were identified in 15,188 cases. The majority (87%) were managed nonoperatively, while 13% required surgical debridement. The most significant risk factors for infection included hemodialysis use (odds ratio [OR], 2.47), chronic anemia (OR, 2.24), age <65 years (OR, 2.08), tobacco use (OR, 1.65), morbid obesity (OR, 1.53), inflammatory arthritis (OR, 1.43), depression (OR, 1.36), hyperlipidemia (OR, 1.33), male sex (OR, 1.32), and chronic lung disease (OR, 1.29).

CONCLUSION

The present study was adequately powered to determine numerous patient-related risk factors for infection following cubital tunnel release.

Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population

BACKGROUND

Shoulder arthroscopy is well established as a highly effective and safe procedure for the treatment for several shoulder disorders and is associated with an exceedingly low risk of infectious complications. Few data exist regarding risk factors for infection after shoulder arthroscopy, as previous studies were not adequately powered to evaluate for infection.

PURPOSE

To determine patient-related risk factors for infection after shoulder arthroscopy by using a large insurance database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005 to 2014 for patients undergoing shoulder arthroscopy. Patients undergoing shoulder arthroscopy for a diagnosis of infection or with a history of prior infection were excluded. Postoperative infection within 90 days postoperatively was then assessed with International Classification of Diseases, Ninth Revision codes for a diagnosis of postoperative infection or septic shoulder arthritis or a procedure for these indications. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection, as well as numerous patient-related risk factors for postoperative infection. Adjusted odds ratios (ORs) and 95% CIs were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

A total of 530,754 patients met all inclusion and exclusion criteria. There were 1409 infections within 90 days postoperatively (0.26%). Revision shoulder arthroscopy was the most significant risk factor for infection (OR, 3.25; 95% CI, 2.7-4.0; P < .0001). Intraoperative steroid injection was also an independent risk factor for postoperative infection (OR, 1.46; 95% CI, 1.2-1.9; P = .002). There were also numerous independent patient-related risk factors for infection, the most significant of which were chronic anemia (OR, 1.58; 95% CI, 1.4-1.8; P < .0001), malnutrition (OR, 1.42; 95% CI, 1.2-1.7; P = .001), male sex (OR, 2.71; 95% CI, 2.4-3.1; P < .0001), morbid obesity (OR, 1.41; 95% CI, 1.2-1.6; P < .0001), and depression (OR, 1.36; 95% CI, 1.2-1.5; P < .0001).

CONCLUSION

Intraoperative steroid injection was a significant independent risk factor for postoperative infection after shoulder arthroscopy. There were also numerous significant patient-related risk factors for postoperative infection, including revision surgery, obesity, male sex, chronic anemia, malnutrition, depression, and alcohol use, among others.

Narcotic Use and Total Knee Arthroplasty

BACKGROUND

Although the United States is in the midst of a narcotic epidemic, risk factors for use and the impact of perioperative narcotic use on total knee arthroplasty (TKA) outcomes is ill-defined.

METHODS

A national database was queried for patients who underwent primary TKA from 2007 to 2015. Patients taking narcotics in the preoperative, and for a prolonged period of time postoperatively, were identified. The risk factors for prolonged narcotic use were analyzed with a regression analysis, in addition to evaluating preoperative and prolonged postoperative use as independent risk factors for short-term and long-term complications.

RESULTS

In total, 113,337 patients met inclusion criteria, of which 31,733 patients were prescribed narcotics preoperatively and 35,770 patients were prescribed narcotics more than 3 months postoperatively. There are several independent risk factors for prolonged narcotic use postoperatively, the most significant being the number of narcotic prescriptions prescribed preoperatively. Preoperative narcotic use was independently associated with an increased risk of emergency room visits, readmission, infection, stiffness, and aseptic revision. Prolonged postoperative use was also associated with significantly increased rates of infection, stiffness, and aseptic revision.

CONCLUSION

Preoperative and prolonged narcotic use following TKA was associated with an increased risk of short-term and long-term complications following TKA. The liberal use of narcotics in the perioperative period should be considered a modifiable risk factor when considering elective TKA.

Adverse Effects of Smoking on Outcomes of Orthopaedic Surgery

Smoking has many adverse effects on the musculoskeletal system, particularly on the outcomes after orthopaedic surgery. Smoking is associated with surgical site infection and postoperative wound complications after spine surgery, total joint arthroplasty, and fracture fixation; nonunion after spinal fusion, ankle fusion, osteotomy, and internal fixation and bone grafting for scaphoid nonunion; worse outcomes after lumbar disc prolapse, spinal stenosis, and cervical myelopathy surgery; periprosthetic joint infection and lower survival after total hip, knee, and shoulder arthroplasty; worse outcome after shoulder rotator cuff repair and anterior cruciate ligament reconstruction; and wound complications after microsurgery. Orthopaedic surgeons should inform smokers and motivate them to quit smoking before orthopaedic operations.

Complication Rates After Total Hip and Knee Arthroplasty in Patients With Hepatitis C Compared With Matched Control Patients

BACKGROUND

A paucity of data exists regarding long-term outcomes among patients with hepatitis C who undergo total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We queried a database for patients with hepatitis C who underwent THA and TKA. We then identified their rates of several postoperative complications and compared them with the same rates among mutually exclusive matched control cohorts.

RESULTS

Patients with hepatitis C who underwent THA and TKA had higher rates of infection, aseptic revision surgery, medical complications, and blood transfusion compared with matched control patients.

DISCUSSION

Our findings suggest that patients with hepatitis C who undergo THA and TKA are at increased risk of experiencing several postoperative complications, which could mean a substantial increase in the cost of care.

CONCLUSIONS

Further research is needed to establish quantifiable associations between hepatitis C and postoperative complications among patients with the disease who undergo total joint arthroplasty.

Is There an Association Between Hemoglobin A1C and Deep Postoperative Infection After TKA?

BACKGROUND

Despite substantial research into the use of glycemic markers to stratify infection risk in patients with diabetes mellitus, there is little evidence to support a perioperative hemoglobin A1c (HbA1c) level associated with an increased risk of deep postoperative infection after TKA.

QUESTIONS/PURPOSES

(1) Is there an association between perioperative HbA1c level in patients with diabetes and deep postoperative infection after primary TKA? (2) Is the perioperative HbA1c level in patients with diabetes a useful test as an independent predictor for postoperative infection after TKA?

METHODS

We queried the PearlDiver Patient Records Database Humana dataset for patients who underwent primary TKA. This is a for-fee insurance patient-records database that contains records for more than 20 million patients with orthopaedic diagnoses from 2007 to the second quarter of 2015. The data for patients from this study were taken from the Humana dataset since this is the only insurer that includes laboratory data among the available databases. Although it is difficult to calculate attrition in this database, in the current study the minimum number of patients with at least 1 year followup was 86%. Patients with diabetes who had an HbA1c level obtained within 3 months of surgery were identified, stratified based on their HbA1c level in 0.5 mg/dL increments, and then compared with patients with diabetes without an HbA1c level within 3 months of surgery. Patients who had an HbA1c level within 3 months of surgery had slightly higher rates of polyneuropathy, chronic renal failure, and chronic kidney disease Stages 2 and 3. Otherwise, these groups were similar regarding rates of peripheral vascular disease, microvascular ischemic disease, metabolic syndrome, gastroparesis, end stage renal disease, age, and gender. Deep infection was defined as an infection resulting in operative intervention within 1 year of the primary TKA, and the incidence of such intervention for each HbA1c group then was identified. A receiver operating characteristic (ROC) analysis was performed to determine a threshold value of the HbA1c, and an area under the curve (AUC) analysis was performed to measure the accuracy and clinical utility of HbA1c as an independent predictor for postoperative infection.

RESULTS

The rate of infection requiring operative intervention ranged from a low of 0.8% with an HbA1c of 5.49 mg/dL or less, up to 3.5% for patients with HbA1c level greater than 11.5 mg/dL. The ROC analysis indicated that the best threshold was an HbA1c of 8.0 mg/dL (1.7; 95% CI, 1.2-2.4 mg/dL; p = 0.004), however, the AUC of 0.548 (95% CI, 0.50-0.59; p = 0.025) indicated that this threshold was inaccurate and only slightly better than chance, and thus alone could not serve as an independent discriminator of infection risk.

CONCLUSIONS

The risk of deep postoperative infection requiring surgical intervention after TKA in patients with diabetes mellitus increases as the perioperative HbA1c increases. While a threshold HbA1c level of 8.0 mg/dL was identified, it cannot by itself serve as an independent predictor of postoperative infection in patients with diabetes mellitus because its sensitivity is so low. Future studies should determine what other confounders other than an elevated HbA1c level contribute to increased infection risk and whether decreasing HbA1c levels before TKA will decrease the subsequent risk of infection after surgery.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Patient-related risk factors for infection following knee arthroscopy: An analysis of over 700,000 patients from two large databases

BACKGROUND

To determine patient-related risk factors for infection following knee arthroscopy using two large databases.

METHODS

A private-payer (PP) and Medicare national insurance database were queried for patients undergoing simple knee arthroscopy procedures from 2005 to 2015. Patients undergoing concomitant open or complex procedures with grafts were excluded. Postoperative infection within 90days was assessed using ICD-9 and CPT codes. A multivariate logistic regression analysis was utilized to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor, with P <0.05 considered statistically significant.

RESULTS

One hundred thousand three hundred ninety nine patients from the PP database and 629,842 patients from the Medicare database met all inclusion and exclusion criteria. In the PP database, there were 250 patients with documented infections (0.25%); the incidence of infection was similar in the Medicare database (1755 patients, 0.28%). There were numerous patient-related comorbidities and demographics independently associated with a significantly increased risk of postoperative infection that were similar across the PP and Medicare patient populations, respectively, including younger age (OR=1.27, 1.43), morbid obesity (OR=1.26, 1.74), tobacco use (OR=1.34, 1.48), inflammatory arthritis (OR=1.61, 1.60), chronic kidney disease (OR=1.65, 1.14), hemodialysis (OR=1.93, 1.36), depression (OR=2.02, 1.73), and a hypercoagulable disorder (OR=2.76, 1.58).

CONCLUSION

The present study identified numerous patient-related risk factors independently associated with an increased risk of infection following knee arthroscopy in PP and Medicare-aged patients.