Esophageal Perforation in a 76-Year-Old Man After C5-C7 Anterior Discectomy and Anterior Plate Fusion.

Anterior cervical discectomy and fusion (ACDF) is indicated for the treatment of various cervical pathologies, including myelopathy, cervical disc degeneration, and radiculopathy. Esophageal perforation is a rare postsurgical complication of ACDF, although it poses serious and potentially fatal outcomes. Esophageal perforation has been described as the most fatal complication of the gastrointestinal tract as delayed diagnosis can lead to sepsis and death. Diagnosis of this complication is often difficult because it can be masked by various symptoms such as recurrent aspiration pneumonia, fever, dysphagia, and neck pain. While this complication usually occurs within the first 24 h post-surgery, it can also develop later and persist chronically in rare cases. Awareness and early recognition of this complication may improve outcomes and reduce mortality and morbidity. A 76-year-old man underwent C5-C7 ACDF in October 2017. A thorough review of the patient's postoperative condition included computed tomography (CT) and esophagogram, which were negative for signs of acute complications. The postoperative recovery was uneventful until several months post-procedure when he began to develop vague dysphagia and weight loss of unknown etiology. A CT scan was obtained 6 months postoperatively and was negative for perforation. He then underwent a battery of inconclusive procedures and scans at multiple institutions. After several months of persistent dysphagia and weight loss without a diagnosis, the patient presented to our network for further workup and treatment recommendations. Upper endoscopy was performed and showed fistulization between the esophagus and the metal hardware in the cervical spine. Esophagram demonstrated no obstruction but decreased peristalsis of the lower esophagus and lateral rightward deviation of the left upper cervical esophagus with minimal mucosal irregularities. These findings were secondary to mass effect of the cervical plate. The patient was successfully treated with a surgical approach using esophagogastroduodenoscopy (EGD) guided repair in layers and a sternocleidomastoid muscle flap. This report demonstrates a rare case of delayed esophageal perforation after ACDF and successful treatment of the perforation by surgical repair using the dual technique.

Alcohol Abuse, Morbid Obesity, Depression, Congestive Heart Failure, and Chronic Pulmonary Disease are Risk Factors for 90-Day Readmission After Arthroscopic Rotator Cuff Repair.

Purpose: The purpose of this study was to report the rate and causes of 90-day readmissions after arthroscopic rotator cuff repair. Methods: A retrospective query from January 2005 to March 2014 was performed using a nationwide administrative claims registry. Patients and complications were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Patients who underwent arthroscopic rotator cuff repair (RCR) and were readmitted within 90 days after their index procedure were identified. Patients not readmitted represented controls. Patients readmitted were stratified into separate cohorts depending on the primary cause of readmission, which included cardiac, endocrine, hematological, infectious, gastrointestinal, musculoskeletal (MSK), neoplastic, neurological or psychiatric, pulmonary, and renal. Risk factors assessed were comorbidities comprising the Elixhauser-Comorbidity Index (ECI). Primary outcomes analyzed and compared included cause for readmission, patient demographics, risk factors, in-hospital length of stay (LOS), and costs. Pearson's chi-square was used to compare patient demographics, and multivariate binomial logistic regression was used to calculate odds ratios (OR) on patient-related risk factors for 90-day readmissions. Results: 10,425 readmitted patients and 301,625 control patients were identified, representing a 90-day readmission rate of 3.5%. The causes of readmissions were primarily related to infectious diseases (15%), MSK (15%), and cardiac (14%) complications. The most common MSK readmissions were osteoarthrosis of the leg or shoulder (24.8%) and spinal spondylosis (8.4%). Multivariate binomial logistic regression analyses demonstrated patients with alcohol abuse (OR, 1.42; P < .0001), morbid obesity (OR, 1.38; P < .0001), depression (OR, 1.35; P < .0001), congestive heart failure (OR, 1.34; P < 0.0001), and chronic pulmonary disease (OR, 1.28; P < .0001) were at the greatest risk of readmissions after RCR. Conclusions: Significant differences exist among patients readmitted, and those patients who do not require hospital readmission within 90 days following arthroscopic rotator cuff repairs. Readmissions are associated with significant patient comorbidities and were primarily related to medically based complications. Level of Evidence: Level III, prognostic, retrospective cohort study.

Comparative Analysis on the Effects of Sarcopenia following Primary Total Knee Arthroplasty: A Retrospective Matched-Control Analysis.

Despite the high incidence of sarcopenia in the orthopaedic community, studies evaluating the influence of sarcopenia following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study is to determine if sarcopenic patients undergoing primary TKA have higher rates of (1) in-hospital lengths of stay (LOS); (2) medical complications; (3) implant-related complications; (4) fall risk; (5) lower extremity fracture risk; and (6) costs of care. Sarcopenia patients were matched to controls in a 1:5 ratio according to age, sex, and medical comorbidities. The query yielded 90,438 patients with (n = 15,073) and without (n = 75,365) sarcopenia undergoing primary TKA. Primary outcomes analyzed included: in-hospital LOS, 90-day medical complications, 2-year implant-related complications, fall risk, lower extremity fracture risk, and costs of care. A p-value of less than 0.05 was considered statistically significant. Patients with sarcopenia undergoing primary TKA had greater in-hospital LOS (4 vs. 3 days, p < 0.0001). Sarcopenic patients were also found to have increased incidence and odds of 90-day medical complications (2.9 vs. 1.1%; odds ratio [OR] = 2.83, p < 0.0001), falls (0.9 vs. 0.3%; OR = 3.54, p < 0.0001), lower extremity fractures (1.0 vs. 0.2%; OR = 5.54, p < 0.0001), and reoperation (0.9 vs. 0.5%; OR = 1.87, p < 0.0001). Additionally, sarcopenic patients had greater 2-year implant-related complications (4.3 vs. 2.4%; OR = 1.80, p < 0.0001), as well as day of surgery ($52,900 vs. 48,248, p < 0.0001), and 90-day ($68,303 vs. $57,671, p < 0.0001) costs compared with controls. This analysis of over 90,000 patients demonstrates that patients with sarcopenia undergoing primary TKA have greater in-hospital LOS, increased odds of 90-day medical complications, falls, lower extremity fractures, and reoperations. Additionally, sarcopenia was associated with greater 2-year implant-related complications, day of surgery costs, and 90-day costs. The study is useful as it can allow orthopaedic surgeons to properly educate these patients of the potential complications which may occur following their surgery.

Robotic-Assisted Lateral Unicompartmental Knee Arthroplasty in a Patient With Nail-Patella Syndrome.

A 59-year-old woman with nail patella syndrome (NPS) presented with progressive and severe right knee pain for the past 3 years. Imaging demonstrated laterally dislocated patella, with asymmetric femoral trochlea, and advanced lateral compartment arthritis. The patient underwent robotic-assisted lateral unicompartmental knee arthroplasty (RAUKA). The patient saw marked improvements in patient-reported outcome measurements from her initial visit to the last follow-up visit. While treatment of knee osteoarthritis in patients with NPS can be difficult, especially with attempts of patellar realignment, we present a case of a patient who underwent RAUKA, with sustained improvements in patient outcomes and range of motion, at the 2-year follow-up visit. This study is the first of its kind to demonstrate the use of a novel technology in a rare condition.

Impact of Postoperative Zolpidem Use on Primary Total Knee Arthroplasty: A Retrospective Matched-Controlled Analysis of a Private Insurance Database.

INTRODUCTION: Zolpidem has gained popularity as a pharmaceutical therapy for insomnia, being the most prescribed hypnotic in the United States today. However, it is associated with increased mortality and morbidity. Literature regarding zolpidem use in the total knee arthroplasty (TKA) population is limited. The aim of the study was to analyze postoperative zolpidem use in the TKA population regarding medical and implant complications, falls, and readmission. METHODS: The study group was queried according to zolpidem use. Controls consisted of patients who underwent primary TKA without a history of hypnotic drug use. Study group patients were matched to controls in a 1:5 ratio by demographics and comorbidities. Results yielded 99,178 study participants and 495,795 controls. Primary endpoints included 90-day medical and implant complications, fall risk, and readmission. Chi-squared test was used to compare categorical variables. Multivariate logistic regression was used to calculate odds (OR) for complications, fall risk, and readmission. A P value less than 0.05 was considered statistically significant. RESULTS: Study group patients had increased odds of medical complications (OR: 1.76, 95% CI: 1.71-1.82, P < .0001) and implant complications (OR: 1.35, 95% CI: 1.23-1.47, P < .0001) compared to controls. Furthermore, patients in the study group were found to have an increased risk of 90- day falls (OR: 1.16, 95% CI: 1.11-1.21, P < .0001). Readmission was similar to controls (5.10% vs 4.84%, P = .12). CONCLUSION: Zolpidem use following primary TKA is associated with the risk of morbidity and falls. The findings are consistent with the literature regarding zolpidem. These findings may affect discussion between orthopedic surgeons and patients in the decision-making process prior to undergoing TKA.

Determining the validity of the Outpatient Arthroplasty Risk Assessment (OARA) tool for identifying patients for safe same-day discharge after primary shoulder arthroplasty.

BACKGROUND: Early discharge has been a target of cost-control efforts given the growing demand for joint replacement surgery. The Outpatient Arthroplasty Risk Assessment (OARA) score, a medically based risk-assessment score, has shown high predictive ability in achieving safe early discharge following outpatient lower-extremity arthroplasty using a score threshold initially set at ≤59 points but more recently adapted to ≤79 points. However, no study has been performed using the OARA tool for shoulder replacement, which has been shown to have lower associated medical risks than lower-extremity arthroplasty. The purpose of this study was to determine the OARA score threshold for same-day discharge (SDD) following shoulder arthroplasty and evaluate its effectiveness in selecting patients for SDD. We hypothesized that the OARA score threshold for shoulder arthroplasty would be higher than that for lower-extremity arthroplasty. METHODS: We performed a retrospective review of 422 patients who underwent primary anatomic or reverse shoulder arthroplasty between April 2018 and October 2019 performed by a single surgeon. As standard practice, all patients were counseled preoperatively regarding SDD and given the choice to stay overnight. Medical history, length of stay, and 90-day readmissions were obtained from medical records. Analysis of variance testing and screening test characteristics compared the performance of the OARA score vs. the American Society of Anesthesiologists Physical Status (ASA-PS) class and a previously published OARA score threshold used to define a low risk of outpatient lower-extremity arthroplasty. RESULTS: A preoperative OARA score cutoff of ≤110 points demonstrated a sensitivity of 98.0% for identifying patients with SDD after shoulder arthroplasty, compared with 66.7% using the hip and knee OARA score threshold of ≤59 points (P < .0001) and 80.4% using ASA-PS class ≤ 2 (P = .008). OARA scores ≤ 110 points also showed a negative predictive value of 98.9% and a false-negative rate of 2.0% but remained incomprehensive with a specificity of 24.0% (P < .0001). Analysis of variance demonstrated that mean OARA scores increased significantly with length of stay (P = .001) compared with ASA-PS classes (P = .82). Patients with OARA scores ≤ 110 points were also 2.5 times less likely to have 90-day emergency department visits (P = .04) than those with OARA scores > 110 points. There was no difference in 30- and 90-day readmission rates for patients with OARA scores ≤ 59 points, OARA scores ≤ 110 points, and ASA-PS classes ≤ 2. CONCLUSION: Our study suggests that a preoperative OARA score threshold of ≤110 points is effective and conservative in screening patients for SDD following shoulder arthroplasty, with low rates of 90-day emergency department visits and readmissions. This threshold is a useful screening tool to identify patients who are not good candidates for SDD.

Pigmented Villonodular Synovitis of the Hip in Patients Undergoing Total Hip Arthroplasty: A Retrospective Case-Controlled Analysis.

BACKGROUND: Pigmented villonodular synovitis (PVNS) is a condition affecting larger joints such as the hip and knee. Little is known regarding the impact of PVNS on total hip arthroplasty (THA). Therefore, the aim of this study is to determine if patients with PVNS of the hip undergoing primary THA experience greater (1) in-hospital lengths of stay (LOS); (2) complications; (3) readmission rates; and (4) costs. METHODS: Patients undergoing primary THA for PVNS of the hip from the years 2005 to 2014 were identified using a nationwide claims registry. PVNS patients were matched to a control cohort in a 1:5 ratio by age, gender, and various comorbidities. The query yielded 7440 patients with (n = 1240) and without (n = 6200) PVNS of the hip undergoing primary THA. Endpoints analyzed included LOS, complications, readmission rates, and costs. Multivariate logistic regression was used to determine odds ratios (OR) of developing complications. Welch's t-tests were used to test for significance in LOS and cost between the cohorts. A P-value less than .001 was considered statistically significant. RESULTS: PVNS patients had approximately 8% longer in-hospital LOS (3.8 vs 3.5 days, P = .0006). PVNS patients had greater odds of (OR 1.60, P < .0001) medical and (OR 1.81, P < .0001) implant-related complications. Furthermore, PVNS patients were found to have higher odds (OR 1.84, P < .0001) of 90-day readmissions. PVNS patients also incurred higher day of surgery ($13,119 vs $11,983, P < .0001) and 90-day costs ($17,169 vs $15,097, P < .0001). CONCLUSION: Without controlling for global trends in LOS, complications, readmissions, or costs between 2005 and 2014, the findings of the study suggest that PVNS of the hip is associated with worse outcomes and higher costs following primary THA. The study is useful as orthopedic surgeons can use the study to educate patients of the complications which may occur following their hip surgery.

Increased Medical Complications, Revisions, In-Hospital Lengths of Stay, and Cost in Patients With Hypogonadism Undergoing Primary Total Knee Arthroplasty.

BACKGROUND: Research regarding the impact of hypogonadism following primary total knee arthroplasty (TKA) is limited. Therefore, the purpose of this study is to investigate whether patients with hypogonadism undergoing primary TKA are at increased odds of (1) medical complications, (2) revisions, (3) in-hospital lengths of stay (LOSs), and (4) cost of care. METHODS: A Humana patient population consisting of 8 million lives was retrospectively analyzed from 2007 to 2017 using International Classification of Disease, 9th Revision codes. Patients were filtered by male gender and patients with hypogonadism were matched to controls in a 1:4 ratio according to age and medical comorbidities. The query yielded 8393 patients with (n = 1681) and without (6712) hypogonadism undergoing primary TKA. Primary outcomes analyzed included medical complications, revision rates, in-hospital LOS, and cost of care. Logistic regression analysis was used to calculate odds ratios (OR) of 90-day medical complications and 2-year revisions. Welch's t-test was used to test for significance in LOS and cost of care between cohorts. A P-value less than .05 was considered statistically significant. RESULTS: Hypogonadal patients undergoing primary TKA were found to have increased incidence and odds (9.45% vs 4.67%; OR 2.12, P < .0001) of developing 90-day medical complications. Hypogonadal patients undergoing primary TKA were found to have a greater incidence and odds (3.99% vs 2.80%; OR 1.89, P < .0001) of 2-year revisions. Hypogonadal patients had a 6.11% longer LOS (3.47 vs 3.27 days, P = .02) compared to controls, and incurred greater 90-day costs ($15,564.31 vs $14,856.69, P = .018) compared to controls. CONCLUSION: This analysis of over 1600 patients demonstrates that patients with hypogonadism undergoing primary TKA have greater odds of postoperative medical complications, revisions, increased LOS, and cost of care.

Partial thickness rotator cuff tears: Patient demographics and surgical trends within a large insurance database.

INTRODUCTION: Partial thickness rotator cuff tears (PTRCT) are a common injury reported in 13-32% of the population, yet most of the current literature focuses on full thickness rotator cuff tears. Therefore, the purpose of this study was to analyze trends among patients with PTRCT including: (1) demographics; (2) comorbidities; (3) cost of care; (4) setting of initial diagnosis; and (5) change in incidence of PTRCT or surgical approach over time. METHODS: A Medicare patient-population consisting of 44 million lives was retrospectively analyzed from 2007 to 2017 using International Classification of Disease, 9th Revision (ICD-9) codes. Patients were identified for PTRCT using ICD-9 code: 726.13. The query yielded a total of 44,978 patients all of which had been previously diagnosed with PTRCT. Primary trends analyzed included: demographics, comorbidities, cost of care, initial setting of diagnosis, and change in incidence of PTRCT or surgical approach over time. RESULTS: PTRCTs and surgical repair of PTRCTs were most common in patients ages 65 to 69 and least common in patients who were 85 and older. Incidence of PTRCT was greater in females (54.12%) than males (45.88%). Comorbidities found within the population included hypertension, hyperlipidemia, diabetes mellitus, tobacco use, obesity, rheumatoid arthritis, and osteoarthritis of the shoulder. The average cost per episode of care totaled $9,923.26. PTRCTs were most commonly diagnosed in patients who resided in assisted living facilities (n = 27,106), making up 60% of the patient population. Reported incidence of PTRCT has increased substantially along with the surgical repair of PTRCT. CONCLUSION: Reported cases of PTRCT and its surgical repair have both increased substantially over time. Approximately 11.70% of patients with PTRCT undergo either open or arthroscopic procedure as a means of surgical repair. With the growing popularity of arthroscopic procedures for rotator cuff repair, further investigation should be performed to analyze trends and risk factors for PTRCT, a seemingly underrepresented orthopedic condition.