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Schoch BS, Werner BC, Shapiro SA, Camp CL, Chalmers PN, Cancienne JM. Effect of Bone Marrow Aspirate Concentrate and Platelet-Rich Plasma Augmentation on the Rate of Revision Rotator Cuff Repair. Orthop J Sports Med 2022; 10:23259671221127004. [PMID: 36353396 PMCID: PMC9638537 DOI: 10.1177/23259671221127004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background: The application of orthobiologics at the time of arthroscopic rotator cuff
repair (RCR) has received an increasing amount of clinical interest despite
a relative scarcity of human clinical studies on their efficacy. Purpose: To utilize a national administrative database to determine the association of
bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP)
applied at the time of RCR with revision surgery rates. Study Design: Cohort study; Level of evidence, 3. Methods: The Mariner data set from the PearlDiver patient records repository was
utilized to identify patients undergoing RCR using Current Procedural
Terminology (CPT) code 29827. Patients receiving BMAC or PRP at the time of
RCR were then identified using CPT coding. For comparison purposes, a
matched cohort was created consisting of patients who underwent RCR without
biologic augmentation in a 5:1 fashion for each biologic separately. Cases
were matched according to age, sex, tobacco use, biceps tenodesis, distal
clavicle excision, and subacromial decompression. All groups were then
queried for revision RCR or conversion to reverse shoulder arthroplasty.
Revision rates were compared utilizing a multivariate binomial logistic
regression analysis. Adjusted odds ratios (ORs) and 95% CIs were
calculated. Results: A total of 760 patients who underwent biologic augmentation during RCR were
identified, including 646 patients in the PRP group and 114 patients in the
BMAC group. They were compared with 3800 matched controls without documented
biologic application at the time of surgery. Compared with matched controls,
patients who received BMAC at the time of surgery experienced a
significantly lower incidence of revision surgery at 2 years (OR, 0.36; 95%
CI, 0.15-0.82; P = .015). There was no significant
difference in revision rates between PRP and matched controls (OR, 0.87; 95%
CI, 0.62-1.23; P = .183). Conclusion: The application of BMAC at the time of RCR was associated with a significant
decrease in the incidence of revision surgery. There was no apparent effect
of PRP on the incidence of revision surgery after primary RCR. Higher-level
clinical studies considering surgical factors are needed to more clearly
define the role of biologic adjuvants in RCR.
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Affiliation(s)
- Bradley S. Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Shane A. Shapiro
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Peter N. Chalmers
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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Cancienne JM, Werner BC. The risk of early infection following intra-articular corticosteroid injection following shoulder arthroplasty. Shoulder Elbow 2021; 13:605-609. [PMID: 34804209 PMCID: PMC8600675 DOI: 10.1177/1758573220925817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is little literature examining the association of corticosteroid injections into shoulders with a pre-existing arthroplasty. The aim of the current study was to determine the risk of early infection following intra-articular corticosteroid injection into a pre-existing shoulder arthroplasty. METHODS The PearlDiver database was retrospectively reviewed to identify patients with a pre-existing shoulder arthroplasty from 2007 to 2017. Patients with an ipsilateral shoulder corticosteroid injection in the postoperative period were identified. A control group of patients without an injection was matched 4:1 by age, gender, and postoperative timepoint. Periprosthetic infection within six months after the injection was then assessed and compared using a logistic regression analysis. RESULTS Nine hundred and fifty-eight patients were identified who underwent a postoperative corticosteroid injection into a pre-existing shoulder arthroplasty and compared to 3832 control patients. After controlling for demographics, comorbidities, and procedure type, the rate of infection in patients who received a postoperative corticosteroid injection (1.77%) was significantly higher than control patients who did not receive an injection (0.91%) (OR 1.98 (95% CI 1.31-2.98), p = 0.0253). CONCLUSIONS There is a significant association between intra-articular shoulder corticosteroid injections in patients with pre-existing shoulder arthroplasties and prosthetic joint infection compared to matched controls without postoperative injections. STUDY DESIGN Level III, retrospective cohort study.
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Affiliation(s)
| | - Brian C Werner
- Department of Orthopaedic Surgery,
University of Virginia Health System, Charlottesville, USA,Brian C Werner, Department of Orthopaedic
Surgery, University of Virginia Health System, PO Box 800159, Charlottesville,
USA.
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Cancienne JM, Dempsey IJ, Garrigues GE, Cole BJ, Brockmeier SF, Werner BC. Trends and impact of three-dimensional preoperative imaging for anatomic total shoulder arthroplasty. Shoulder Elbow 2021; 13:380-387. [PMID: 34394735 PMCID: PMC8355644 DOI: 10.1177/1758573220908865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/29/2019] [Accepted: 01/29/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The goals of this study were to determine the incidence in the United States of preoperative three-dimensional imaging prior to anatomic total shoulder arthroplasty for osteoarthritis and to determine if preoperative imaging is associated with decreased complication rates. METHODS Using a Medicare insurance database, we identified all patients who underwent computed tomography (n = 9380) and/or magnetic resonance imaging (n = 15,653) prior to anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis from 2005 to 2014. The incidence of imaging over time was analyzed and complication rates compared between patients with imaging to matched controls. RESULTS The incidence of preoperative three-dimensional imaging significantly increased over time, with computed tomography increasing more than magnetic resonance imaging. Compared to controls, patients with preoperative computed tomography imaging had significantly lower revision rates at two years (odds ratio 0.72 (0.64-0.82), p = 0.008). There were no other significant differences in the other complications studied. CONCLUSIONS The use of preoperative three-dimensional imaging for anatomic total shoulder arthroplasty for a diagnosis of osteoarthritis has increased dramatically, with the use of computed tomography increasing the most. Patients who underwent preoperative computed tomography imaging experienced lower revision rates at two years postoperatively compared to matched controls without such imaging. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
| | - Ian J Dempsey
- Department of Orthopaedic Surgery, Rush
University Medical Center, Chicago, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush
University Medical Center, Chicago, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush
University Medical Center, Chicago, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
- Brian C Werner, Department of Orthopaedic
Surgery, University of Virginia Health System, PO Box 800159, Charlottesville,
VA, USA.
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Cancienne JM, Denard PJ, Garrigues GE, Werner BC. The Relationship of Staged, Bilateral Arthroscopic Primary Rotator Cuff Repair Timing and Postoperative Complications. Am J Sports Med 2021; 49:2027-2034. [PMID: 34081550 DOI: 10.1177/03635465211015198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Smith JM, Cancienne JM, Brockmeier SF, Werner BC. Vitamin D deficiency and total shoulder arthroplasty complications. Shoulder Elbow 2021; 13:99-105. [PMID: 33717223 PMCID: PMC7905506 DOI: 10.1177/1758573220906520] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/12/2019] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The primary objective of this study was to examine the relationship between vitamin D deficiency and implant-related and medical complications following total shoulder arthroplasty. METHODS Using the PearlDiver database, patients who underwent total shoulder arthroplasty from 2005 to 2016 with vitamin D deficiency were identified. These were compared to a 3:1 control group matched by age, sex, and presence of a concomitant osteoporosis diagnosis. Primary outcome measures were implant-related complications (loosening, periprosthetic fracture, periprosthetic joint infection, and revision total shoulder arthroplasty) in addition to medical complications within 90 days of surgery. A multivariable logistic regression analysis was utilized to control for patient demographics and comorbidities. RESULTS One thousand and six hundred and seventy-four patients with vitamin D deficiency were identified and compared to 5022 controls. There was a significantly higher rate of revision total shoulder arthroplasty in the vitamin D deficient patients compared to controls (2.3% versus 0.8%, odds ratio 3.3, p < 0.0001). After controlling for confounding variables, there were no significant differences in any of the remaining implant-related or medical complications with the exception of higher rates of urinary tract infections in patients with vitamin D deficiency. CONCLUSIONS Vitamin D deficiency is associated with a higher rate of all-cause revision total shoulder arthroplasty but not medical complications compared to controls.Level of evidence: Level III case control study.
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Affiliation(s)
- J Michael Smith
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
| | | | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, USA,Brian C Werner, Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA, USA.
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Beck EC, Chahla J, Suppauksorn S, Cancienne JM, Krivicich LM, Nho SJ. Author Reply to "Letter to the Editor Regarding 'Comparison of Suction Seal and Contact Pressures Between 270° Labral Reconstruction, Labral Repair, and the Intact Labrum'". Arthroscopy 2020; 36:2947-2948. [PMID: 33276882 DOI: 10.1016/j.arthro.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/09/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - Jorge Chahla
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | | | - Laura M Krivicich
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Cancienne JM, Browning R, Werner BC. Patient-Related Risk Factors for Contralateral Anterior Cruciate Ligament (ACL) Tear After ACL Reconstruction: An Analysis of 3707 Primary ACL Reconstructions. HSS J 2020; 16:226-229. [PMID: 33380951 PMCID: PMC7749876 DOI: 10.1007/s11420-019-09687-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/16/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
| | - Robert Browning
- Midwest Orthopedics at Rush, 1611 W Harrison St, Chicago, IL 60612 USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908 USA
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Cancienne JM, Browning R, Haug E, Browne JA, Werner BC. Certificate-of-Need Programs Are Associated with a Reduced Incidence, Expenditure, and Rate of Complications with Respect to Knee Arthroscopy in the Medicare Population. HSS J 2020; 16:264-271. [PMID: 33380956 PMCID: PMC7749925 DOI: 10.1007/s11420-019-09693-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND To curb costs at the state level, improve care quality, and promote access to care, certificate-of-need (CON) laws were established in many states in 1974. It is not known how CON regulations have affected the provision of knee arthroscopy, one of the most common orthopedic procedures performed in the USA. QUESTIONS/PURPOSES We sought to characterize the effects of CON regulations on knee arthroscopy in the national Medicare population by examining trends in procedure volumes, comparing trends in procedure charges, evaluating distribution of procedure volumes between high-, mid-, and low-volume facilities, and comparing adverse event and complication rates after knee arthroscopy between states with and without CON regulations. METHODS States with CON regulations covering both inpatient and outpatient operating rooms formed the study group (n = 25 states) and were compared with states without CON laws or laws that did not cover operating rooms during the study period (n = 20 states). The 100% Medicare Standard Analytical Files from 2005 through 2014 were used to compare knee arthroscopy procedure volumes, charges, reimbursements, distribution of procedures based on facility volumes and adverse events between the two groups. RESULTS The rate of decrease in the incidence of knee arthroscopy was significantly greater in CON states than that in non-CON states. CON states also had significantly lower charges at all time points, and overall, compared with non-CON states. There were significantly more high- and mid-volume facilities in CON states than in non-CON states, and there were significantly more low-volume facilities in non-CON states than in CON states. Finally, there were significantly higher rates of emergency room visits within 30 days and infection within 6 months in non-CON states than in CON states. CONCLUSIONS CON regulations appear to have achieved several of their intended goals for knee arthroscopy. Further research is needed to determine if CON regulations affect the quality and sustainability of care provided to patients undergoing knee arthroscopy.
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Affiliation(s)
| | - Robert Browning
- Midwest Orthopaedics at Rush, 1611 W Harrison St, Chicago, IL USA
| | - Emmanuel Haug
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA 22908 USA
| | - James A. Browne
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA 22908 USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA 22908 USA
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Agarwalla A, Lu Y, Chang E, Patel BH, Cancienne JM, Cole BJ, Verma N, Forsythe B. Influence of mental health on postoperative outcomes in patients following biceps tenodesis. J Shoulder Elbow Surg 2020; 29:2248-2256. [PMID: 32684282 DOI: 10.1016/j.jse.2020.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/16/2020] [Accepted: 03/20/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis. METHODS The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS. RESULTS Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008). CONCLUSION Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.
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Affiliation(s)
- Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, USA
| | - Yining Lu
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Chang
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Bhavik H Patel
- Department of Orthopaedic Surgery, University of Illinois, Chicago, IL, USA
| | | | - Brian J Cole
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
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Suppauksorn S, Beck EC, Chahla J, Cancienne JM, Krivicich LM, Rasio J, Shewman E, Nho SJ. Comparison of Suction Seal and Contact Pressures Between 270° Labral Reconstruction, Labral Repair, and the Intact Labrum. Arthroscopy 2020; 36:2433-2442. [PMID: 32504714 DOI: 10.1016/j.arthro.2020.05.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To biomechanically compare the suction seal, contact area, contact pressures, and peak forces of the intact native labrum, torn labrum, 12- to 3-o'clock labral repair, and 270° labral reconstruction in the hip. METHODS A cadaveric study was performed using 8 fresh-frozen hemipelvises with intact labra and without osteoarthritis. Intra-articular pressure maps were produced for each specimen using an electromechanical testing system under the following conditions: (1) intact labrum, (2) labral tear, (3) labral repair between the 12- and 3-o'clock positions, and (4) 270° labral reconstruction using iliotibial band allograft. Specimens were examined in neutral position, 20° of extension, and 60° of flexion. In each condition, contact pressure, contact area, and peak force were obtained. Repeated-measures analysis of variance was used to identify differences in biomechanical parameters among the 3 conditions. Qualitative differences in suction seal were compared between labral repair and labral reconstruction using the Fisher exact test. RESULTS Repeated-measures analysis of variance for contact area in neutral position, extension, and flexion showed statistically significant differences between the normalized study states (P < .05). Post hoc analysis showed significantly larger contact areas measured in labral repair specimens than in labral reconstruction specimens in the extension and flexion positions. Region-of-interest analysis for the normalized contact area in the extension and flexion positions, as well as normalized contact pressures in neutral position, showed statistically significant differences between the labral states (P < .05). Finally, 8 labral repairs (100%) versus only 1 labral reconstruction (12.5%) retained the manually tested suction seal (P < .001). CONCLUSIONS In this in vitro biomechanical model, 270° labral reconstruction resulted in decreased intra-articular contact area and loss of suction seal when compared with labral repair. Clinically, labral reconstruction may not restore the biomechanical characteristics of the native labrum as compared with labral repair. CLINICAL RELEVANCE Labral reconstruction may result in lower intra-articular hip contact area and loss of suction seal, affecting the native biomechanical function of the acetabular labrum. Further biomechanical studies and clinical studies are necessary to determine whether there are any long-term consequences of 270° labral reconstruction.
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Affiliation(s)
- Sunikom Suppauksorn
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A..
| | - Jorge Chahla
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jourdan M Cancienne
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Laura M Krivicich
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jonathan Rasio
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Elizabeth Shewman
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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11
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Suppauksorn S, Beck EC, Rasio J, Cancienne JM, Shewman E, Chahla J, Krivicich LM, Nho SJ. A Cadaveric Study of Cam-Type Femoroacetabular Impingement: Biomechanical Comparison of Contact Pressures Between Cam Morphology, Partial Femoral Osteoplasty, and Complete Femoral Osteoplasty. Arthroscopy 2020; 36:2425-2432. [PMID: 32461022 DOI: 10.1016/j.arthro.2020.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the biomechanical properties of the hip joint with an intact femoral cam lesion, partial cam resection, and complete cam resection. METHODS A cadaveric study was performed using 8 hemipelvises with cam-type morphology (alpha angle > 55°) and intact labra. Intra-articular pressure maps were produced for each specimen under the following conditions: (1) native cam morphology (intact), (2) cam morphology with incomplete resection (partial), and (3) cam morphology with complete resection (complete). By use of an open technique, resection of the superior portion of the cam morphology was performed with a 5.5-mm burr to create the partial resection, followed by the inferior portion to create the complete resection. In each condition, 3 biomechanical parameters were obtained: contact pressure, contact area, and peak force within a region of interest. Measurements were performed 3 times in each condition, and the average value was used for statistical analysis. Analysis of variance was used to compare biomechanical parameters between conditions. RESULTS A statistically significant difference was found between the pre- and post-resection alpha angles (62.2° ± 3.9° vs 40.9° ± 1.4°, P < .001). Repeated-measures analysis of variance showed that the normalized average pressure values of hips with complete resection of cam lesions were significantly lower than those of hips with incomplete femoral cam lesions and hips with intact cam morphology (100% vs 93.6% ± 8.3% and 82.6% ± 16.2%, respectively; P < .0001). The percentage reduction of contact pressure in the complete and partial groups was 17.4% and 6.4%, respectively, compared with the intact group. Contact area and peak force showed no statistically significant differences across the 3 conditions (P > .05). CONCLUSIONS Complete cam resection results in significantly lower intra-articular hip contact pressures than incomplete cam resection and native cam morphology in a cadaveric hip model. These observations underscore the importance of ensuring complete resection of femoral cam lesions in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. CLINICAL RELEVANCE Previous studies have shown that the most common reason for revision hip arthroscopy in patients with femoroacetabular impingement syndrome is incomplete femoral cam resection during the index operation. This study shows biomechanical differences associated with partial cam resection compared with the complete cam resection state that may translate to persistent symptoms.
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Affiliation(s)
- Sunikom Suppauksorn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A..
| | - Jonathan Rasio
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jourdan M Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Elizabeth Shewman
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Laura M Krivicich
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Cancienne JM. Editorial Commentary: Go Ahead and Repair My Rotator Cuff. I Dare You. Arthroscopy 2020; 36:2389-2390. [PMID: 32891241 DOI: 10.1016/j.arthro.2020.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 02/02/2023]
Abstract
A national database in the United States was used to identify increasing age, male sex, smoking, obesity, hyperlipidemia, and vitamin D deficiency as significant independent patient-specific risk factors for rotator cuff repair failure requiring revision repair. Understanding risks for repair failure can help counsel patients, inform treatment strategies, and consider treatment alternatives for patients with symptomatic rotator cuff tears.
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Chahla J, Cancienne JM, Beletsky A, Manderle BJ, Verma NN. Arthroscopic Superior Capsular Reconstruction with Dermal Allograft for the Treatment of a Massive Irreparable Rotator Cuff Tear. JBJS Essent Surg Tech 2020; 10:ST-D-19-00012. [PMID: 32983600 DOI: 10.2106/jbjs.st.19.00012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A massive, irreparable rotator cuff tear represents a challenging treatment scenario with respect to surgical intervention. Traditionally, surgical options have included reverse total shoulder arthroplasty, hemiarthroplasty, or rotator cuff repair; however, these techniques may not necessarily restore proper anatomy to the superior capsule, a structure implicated in the maintenance of subacromial contact pressures and the prevention of superior glenohumeral translation. Indications for arthroscopic superior capsular reconstruction include massive, irreparable supraspinatus and/or infraspinatus tears and failure of conservative treatment beyond subjective pain thresholds and dysfunction tolerability. Adequate latissimus dorsi, pectoralis major, and deltoid function helps to ensure the appropriate level of shoulder stability and the ability to complete the necessary rehabilitation protocol. The current surgical guide details the clinical evaluation, surgical technique, and rehabilitation protocol for patients undergoing arthroscopic superior capsular reconstruction for a massive, irreparable rotator cuff tear involving the subscapularis, supraspinatus, and infraspinatus. The procedure is performed arthroscopically with the patient in a beach-chair position, starting first with anterior and lateral portal placement for comprehensive diagnostic shoulder arthroscopy assessing rotator cuff damage. Single-row suture repair of the subscapularis and infraspinatus is performed, followed by concomitant subacromial bursectomy, decompression, and coracoplasty to aid in visualization, avoid graft abrasion, and provide access to marrow elements. Suture anchor placement, allograft fixation, and appropriate suture management are highlighted, as well as rehabilitation timelines, complications, and clinical pearls.
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Affiliation(s)
- Jorge Chahla
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University, Chicago, Illinois
| | - Jourdan M Cancienne
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University, Chicago, Illinois
| | - Alexander Beletsky
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University, Chicago, Illinois
| | - Brandon J Manderle
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University, Chicago, Illinois
| | - Nikhil N Verma
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University, Chicago, Illinois
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Cancienne JM, Awowale JT, Camp CL, Degen RM, Shiu B, Wang D, Werner BC. Therapeutic postoperative anticoagulation is a risk factor for wound complications, infection, and revision after shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:S67-S72. [PMID: 32192881 DOI: 10.1016/j.jse.2019.11.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/19/2019] [Accepted: 11/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of the present study was to examine the relationship between postoperative therapeutic anticoagulation, wound complications, infection, and revision. METHODS Using a national insurance database from 2007 to 2016, patients who underwent shoulder arthroplasty with an indication for postoperative therapeutic anticoagulation in the case of atrial fibrillation or acute postoperative venous thromboembolism were identified. Those with a prescription for a therapeutic anticoagulant within 2 weeks of surgery were identified and compared with controls without postoperative therapeutic anticoagulant prescriptions. Wound complications and postoperative infection at 3 and 6 months, and revision shoulder arthroplasty at 6 months and all time points were then compared in the database using a multivariable logistic regression analysis. RESULTS A total of 17,272 patients were included, including 684 patients who received therapeutic anticoagulation and 16,588 controls. Patients receiving therapeutic anticoagulation experienced increased wound complications at 3 months (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.0-4.6, P < .0001) and 6 months (OR 2.5, 95% CI 1.7-3.8, P < .0001). Patients receiving therapeutic anticoagulation also experienced increased rates of wound infection at 3 months (OR 1.5, 95% CI 1.1-2.0, P = .007) and 6 months (OR 1.8, 95% CI 1.4-2.3, P < .0001). Finally, patients receiving therapeutic anticoagulation experienced increased rates of revision surgery at 6 months (OR 1.8, 95% CI 1.3-2.5, P = .0003) and within 9 years (OR 1.5, 95% CI 1.1-2.0, P = .007). CONCLUSIONS Wound complications and revision rates in patients undergoing shoulder arthroplasty who require postoperative therapeutic anticoagulation are significantly elevated compared with controls.
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Affiliation(s)
| | - John T Awowale
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Ryan M Degen
- Fowler Kennedy Sports Medicine Clinic, Western University, London, ON, Canada
| | - Brian Shiu
- Ruxton Professional Center, University of Maryland School of Medicine, Towson, MD, USA
| | - Dean Wang
- Division of Sports Medicine, Department of Orthopaedic Surgery, UC Irvine Health, Orange, CA, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
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15
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Otte RS, Naylor AJ, Blanchard KN, Cancienne JM, Chan W, Romeo AA, Garrigues GE, Nicholson GP. Salvage reverse total shoulder arthroplasty for failed anatomic total shoulder arthroplasty: a cohort analysis. J Shoulder Elbow Surg 2020; 29:S134-S138. [PMID: 32643607 DOI: 10.1016/j.jse.2020.04.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed anatomic total shoulder arthroplasty (TSA) is increasing in incidence. The purpose of this study was to analyze the results of RTSA as a revision salvage procedure for failed TSA and identify factors that influenced those outcomes. METHODS All anatomic TSAs that were revised to RTSAs in adult patients, under the care of 2 senior surgeons at a single academic center from 2006 to 2018, were queried and reviewed. Cases in which hemiarthroplasty or RTSA was revised to RTSA were excluded. Electronic medical records and survey databases were reviewed for each subject. Demographic and surgical details were reviewed and analyzed with descriptive statistics. Preoperative and postoperative range of motion (ROM) including active forward elevation and active external rotation were evaluated. Patient-reported outcome surveys including the American Shoulder and Elbow Surgeons survey, Single Assessment Numeric Evaluation, and visual analog scale for pain were collected and analyzed. Improvement in ROM and outcome survey measures was assessed with 2-sample t tests. Complication and reoperation rates were analyzed with descriptive statistics. RESULTS A total of 75 patients (32 men and 43 women) were available for analysis at a mean of 22.3 months. The subjects were aged 60.3 ± 11.3 years at the time of TSA and 64.6 ± 9.7 years at the time of RTSA. The average period between TSA and RTSA was 4.3 years. The 3 most common indications for revision RTSA were painful arthroplasty (n = 62, 82.7%), rotator cuff failure (n = 56, 74.7%), and unstable arthroplasty (n = 25, 33.3%), but the majority of patients had multiple indications for surgery (n = 69, 92%). Significant improvements were found in all outcome measures from the time of failed TSA diagnosis to most recent follow-up after salvage RTSA with the exception of active external rotation: American Shoulder and Elbow Surgeons score, 39 ± 15 preoperatively vs. 62 ± 25 postoperatively; Single Assessment Numeric Evaluation, 27 ± 23 vs. 60 ± 30; visual analog scale pain score, 5 ± 2 vs. 3 ± 3; and active forward elevation, 79° ± 41° vs. 128° ± 33°. Major complications occurred in 21 patients (28.4%) after salvage RTSA, and 9 (12%) underwent reoperation. CONCLUSIONS RTSA for failed TSA can improve pain, function, and quality-of-life measures in patients with various TSA failure etiologies. However, postoperative ROM and patient-reported outcomes do not reach the values seen in the primary RTSA population.
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Affiliation(s)
| | - Amanda J Naylor
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | | | - William Chan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
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Werner BC, Cancienne JM, Browning R, Verma NN, Cole BJ. An Analysis of Current Treatment Trends in Platelet-Rich Plasma Therapy in the Medicare Database. Orthop J Sports Med 2020; 8:2325967119900811. [PMID: 32083143 PMCID: PMC7005975 DOI: 10.1177/2325967119900811] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022] Open
Abstract
Background: The use of platelet-rich plasma (PRP) in the Medicare population is not well described. Purpose: To investigate the national use of PRP among Medicare beneficiaries, including the incidence and conditions for which it was used in both operative and nonoperative settings, and determine charges to Medicare. Study Design: Descriptive epidemiology study. Methods: The Medicare Standard Analytical Files within the PearlDiver database were queried for PRP injections by use of Current Procedural Terminology (CPT) code 0232T from 2010 to 2014. A search of every associated International Classification of Diseases, 9th Revision, code and CPT code on the day of the injection was performed, and codes were broadly categorized as shoulder, knee, elbow, hip, and foot/ankle. These categories were then subdivided into 2 groups based on whether the injection was performed at the time of surgery or for a nonoperative condition. The patient data were analyzed by demographics and geographic region. In further analysis, the charges sent to Medicare for PRP injections were stratified by year and musculoskeletal site. Results: A total of 3654 PRP injections were coded for and administered during the study period; 57% of recipients were men and 33% were 65 to 69 years of age. We found that 42% of all PRP injections were administered in the southern geographic region. PRP injections were most commonly associated with shoulder diagnoses, followed closely by the foot and ankle and by the knee. The majority of injections given for shoulder conditions were performed at the time of surgery, whereas the majority of knee conditions treated with PRP were associated with nonoperative treatments. Annual charges to Medicare for PRP injections increased 400%, from $500,000 in 2010 to more than $2 million in 2014. Conclusion: The use and breadth of PRP therapy have increased substantially in Medicare beneficiaries. Further research is required to obtain a consensus on treatment recommendations for PRP use in this population in addition to strategies to obtain insurance reimbursement.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | | | | | - Brian J Cole
- Midwest Orthopaedics at Rush, Chicago, Illinois, USA
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Nwachukwu BU, Beck EC, Lee EK, Cancienne JM, Waterman BR, Paul K, Nho SJ. Application of Machine Learning for Predicting Clinically Meaningful Outcome After Arthroscopic Femoroacetabular Impingement Surgery. Am J Sports Med 2020; 48:415-423. [PMID: 31869249 DOI: 10.1177/0363546519892905] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hip arthroscopy has become an important tool for surgical treatment of intra-articular hip pathology. Predictive models for clinically meaningful outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are unknown. PURPOSE To apply a machine learning model to determine preoperative variables predictive for achieving the minimal clinically important difference (MCID) at 2 years after hip arthroscopy for FAIS. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were analyzed for patients who underwent hip arthroscopy for FAIS by a high-volume fellowship-trained surgeon between January 2012 and July 2016. The MCID cutoffs for the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport Specific (HOS-SS), and modified Harris Hip Score (mHHS) were 9.8, 14.4, and 9.14, respectively. Predictive models for achieving the MCID with respect to each were built with the LASSO algorithm (least absolute shrinkage and selection operator) for feature selection, followed by logistic regression on the selected features. Study data were analyzed with PatientIQ, a cloud-based research and analytics platform for health care. RESULTS Of 1103 patients who met inclusion criteria, 898 (81.4%) had a minimum of 2-year reported outcomes and were entered into the modeling algorithm. A total of 74.0%, 73.5%, and 79.9% met the HOS-ADL, HOS-SS, and mHHS threshold scores for achieving the MCID. Predictors of not achieving the HOS-ADL MCID included anxiety/depression, symptom duration for >2 years before surgery, higher body mass index, high preoperative HOS-ADL score, and preoperative hip injection (all P < .05). Predictors of not achieving the HOS-SS MCID included anxiety/depression, preoperative symptom duration for >2 years, high preoperative HOS-SS score, and preoperative hip injection, while running at least at the recreational level was a predictor of achieving HOS-SS MCID (all P < .05). Predictors of not achieving the mHHS MCID included history of anxiety or depression, high preoperative mHHS score, and hip injections, while being female was predictive of achieving the MCID (all P < .05). CONCLUSION This study identified predictive variables for achieving clinically meaningful outcome after hip arthroscopy for FAIS. Patient factors including anxiety/depression, symptom duration >2 years, preoperative intra-articular injection, and high preoperative outcome scores are most consistently predictive of inability to achieve clinically meaningful outcome. These findings have important implications for shared decision-making algorithms and management of preoperative expectations after hip arthroscopy for FAI.
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Affiliation(s)
- Benedict U Nwachukwu
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Edward C Beck
- Division of Sports Medicine, Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | - Jourdan M Cancienne
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian R Waterman
- Division of Sports Medicine, Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Katlynn Paul
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Khazi ZM, Lu Y, Patel BH, Cancienne JM, Werner B, Forsythe B. Risk factors for opioid use after total shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:235-243. [PMID: 31495704 DOI: 10.1016/j.jse.2019.06.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/09/2019] [Accepted: 06/18/2019] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose was to assess opioid use before and after anatomic and reverse total shoulder arthroplasty (TSA) and determine patient factors associated with prolonged postoperative opioid use. METHODS Patients undergoing primary TSA (anatomic or reverse) were identified within the Humana database from 2007 to 2015. Patients were categorized as opioid-naive patients who did not fill a prescription prior to surgery or those who filled opioid prescriptions within 3 months preoperatively (OU); the OU cohort was subdivided into those filling opioid prescriptions within 1 month preoperatively and those filling opioid prescriptions between 1 and 3 months preoperatively. The incidence of opioid use was evaluated preoperatively and longitudinally tracked for each cohort. Multivariate analysis was used to identify factors associated with opioid use at 12 months after surgery, with statistical significance defined as P < .05. RESULTS Overall, 12,038 patients (5180 in OU cohort, 43%) underwent primary TSA during the study period. Opioid use declined after the first postoperative month; however, the incidence of opioid use was significantly higher in the OU cohort than in the opioid-naive cohort at 1 year (31.4% vs. 3.1%, P < .0001). Subgroup analysis revealed a similar decline in postoperative opioid use for anatomic and reverse TSA (P < .0001 for both). Multivariate analysis identified chronic preoperative opioid use (ie, filling an opioid prescription between 1 and 3 months prior to surgery) as the strongest risk factor for opioid use at 12 months after anatomic and reverse TSA (P < .0001). CONCLUSION More than 40% of patients undergoing TSA received opioid medications within 3 months before surgery. Preoperative opioid use, age younger than 65 years, and fibromyalgia were independent risk factors for opioid use 1 year following anatomic and reverse TSA. Chronic preoperative opioid use conferred the highest risk of prolonged postoperative opioid use.
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Affiliation(s)
- Zain M Khazi
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Yining Lu
- Division of Sports Medicine, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Bhavik H Patel
- Division of Sports Medicine, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Jourdan M Cancienne
- Division of Sports Medicine, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL, USA
| | - Brian Werner
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Brian Forsythe
- Division of Sports Medicine, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL, USA.
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Casp AJ, Montgomery SR, Cancienne JM, Brockmeier SF, Werner BC. Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2020; 28:121-127. [PMID: 31977612 DOI: 10.5435/jaaos-d-18-00537] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Osteoporosis is a widespread and growing medical condition, with significant orthopaedic implications. However, the effect of osteoporosis on outcomes after total shoulder arthroplasty (TSA) is not well understood. The goal of the present study was to characterize the incidence of osteoporosis in patients undergoing shoulder arthroplasty and to examine whether patients with osteoporosis undergoing anatomic and reverse TSA are at an increased risk of prosthetic-related complications. METHODS Complication rates were calculated for patients with osteoporosis who underwent anatomic and reverse TSA as separate cohorts within 2 years of surgery including loosening/osteolysis, periprosthetic fracture, periprosthetic dislocation, and revision shoulder arthroplasty and compared using a multivariable logistic regression analysis to control for patient demographics and comorbidities during comparisons, including the indication for reverse TSA. RESULTS The prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients. Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls. DISCUSSION A significant number of patients undergoing both anatomic and reverse TSA have a concurrent diagnosis of osteoporosis. Osteoporosis represents a significant independent risk factor for periprosthetic fracture and revision shoulder arthroplasty within 2 years of surgery, regardless of the type of implant. Patients with osteoporosis should be counseled on their increased risk of complications after shoulder arthroplasty.
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Affiliation(s)
- Aaron J Casp
- From the Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA (Dr. Casp, Dr. Cancienne, Dr. Brockmeier, and Dr. Werner), and the University of Virginia School of Medicine, Charlottesville, VA (Mr. Montgomery)
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Beletsky A, Cancienne JM, Manderle BJ, Mehta N, Wilk KE, Verma NN. A Comparison of Physical Therapy Protocols Between Open Latarjet Coracoid Transfer and Arthroscopic Bankart Repair. Sports Health 2020; 12:124-131. [PMID: 31916920 DOI: 10.1177/1941738119887396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
CONTEXT Recent studies examining return to sport after traumatic shoulder instability suggest faster return-to-sport time lines after bony stabilization when compared with soft tissue stabilization. The purpose of the current study was to define variability across online Latarjet rehabilitation protocols and to compare Latarjet with Bankart repair rehabilitation time lines. EVIDENCE ACQUISITION Online searches were utilized to identify publicly available rehabilitation protocols from Accreditation Council for Graduate Medical Education (ACGME)-accredited academic orthopaedic surgery programs. STUDY DESIGN Descriptive epidemiology study. LEVEL OF EVIDENCE Level 3. RESULTS Of the 183 ACGME-accredited orthopaedic programs reviewed, 14 institutions (7.65%) had publicly available rehabilitation protocols. A web-based search yielded 17 additional protocols from private sports medicine practices. Of the 31 protocols included, 31 (100%) recommended postoperative sling use and 26 (84%) recommended elbow, wrist, and hand range of motion exercises. Full passive forward flexion goals averaged 3.22 ± 2.38 weeks postoperatively, active range of motion began on average at 5.22 ± 1.28 weeks, and normal scapulothoracic motion by 9.26 ± 4.8 weeks postoperatively. Twenty (65%) protocols provided specific recommendations for return to nonoverhead sport-specific activities, beginning at an average of 17 ± 2.8 weeks postoperatively. This was compared with overhead sports or throwing activities, for which 18 (58%) of protocols recommended beginning at a similar average of 17.1 ± 3.3 weeks. CONCLUSION Similar to Bankart repair protocols, Latarjet rehabilitation protocols contain a high degree of variability with regard to exercises and motion goal recommendations. However, many milestones and start dates occur earlier in Latarjet protocols when compared with Bankart-specific protocols. Consequently, variability in the timing of rehabilitation goals may contribute to earlier return to play metrics identified in the broader literature for the Latarjet procedure when compared with arthroscopic Bankart repair. STRENGTH OF RECOMMENDATION TAXONOMY (SORT) Level C.
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Affiliation(s)
- Alexander Beletsky
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | | | - Brandon J Manderle
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Nabil Mehta
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Kevin E Wilk
- Champion Sports Medicine, American Sports Medicine Institute, Birmingham, Alabama
| | - Nikhil N Verma
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois
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Cancienne JM, Christian DR, Redondo ML, Huddleston HP, Shewman EF, Farr J, Cole BJ, Yanke AB. The Biomechanical Effects of Limited Lateral Retinacular and Capsular Release on Lateral Patellar Translation at Various Flexion Angles in Cadaveric Specimens. Arthrosc Sports Med Rehabil 2019; 1:e137-e144. [PMID: 32266351 PMCID: PMC7120862 DOI: 10.1016/j.asmr.2019.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 09/08/2019] [Indexed: 01/14/2023] Open
Abstract
Purpose To determine the biomechanical effect of limited lateral retinacular and capsular release on lateral patellar translation as a function of constant force at various knee flexion angles. Methods Six pairs of bilateral cadaveric knee specimens (12 knees) were obtained from a tissue bank, dissected, and potted in a perfect lateral position based on fluoroscopy. A direct lateral force was applied to the patella through an eye screw in the midpoint of the lateral patella, and each knee underwent testing in the intact state and after lateral retinacular and capsular release. All knees were tested at 0°, 10°, 20°, 30°, 45°, 60°, and 90° of flexion using a custom-machined jig on a materials testing system with a 20-N lateral force applied to the patella. Patellar displacement was recorded and compared for each specimen. Results Lateral displacement was significantly greater at all degrees of flexion for the lateral-release specimens than for an intact lateral retinaculum (P < .05). Compared with intact specimens, lateral-release specimens experienced 30% more translation at 0° of flexion and between 6% and 9% more lateral translation at 10° to 90° of flexion. Conclusions Lateral retinacular and capsular release results in significantly increased lateral patellar translation at all flexion angles compared with intact specimens. This finding suggests that the lateral retinaculum may function as a significant restraint to lateral translation even with intact medial soft-tissue restraints. Clinical Relevance Arthroscopic and open limited lateral retinacular releases should be performed with extreme caution when treating lateral patellar instability given the lateral retinaculum’s apparent role as a secondary restraint.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - David R Christian
- McGaw Medical Center at Northwestern University, Chicago, Illinois, U.S.A
| | | | - Hailey P Huddleston
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Elizbeth F Shewman
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jack Farr
- OrthoIndy, Greenwood, Indiana, U.S.A
| | - Brian J Cole
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Adam B Yanke
- Department of Orthopaedics, Rush University Medical Center, Chicago, Illinois, U.S.A
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Beletsky A, Cancienne JM, Leroux T, Manderle BJ, Chahla J, Verma NN. Arthroscopic Tenodesis of the Long Head Biceps Tendon Using a Double Lasso-Loop Suture Anchor Configuration. Arthrosc Tech 2019; 8:e1137-e1143. [PMID: 31921587 PMCID: PMC6948130 DOI: 10.1016/j.eats.2019.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/27/2019] [Indexed: 02/03/2023] Open
Abstract
Multiple different techniques exist for performing a biceps tenodesis, and the literature has yet to define a particular technique as superior with respect to outcomes. Factors as the center of various clinical and biomechanical studies include analyzing arthroscopic versus open techniques, optimal fixation sites, and the use specific fixation devices (i.e., anchor, screw). This article details an all-arthroscopic approach for proximal tenodesis of the long head of the biceps tendon (LHBT) using a 2-portal method in a minimally invasive manner. Optimal biomechanical fixation of the LHBT is achieve by using 2 suture anchors in the creation of a dual lasso-loop configuration at the level of the bicipital groove. Technical pearls with respect to optimal arthroscopic viewing, efficient identification of the LHBT and subsequent release from the bicipital groove, and appropriate use of suture anchors for lasso-loop creation are presented for review. Two specific technical advantages of this technique include 2 fixation points for the LHBT to minimize failure risk, and smaller drill holes when compared with commonly performed tenodesis screw techniques to theoretically limit humeral fracture risk.
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Affiliation(s)
| | | | | | | | | | - Nikhil N. Verma
- Address correspondence to Nikhil N. Verma, M.D., Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison St, Suite 300, Chicago, IL 60612, U.S.A.
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Chahla J, Beck EC, Okoroha K, Cancienne JM, Kunze KN, Nho SJ. Prevalence and Clinical Implications of Chondral Injuries After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome. Am J Sports Med 2019; 47:2626-2635. [PMID: 31411901 DOI: 10.1177/0363546519865912] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited. PURPOSE To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID). STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS. RESULTS There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m2. A total of 493 (77.8%) patients had no evidence of chondral damage, 92 (14.5%) patients had partial-thickness chondral defects, and 49 (7.7%) patients had full-thickness chondral defects. There were statistically significant differences in the Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris Hip Score, pain, and satisfaction (P < .01) among the 3 groups. Patients with grade IV chondromalacia experienced the poorest outcomes and lowest percentage of achieving the PASS. Predictors for achieving any PASS threshold included preoperative alpha angle (odds ratio [OR], 0.96; P = .016), absence of preoperative limping (OR, 7.25; P = .002), absence of preoperative chronic pain (OR, 5.83; P = .019), primary hip arthroscopic surgery (OR, 0.17; P = .050), patients who self-identified as runners (OR, 2.27; P = .037), and Tönnis grade 0 (OR, 2.86; P = .032). Male sex (OR, 2.49; P = .015) was the only predictor of achieving any MCID threshold. CONCLUSION Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.
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Affiliation(s)
- Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Edward C Beck
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kelechi Okoroha
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jourdan M Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle N Kunze
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Krishnamoorthy VP, Beck EC, Kunze KN, Cancienne JM, Krivicich LM, Suppauksorn S, Ayeni OR, Nho SJ. Radiographic Prevalence of Sacroiliac Joint Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome. Arthroscopy 2019; 35:2598-2605.e1. [PMID: 31500745 DOI: 10.1016/j.arthro.2019.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To quantify the prevalence of sacroiliac joint (SIJ) abnormalities in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) by use of various imaging modalities and to compare outcomes based on SIJ abnormalities. METHODS Plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. The exclusion criteria included patients undergoing bilateral or revision surgery, those with a history of dysplasia, and those with less than 2 years' follow-up. On radiographs, the SIJs were graded using modified New York criteria for spondyloarthropathy. CT and MRI scans were reviewed for joint surface erosion, subchondral sclerosis, joint space narrowing, pseudo-widening, bone marrow edema, and ankylosis. Patients with SIJ abnormalities were matched to patients without SIJ abnormalities in a 1:2 ratio by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. RESULTS Of 1,009 consecutive patients, 743 (73.6%) were included; 187 (25.2%) showed SIJ changes. Of these 187 patients, 164 (87.7%) had changes on plain radiographs, 88 (47.1%) had changes on CT, and 125 (66.8%) had changes on MRI. SIJ changes on any imaging modality were weakly correlated with pain to palpation of the SIJ (r = 0.11, P = .004) on physical examination. Pain to palpation of the SIJ on physical examination (odds ratio [OR], 1.12; P = .031) and a history of SIJ pain (OR, 1.93; P = .018) increased the odds of having an SIJ abnormality on any imaging modality. After matching, patients without SIJ abnormalities had a significantly greater HOS-ADL (95.4 vs 90.6, P = .001), HOS-SS (91.1 vs 77.5, P < .001), and mHHS (91.3 vs 84.5, P < .001) and a significantly lower VAS pain score (10.9 vs 25.7, P < .001) than patients with abnormalities at a mean follow-up of 34.1 ± 9.7 months (range, 24-54 months). Patients without SIJ abnormalities had greater odds of achieving the minimal clinically important difference for the HOS-ADL (OR, 2.91; P = .001) and for the HOS-SS (OR, 2.83; P < .001) but not for the mHHS (OR, 1.73; P = .081). CONCLUSIONS A high prevalence of SIJ abnormalities (25.2%) is seen on imaging in FAIS patients. These patients may show significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment. The results of this study may allow treating orthopaedic surgeons to better inform patients with SIJ abnormalities that they may not achieve clinically significant outcome improvement after hip arthroscopy. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Vignesh P Krishnamoorthy
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C Beck
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Kyle N Kunze
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jourdan M Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Laura M Krivicich
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Sunikom Suppauksorn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Abstract
Objectives: Certificates of Need (CON) laws were introduced to improve resource utilization and reduce unnecessary health-care expansion. While many states have repealed their use, the debate continues as to their efficacy in achieving these goals. As such, we asked: 1) Are there differences in TSA incidence in CON/non-CON states? 2) Are there differences in procedural charges or reimbursement between CON/non-CON states? 3) Are there differences in the proportion of cases treated in high-, mid- or low-volume facilities between groups? 4) Are there differences in complications and length-of-stay (LOS) between high-volume and low-volume facilities? Methods: The 100% Medicare Standard Analytic files were queried for all TSA between 2005 and 2013, with minimum 1-year follow-up. Publically available data was used to identify states that upheld or repealed CON regulations, and comparisons were subsequently made between groups for normalized incidence of TSA per year and procedural charges and reimbursement rates. Comparisons were then made regarding the distribution of high-, mid- and low volume facilities, post-operative complication rates, and length-of-stay (LOS) between the different volume centers. Results: 167,288 patients undergoing TSA were identified. Normalized rates of TSA increased in both groups. Non-CON states had higher per-patient reimbursement, but paradoxically lower reimbursement rates compared with CON states. CON regulations lead to a greater proportion of procedures being performed in high-volume facilities compared with non-CON (p = 0.002). Finally, 30-day and 1-year complications, and length-of-stay, were significantly lower in high-volume facilities versus low-volume facilities (p ≤ 0.016). Conclusions: Where upheld, CON regulations contributed to a notable increase in the percentage of procedures performed in high-volume facilities, which in turn lead to a significant reduction in post-operative complications and LOS. Further study is necessary to definitely establish this relationship and the utility of CON regulations for the delivery of TSA care, particularly as it relates to clinical outcomes.
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Affiliation(s)
- Ryan M Degen
- Sports Medicine and Shoulder, Hospital for Special Surgery , New York , NY , USA
| | - Jourdan M Cancienne
- Orthopedic Surgery, University of Virginia Health System , Charlottesville , VA , USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System , Charlottesville , VA , USA
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Cancienne JM, Brockmeier SF, Kew ME, Deasey MJ, Werner BC. The Association of Osteoporosis and Bisphosphonate Use With Revision Shoulder Surgery After Rotator Cuff Repair. Arthroscopy 2019; 35:2314-2320. [PMID: 31231005 DOI: 10.1016/j.arthro.2019.03.036] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/26/2019] [Accepted: 03/16/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine any association between osteoporosis and the failure of arthroscopic rotator cuff repair (ARCR) leading to revision surgery and to investigate whether the use of bisphosphonates had any influence on the observed associations. METHODS Patients who underwent ARCR with a diagnosis of osteoporosis were identified from the PearlDiver database and stratified according to whether there was a filled prescription for a bisphosphonate in the perioperative period. Patients with osteoporosis who underwent ARCR with bisphosphonate use were compared with age- and sex-matched patients who underwent ARCR with osteoporosis without a prescription for a bisphosphonate within 1 year of surgery and patients who underwent ARCR without a diagnosis of osteoporosis and no bisphosphonate use. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair, debridement for a diagnosis of a rotator cuff tear, or reverse shoulder arthroplasty. A multivariable logistic regression analysis was used to control for patient demographic characteristics and comorbidities during comparisons. RESULTS We identified 2,706 patients, including 451 in the bisphosphonate study group; 902 in the osteoporosis, no-bisphosphonate control group; and 1,353 in the non-osteoporosis control group. Patients with osteoporosis, including those to whom bisphosphonates were prescribed, had a significantly higher rate of revision rotator cuff surgery (6.58%) than patients without osteoporosis (4.51%) (odds ratio, 1.60; 95% confidence interval, 1.30-1.97; P = .008). No significant difference in the rate of revision surgery was found between patients with osteoporosis using bisphosphonates (6.65%) and age- and sex-matched patients with osteoporosis not using bisphosphonates (6.54%, P = .718). CONCLUSIONS By using an administrative database, this study was able to show a substantial difference in the revision surgery rate after ARCR in patients with osteoporosis compared with matched controls. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Matthew J Deasey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Browne JA, Casp AJ, Cancienne JM, Werner BC. Peritoneal Dialysis Does Not Carry the Same Risk as Hemodialysis in Patients Undergoing Hip or Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:1271-1277. [PMID: 31318806 DOI: 10.2106/jbjs.18.00936] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Dialysis has been associated with increased complication rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The current literature on this issue is limited and does not distinguish between hemodialysis and peritoneal dialysis. The purpose of this study was to determine (1) the differences in the infection and other complication rates after THA or TKA between patients on peritoneal dialysis and those on hemodialysis and (2) the differences in complication rates after THA or TKA between patients on peritoneal dialysis and matched controls without dialysis dependence. METHODS Patients who had undergone primary THA or TKA from 2005 to 2014 were identified in the 100% Medicare files; 531 patients who underwent TKA and 572 patients who underwent THA were on peritoneal dialysis. These patients were matched 1:1 to patients on hemodialysis and 1:3 with patients who were not receiving either form of dialysis. Multivariate regression analysis was performed to examine several adverse events, including the prevalence of infection at 1 year and hospital readmission at 30 days. RESULTS The infection rates at 1 year after THA were significantly lower in the peritoneal dialysis group than in the hemodialysis group: 1.57% (95% confidence interval [CI] = 0.7% to 3.0%) and 4.20% (95% CI = 2.7% to 6.2%), respectively, with an odds ratio (OR) of 0.30 (95% CI = 0.12 to 0.71). This was also the case for the infection rates 1 year after TKA (3.39% [95% CI = 2.0% to 5.3%] and 6.03% [95% CI = 4.2% to 8.4%], respectively; OR = 0.67 [95% CI = 0.49 to 0.93]). Peritoneal dialysis appears to result in a similar infection rate when compared with matched controls. The rates of other assessed complications, such as hospital readmission, emergency room visits, and mortality, were very similar between the peritoneal dialysis and hemodialysis groups but were often significantly higher than the rates in non-dialysis-dependent controls. CONCLUSIONS The increased risk of complications in dialysis-dependent patients following THA or TKA depends on the mode of the dialysis. Whereas patients on hemodialysis have a significantly higher risk of infection, patients on peritoneal dialysis do not appear to have this same risk when compared with non-dialysis-dependent patients. These results suggest that the mode of dialysis should be considered when assessing the risk associated with THA or TKA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James A Browne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Aaron J Casp
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jourdan M Cancienne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, Virginia
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Abstract
BACKGROUND The purpose of this study is to: (1) characterise risk factors for prolonged narcotic use following total hip arthroplasty (THA); (2) examine preoperative and prolonged postoperative narcotic use as independent risk factors for complications following THA. METHODS A national database identified primary THA patients from 2007-2015. Preoperative (POU) and prolonged postoperative narcotics users (PPU) were identified. A multivariable logistic regression analysis was utilised to identify any patient-related risk factors for prolonged use, and examined POU and PPU as risk factors for complications following THA. RESULTS 55,354 THA patients were included, 18,740 (33.8%) POU and 14,996 (27.1%) PPU. Preoperative narcotics use was the most significant factor associated with prolonged postoperative narcotic use. Preoperative and prolonged postoperative use were associated with significantly higher complications postoperatively. CONCLUSIONS Preoperative narcotic use is the most significant patient specific risk factor for prolonged postoperative narcotic use. POUs and PPUs are at a significantly higher risk of postoperative infection and revision surgery.
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Affiliation(s)
| | - Aaron A Casp
- University of Virginia Health System, Charlottesville, VA, USA
| | | | - Brian C Werner
- University of Virginia Health System, Charlottesville, VA, USA
| | - James A Browne
- University of Virginia Health System, Charlottesville, VA, USA
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Mehta N, Alter T, Beck EC, Cancienne JM, Bressler LR, Liu JN, Nho SJ. Endoscopic Repair of Proximal Hamstring Tear With Double-Row Suture Bridge Construct. Arthrosc Tech 2019; 8:e675-e678. [PMID: 31467836 PMCID: PMC6713840 DOI: 10.1016/j.eats.2019.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/28/2019] [Indexed: 02/03/2023] Open
Abstract
Hamstring strains account for 25% to 30% of all muscle strains and are an exceedingly common injury in the athletic population. Although proximal hamstring avulsion injuries occur less commonly than strains at the myotendinous junction, they are more severe and debilitating. Proximal hamstring avulsions do not respond well to conservative treatment and are more likely to require surgical intervention. Surgical repair of proximal hamstring avulsions is indicated when the injury fails to respond to conservative treatment, in cases of osseous avulsion with retraction, and in cases of tearing of all 3 hamstring tendons. Endoscopic repair of proximal hamstring avulsions is a promising technique to repair these injuries while reducing morbidity. We describe our technique for endoscopic proximal hamstring repair, which uses a double-row suture bridge construct to reattach the tendons to the ischial tuberosity.
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Affiliation(s)
- Nabil Mehta
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Thomas Alter
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Edward C. Beck
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jourdan M. Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Leah R. Bressler
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joseph N. Liu
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Shane J. Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.,Address correspondence to Shane J. Nho, M.D., M.S., Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Ste 300, Chicago, IL 60612, U.S.A.
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Cancienne JM, Kew ME, Smith MK, Carson EW, Miller MD, Werner BC. The Timing of Corticosteroid Injections Following Simple Knee Arthroscopy Is Associated With Infection Risk. Arthroscopy 2019; 35:1688-1694. [PMID: 31027921 DOI: 10.1016/j.arthro.2019.01.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 01/03/2019] [Accepted: 01/09/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine any association between the timing of ipsilateral postoperative corticosteroid injection following simple knee arthroscopy and infection. METHODS Private payer (PP) and Medicare (MC) national insurance databases were queried for patients who underwent simple arthroscopic knee procedures. Patients undergoing concomitant open or more complex procedures with grafts were excluded. Patients who underwent ipsilateral corticosteroid injections within 2, 4, 6, and 8 weeks postoperatively were then identified. Postoperative infection within 90 days after the injection was assessed using International Classification of Diseases, 9th Revision, and Current Procedural Terminology coding and compared using a multivariate binomial logistic regression analysis. RESULTS A total of 5,533 patients were identified, including 725 that received an injection within 2 weeks; 1,236 patients within 4 weeks; 1,716 patients within 6 weeks; and 1,856 patients that received an injection within 8 weeks postoperatively. In both the PP and MC datasets, the rate of infection was significantly higher in the 2-week group compared with the 6- (PP: odds ratio [OR] 3.81, P = .012; MC: OR 9.36, P = .001) and 8-week (PP: OR 8.59, P = .003; MC: OR 7.80, P = .001) groups. The rate of infection was also higher in the 4-week group compared with the 6- (PP: OR 2.54, P = .024; MC: OR 8.91, P = .001) and 8-week (PP: OR 5.64, P = .009; MC: OR 7.80, P = .001) groups. There was no difference in infection rates between the 2- and 4-week groups in either dataset (PP: P = .278; MC: P = .861). CONCLUSIONS There is a significant association between intra-articular knee corticosteroid injections within 4 weeks of surgery and an increased incidence of postoperative infection in both MC and PP patients after knee arthroscopy compared with patients with steroid injections more than 4 weeks postoperatively and matched controls who did not receive injections. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Marvin K Smith
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Eric W Carson
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Cancienne JM, Deasey MJ, Kew ME, Werner BC. The Association of Perioperative Glycemic Control With Adverse Outcomes Within 6 Months After Arthroscopic Rotator Cuff Repair. Arthroscopy 2019; 35:1771-1778. [PMID: 31027919 DOI: 10.1016/j.arthro.2019.01.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/16/2018] [Accepted: 01/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the association between glycemic control and adverse events after arthroscopic rotator cuff repair (RCR). METHODS Patients with a diagnosis of diabetes mellitus who underwent arthroscopic RCR and had a hemoglobin A1c (HbA1c) level determined within 3 months before or after surgery were identified in a national database and stratified by HbA1c level. The incidence of postoperative infection within 6 months was determined using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) curve analysis was performed to determine whether a threshold HbA1c level existed above which the risk of infection, revision rotator cuff surgery, and lysis of adhesions (LOA)-manipulation under anesthesia (MUA) after arthroscopic RCR was significantly increased. This threshold was then tested using a logistic regression analysis. RESULTS The study included 3,740 patients with an infection rate ranging from a low of 0.29% to a high of 1.14% after RCR. The inflection point of the ROC curve for infection corresponded to an HbA1c level between 7.0 and 8.0 mg/dL (P = .035; area under the curve, 0.648; specificity, 61%; sensitivity, 59%). We then used 8.0 mg/dL as a threshold to test for adverse outcomes. We found a significant difference in infection rates for patients with levels below versus above the threshold (0.30% vs 0.84%; OR, 2.0; 95% confidence interval, 1.2-3.4; P = .014) but no difference in revision rates (P = .240) or LOA-MUA (P = .650) in patients with levels above versus below the threshold. CONCLUSIONS The risk of infection after RCR in patients with diabetes mellitus increases as the perioperative HbA1c level increases and, although statistically significant, remains low. ROC curve analysis determined that a perioperative HbA1c level above 8.0 mg/dL could serve as a threshold level; however, the area under the curve and low sensitivity reflected the poor utility of this test as an independent predictor. This study did not find an association between increased perioperative HbA1c levels and rates of revision rotator cuff surgery or LOA-MUA after RCR. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Matthew J Deasey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Krishnamoorthy VP, Kunze KN, Beck EC, Cancienne JM, O'Keefe LS, Ayeni OR, Nho SJ. Radiographic Prevalence of Symphysis Pubis Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome. Am J Sports Med 2019; 47:1467-1472. [PMID: 30995415 DOI: 10.1177/0363546519837203] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis. PURPOSE To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction. RESULTS 830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013). CONCLUSION A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.
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Affiliation(s)
- Vignesh P Krishnamoorthy
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyle N Kunze
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Edward C Beck
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Jourdan M Cancienne
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Lauren S O'Keefe
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Casp AJ, Durig NE, Cancienne JM, Werner BC, Browne JA. Certificate-of-Need State Laws and Total Hip Arthroplasty. J Arthroplasty 2019; 34:401-407. [PMID: 30580894 DOI: 10.1016/j.arth.2018.11.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Many states have certificate-of-need (CON) programs requiring governmental approval to open or expand healthcare services, with the goal of limiting cost and coordinating utilization of healthcare resources. The purpose of the present study was to evaluate the associations between these state-level CON regulations and total hip arthroplasty (THA). METHODS States were designated as CON or non-CON based on existing laws. The 100% Medicare Standard Analytic Files from 2005 to 2014 were used to compare THA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the CON and non-CON states. Adverse postoperative outcomes were also analyzed. RESULTS The per capita incidence of THA was higher in non-CON states than CON states at each time period and overall (P < .0001). However, the rate of change in THA incidence over the time period was higher in CON states (1.0 per 10,000 per year) compared to non-CON states (0.68 per 10,000 per year) although not statistically significant. Length of stay was higher and a higher percentage of patients received care in high-volume hospitals in CON states (both P < .0001). No meaningful differences in postoperative complications were found. CONCLUSION CON laws did not appear to have limited the growth in incidence of THA nor improved quality of care or outcomes during the study time period. It does appear that CON laws are associated with increased concentration of THA procedures at higher volume facilities. Given the inherent potential confounding population and geographic factors, additional research is needed to confirm these findings.
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Affiliation(s)
- Aaron J Casp
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicole E Durig
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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Cancienne JM, Brockmeier SF, Kew ME, Werner BC. Perioperative Serum 25-Hydroxyvitamin D Levels Affect Revision Surgery Rates After Arthroscopic Rotator Cuff Repair. Arthroscopy 2019; 35:763-769. [PMID: 30704888 DOI: 10.1016/j.arthro.2018.09.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/05/2018] [Accepted: 09/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine any association between perioperative serum 25-hydroxyvitamin D levels and failure of arthroscopic rotator cuff repair (RCR) requiring revision surgery. METHODS Using a private-payer national insurance database, patients who underwent arthroscopic RCR with perioperative serum 25-hydroxyvitamin D levels recorded were included. Patients were stratified into groups of (1) serum 25-hydroxyvitamin D deficiency (<20 ng/mL), (2) insufficiency (20-30 ng/mL), or (3) sufficient (>30-<150 ng/mL). The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair, debridement, or reverse shoulder arthroplasty. A multivariable logistic regression analysis was used to control for patient demographics and comorbidities during comparisons. RESULTS A total of 982 patients were included in the study. The rate of revision rotator cuff surgery was significantly higher in patients in the serum 25-hydroxyvitamin D-deficient group (5.88%) compared with the serum 25-hydroxyvitamin D-sufficient control group (3.7%) (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.6-5.8; P = .007). Patients with serum 25-hydroxyvitamin D deficiency (5.88%) also had a significantly higher incidence of revision surgery compared with patients with serum 25-hydroxyvitamin D insufficiency (OR, 2.4; 95% CI, 1.5-3.9; P = .011). There was no significant difference in the incidence of revision surgery in the serum 25-hydroxyvitamin D-insufficient group (4.97%) compared with the serum 25-hydroxyvitamin D-sufficient control group (3.7%) (OR, 1.4; 95% CI, 0.8-2.3; P = .250). The absolute risk reduction of revision surgery for 25-hydroxyvitamin D-deficient patients compared with controls was 2.2%, corresponding to a number needed to treat to avoid 1 revision surgery of 46 patients, relative risk reduction = 0.59. CONCLUSIONS Although the present study found a significant statistical association between serum 25-hydroxyvitamin D deficiency and insufficiency and the rate of revision rotator cuff surgery after primary arthroscopic RCR, the absolute differences of these revision rates are minimal and are accompanied with overlapping confidence intervals limiting the clinical significance of these findings. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Kew ME, Cancienne JM, Christensen JE, Werner BC. The Timing of Corticosteroid Injections After Arthroscopic Shoulder Procedures Affects Postoperative Infection Risk. Am J Sports Med 2019; 47:915-921. [PMID: 30758977 DOI: 10.1177/0363546518825348] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injections are sometimes used in the postoperative period after shoulder arthroscopy; however, a well-defined safety profile has not been established. PURPOSE To examine the association between the timing of postoperative corticosteroid injections and rates of infection after shoulder arthroscopy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Private payer and Medicare national insurance databases were queried for patients who underwent arthroscopic rotator cuff repair, debridement, or subacromial decompression. Patients who underwent corticosteroid injections within 1, 2, 3, or 4 months postoperatively were identified and compared with a matched control group that underwent the same procedures without a postoperative steroid injection. International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes were used to identify rates of postoperative infection within 90 days after injection for the study groups and controls. Multivariate binomial logistic regression analysis was used to compare groups, and adjusted odds ratios (ORs) and 95% CIs were calculated, with P < .05 considered significant. RESULTS A total of 3946 patients were identified, including 264 patients who received an injection within 1 month after surgery, 471 within 2 months, 1037 within 3 months, 1874 within 4 months, and 2640 matched controls. When compared with controls, patients who underwent a corticosteroid injection within 1 month postoperatively had a significantly higher rate of infection (private payer: OR, 2.63; P = .014; Medicare: OR, 11.2; P < .0001). There were no differences in infection rates at all other time points ( P = .264-.835). CONCLUSION This study adds to the evidence suggesting caution when administering injections in the immediate postoperative period after shoulder arthroscopy. Although causality cannot be determined on the basis of this database review, the authors found a significant association between intra-articular corticosteroid injections administered 1 month postoperatively and an increased rate of postoperative infection in Medicare and private payer patient cohorts as compared with a control group.
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Affiliation(s)
- Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - James E Christensen
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Cancienne JM, Kew ME, Deasey MJ, Brockmeier SF, Werner BC. Dialysis dependence and modality impact complication rates after shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:e71-e77. [PMID: 30392936 DOI: 10.1016/j.jse.2018.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 08/19/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The goals of the study were to determine (1) the incidence of dialysis patients undergoing shoulder arthroplasty (SA), (2) the association of dialysis modality with complications after SA, and (3) the association of dialysis dependence with death in patients undergoing SA and nonsurgical dialysis-dependent controls. METHODS Using an insurance database, we identified dialysis-dependent patients undergoing SA and compared them with a matched control cohort without dialysis use. We performed an analysis comparing patients using peritoneal dialysis (PD), patients using hemodialysis (HD), matched non-dialysis-dependent controls, and matched PD and HD nonsurgical patients. Complications including in-hospital death, emergency department visits, hospital readmission, infection, and revision surgery were assessed. RESULTS The incidence of SA in dialysis patients has significantly increased. Compared with controls, dialysis-dependent patients had increased rates of in-hospital death (odds ratio [OR], 7.60; P < .0001), emergency department visits (OR, 4.16; P < .0001), hospital admission (OR, 1.63; P < .0001), and infection within 1 year (OR, 1.90; P = .009). Compared with patients receiving HD, PD patients had lower rates of death (OR, 0.40; P = .008), hospital readmission (OR, 0.43; P = .047), and revision surgery (OR, 0.23; P = .037). as well as a lower incidence of infection (OR, 0.30; P = .018). Compared with controls, PD patients had similar rates of most complications. Compared with nonsurgical dialysis-dependent patients, the SA procedure itself was not associated with an increased mortality rate. CONCLUSIONS Although dialysis represents a significant independent risk factor for complications after SA, this risk is highly influenced by the type of dialysis.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Matthew J Deasey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA, USA.
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Wiggins AJ, Cancienne JM, Camp CL, Degen RM, Altchek DW, Dines JS, Werner BC. Disease Burden of Medial Epicondylitis in the USA Is Increasing: An Analysis of 19,856 Patients From 2007 to 2014. HSS J 2018; 14:233-237. [PMID: 30258326 PMCID: PMC6148579 DOI: 10.1007/s11420-018-9617-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Medial epicondylitis (ME), or "golfer's elbow," is often treated initially by conservative means. Up to 15% of recalcitrant cases require surgical intervention, according to small sample populations, but no national study has determined the incidence of the diagnosis or corroborated the rate of surgical intervention. PURPOSE/QUESTION We sought to review the annual incidence of ME, surgical rates, and health care costs in a population setting. METHODS A national database was queried for ME from 2007 to 2014. Annual rates and the percentage of diagnosed cases subjected to surgical intervention were recorded. Epidemiologic data was reported with descriptive statistics, and the significant trends over time were analyzed using linear regression. RESULTS We identified 19,856 cases of ME in the study period. There was a significant increase in the annual incidence and overall incidence per 10,000 patients. The proportion of diagnoses in patients under 65 years of age decreased significantly, while the proportion in those 65 years of age or older significantly increased. The annual number of surgical interventions significantly increased over the study period, although the annual proportion of diagnosed cases proceeding to surgery remained constant. The proportion of patients 65 years of age or older undergoing surgery significantly increased. Total reimbursement for the management of ME during the study period was $1,877,189. While there was a significant increase in the total annual reimbursement, annual per-patient reimbursement did not change significantly. CONCLUSIONS While the annual incidence of ME and surgical treatment of ME increased significantly from 2007 to 2014, the proportion of cases treated surgically did not. Notably, the proportion of patients 65 years of age or older diagnosed with and being surgically treated for ME has increased in recent years. Total reimbursement for ME has steadily risen, although per-patient reimbursement rates have not significantly changed.
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Affiliation(s)
- Anthony J. Wiggins
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908 USA
| | - Jourdan M. Cancienne
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908 USA
| | - Christopher L. Camp
- Department of Orthopedics, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 USA
| | - Ryan M. Degen
- Division of Orthopaedic Surgery, The University of Western Ontario, 1151 Richmond St N, London, ON N6A 3K7 Canada
| | - David W. Altchek
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Main Campus, 525 East 71st Street, 1st Floor, New York, NY 10021 USA
| | - Joshua S. Dines
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Main Campus, 525 East 71st Street, 1st Floor, New York, NY 10021 USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908 USA
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Althoff A, Cancienne JM, Cooper MT, Werner BC. Patient-Related Risk Factors for Periprosthetic Ankle Joint Infection: An Analysis of 6977 Total Ankle Arthroplasties. J Foot Ankle Surg 2018; 57:269-272. [PMID: 29249326 DOI: 10.1053/j.jfas.2017.09.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Indexed: 02/03/2023]
Abstract
Periprosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a devastating complication that often results in explantation to resolve the infection. The purpose of the present investigation was to determine the patient-related risk factors for PJI after TAA. A national insurance database was queried for patients undergoing TAA using the Current Procedural Terminology and International Classification of Diseases, ninth revision, procedure codes from 2005 to 2012. Patients undergoing TAA with concomitant fusion procedures or more complex forefoot procedures were excluded. PJI within 6 months was then assessed using the International Classification of Diseases, ninth revision, codes for diagnosis or treatment of postoperative PJI. Multivariate binomial logistic regression analysis was performed to evaluate the patient-related risk factors for PJI. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor, with p < .05 considered statistically significant. A total of 6977 patients were included in the present study. Of these 6977 patients, 294 (4%) had a diagnosis of, or had undergone a procedure for, PJI. The independent risk factors for PJI included age <65 years (OR 1.44; p = .036), body mass index <19 kg/m2 (OR 3.35; p = .013), body mass index >30 kg/m2 (OR 1.49; p = .034), tobacco use (OR 1.59; p = .002), diabetes mellitus (OR 1.36; p = .017), inflammatory arthritis (OR 2.38; p < .0001), peripheral vascular disease (OR 1.64; p < .0001), chronic lung disease (OR 1.37; p = .022), and hypothyroidism (OR 1.32; p = .022). The independent patient-related risk factors identified in the present study should help guide physicians and patients considering elective TAA and develop risk stratification algorithms that could decrease the risk of deep, postoperative infection.
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Affiliation(s)
- Alyssa Althoff
- Medical Student, Medical University of South Carolina, Charleston, SC
| | - Jourdan M Cancienne
- Resident Physician, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA.
| | - Minton T Cooper
- Assistant Professor, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brian C Werner
- Assistant Professor, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Anciano Granadillo V, Cancienne JM, Gwathmey FW, Werner BC. Perioperative Opioid Analgesics and Hip Arthroscopy: Trends, Risk Factors for Prolonged Use, and Complications. Arthroscopy 2018; 34:2359-2367. [PMID: 29730217 DOI: 10.1016/j.arthro.2018.03.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/27/2018] [Accepted: 03/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this article is to (1) examine trends in preoperative and prolonged postoperative opioid analgesic use in patient undergoing hip arthroscopy, (2) characterize risk factors for prolonged opioid analgesic use following hip arthroscopy, and (3) explore preoperative and prolonged postoperative opioid analgesic use as independent risk factors for complications following hip arthroscopy. METHODS A private insurance database was queried for patients undergoing hip arthroscopy from 2007 to 2015 with a minimum of 6 months of follow-up. Independent risk factors for prolonged opioid analgesic use were determined. Preoperative and prolonged opioid analgesic use as risk factors for complications were examined. RESULTS There was a significantly decreasing trend in preoperative (P = .002) and prolonged postoperative (P = .009) opioid analgesic use. The most significant risk factor for prolonged postoperative opioid analgesic use was preoperative use (odds ratio [OR], 3.61; P < .0001). Other preoperative prescriptions, including muscle relaxants (OR, 1.5; P < .0001) and anxiolytics (OR, 2.0; P < .0001), were also significant risk factors. Preoperative opioid analgesic use was a significant risk factor for postoperative complications, including emergency room visits (OR, 2.1; P < .0001) and conversion to total hip arthroplasty (THA) (OR, 1.6; P < .0001). Prolonged postoperative opioid analgesic use was associated with a higher risk of revision hip arthroscopy (OR, 1.4; P = .0004) and conversion to THA (OR, 1.8; P < .0001). CONCLUSIONS More than a quarter of patients undergoing hip arthroscopy continue to receive opioid analgesic prescriptions more than 3 months postoperatively. The most significant risk factor for prolonged opioid analgesic use is preoperative opioid analgesic use. Additionally, anxiolytics, substance use or abuse, morbid obesity, and back pain were among the more notable risk factors for prolonged postoperative opioid analgesic use. Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of several adverse effects/complications. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Victor Anciano Granadillo
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Burrus MT, Cancienne JM, Boatright JD, Yang S, Brockmeier SF, Werner BC. Correction to: Shoulder Arthroplasty for Humeral Head Avascular Necrosis Is Associated with Increased Postoperative Complications. HSS J 2018; 14:225. [PMID: 29983669 PMCID: PMC6031534 DOI: 10.1007/s11420-018-9612-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
[This corrects the article DOI: 10.1007/s11420-017-9562-8.].
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Affiliation(s)
- M. Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Michigan Health System, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106-0391 USA
| | - Jourdan M. Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159 HSC, Charlottesville, VA 22908 USA
| | - Jeffrey D. Boatright
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159 HSC, Charlottesville, VA 22908 USA
| | - Scott Yang
- Oregon Health and Science University, 700 S.W. Campus Drive, 7th floor, Portland, OR 97239 USA
| | - Stephen F. Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159 HSC, Charlottesville, VA 22908 USA
| | - Brian C. Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159 HSC, Charlottesville, VA 22908 USA
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Abstract
BACKGROUND Many states in the United States have certificate-of-need (CON) programs designed to restrain health care costs and prevent overutilization of health care resources. The goal of this study was to characterize the associations between CON regulations and total knee arthroplasty (TKA) by comparing states with and without CON programs. METHODS Publicly available data were used to classify states in to CON or non-CON categories. The 100% Medicare Standard Analytical Files from 2005 through 2014 were then used to compare primary TKA procedure volumes, charges, reimbursements, and distribution of procedures based on facility volumes between the groups. Adverse events such as infection and emergency room visits after TKA were also evaluated. RESULTS Although CON status was associated with lower per capita utilization of TKA, the annual incidence of TKA appears to have increased over time more rapidly in states with CON laws compared with non-CON states (overall increase of 5.6% vs 2.3%, P < .01). When normalized to the Medicare population, the incidence of TKA increased 2.0% in CON states, whereas it actually decreased 7.2% in states without CON regulations (P = .011). Average reimbursement (and thus Medicare spend) was 5% to 10% lower in non-CON states at all time points (P < .0001). In non-CON states, relatively more TKAs appear to be performed in lower volume hospitals. Examination of adverse events rates did not reveal any strong associations between any adverse outcome and CON status. CONCLUSION CON programs appear to have influenced the delivery of care for TKA. Although our data suggest that these laws are associated with lower per capita utilization of TKA and the use of higher-volume facilities, we were unable to detect any strong evidence that CON regulations have been associated with improved quality of care or have limited growth in the utilization of this procedure over time. Confounding population and geographic factors may influence these findings and further study is needed to determine whether or not these programs have served their purpose and should be retained.
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Affiliation(s)
- James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Aaron J Casp
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Wendy M Novicoff
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
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Steiner SRH, Cancienne JM, Werner BC. Narcotics and Knee Arthroscopy: Trends in Use and Factors Associated With Prolonged Use and Postoperative Complications. Arthroscopy 2018; 34:1931-1939. [PMID: 29685836 DOI: 10.1016/j.arthro.2018.01.052] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 01/20/2018] [Accepted: 01/30/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) examine trends in the prevalence of preoperative and prolonged postoperative narcotic use in patients undergoing knee arthroscopy, (2) characterize factors associated with prolonged narcotic use after knee arthroscopy, and (3) explore the association of preoperative and prolonged postoperative narcotic use with complications after knee arthroscopy. METHODS The PearlDiver database was reviewed for patients who underwent knee arthroscopy from 2007 to 2015 with a minimum of 6 months' follow up. Patients with preoperative or prolonged postoperative narcotic use were identified and analyzed for trends. Predictors for prolonged postoperative use were identified, and regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A total of 75,372 patients were included, of which 23.9% used narcotics preoperatively and 22.6% used narcotics for a prolonged period postoperatively. There was no statistically significant trend on a year-to-year basis in preoperative (P = .744) or prolonged postoperative (P = .304) narcotic use. The most significant predictor for prolonged postoperative use was preoperative use (OR 5.33, CI 5.11-5.56, P < .0001), with the odds increasing as the number of preoperative prescriptions increased. Preoperative narcotic use was associated with increased emergency department visits (OR 1.25, CI 1.15-1.36, P < .0001), hospital admission (OR 1.15, CI 1.00-1.33, P = .046), and infection (OR 1.31, CI 1.07-1.59, P = .007). Prolonged postoperative narcotic use was associated with subsequent ipsilateral knee arthroscopy (OR 1.64, CI 1.45-1.86, P < .0001) as well as subsequent knee arthroplasty (OR 1.98, CI 1.83-2.14, P < .0001). CONCLUSIONS The results of this study did not show a trend in the use of narcotics, preoperatively or on a prolonged basis postoperatively, during the study period. The degree of preoperative narcotic use is correlated with prolonged narcotic use. The use of narcotics preoperatively and for a prolonged period postoperatively is associated with increased complications. LEVEL OF EVIDENCE Level IV, case series, therapeutic.
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Affiliation(s)
- Samuel R H Steiner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Cancienne JM, Miller MD, Browne JA, Werner BC. Not All Patients With Diabetes Have the Same Risks: Perioperative Glycemic Control Is Associated With Postoperative Infection Following Knee Arthroscopy. Arthroscopy 2018; 34:1561-1569. [PMID: 29398213 DOI: 10.1016/j.arthro.2017.11.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, U.S.A
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, U.S.A
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, U.S.A..
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Chen DQ, Cancienne JM, Werner BC, Cui Q. Is osteonecrosis due to systemic lupus erythematosus associated with increased risk of complications following total hip arthroplasty? Int Orthop 2018; 42:1485-1490. [PMID: 29550912 DOI: 10.1007/s00264-018-3871-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/27/2018] [Indexed: 01/22/2023]
Abstract
PURPOSE As the medical treatment of systemic lupus erythematosus (SLE) has evolved, the rate of total hip arthroplasty (THA) in SLE patients has increased, with osteonecrosis (ON) being the primary indication for arthroplasty in a quarter of cases. Comparative literature evaluating outcomes following THA for patients with SLE and ON versus patients with non-SLE-related ON or patients with osteoarthritis (OA) is limited. The goal of the present study was to investigate the current trend in SLE patients undergoing THA and compare complications following THA for ON with SLE, ON without SLE, and OA. METHODS The PearlDiver patient records database ( www.pearldiverinc.com , Colorado Springs, CO), a for-fee insurance-based patient records database, was utilized for this study. Two hundred forty-four patients who underwent THA for ON associated with SLE were identified and compared to control cohorts of 7836 patients with ON without SLE and 64,235 patients with OA using a multivariate analysis. RESULTS We found patients with SLE undergoing THA for ON experienced lower rates of infection and revision but a higher rate of medical complications compared to patients undergoing THA for non-SLE ON diagnoses. Patients with SLE undergoing THA for ON experienced decreased rates of infection but increased rates of transfusion and medical complications compared to patients undergoing THA for OA. CONCLUSIONS Our data demonstrate that THA can be safely performed on SLE patients with ON without significantly increased morbidity compared to that in patients with non-SLE-associated ON or patients with OA.
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Affiliation(s)
- Dennis Q Chen
- Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA, 22903, USA
| | - Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA, 22903, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA, 22903, USA
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia Health System, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA, 22903, USA.
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Abstract
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.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Eric W Carson
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Cancienne JM, Granadillo VA, Patel KJ, Werner BC, Browne JA. Risk Factors for Repeat Debridement, Spacer Retention, Amputation, Arthrodesis, and Mortality After Removal of an Infected Total Knee Arthroplasty With Spacer Placement. J Arthroplasty 2018; 33:515-520. [PMID: 28958659 DOI: 10.1016/j.arth.2017.08.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 07/29/2017] [Accepted: 08/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Chronic periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is most commonly addressed with a 2-stage exchange procedure. The purpose of this study is to examine the natural history of patients who have undergone prosthesis removal and spacer placement and evaluate risk factors for outcomes other than reimplantation. METHODS Patients who underwent removal of an infected TKA and placement of an antibiotic spacer for PJI were identified in a Medicare database. Patients with a study outcome within 1 year were then identified: (1) in hospital mortality, (2) knee arthrodesis, (3) amputation, (4) repeat debridement procedure without reimplantation, and (5) reimplantation. Independent risk factors for these outcomes were evaluated with a multivariate logistic regression analysis. RESULTS A total of 18,533 patients were included. Within 1 year postoperatively, 691 patients (3.7%) died in a hospital setting, 852 patients (4.5%) underwent a knee arthrodesis, 574 patients (3.1%) underwent an amputation, 2683 patients (14.5%) underwent a repeat debridement procedure without being reimplanted, 2323 patients (12.5%) retained their spacer, and 11,420 patients (61.6%) underwent spacer removal and reimplantation within 1 year. Numerous independent patient-related risk factors for these outcomes were identified. CONCLUSION A large number of patients (38.4%) do not undergo reimplantation within 1 year of prosthesis removal and spacer placement. Outcomes after prosthesis removal and antibiotic spacer placement are variable, and there are several independent risk factors for such outcomes that may be used to develop and improve existing treatment strategies for patients presenting with chronic PJI after TKA.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Victor A Granadillo
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kishan J Patel
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Cancienne JM, Patel KJ, Browne JA, Werner BC. Narcotic Use and Total Knee Arthroplasty. J Arthroplasty 2018; 33:113-118. [PMID: 28887020 DOI: 10.1016/j.arth.2017.08.006] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/28/2017] [Accepted: 08/02/2017] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kishan J Patel
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Cancienne JM, Brockmeier SF, Rodeo SA, Werner BC. Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery Rate After Arthroscopic Rotator Cuff Repair. Am J Sports Med 2017; 45:2948-2954. [PMID: 28787187 DOI: 10.1177/0363546517717686] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent animal studies have demonstrated that hyperlipidemia is associated with poor tendon-bone healing after rotator cuff repair; however, these findings have not been substantiated in human studies. PURPOSE To examine any association between hyperlipidemia and the failure of arthroscopic rotator cuff repair requiring revision surgery and to investigate whether the use of statin lipid-lowering agents had any influence on observed associations. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS From a national insurance database, patients who underwent arthroscopic rotator cuff repair with perioperative lipid levels (total cholesterol, low-density lipoprotein [LDL], and triglycerides) recorded were reviewed. For each lipid test, patients were stratified into normal, moderate, and high groups based on published standards. For the total cholesterol and LDL cohorts, a subgroup analysis of patients stratified by statin use was performed. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair or debridement. A logistic regression analysis controlling for patient demographics and comorbidities was utilized for comparison. RESULTS There were 30,638 patients included in the study. The rate of revision rotator cuff surgery was significantly increased in patients with moderate (odds ratio [OR], 1.20; 95% CI, 1.03-1.40; P = .022) and high total cholesterol levels (OR, 1.36; 95% CI, 1.10-1.55; P = .006) compared with patients with normal total cholesterol levels perioperatively. Within each of these groups, patients without statin use had significantly higher rates of revision surgery, while those with statin prescriptions did not. The absolute risk reduction for statin use ranged from 0.24% to 1.87% when stratified by the total cholesterol level, yielding a number needed to treat from 54 to 408 patients. The rate of revision surgery was significantly increased in patients with moderate (OR, 1.24; 95% CI, 1.10-1.41; P = .001) and high LDL levels (OR, 1.46; 95% CI, 1.08-1.99; P = .014) compared with patients with normal LDL levels perioperatively. Again, patients without statin prescriptions had significantly increased rates of revision surgery, whereas patients with statin use did not. The absolute risk reduction for statin use ranged from 0.26% to 1.89% when stratified by the LDL level, yielding a number needed to treat from 53 to 387 patients. There were no significant differences in the rates of revision rotator cuff surgery between patients with moderate and high triglyceride levels compared with patients with normal triglyceride levels. CONCLUSION The present study found a significant association between moderate and high perioperative total cholesterol and LDL levels and the rate of revision surgery after primary arthroscopic rotator cuff repair. Furthermore, the use of statin agents appeared to mitigate the need for revision rotator cuff repair. Further prospective studies are necessary to validate these preliminary findings and determine if better perioperative lipid control can improve clinical outcomes after arthroscopic rotator cuff repair.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Scott A Rodeo
- Sports Medicine & Shoulder Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Degen RM, Cancienne JM, Camp CL, Altchek DW, Dines JS, Werner BC. Patient-related risk factors for requiring surgical intervention following a failed injection for the treatment of medial and lateral epicondylitis. PHYSICIAN SPORTSMED 2017; 45:433-437. [PMID: 28862069 DOI: 10.1080/00913847.2017.1374811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To identify risk factors for failure of a therapeutic injection leading to operative management of both medial and lateral epicondylitis. METHODS A national database was used to query Medicare Standard Analytic Files from 2005-2012 for patients treated with therapeutic injections for medial or lateral epicondylitis using CPT codes for injections associated with corresponding ICD-9 diagnostic codes (726.31 and 726.32, respectively). Those who subsequently underwent surgical treatment following injection were identified. A multivariate binomial logistic regression analysis was utilized to evaluate patient-related risk factors for requiring surgery within 2 years after therapeutic injection. RESULTS 1,837 patients received therapeutic injections for medial epicondylitis. 52 (2.8%) required ipsilateral surgery at a mean of 429 ± 28 days post-injection. Risk factors for requiring surgical intervention included age <65, obesity, and morbid obesity. 6,561 patients received therapeutic injections for lateral epicondylitis. 201 (3.1%) required subsequent surgery at a mean of 383 ± 128 days' post-injection. Risk factors included age <65, tobacco use, diabetes mellitus and peripheral vascular disease. CONCLUSION The incidence of surgical intervention following a failed therapeutic injection for medial or lateral epicondylitis is low (~3%). Risk factors for failing a therapeutic injection include age <65 years and obesity (BMI > 30) for medial epicondylitis and age <65 years, smoking, diabetes mellitus and peripheral vascular disease for lateral epicondylitis. Patients with these identified risk factors presenting with medial or lateral epicondylitis should be cautioned that they carry a higher risk of subsequent surgical treatment. LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Ryan M Degen
- a Sports Medicine and Shoulder Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Jourdan M Cancienne
- b Department of Orthopedic Surgery , University of Virginia Health System , Charlottesville , VA , USA
| | - Christopher L Camp
- a Sports Medicine and Shoulder Surgery , Hospital for Special Surgery , New York , NY , USA
| | - David W Altchek
- a Sports Medicine and Shoulder Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Joshua S Dines
- a Sports Medicine and Shoulder Surgery , Hospital for Special Surgery , New York , NY , USA
| | - Brian C Werner
- b Department of Orthopedic Surgery , University of Virginia Health System , Charlottesville , VA , USA
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Cancienne JM, Werner BC, Burrus MT, Kandil A, Conte EJ, Gwathmey FW, Miller MD. The Transseptal Arthroscopic Knee Portal Is in Close Proximity to the Popliteal Artery: A Cadaveric Study. J Knee Surg 2017; 30:920-924. [PMID: 28282670 DOI: 10.1055/s-0037-1599252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to use fluoroscopy to measure the distance between the transseptal portal and the popliteal artery under arthroscopic conditions with an intact posterior knee capsule, and to determine the difference between 90 degrees of knee flexion and full extension. The popliteal artery of eight fresh-frozen cadaveric knees was dissected and cannulated proximal to the knee joint. The posterolateral, posteromedial, and transseptal portals were then established at 90 degrees of flexion. A 4-mm switching stick was placed through the transseptal portal, and barium contrast was injected into the popliteal artery. A lateral fluoroscopic image was taken with the knee in 90 degrees of flexion and full extension, and the distance between the popliteal artery and the switching stick was measured and compared using a paired t-test. In knee flexion, the average distance between the transseptal portal and the anterior aspect of the popliteal artery for the eight cadaveric specimens was 12.0 mm ± 3.3 mm; in extension, this decreased to 9.0 mm ± 2.7 mm. The distance between the transseptal portal and popliteal artery was significantly higher at 90 degrees of knee flexion as compared with extension (p = 0.0005). The transseptal posterior knee arthroscopic portal must be carefully created due to the close proximity to the popliteal artery, and may be closer to the artery than previously reported in specimens with an intact posterior knee capsule. Creating the portal with the knee in flexion significantly displaces the popliteal artery away from the portal reducing the risk of arterial injury.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Abdurrahman Kandil
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Evan J Conte
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Frank W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mark D Miller
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia
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