Increased prevalence of lower extremity soft tissue injuries and surgeries in patients with anorexia nervosa and bulimia nervosa

PURPOSE

An abundance of literature exists linking eating disorders and fracture risk. However, no studies, to our knowledge, have investigated the impact of eating disorders on lower extremity soft tissue injury or surgery risk. The purpose of this study was to determine if anorexia nervosa and bulimia nervosa are associated with prevalence of lower extremity soft tissue injuries and surgeries.

METHODS

Patients with anorexia nervosa or bulimia nervosa over 2010-2020 were identified through the International Classification of Diseases (ICD) codes in the PearlDiver Claims Database. Patients were matched by age, gender, comorbidities, record dates, and region to control groups without anorexia or bulimia. Soft tissue injuries were identified through ICD codes, and surgeries were identified through Current Procedural Terminology codes. Differences in relative prevalence were analyzed using chi-square analysis.

RESULTS

Patients with anorexia had a significantly increased prevalence of meniscus tears (RR = 1.57, CI 1.22-2.03, p = 0.001) or deltoid ligament sprains (RR = 1.83, CI 1.10-3.03, p = 0.025), and patients with bulimia had a significantly increased prevalence of meniscus tears (RR = 1.98, CI 1.56-2.51, p < 0.001), medial collateral ligament sprains (RR = 3.07, CI 1.72-5.48, p < 0.001), any cruciate ligament tears (RR = 2.14, CI 1.29-3.53, p = 0.004), unspecified ankle sprains (RR = 1.56, CI 1.22-1.99, p < 0.001), or any ankle ligament sprains (RR = 1.27, CI 1.07-1.52, p = 0.008). Patients with anorexia had a significantly increased prevalence of anterior cruciate ligament reconstructions (RR = 2.83, CI 1.12-7.17, p = 0.037) or any meniscus surgeries (RR = 1.54, CI 1.03-2.29, p = 0.042), and patients with bulimia had a significantly increased prevalence of partial meniscectomies (RR = 1.80, CI 1.26-2.58, p = 0.002) or any meniscus surgeries (RR = 1.83, CI 1.29-2.60, p < 0.001).

CONCLUSIONS

Anorexia and bulimia are associated with increased prevalence of soft tissue injuries and surgeries. Orthopedic surgeons should be aware of this risk, and patients presenting to clinics should be informed of the risks associated with these diagnoses and provided with resources promoting recovery to help prevent further injury or surgery.

The cumulative incidence and risk factors associated with 5-year conversion to knee arthroplasty following primary meniscus repair or primary meniscectomy

Background

This study aimed to observe the 5-year knee arthroplasty conversion incidence rate and associated risk factors in patients who underwent meniscus procedures.

Methods

Using a national database, we analyzed patients who had undergone primary meniscus repair or meniscectomy without prior knee surgeries. The cumulative knee arthroplasty conversion incidence was determined via Kaplan Meier analysis. Risk factors for conversion within 5 years were assessed using a Cox proportional hazard ratio model, with results as hazard ratios (HR).

Results

8125 patients had meniscus repair, while 240,209 had meniscectomy. 5-year conversion rates: repair 1.7%, meniscectomy 8.4%. Arthroplasty likelihood decreased as age decreased for repair (70+ [HR: 162.20]; 60-69 [HR: 81.64]; 50-59 [HR: 49.85]; 40-49 [HR: 17.79]; p < 0.001 all). Additional risk factors included male sex (HR: 0.35; p < 0.001) and higher Charlson Comorbidity Index (CCI) (CCI1 [HR: 1.28; p = 0.012]). For meniscectomy, arthroplasty likelihood also decreased with age (70+ [HR: 99.41]; 60-69 [HR: 84.57]; 50-59 [HR: 66.60]; 40-49 [HR: 36.15]; 30-39 [HR: 10.18]; p < 0.001 all). Additional risk factors included male sex (HR: 0.68; p < 0.001), obesity (HR: 1.18; p < 0.001), smoking (HR: 0.1.12; p = 0.010), and higher CCI (CCI1 [HR: 1.25]; CCI2 [HR 1.39]; CCI3+ [HR 1.46]; p < 0.001 all).

Conclusion

This study revealed the national 5-year conversion incidence following primary meniscus repair (1.7%) and meniscectomy (8.4%). It also enhanced understanding of age, sex, obesity, smoking, comorbidities (CCI), and knee arthroplasty likelihood after meniscus procedures.

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head

INTRODUCTION

Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies.

METHODS

Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness.

RESULTS

In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all).

CONCLUSION

After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Five-Year Mortality Rates Following Elective Shoulder Arthroplasty and Shoulder Arthroplasty for Fracture in Patients Over Age 65

Background

To effectively counsel patients prior to shoulder arthroplasty, surgeons should understand the overall life trajectory and life expectancy of patients in the context of the patient's shoulder pathology and medical comorbidities. Such an understanding can influence both operative and nonoperative decision-making and implant choices. This study evaluated 5-year mortality following shoulder arthroplasty in patients ≥65 years old and identified associated risk factors.

Methods

We utilized Centers for Medicare & Medicaid Services Fee-for-Service inpatient and outpatient claims data to investigate the 5-year mortality rate following shoulder arthroplasty procedures performed from 2014 to 2016. The impact of patient demographics, including fracture diagnosis, year fixed effects, and state fixed effects; patient comorbidities; and hospital-level characteristics on 5-year mortality rates were assessed with use of a Cox proportional hazards regression model. A p value of <0.05 was considered significant.

Results

A total of 108,667 shoulder arthroplasty cases (96,104 nonfracture and 12,563 fracture) were examined. The cohort was 62.7% female and 5.8% non-White and had a mean age at surgery of 74.3 years. The mean 5-year mortality rate was 16.6% across all shoulder arthroplasty cases, 14.9% for nonfracture cases, and 29.9% for fracture cases. The trend toward higher mortality in the fracture group compared with the nonfracture group was sustained throughout the 5-year postoperative period, with a fracture diagnosis being associated with a hazard ratio of 1.63 for mortality (p < 0.001). Medical comorbidities were associated with an increased risk of mortality, with liver disease bearing the highest hazard ratio (3.07; p < 0.001), followed by chronic kidney disease (2.59; p < 0.001), chronic obstructive pulmonary disease (1.92; p < 0.001), and congestive heart failure (1.90; p < 0.001).

Conclusions

The mean 5-year mortality following shoulder arthroplasty was 16.6%. Patients with a fracture diagnosis had a significantly higher 5-year mortality risk (29.9%) than those with a nonfracture diagnosis (14.9%). Medical comorbidities had the greatest impact on mortality risk, with chronic liver and kidney disease being the most noteworthy. This novel longer-term data can help with patient education and risk stratification prior to undergoing shoulder replacement.

Level of Evidence

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

Trends and outcomes of outpatient total shoulder arthroplasty after its removal from CMS's inpatient-only list

BACKGROUND

In January 2021, the US Medicare program approved reimbursement of outpatient total shoulder arthroplasties (TSA), including anatomic and reverse TSAs. It remains unclear whether shifting TSAs from the inpatient to outpatient setting has affected clinical outcomes. Herein, we describe the rate of outpatient TSA growth and compare inpatient and outpatient TSA complications, readmissions, and mortality.

METHODS

Medicare fee-for-service claims for 2019-2022Q1 were analyzed to identify the trends in outpatient TSAs and to compare 90-day postoperative complications, all-cause hospital readmissions, and mortality between outpatients and inpatients. Outpatient cases were defined as those discharged on the same day of the surgery. To reduce the COVID-19 pandemic's impact and selection bias, we excluded 2020Q2-Q4 data and used propensity scores to match 2021-2022Q1 outpatients with inpatients from the same period (the primary analysis) and from 2019-2020Q1 (the secondary analysis), respectively. We performed both propensity score-matched and -weighted multivariate analyses to compare outcomes between the two groups. Covariates included sociodemographics, preoperative diagnosis, comorbid conditions, the Hierarchical Condition Category risk score, prior year hospital/skilled nursing home admissions, annual surgeon volume, and hospital characteristics.

RESULTS

Nationally, the proportion of outpatient TSAs increased from 3% (619) in 2019Q1 to 22% (3456) in 2021Q1 and 38% (6778) in 2022Q1. A total of 55,166 cases were identified for the primary analysis (14,540 outpatients and 40,576 inpatients). Overall, glenohumeral osteoarthritis was the most common indication for surgery (70.8%), followed by rotator cuff pathology (14.6%). The unadjusted rates of complications (1.3 vs 2.4%, P < .001), readmissions (3.7 vs 6.1%, P < .001), and mortality (0.2 vs 0.4%, P = .024) were significantly lower among outpatient TSAs than inpatient TSAs. Using 1:1 nearest matching, 12,703 patient pairs were identified. Propensity score-matched multivariate analyses showed similar rates of postoperative complications, hospital readmissions, and mortality between outpatients and inpatients. Propensity score-weighted multivariate analyses resulted in similar conclusions. The secondary analysis showed a lower hospital readmission rate in outpatients (odds ratio: 0.8, P < .001).

CONCLUSIONS

There has been accelerated growth in outpatient TSAs since 2019. Outpatient and inpatient TSAs have similar rates of postoperative complication, hospital readmission, and mortality.

Trends in the Adoption of Outpatient Joint Arthroplasties and Patient Risk: A Retrospective Analysis of 2019 to 2021 Medicare Claims Data

INTRODUCTION

Total joint arthroplasties (TJAs) have recently been shifting toward outpatient arthroplasty. This study aims to explore recent trends in outpatient total joint arthroplasty (TJA) procedures and examine whether patients with a higher comorbidity burden are undergoing outpatient arthroplasty.

METHODS

Medicare fee-for-service claims were screened for patients who underwent total hip, knee, or shoulder arthroplasty procedures between January 2019 and December 2022. The procedure was considered to be outpatient if the patient was discharged on the same date of the procedure. The Hierarchical Condition Category Score (HCC) and the Charlson Comorbidity Index (CCI) scores were used to assess patient comorbidity burden. Patient adverse outcomes included all-cause hospital readmission, mortality, and postoperative complications. Logistic regression analyses were used to evaluate if higher HCC/CCI scores were associated with adverse patient outcomes.

RESULTS

A total of 69,520, 116,411, and 41,922 respective total knee, hip, and shoulder arthroplasties were identified, respectively. Despite earlier removal from the inpatient-only list, outpatient knee and hip surgical volume did not markedly increase until the pandemic started. By 2022Q4, 16%, 23%, and 36% of hip, knee, and shoulder arthroplasties were discharged on the same day of surgery, respectively. Both HCC and CCI risk scores in outpatients increased over time (P < 0.001).

DISCUSSION

TJA procedures are shifting toward outpatient surgery over time, largely driven by the COVID-19 pandemic. TJA outpatients' HCC and CCI risk scores increased over this same period, and additional research to determine the effects of this should be pursued.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort study.

Social determinants of health disparities impact postoperative complications in patients undergoing total shoulder arthroplasty

BACKGROUND

Understanding the role of social determinants of health disparities (SDHDs) in surgical outcomes can better prepare providers to improve postoperative care. In this study, we use International Classification of Diseases (ICD) codes to identify SDHDs and investigate the risk of postoperative complication rates among patients undergoing total shoulder arthroplasty (TSA).

METHODS

A retrospective cohort analysis was conducted using a national insurance claims database. Using ICD and Current Procedural Terminology (CPT) codes, patients who underwent primary TSA with at least 2 years of follow-up in the database were identified. Patients with a history of SDHDs were identified using appropriate ICD-9 and ICD-10 codes. Patients were grouped in one of 2 cohorts: (1) patients with no history of SDHDs (control) and (2) patients with a history of SDHDs (SDHD group) prior to TSA. The SDHD and control groups were matched 1:1 for comorbidities and demographics prior to conducting multivariable analysis for 90-day medical complications and 2-year surgical complications.

RESULTS

After matching, there were 8023 patients in the SDHD group and 8023 patients in the control group. The SDHD group had significantly higher odds for 90-day medical complications including heart failure, cerebrovascular accident, renal failure, deep vein thrombosis, pneumonia, sepsis, and urinary tract infection. Additionally, the SDHD group had significantly higher odds for revision surgery within 2 years following TSA. Patients in the SDHD group also had a significantly longer length of hospital stay following TSA.

DISCUSSION

This study highlights the association between SDHDs and postoperative complications following TSA. Quantifying the risk of complications and differences in length of stay for TSA patients with a history of SDHDs is important in determining value-based payment models and risk stratifying to optimize patient care.

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair

INTRODUCTION

We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT.

METHODS

A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted.

RESULTS

Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT.

DISCUSSION

In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

Use of custom glenoid components for reverse total shoulder arthroplasty

BACKGROUND

Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications.

METHODS

This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported.

RESULTS

Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both).

CONCLUSIONS

Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.

Graft failure within 2 years of isolated anterior cruciate ligament reconstruction is associated with increased risk of secondary meniscus tears

PURPOSE

A debilitating complication following anterior cruciate ligament reconstruction is a secondary meniscus tear. Currently, the literature is mixed regarding the risk factors associated with the incidence of secondary meniscus tears. The aim of this study was to investigate risk factors associated with meniscus tears following an isolated primary anterior cruciate ligament reconstruction. ACL graft failure was hypothesized to be the strongest risk factor for secondary meniscal injury occurrence.

METHODS

A retrospective cohort analysis was performed using the PearlDiver Database. Patients with a primary anterior cruciate ligament reconstruction were identified in the database. Patients with concomitant knee ligament injury or meniscus injury present at the time the index procedure were excluded. Patients were grouped to those who had a secondary meniscus tear within 2 years following anterior cruciate ligament reconstruction and those who did not. Univariate analysis and multivariable regression analysis was conducted to identify significant risk factors for a secondary meniscus tear.

RESULTS

There were 25,622 patients meeting criteria for inclusion in this study. Within 2 years from the primary anterior cruciate ligament reconstruction, there were 1,781 patients (7.0%) that experienced a meniscus tear. Graft failure had the highest odds of having a postoperative meniscus tear within 2 years (OR: 4.1; CI 3.5-4.8; p < 0.002). Additional significant risk factors included tobacco use (OR: 2.0; CI 1.0-3.1; p < 0.001), increased Charlson Comorbidity Index (OR: 1.2; CI 1.1-1.4), male gender (OR: 1.1; CI 1.1-1.2; p < 0.001), obesity (OR: 1.1; CI 1.1-1.2; p < 0.001), delayed surgery (OR:1.1; CI 1.1-1.2; p < 0.002), and patients age 30 and older (OR: 1.0; CI 1.0-1.0; p < 0.001).

CONCLUSIONS

This study found that anterior cruciate ligament graft failure is the strongest predictor of post-operative meniscus tears. Other risk factors, including tobacco use, increased CCI, male gender, obesity, delayed surgery, and age 30 and older, were established, with several being modifiable. Therefore, targeted preoperative optimization of modifiable risk factors and postoperative protocols may reduce the risk of secondary meniscus tears.

LEVEL OF EVIDENCE

Level III, prognostic trial.

Epidemiologic trends in hand injuries in the National Football League from 2009-2010 to 2019-2020

OBJECTIVES

In American football, hand injuries have been shown to negatively impact performance. The purpose of this study is to characterize the prevalence and severity of hand injuries in National Football League (NFL) players.

METHODS

A public online database was utilized to identify hand injuries in NFL players from 2009-2010 to 2019-2020. The primary outcome was to analyze the overall incidence of hand injuries (including wrist, metacarpus, finger, and thumb), injury type by each aforementioned anatomic location, and player position. Injury severity was evaluated based on percentage of injuries in which players returned to play (RTP), number of games missed before RTP, and the percentage of injuries resulting in the player being placed on injured reserve (IR).

RESULTS

Of the 6,127 players included, 847 (13.8%) players sustained a hand injury, of which 24.8%, 34.3%, 17.9%, and 22.9% occurred at the wrist, metacarpus, finger, and thumb, respectively. Of the injured players, 97.4% returned to play following their injury, 14.8% were put on IR, and an average of 1.7 (SD 3.3) games were missed. Quarterbacks were the most likely to sustain hand injuries at all anatomic locations. Wrist injuries were associated with the lowest RTP rate (93.3%), the most players placed on injured reserve (28.6%), and the greatest number of games missed (mean 2.5, SD 4.2).

CONCLUSION

Hand injuries decreased in prevalence by 65.6% over the 11 NFL seasons evaluated. This trend coincides with the implementation of several safety rules that relate to components of play involving the hands. Quarterbacks experienced the greatest prevalence and severity for all hand injuries. Wrist injuries represent the anatomic location associated with the greatest severity. These findings may be able to inform tailored injury prevention practices by position, and advocate for the further adoption of safety rules to protect players from further injury.

Outpatient Versus Inpatient Total Shoulder Arthroplasty: A Matched Cohort Analysis of Postoperative Complications, Surgical Outcomes, and Reimbursements

INTRODUCTION

There has been a trend toward performing arthroplasty in the ambulatory setting. The primary purpose of this study was to compare outpatient and inpatient total shoulder arthroplasties (TSAs) for postoperative medical complications, healthcare utilization outcomes, and surgical outcomes.

METHODS

Patients who underwent outpatient TSA or inpatient TSA with a minimum 5-year follow-up were identified in the PearlDiver database. These cohorts were propensity-matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index > 30). All outcomes were analyzed using chi square and Student t-tests where appropriate.

RESULTS

Outpatient TSA patients had markedly lower rates of various 90-day medical complications. Outpatient TSA patients had lower risk of aseptic loosening at 2 years postoperation and lower risk of periprosthetic joint infection at 5 years postoperation relative to inpatient TSA patients. Outpatient TSA reimbursements were markedly lower than inpatient TSA reimbursements at the 30-day, 90-day, and 1-year postoperative intervals.

CONCLUSION

This study found patients undergoing outpatient TSA to be at lowers odds for both postoperative medical and surgical complications compared with those undergoing inpatient TSA. Despite increased risk of postoperative healthcare utilization for readmissions and emergency department visits, outpatient TSA was markedly less expensive at every postoperative time point assessed.

Social determinants of health and race are independent predictors of reduced rotator cuff surgery rates in the Medicare population

BACKGROUND

Racial disparities have been shown to influence rates of surgery for patients with rotator cuff disease. Some individuals have attributed adverse social determinants of health (SDOHs) as potential confounders of this relationship between race and surgery rate. However, there is a paucity of literature observing whether adverse SDOHs and race independently influence rotator cuff surgery rates. Therefore, the purpose of this study was to determine whether adverse SDOHs and race are independent predictors of rotator cuff surgery rates for Medicare beneficiaries.

METHODS

A retrospective analysis was conducting using the Medicare Standard Analytic Files (SAF) data set of the PearlDiver database, observing 211,340 patients with rotator cuff pathology. Univariate and multivariable regression analyses were performed to observe whether race and adverse SDOHs were independent variables associated with rotator cuff surgery rates. To determine whether adverse SDOHs significantly influenced racial disparities, stratified analyses of patients with ≥1 adverse SDOH and those without adverse SDOHs were conducted to compare the odds ratios (ORs) and 95% confidence intervals (CIs) of racial disparities.

RESULTS

Among patients with rotator cuff disease, 21,679 (10.26%) were of nonwhite race and 21,835 (10.33%) had ≥1 adverse SDOH. The variables of nonwhite race (OR, 0.622; 95% CI, 0.599-0.668; P < .001) and having ≥1 adverse SDOH (OR, 0.715; 95% CI, 0.501-0.814; P < .001) were independent predictors of not undergoing surgery. On stratified analysis, there was no significant difference in racial disparities in patients with ≥1 adverse SDOH (OR, 0.620; 95% CI, 0.440-0.875) and those without adverse SDOHs (0.635; 95% CI, 0.601-0.671) based on overlapping 95% CIs.

DISCUSSION

This study demonstrated that among Medicare beneficiaries, adverse SDOHs and race are independent predictors of lower rotator cuff surgery rates, emphasizing the need to address disparities based on race alone.

Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status

INTRODUCTION

Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020.

METHODS

A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals.

RESULTS

From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years.

CONCLUSION

The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.

Impact of preoperative urinary tract infection on postoperative outcomes following total shoulder arthroplasty for osteoarthritis

Introduction

As the utilization of total shoulder arthroplasty (TSA) increases, it is essential to identify risk factors associated with postoperative complications. Urinary tract infection (UTI) is one such example. Our objective is to identify whether UTI is associated with increased rates of prosthetic joint infection (PJI) and determine whether its treatment reduces PJI rates.

Methods

Patients who underwent primary TSA for glenohumeral osteoarthritis between 2010 and 2019 with minimum two-year follow-up were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases codes. These patients were stratified into two cohorts: those with preoperative UTI within two weeks of TSA and those without. The preoperative UTI cohort was stratified into those treated and those untreated prior to TSA. Univariate and multivariable analyses were performed.

Results

Following multivariable analysis, there were significantly higher odds of postoperative anemia, pulmonary embolism, and death in the UTI cohort. Comparing treated to untreated UTI, there were no significant differences in multivariable analysis for any 90-day medical or two-year surgical complications.

Discussion

This study showed that UTI was not associated with increased rates of PJI. UTI was, however, associated with postoperative medical complications that surgeons should be aware of.

The influence of elevated international normalized ratio on complications following total shoulder arthroplasty

Background

Identifying preoperative risk factors for complications following total shoulder arthroplasty (TSA) has both clinical and financial implications. The purpose of this study was to determine the influence of different degrees of preoperative INR elevation on complications following TSA.

Methods

Patients undergoing primary TSA from 2007 to 2018 were identified in a national database. Patients were stratified into 4 cohorts: INR of <1.0, INR of >1.0 to 1.25, INR of >1.25 to 1.5, and INR of >1.5. Postoperative complications were assessed. Multivariate logistic regressions were performed to adjust for differences in demographics and comorbidities among the INR groups.

Results

Following adjustment and relative to patients with an INR of <1.0, those with INR of >1.0-1.25, >1.25-1.5, and >1.5 had 1.6-times, 2.4-times, and 2.8-times higher odds of having postoperative bleeding requiring transfusion, respectively (p < 0.05 for all). Relative to patients with INR <1.0, those with INR of > 1.25-1.5 and INR of >1.5 had 7.8-times and 7.0-times higher odds of having pulmonary complications, respectively (p < 0.05 for both).

Discussion

With increasing INR levels, there is an independent and step-wise increase in odd ratios for postoperative complications. Current guidelines for preoperative INR thresholds may need to be adjusted for more predictive risk-stratification for TSA.

Level of Evidence

III.

Massive rotator cuff tears: algorithmic approach to surgical treatment

The management of massive rotator cuff tears (MRCT) presents a unique challenge to many orthopedic specialists. Unlike tears that are predicted to do well with primary, complete repair, MRCT are affected by tissue retraction, in-elasticity, bursal scarring, muscle atrophy, and fatty degeneration; operative repair thus portends worse healing rates than smaller tears and is associated with recurrent tear rates of up to 91% based on ultrasonography and magnetic resonance imaging (MRI). Rotator cuff tears are a common condition in patients over the age of 50. Thus, multiple advances in treatment strategies have been made to combat the limited efficacy of complete or partial rotator cuff repair in the setting of a massive or irreparable rotator cuff tears. It is of utmost importance that the operating orthopedic surgeon be familiar with these various treatment modalities to best serve the patient and that they harbor these skills within their armamentarium. This article details a review of the current literature including nonoperative and operative treatments for the management of massive and irreparable rotator cuff tears. The primary objective is to propose a literature-based algorithm for the treatment of massive and often irreparable rotator cuff tears to allow for informed ease in the decision-making process.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs

Background

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.

Methods

Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.

Results

The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.

Conclusion

Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Publication Trends in Research on Mental Health and Mental Illness in Orthopaedic Surgery: A Systematic Review

BACKGROUND

Mental health conditions affect tens of millions of Americans. In recent years, particularly with the advent of the coronavirus disease 2019 pandemic, there has been a burst of interest in mental health and mental illness among orthopaedic surgical patients. The mental health of orthopaedic surgeons themselves has also come into focus, with high reported rates of burnout and depression. The aim of this article was to evaluate trends in publication on mental health and mental illness in orthopaedic surgery.

METHODS

Web of Science and PubMed were queried to conduct a systematic review. Studies that discussed orthopaedic surgery and mental illnesses or mental health topics over 2001 to 2022 were included. Publications were analyzed by article-, author-, and topic-level characteristics.

RESULTS

A total of 416 studies were analyzed after application of inclusion and exclusion criteria. Publication volume increased dramatically, demonstrating quadratic growth over 2001 to 2022 (p < 0.001). Eighty-eight percent of studies focused on patients and 10% on surgeons, with studies about patients more likely to focus on mental illness and those about surgeons more likely to focus on mental health (p < 0.001). Twenty percent of publications had a female senior author, and 5 authors collectively accounted for 10% of all publications. Eight journals published more than 10 publications, accounting for 35% of all publications. The most productive subspecialties were arthroplasty (135, 30%), general orthopaedics (87, 21%), and spine (69, 17%). Mental illnesses that were least represented included schizophrenia, bipolar disorder, eating disorders, attention-deficit/hyperactivity disorder, and personality disorders (1% or less of total publications each).

CONCLUSION

This analysis showed a dramatically increasing trend in publications on mental health and mental illness in orthopaedic surgery. A high concentration of publications came from a subset of journals and senior authors, and women were overrepresented as senior authors relative to their representation in the field. The results of this analysis identified gaps in the literature, including underrepresented subspecialties, understudied mental illnesses, and study of orthopaedic surgeon mental health, and thus highlighted areas for future investigation.

LEVEL OF EVIDENCE

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

Preoperative Dehydration Increases the Risk of Extended Length of Hospital Stay Following Total Ankle Arthroplasty

INTRODUCTION

The effects of preoperative dehydration on outcomes following total ankle arthroplasty (TAA) remain unknown. Therefore, the purpose of this study is to evaluate the association between dehydration and postoperative complications for patients undergoing TAA.

METHODS

Patients undergoing TAA from 2007 to 2019 were identified in the National Surgical Quality Improvement Program (NSQIP) database. A preoperative serum blood urea nitrogen/creatinine (BUN/Cr) greater than 20 was used to define preoperative dehydration. Patients were stratified into 2 cohorts: patients who were dehydrated (BUN/Cr > 20) and patients without dehydration (BUN/Cr ≤ 20). In this analysis, various postoperative outcomes were assessed with bivariate and multivariate analyses.

RESULTS

In total, 1033 patients underwent TAA and had their serum BUN and Cr values recorded. For both BUN and Cr, the patients in this study had their serum values recorded a mean of 15 days before their surgery. A total of 588 patients (56.9%) did not have dehydration preoperatively and 445 patients (43.1%) were dehydrated. Following adjustment on multivariate analysis, an increased risk of extended length of hospital stay (odds ratio [OR] = 1.457; p = 0.024) was seen in the dehydrated group compared with those who were noted to be well hydrated.

CONCLUSION

As fluid intake is one modifiable preoperative variable that can be easily monitored during elective procedures, it is important for physicians to be aware of patients who are dehydrated and adjust their fluids appropriately to optimize postoperative outcomes.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Risk Factors for Readmission following Anterior Cruciate Ligament Reconstruction

The purpose of this study is to identify risk factors for readmission after anterior cruciate ligament (ACL) reconstruction and to determine costs associated with readmission. Using a private insurance claims' database, we identified patients who underwent ACL reconstruction from 2010 to 2015 using the International Classification of Diseases, Version 9 (ICD-9) and Current Procedural Terminology (CPT) codes. Univariate analysis was performed on demographic data, surgical characteristics, and comorbidities. Variables with p < 0.10 were added to a multivariate logistic regression model which was created to identify independent risk factors for all-cause readmission within 90 days postoperatively. Significance was considered at p < 0.05. Overall, 90,263 patients were included (average age: 29 ± 13 years, 44% female), and 1,066 (1.2%) of patients had a hospital readmission within 90 days following surgery. Risk factors for hospital readmission included cerebrovascular disease (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 1.9, 6.2), diabetes mellitus (OR = 2.6, 95% CI: 1.9, 3.5), concomitant medial collateral ligament (MCL) or lateral collateral ligament (LCL) reconstruction (OR = 2.5, 95% CI: 1.9, 3.3), concomitant posterior cruciate ligament (PCL) reconstruction (OR = 2.2, 95% CI: 1.4, 3.3), age between 44 and 65 years (OR = 2.1, 95% CI: 1.6, 2.9), and depression (OR = 1.88, 95% CI: 1.49, 2.38, p < 0.001). Female sex was associated with decreased odds of 90-day hospital readmission (OR = 0.8, 95% CI: 0.7, 0.9). Each hospital readmission accounted for an estimated $17,841 (95% CI: $17,173, 18,509) in gross health care payments, and patients with readmissions had substantially higher 1-year cumulative health care costs. Readmission after ACL reconstruction was 1.2%. The strongest risk factors for 90-day readmission include cerebrovascular disease, diabetes mellitus, concomitant MCL/LCL reconstruction, concomitant PCL reconstruction, and age between 44 and 65 years. Readmission was associated with substantial health care costs.

Trends in Venous Thromboembolism After Shoulder Arthroplasty in the United States: Analysis Following the 2009 American Academy of Orthopaedic Surgeons Clinical Practical Guidelines

BACKGROUND

In 2009, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total shoulder arthroplasty (TSA). The purpose of this study was to examine the (1) change in incidence of 90-day VTE, deep vein thrombosis (DVT), and pulmonary embolism; (2) change in utilization of chemoprophylaxis; and (3) change in the economic burden associated with VTE after TSA from 2010 to 2019.

METHODS

Using the PearlDiver database, national data from 2010 to 2019 were used to identify patients who underwent primary TSA for osteoarthritis and/or rotator cuff arthropathy. Exclusions entailed liver pathology, coagulopathy, or those on prior prescribed blood thinners before TSA. Multivariable regression was used controlling for age and Charlson Comorbidity Index for all years with 2010 as the reference year.

RESULTS

From 2010 to 2019, there was a reduction in VTE rates from 0.89% in 2010 to 0.78% in 2019. Regarding implant type, there was no notable change in incidence of VTE, DVT, and pulmonary embolism within 90 days after anatomic TSA. Notable reductions were observed in both VTE and DVT after reverse TSA from 2010 to 2019. Prescribed chemical VTE prophylaxis utilization after TSA markedly increased from 4.41% in 2010 to 11.70% utilization in 2019. The utilization of aspirin markedly increased from 17.27% in 2010 to 65.17% in 2019. Among anticoagulants, the utilization of direct factor Xa inhibitors increased from 0.0% utilization in 2010 to 66.09% utilization in 2019. The added reimbursements associated with VTE after TSA markedly decreased from $14,122 in 2010 to $4,348 in 2019.

CONCLUSION

The incidence and economic burden associated with VTE after TSA have markedly declined following the 2010 American Academy of Orthopaedic Surgeons clinical practice guidelines. This reduction can be attributed to both an increase in VTE prevention through increased utilization of prescribed chemoprophylaxis and improvement in VTE treatment strategies.

LEVEL OF EVIDENCE

Therapeutic, III.

SLAP repair and bicep tenodesis: a comparison of utilization and revision rates for SLAP tears

Hypothesis

The management of superior labrum anterior to posterior (SLAP) tears typically consists of either repair or biceps tenodesis (BT). While repair is more frequently recommended in younger patients, patients older than 40 years are often treated with BT. The purpose of this study is to determine whether there has been a change in utilization of these procedures over the past decade with respect to patient age as well as compare reoperation rates between the two procedures.

Methods

The Pearldiver database was queried to identify BT and SLAP repairs indicated for SLAP tears performed from 2010 to 2019. The primary outcome was utilization rate, stratified by age. A secondary outcome was 2-year shoulder reoperation rates. Trends were reported in terms of compounded annual growth rate. Outcome analysis was conducted using univariate and multivariable analysis.

Results

From 2010 to 2019, SLAP repair was the most common procedure performed for SLAP tears. Regardless of age, BT performed for SLAP tear had a significantly increased utilization rate; whereas, SLAP repair had a significantly decreased utilization rate. SLAP repair was more commonly performed in younger patients compared to BT. Following multivariable analysis, patients who underwent SLAP repair had significantly higher odds (odds ratio (OR): 1.453; 95% confidence interval (CI): 1.26-1.68; P < .001) of requiring an arthroscopic reoperation within 2 years when compared to those who underwent BT with no significant difference with respect to 2-year open reoperation.

Conclusion

Although SLAP repair is still more commonly used to treat SLAP tears than BT, especially for younger patients, the utilization of SLAP repair is decreasing while BT is increasing. The increased utilization of BT may be associated with lower rates of shoulder reoperation for problematic SLAP tears.

The impact of the COVID-19 pandemic on racial disparities in patients undergoing total shoulder arthroplasty in the United States

Introduction

The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the United States and to determine whether these disparities were affected by the COVID-19 pandemic.

Methods

Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April to December from 2019 to 2020. Utilization was assessed for White, Black, Hispanic, and Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age, sex, CMS-hierarchical condition categories (HCC) score, dual enrollment (proxy for socioeconomic status), time-fixed effects, and core-based statistical area fixed effects was used to study difference across groups.

Results

In 2019, the TSA volume per 1000 beneficiaries was 1.51 for White and 0.57 for non-White, with a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P < .01). There was an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference; 8.7%, P = .02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%, P = .05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture.

Conclusions

During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA, while disparities were less apparent for proximal humerus fracture.

Delay of Timing of Anterior Cruciate Ligament Reconstruction Is Associated With Lower Risk of Arthrofibrosis Requiring Intervention

PURPOSE

To conduct 2 separate stratum-specific likelihood ratio analyses in patients younger than 40 year of age (<40 years) and those aged 40 and older (40+ years) at time of anterior cruciate ligament (ACL) reconstruction to define data-driven strata between ACL tear and primary isolated ACL reconstruction in which the risk of arthrofibrosis, using manipulation under anesthesia and arthroscopic lysis of adhesions as surrogates, is significantly different.

METHODS

A retrospective cohort analysis was conducted using the PearlDiver Database. Patients who underwent ACL reconstruction were identified using the Current Procedure Terminology code 29888. Patients were stratified to those aged younger than 40 (<40) and those 40 and older (40+) at time of ACL reconstruction. The incidence of 2-year arthrofibrosis was calculated for weekly intervals from initial ACL injury to reconstruction. Stratum specific likelihood ratio analysis was conducted to determine data-driven intervals from initial ACL tear to reconstruction that optimize differences in 2-year arthrofibrosis. Following the identification of these intervals for both those <40 and 40+, multivariable analysis was conducted.

RESULTS

For those <40, stratum-specific likelihood ratio analysis identified only 2 data-driven timing strata: 0-5 and 6-26 weeks. For those 40+, stratum-specific likelihood ratio analysis also only identified 2 data-driven strata: 0-9 and 10-26 weeks. A delay in ACL reconstruction from initial injury by at least 6 weeks in patients younger than 40 and at least 10 weeks in patients older than 40 years is associated with a 65% and 35% reduction of 2-year manipulation under anesthesia and arthroscopic lysis of adhesions, respectively.

CONCLUSIONS

Our analysis showed a delay in ACLR of at least 6 weeks in patients younger than 40 years to be associated with a 65% reduction in the risk of surgical intervention for arthrofibrosis and a delay of at least 10 weeks in patients 40 years and older to be associated with only a 35% reduction in the risk of surgical intervention for arthrofibrosis. The authors propose this difference in reduction to be multifactorial and potentially associated with mechanism of injury, activity level, and preoperative factors such as amount of physical therapy, rather than solely timing.

LEVEL OF EVIDENCE

III, retrospective comparative prognostic study.

A Comparison of Complications and Survivorship after Reverse Total Shoulder Arthroplasty for Proximal Humerus Fracture compared with Cuff Tear Arthropathy

Objectives

Traditionally used to treat rotator cuff tear arthropathy (CTA), reverse total shoulder arthroplasty (RTSA) is becoming increasingly utilized for the treatment of proximal humeral fractures (PHF). The purpose of this study was to use a matched cohort analysis to assess differences in 90-day complications as well as 2-year and 5-year implant survival between patients undergoing RTSA for CTA and patients undergoing RTSA for PHF.

Methods

Patients with at least a 5-year follow-up who underwent primary RTSA for either PHF or CTA were identified in a national database (PearlDiver Technologies) using current procedural terminology (CPT) and international classification of diseases (ICD) 9 and 10 codes. Patients with a surgical indication of PHF were matched with patients with a surgical indication of CTA based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index (BMI)>30). All-cause revision at the 2-year and 5-year postoperative time intervals were assessed. Reimbursements for the surgical care episode up to the 30-day, 90-day, and 1-year postoperative intervals were also assessed. Bivariate analysis was performed with a significance set at P<0.05.

Results

In total, 802 PHF patients were matched with 802 CTA patients. Compared to CTA patients, PHF patients undergoing RTSA were significantly at increased risk of atrial fibrillation, anemia, and heart failure within 90 days of surgery. Notably, there was no significant difference in all-cause revision surgery at 2-year and 5-year postoperative intervals or hospital reimbursements at the 30-day, 90-day, and 1-year postoperative intervals.

Conclusion

Preoperative indication appears to be an important driver of healthcare utilization for RTSA, as PHF patients undergoing RTSA have a higher risk of short-term postoperative complications compared to CTA patients. However, there is no difference in hospital reimbursement for the two indications of RTSA, suggesting that current payment modalities may not appropriately adjust for risk based on the surgical indication.

The Persistent Backlog of Knee and Shoulder Orthopedic Sport Surgery Case Volume Following the COVID-19 Pandemic

Objectives

As COVID-19 will not be the last pandemic, understanding our historical response allows us to predict and improve our current practices in preparation for the next pandemic. Following the removal of the elective surgery suspension at the onset of the COVID-19 pandemic, it is unclear whether sports medicine surgery volume has returned to pre-pandemic levels as well as whether the backlog from the original suspension was addressed. The purpose of this study to observe the monthly changes in volume and backlog of knee and shoulder sports surgery one year since the original suspension.

Methods

National all-payer data was utilized to identify patients undergoing knee and shoulder sports procedures from January 2017 to April 2021. Descriptive analysis was utilized to report the monthly changes in surgeries. A linear forecast analysis using historical data was utilized to determine the expected volume. This was compared to the observed case volume. The difference in expected and observed volume was utilized to calculate the estimated change in backlog.

Results

From March to May 2020, there was a persistent decrease in the observed shoulder and knee sports volume when compared to the expected volume. By June 2020, all knee and shoulder sports volume reached the expected volume. By April 2021, the estimated backlog for shoulder and knee procedures had increased by 49.8% (26,412 total cases) and 19.0% (26,412 total cases), respectively, with respect to the original calculated backlog from March to May 2020.

Conclusion

Within four months, the sudden decrease in volume for knee and shoulder sports procedures had returned to pre-pandemic levels; however, the original backlog in cases has continually increased one year following the suspension. Additionally, the backlog is significantly higher for knee when compared to shoulder surgeries.

Increased Incidence of Upper Extremity Soft Tissue Injuries and Orthopaedic Surgeries in Patients with Eating Disorders

Background

Despite an established increased fracture risk in eating disorder patients, no studies, to our knowledge, have investigated the association between eating disorders and upper extremity soft tissue injury or surgery incidence. Given the association of eating disorders with nutritional deficiency and musculoskeletal sequelae, we hypothesized that patients with eating disorders would have an increased risk of soft tissue injury and surgery. The aim of this study was to elucidate this link and investigate if these incidences are increased in patients with eating disorders.

Methods

Cohorts of patients with anorexia ner-vosa or bulimia nervosa, identified using International Classification of Diseases (ICD) -9 and -10 codes, were identified in a large national claims database over 2010-2021. Control groups without these respective diagnoses were constructed, matched by age, sex, Charlson Comorbidity Index, record date, and geographical region. Upper extremity soft tissue injuries were identified using ICD-9 and -10 codes and surgeries using Current Procedural Terminology codes. Differences in incidence were analyzed using chi-square tests.

Results

Patients with anorexia and bulimia were significantly more likely to sustain a shoulder sprain (RR=1.77; RR=2.01, respectively), rotator cuff tear (RR=1.39; RR=1.62), elbow sprain (RR=1.85; RR=1.95), hand/wrist sprain (RR=1.73; RR=16.0), hand/wrist ligament rupture (RR=3.33; RR=1.85), any upper extremity sprain (RR=1.72; RR=1.85), or any upper extremity tendon rupture (RR=1.41; RR=1.65). Patients with bulimia were also more likely to sustain any upper extremity ligament rupture (RR=2.88). Patients with anorexia and bulimia were significantly more likely to undergo SLAP repair (RR=2.37; RR=2.03, respectively), rotator cuff repair (RR=1.77; RR=2.10), biceps tenodesis (RR=2.73; RR=2.58), any shoulder surgery (RR=2.02; RR=2.25), hand tendon repair (RR=2.09; RR=2.12), any hand surgery (RR=2.14; RR=2.22), or any hand/wrist surgery (RR=1.87; RR=2.06).

Conclusion

Eating disorders are associated with an increased incidence of numerous upper extremity soft tissue injuries and orthopaedic surgeries. Further work should be undertaken to elucidate the drivers of this increased risk. Level of Evidence: III.

Impact of the COVID-19 pandemic on shoulder arthroplasty: surgical trends and postoperative care pathway analysis

BACKGROUND

COVID-19 triggered disruption in the conventional care pathways for many orthopedic procedures. The current study aims to quantify the impact of the COVID-19 pandemic on shoulder arthroplasty hospital surgical volume, trends in surgical case distribution, length of hospitalization, posthospital disposition, and 30-day readmission rates.

METHODS

This study queried all Medicare (100% sample) fee-for-service beneficiaries who underwent a shoulder arthroplasty procedure (Diagnosis-Related Group code 483, Current Procedural Terminology code 23472) from January 1, 2019, to December 18, 2020. Fracture cases were separated from nonfracture cases, which were further subdivided into anatomic or reverse arthroplasty. Volume per 1000 Medicare beneficiaries was calculated from April to December 2020 and compared to the same months in 2019. Length of stay (LOS), discharged-home rate, and 30-day readmission for the same period were obtained. The yearly difference adjusted for age, sex, race (white vs. nonwhite), Centers for Medicare & Medicaid Services Hierarchical Condition Category risk score, month fixed effects, and Core-Based Statistical Area fixed effects, with standard errors clustered at the provider level, was calculated using a multivariate analysis (P < .05).

RESULTS

A total of 49,412 and 41,554 total shoulder arthroplasty (TSA) cases were observed April through December for 2019 and 2020, respectively. There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% (19% reduction in anatomic TSA, 13% reduction in reverse shoulder arthroplasty, and 3% reduction in fracture cases). LOS for all shoulder arthroplasty cases decreased by 16% (-0.27 days, P < .001) when adjusted for confounders. There was a 5% increase in the discharged-home rate (88.0% to 92.7%, P < .001), which was most prominent in fracture cases, with a 20% increase in discharged-home cases (65.0% to 73.4%, P < .001). There was no significant change in 30-day hospital readmission rates overall (P = .20) or when broken down by individual procedures.

CONCLUSIONS

There was an overall decrease in shoulder arthroplasty volume per 1000 Medicare beneficiaries by 14% during the COVID-19 pandemic. A decrease in LOS and increase in the discharged-home rates was also observed with no significant change in 30-day hospital readmission, indicating that a shift toward an outpatient surgical model can be performed safely and efficiently and has the potential to provide value.

The effect of obesity on complications following isolated posterior cruciate ligament reconstruction

BACKGROUND

This study assessed the risk of 30-day complications for obese patients compared to non-obese patients undergoing isolated posterior cruciate ligament (PCL) reconstruction.

METHODS

From 2006 to 2019, the National Surgical Quality Improvement Program database was queried for patients undergoing isolated PCL reconstruction. Two patient cohorts were defined: patients with obesity (BMI ≥ 30.0 kg/m²) and patients without obesity (BMI < 30 kg/m²). Patients' baseline demographics and medical comorbidities were collected and compared between the cohorts. Postoperative outcomes were assessed using bivariate and multivariate analyses.

RESULTS

414 patients underwent PCL reconstruction. 258 patients (62.3%) were non-obese and 156 patients (37.7%) were obese. Obese patients were more likely to be older, have a higher American Society of Anesthesiologists classification, and have hypertension compared to non-obese patients (p < 0.05 for all). The rates of superficial surgical site infections, wound dehiscence, transfusion necessity, deep vein thrombosis, and re-operation were not significant between obese and non-obese patients. Following adjustment on multivariate analyses, relative to patients without obesity, those with obesity had an increased risk of admission to the hospital overnight (OR 1.66; p = 0.048).

CONCLUSIONS

To our knowledge, this is the first study to evaluate obesity on complications in isolated PCL reconstruction. Our results and the heterogeneity in the literature indicate that obesity significantly impacts the rates of hospital readmission for PCL reconstruction. Therefore, surgeons should carefully weigh the risks and benefits of operating on obese patients and plan accordingly as obese patients may require postoperative hospital admission after PCL reconstruction.

LEVEL OF EVIDENCE

III.

Hypoalbuminemia and the Higher Risk of Perioperative Sentinel Adverse Events in Patients Undergoing Total Shoulder Arthroplasty: A Propensity Score Matched Analysis

BACKGROUND

The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse events after total shoulder arthroplasty (TSA).

METHODS

Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical Quality Improvement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients with normal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression was performed to evaluate the effect of HA on sentinel adverse events after surgery.

RESULTS

A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates of sentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation (4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, p <0.01) and pulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event for patients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group.

CONCLUSION

Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients with normal serum albumin levels.

Racial disparities in arthroscopic rotator cuff repair: an analysis of utilization and perioperative outcomes

Background

There remains a paucity of literature addressing racial disparities in utilization and perioperative metrics in arthroscopic rotator cuff repair procedures.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to evaluate patients undergoing arthroscopic rotator cuff repair from 2010 to 2019. Baseline demographics, utilization trends, and perioperative measures, including adverse events, operative time, length of hospital stay, days from operation to discharge, and readmission, were analyzed.

Results

Of 42,443 included patients, 38,090 (89.7%) were White, and 4353 (10.3%) were Black or African American. Black or African American patients had a significantly higher percentage of diabetes mellitus (23.6% vs. 15.6%), smoking (16.9% vs. 14.8%), congestive heart failure (0.3% vs. 0.1%), and hypertension (59.2% vs. 45.9%). In addition, logistic regression showed that Black or African American patients had increased odds of longer operative time (adjusted rate ratio 1.07, 95% confidence interval 1.05-1.08) and time from operation to discharge (adjusted rate ratio 1.19, 95% confidence interval 1.04-1.37). Disparities in relative utilization decreased as the proportion of Black or African American patients undergoing arthroscopic rotator cuff repair increased (7.4% in 2010 vs. 10.4% in 2019) compared with White patients (P _trend < .0001).

Conclusion

Racial disparities exist regarding baseline comorbidities and perioperative metrics in arthroscopic rotator cuff repair. Further investigation is needed to fully understand and address the causes of these inequalities to provide equitable care.

Preoperative Hypoalbuminemia Is Associated With Early Morbidity and Mortality After Revision Total Hip Arthroplasty

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P<.025. A total of 2492 revision THAs with complete data were identified, of which 486 (20%) had preoperative hypoalbuminemia. Preoperative hypoalbuminemia increased the absolute risk of a major complication by 15.3% compared with patients with revision THA without hypoalbuminemia (30% vs 14.7%, P<.001). Patients with preoperative hypoalbuminemia also had nearly a 7-fold higher incidence of death (3.3%) compared with those with revision THA without preoperative hypoalbuminemia (0.5%, P<.001). After logistic regression, the odds of having a major complication after revision THA with preoperative hypoalbuminemia within 30 days were increased by 80% (odds ratio, 1.8; 95% CI, 1.4-2.3; P<.001), and the odds of death within 30 days were increased by 210% (odds ratio, 3.1; 95% CI, 1.2-7.8; P=.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [Orthopedics. 2022;45(5):281-286.].

Extremity fasciotomy for patients on extracorporeal membrane oxygenation is independently associated with inpatient mortality

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) maintains end-organ perfusion in critically ill patients with cardiac or respiratory failure; however, ECMO cannulation in the extremities has been associated with significant limb ischemia and risk of compartment syndrome. Current literature on ECMO and fasciotomies is limited to small single-center retrospective studies. This study aimed to (1) compare the incidence of postoperative outcomes and mortality in patients undergoing fasciotomy while on ECMO to those of non-fasciotomy ECMO patients, and (2) assess the difference in adjusted mortality risk between the two groups.

HYPOTHESIS

We hypothesized that patients undergoing fasciotomy while on ECMO would have significantly higher odds of in-hospital mortality than non-fasciotomy ECMO patients after adjustment for perioperative variables.

METHODS

We conducted a retrospective review of NIS from January 1st, 2012-September 30, 2015 for all hospitalizations involving ECMO and stratified them into two cohorts based on whether they underwent fasciotomy after ECMO. Patient baseline characteristics, in-hospital procedures, and postoperative outcomes were compared between the two cohorts. Logistic regression was used to assess in-hospital mortality risk between the two cohorts adjusting for age, sex, Elixhauser score, and perioperative procedures and non-fasciotomy perioperative morbidity.

RESULTS

There were 7,085 estimated eligible discharges between 2012 and 2015 identified, 149 (2.1%) of which underwent fasciotomy following ECMO. One hundred and thirteen of the 149 hospitalizations (77%) in the fasciotomy cohort resulted in in-hospital mortality, compared to 3,805 of the 6,936 (55%) in the non-fasciotomy cohort. There were no differences in rates of transfusion (p=0.290), length of stay (p=0.282), or discharge disposition (p=0.126) between the two cohorts. In the logistic regression model, the fasciotomy cohort had a higher odds of in-hospital mortality than non-fasciotomy cohort (OR, 2.5; 95% CI, 1.1-5.6).

DISCUSSION

Operative treatment of acute compartment syndrome for patients on ECMO therapy is associated with significantly increased mortality and morbidity. Whether fasciotomy is a marker of sickness or represents a cause-and-effect relationship is unknown and future should investigate the role of non-operative treatment of compartment syndrome on mortality in this population.

LEVEL OF EVIDENCE

III; Prognostic.

Sex Differences in Utilization and Perioperative Outcomes of Arthroscopic Rotator Cuff Repair

Background

As the volume and proportion of patients treated arthroscopically for rotator cuff repair increases, it is important to recognize sex differences in utilization and outcomes.

Methods

Patients who underwent arthroscopic rotator cuff repair between 2010 and 2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Baseline demographic and clinical characteristics were collected, and information concerning utilization, operative time, length of hospital stay, days from operation to discharge, readmission, and adverse events were analyzed by sex.

Results

Of 42,443 included patients, 57.7% were male and 42.3% were female. Comparably, females were generally older (P < .001) and less healthy as indicated by American Society of Anesthesiologists class (P < .001) and rates of obesity (52.0% vs. 47.8%, P < .001), chronic obstructive pulmonary disease (4.0% vs. 2.7%, P < .001), and steroid use (2.7% vs. 1.6%, P < .001). Females experienced shorter operative times (mean difference [MD] 11.5 minutes, P < .001), longer hospital stays (MD 0.03 days, P < .001), longer times from operation to discharge (MD 0.03 days, P < .001), and more minor adverse events (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.24-2.47) after baseline adjustment. Conversely, rates of serious adverse events (OR, 0.69; 95% CI, 0.55-0.86) and readmissions (OR, 0.88; 95% CI, 0.66-0.97) were lower among females. Disparities in utilization increased over the study period (P = .008), whereas length of stay (P = .509) and adverse events (P = .967) remained stable.

Conclusion

Sex differences among patients undergoing arthroscopic rotator cuff repair are evident, indicating the need for further research to understand and address the root causes of inequality and optimize care for all.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database

Background

Early initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending.

Methods

Using the Truven MarketScan database, we identified nearly 980,000 US adults ages 18–64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05.

Results

At 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40–0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47–0.51), emergency department visits (OR = 0.51, 95% CI = 0.49–0.54), advanced imaging (OR = 0.57, 95% CI = 0.56–0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66–0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65–0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4–25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to −$410; P < 0.001).

Conclusion

Early PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state.

Level of evidence

IV

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08255-0.

Total Knee Arthroplasty after Anterior Cruciate Ligament Reconstruction

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

The association between diabetes status and postoperative complications for patients receiving ACL reconstruction

PURPOSE

It is well established that diabetes is associated with complications following surgical procedures across the wide array of surgical subspecialties. The evidence on the effect of diabetes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction (ACLR), however, is not as robust, and findings have not been consistent. It was hypothesized that patients with diabetes are at increased risk of complications and a higher rate of hospital admission following ACLR.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing ACL reconstruction from 2006 to 2019. Two patient cohorts were defined in this retrospective study: patients with diabetes and patients without diabetes. The various patient demographics, medical comorbidities, and postoperative outcomes were compared between the two groups, with the use of bivariate and multivariate analyses.

RESULTS

Of 9,576 patients who underwent ACL reconstruction, 9,443 patients (98.6%) did not have diabetes, whereas 133 patients (1.4%) had diabetes. Following adjustment on multivariate analyses, compared to non-diabetic patients, those with diabetes had an increased risk of admission to the hospital within thirty days of the surgery (OR 2.14; p = 0.002).

CONCLUSION

Patients with diabetes have a significantly higher risk of being admitted to the hospital compared to those without the disease. Clinicians should be aware of diabetic patients who undergo ACLR to ensure appropriate pre- and postoperative care to minimize complications in this patient population.

Outcome of arthroscopic pectoralis minor release and scapulopexy for the management of scapulothoracic abnormal motion

BACKGROUND

Management of persistent symptomatic scapulothoracic abnormal motion (STAM) in the absence of periscapular muscle paralysis may be challenging. This study reports the outcomes of arthroscopic pectoralis minor release and scapulopexy for the management of symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity in the absence of periscapular paralysis.

METHODS

This was a retrospective cohort study with prospectively collected data of patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity. Surgery was indicated if patients failed 6 months of conservative management. Patient outcomes were assessed with shoulder range of motion (ROM) measurements, numerical pain scale, shoulder subjective value (SSV), and Constant score. Data were analyzed with Fischer's exact test for categorical variables and Student's t-test of unequal variance for continuous and categorical variables.

RESULTS

Thirty-one consecutive patients were included in the study period between 2017 and 2020. Average age at the time of surgery was 24 years (range, 14-44 years), 80% of patients were female, and average follow-up after surgery was 23 months (range, 15-39 months). Thirteen patients also had a diagnosis of recurrent posterior instability. At final follow-up, 81% reported significant improvements in their STAM, as demonstrated by improved mean pain scale, ROM, SSV, and Constant scores. Pain improved from 6 (range, 4-10) to 2 (range, 1-4), SSV from 30% (range, 10%-40%) to 75% (range, 60%-100%), and Constant score from 49 (range, 43-61) preoperatively to 79 (range, 51-100) postoperatively (P < .01). All 13 patients with recurrent associated posterior instability had resolution of their instability. Flexion ROM improved from average 100° (range, 60°-150°) to 140° (range, 120°-160°). One patient had traumatic rupture of her scapulopexy 7 weeks postoperatively and underwent revision scapulopexy. Thirteen percent had minimal improvement after surgery and experienced recurrence 3 months postoperatively.

CONCLUSION

In patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity, arthroscopic pectoralis minor release and scapulopexy is an effective surgical option.

Accelerated versus standard physical therapy in patients with transtendinous rotator cuff repair: a propensity-matched cohort study

BACKGROUND

Partial-thickness rotator cuff tears that remain symptomatic despite conservative management can be repaired operatively through a transtendinous approach. Although transtendinous repairs have been linked to superior long-term biomechanical outcomes compared with other surgical techniques, they are classically associated with early postoperative stiffness and a slower rate of recovery.

PURPOSE

To examine the impact of expediting the physical therapy (PT) regimen after transtendinous repair on postoperative range of motion and complications.

METHODS

The first 61 patients to receive accelerated PT after transtendinous repair were compared with a historical cohort of 61 patients who underwent standard postoperative management. The patients were propensity matched on age, sex, smoking status, and biceps procedure performed at the time of rotator cuff repair. Primary outcome measures included active range of motion (AROM) in forward flexion, abduction, external rotation, and internal rotation at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively. Secondary outcome measures included development of severe stiffness or symptomatic rotator cuff retear at 1-year follow-up. Patients with full-thickness tears and those undergoing revision surgery or tear-completion and repair were excluded.

RESULTS

The accelerated PT cohort showed significantly increased AROM at 6 weeks and 3 months postoperatively. At 6 weeks, AROM in forward flexion (137.0° vs. 114.9°; P < .001), abduction (126.1° vs. 105.3°; P = .009), and external rotation (51.7° vs. 36.5°; P = .005) were all significantly higher in the accelerated PT cohort. A similar increase was seen at 3 months, with superior forward flexion (147.5° vs. 134.0°; P = .01) and external rotation (57.7° vs. 44.0°; P = .008) in patients who received accelerated PT. Severe postoperative stiffness was significantly less common in the accelerated PT cohort (3.3% vs. 18.0%; P = .02), and there were no symptomatic retears (0.00%) in the accelerated PT cohort as compared with 1 symptomatic retear (1.64%) in the standard PT cohort (P = 1.00).

CONCLUSION

Accelerated PT after transtendinous rotator cuff repair is associated with significant improvement in AROM at 6 weeks and 3 months postoperatively. Further, the early motion may help obviate the development of severe postoperative stiffness without any evidence of higher rotator cuff retear rates.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison; Treatment Study.

Factors associated with RVU generation in common sports medicine procedures

INTRODUCTION

Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based.

METHODS

We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour.

RESULTS

Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time.

CONCLUSION

wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.

Risk Factors for Complications, Longer Hospital Stay, and Readmission After Total Ankle Arthroplasty

BACKGROUND

Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA.

METHODS

We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission.

RESULTS

Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission.

CONCLUSIONS

TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA.

LEVELS OF EVIDENCE

Level III.

Increased Risk of Surgical-Site Infection and Need for Manipulation Under Anesthesia for Those Who Undergo Open Versus Arthroscopic Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Level of Evidence

A retrospective study evaluating the association between hypoalbuminemia and postoperative outcomes for patients receiving open rotator cuff repair

PURPOSE

Malnutrition has historically been shown to influence surgical outcomes. Although the diagnosis of malnutrition can be multifactorial, serum albumin levels serve as a useful indicator of malnutrition in patients undergoing orthopaedic surgery. The purpose of this study is to examine the prevalence of post-operative complications in patients with malnutrition (hypoalbuminemia) who underwent open rotator cuff repair. We hypothesized that patients with low preoperative albumin levels will have an increased risk for postoperative complications, readmission, reoperation, and prolonged hospital stay.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing open rotator cuff repair from 2006 to 2019. Two patient cohorts were defined: patients with hypoalbuminemia (<3.5 g/dL) and patients with normal preoperative serum albumin (≥3.5 g/dL), with the former being an indicator for malnutrition. In this analysis, demographics, comorbidities, and postoperative complications were compared between the two cohorts using bivariate analyses. Confounding factors found in the control group included sex, race, age, body mass index, smoking status, chronic obstructive pulmonary disease, hypertension, dialysis, diabetes, and dyspnea. To eliminate potential biases, multivariable logistic regression was used to adjust for these confounding factors.

RESULTS

Of 3,052 patients undergoing open rotator cuff repair with serum albumin levels recorded within 90 days before the surgery, 2,914 patients (95.5%), with an age range of 21-90 years, had normal albumin levels and 138 patients (4.5%), with an age range of 24-87 years, were hypoalbuminemic. Following adjustment on multivariate analyses, compared to patients with normal preoperative serum albumin, those with hypoalbuminemia had an increased risk of extended length of hospital stay (OR 7.47; p < 0.001) and hospital readmission (OR 4.16; p = 0.002).

CONCLUSION

Hypoalbuminemia is associated with extended length of stay and readmission after receiving open rotator cuff repair surgery.

Comparison of Perioperative Complications Following Surgical Treatment of Shoulder Instability

Background

Surgical repair for shoulder instability includes arthroscopic Bankart, open Bankart, and Latarjet-Bristow.

Methods

This is a cohort study of patients who underwent arthroscopic Bankart, open Bankart, or Latarjet-Bristow procedures that were identified within the National Surgical Quality Improvement Program database (2007-2019). Unadjusted and adjusted analyses were performed (α = 0.05). Outcomes included 30-day adverse events, readmission, and operative time.

Results

This study included 10,955 patients (9128 arthroscopic Bankart, 1148 open Bankart, and 679 Latarjet-Bristow). Compared with arthroscopic Bankart, Latarjet-Bristow had longer operative times (129.96 [95% CI: 126.49-133.43] vs. 86.35 [85.51-87.19] minutes), along with a higher percentage of serious adverse events (2.5% vs. 0.4%), reoperation (1.9% vs. 0.1%), readmission (1.8% vs. 0.3%), thromboembolic complications (0.4% vs. 0.1%), and sepsis (0.4% vs. 0.0%) (P < .05 for all). Open Bankart had longer operative times (98.17 [95.52-100.82] vs. 86.35 [85.51-87.19] minutes) and a higher percentage of sepsis (0.2% vs. 0.0%) (P < .05 both). Latarjet-Bristow had increased odds of a serious adverse event (odds ratio [OR]: 7.68 [4.19-14.07]), reoperation (OR: 17.32 [7.58-39.56]), readmission (OR: 5.73 [2.84-11.54]), and deep wound complications (OR: 14.98 [3.92-57.23]) (P < .05 for all). In comparing the relative utilization of arthroscopic versus open Bankart, arthroscopic Bankart increased (83.4% to 91.2%) while open Bankart decreased (16.6% to 8.8%) from the 2011-2013 time period to 2017-2019 (P_trend < .001).

Conclusion

In addition to a low complication rate, the relative utilization of arthroscopic Bankart increased compared with open Bankart over the past decade. Furthermore, Latarjet-Bristow was associated with a higher incidence of serious adverse events than arthroscopic Bankart.

Incidence and risk factors for perioperative death after revision total hip arthroplasty: a 20-year analysis

INTRODUCTION

The number of revision total hip arthroplasty (THA) procedures is increasing in the US. Revision THA is associated with higher complication rates compared with primary THA. We describe patterns in incidence and risk factors for perioperative death after revision THA.

METHODS

Using the National Hospital Discharge Survey, we identified nearly 700,000 cases of revision THA from 1990 through 2010. Procedure incidence, perioperative mortality rates, comorbidities, discharge disposition, and duration of hospital stay were analysed. Multivariable logistic regression was used to identify independent risk factors for perioperative death. Alpha = 0.01.

RESULTS

Population-adjusted incidence of revision THA per 100,000 people increased from 9.2 cases in 1990 to 15 cases in 2010 (p < 0.001). The rate of perioperative death was 0.9% during the study period and decreased from 1.5% during the "first" period (1990-1999) to 0.5% during the "second" period (2000-2010) (p < 0.001), despite an increase in comorbidity burden over time. Factors associated with the greatest odds of perioperative death were acute myocardial infarction (odds ratio [OR], 37; 95% confidence interval [CI], 33-40; p < 0.001), pneumonia (OR, 16; 95% CI, 15-18; p < 0.001), and pulmonary embolism (OR, 13; 95% CI, 11-15; p < 0.001).

CONCLUSIONS

The rate of perioperative death in patients undergoing revision THA in the US decreased from 1990 to 2010 despite an increase in comorbidities. Acute myocardial infarction, pneumonia, and pulmonary embolism were associated with the highest odds of perioperative death after revision THA.

Neural network prediction of 30-day mortality following primary total hip arthroplasty

Purpose

The purpose is to utilize an artificial neural network (ANN) model to determine the most important variables in predicting mortality following total hip arthroplasty (THA).

Methods

Patients that underwent primary THA were included from a national database. Demographic, preoperative, and intraoperative variables were analyzed based on their contribution to 30-day mortality with the use of an ANN model.

Results

The five most important factors in predicting mortality following THA were preoperative international normalized ratio, age, body mass index, operative time, and preoperative hematocrit.

Conclusion

ANN modeling represents a novel approach to determining perioperative factors that predict mortality following THA.

Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion.  PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients.

METHODS

The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05).

RESULTS

Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients.

CONCLUSIONS

Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.