Association of Pelvic Trauma With Rates of Cesarean Section, Sexual Dysfunction, and Genitourinary Dysfunction in a National Database.

INTRODUCTION: Pelvic fractures are severe injuries that can drastically affect a woman's quality of life through sexual dysfunction (SD), genitourinary dysfunction (GD), and increasing the potential need for future cesarean section (C-section). Limited research has captured long-term outcomes after pelvic fractures in women of childbearing age. This study aimed to determine the association between pelvic fractures and rates of C-section, SD, and GD. METHODS: All women of childbearing age who sustained a pelvic fracture were identified in a national insurance database. A comparison group of patients with lower extremity long-bone fractures was selected. Patients who gave birth after injury were additionally identified. A minimum of 5 years of follow-up was required for inclusion. Rates of C-section, SD, and GD were compared between cohorts. Multivariate logistic regression analysis was conducted with the inclusion of diabetes, tobacco, hypertension, obesity, and advanced maternal age. RESULTS: A total of 6,174 patients with pelvic fracture and 27,154 control fracture patients were identified. 434 patients with pelvic fracture (7.0%) and 1,258 control fracture patients (4.6%) gave birth after fracture. Patients with pelvic fracture had a significantly higher rate of C-section (50.0% versus 38.8%, P < 0.001), SD diagnosis (10.9% versus 8.8%, P < 0.001), and urinary retention diagnosis (3.5% versus 2.8%, P < 0.001). No significant difference in global GD diagnosis was identified. Multivariate analyses showed that pelvic fracture was associated with C-section (odds ratio [OR]: 1.78; 95% confidence interval [95% CI]: 1.42 to 2.23, P < 0.001), SD diagnosis (OR: 1.23; 95% CI: 1.12 to 1.35, P < 0.001), and urinary retention diagnosis (OR: 1.35; 95% CI: 1.15 to 1.57, P < 0.001). DISCUSSION: Pelvic fractures confer an intrinsic level of risk of C-section, SD, and urinary retention that is elevated beyond what would be expected from a traumatic lower extremity injury alone. Treating orthopaedic surgeons should actively counsel women regarding increased risks, openly discuss postinjury sequelae, and coordinate interspecialty care beyond initial treatment of acute trauma.

Surgical Outcomes, Trends, and Risk Factors of Distal Triceps Repairs.

BACKGROUND: Distal triceps ruptures are rare, and complete ruptures are commonly treated with surgery. Studies of patients in small cohorts with distal triceps tear have reported outcomes and risk factors; however, large-scale data are scant. This study seeks to determine current trends, outcomes, and risk factors of distal triceps tears. METHODS: Within a large insurance claims database, distal triceps repair patients were identified through Current Procedural Terminology coding with concomitant distal triceps International Classification of Diseases, 9th Revision/10th Revision diagnosis codes and 1-year active status before and after surgery. Demographics, total costs, 90-day complications, and revision rates within 1 year of index surgery were analyzed. Logistic regression was performed for revision and complication rates using sex, age, and comorbidities (anabolic steroid use, diabetes, ischemic heart disease, tobacco use, rheumatoid arthritis, and chronic kidney disease). RESULTS: A total of 8143 patients were included in the cohort. Male patients and patients aged 40 to 59 years comprised most of the study population. The postoperative complication rate was 5.8%, and the 1-year revision rate was 2.6%. Male sex, age >60 years, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease were statistically significant risk factors for higher 90-day complication rates. Anabolic steroid use significantly increased the risk of surgical revision. CONCLUSIONS: Distal triceps repairs in this large cohort study occur most frequently in men aged 40 to 59 years. Complications are generally low, with age >60 years, male sex, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease as risk factors for 90-day complications and prior anabolic steroid use as a risk factor for 1-year revision surgery. This information can help to improve education and expectations of this procedure.

Rates of Future Lumbar Fusion in Patients with Cauda Equina Syndrome Treated With Decompression.

INTRODUCTION: The long-term risk of conversion to lumbar fusion is ill-defined for patients with cauda equina syndrome (CES) treated with decompression. This study aimed to identify the rates of fusion in patients with CES and compare those rates with a matched lumbar spinal stenosis (LSS) group. METHODS: Patients with CES who underwent decompression were identified in a national database and matched to control patients with LSS. The rates of conversion to fusion were identified and compared. Multivariate logistic regression analysis identified independently associated risk factors. A subanalysis was conducted after stratifying by timing between CES diagnosis and decompression. RESULTS: The rate of lumbar fusion in the CES cohort was 3.6% after 1 year, 6.7% after 3 years, and 7.8% after 5 years, significantly higher than the LSS control group at all time points (1 year: 1.6%, P = 0.001; 3 years: 3.0%, P < 0.001; 5 years: 3.8%, P < 0.001). CES was independently associated with increased risk of conversion to fusion (odds ratio: 2.13; 95% confidence interval: 1.56 to 2.97; P < 0.001). Surgical timing was not associated with risk of conversion to fusion. CONCLUSIONS: After 5 years, 7.8% of patients with CES underwent fusion, a markedly higher rate compared with patients with LSS. Counseling patients with CES on this increased risk of future surgery is important for patient education and satisfaction.

Postoperative Anterior Cruciate Ligament Reconstruction Quadricep and Patella Tendon Rupture, Infection, and Lysis of Adhesions Decreased Despite Changing Graft Trends Over the Past Decade.

Purpose: To investigate recent trends in postoperative complications following anterior cruciate ligament (ACL) reconstruction. Methods: Patients who underwent ACL reconstruction surgery were identified in a national insurance database and separated into 2 cohorts based on the date of their initial surgery comprising the years 2010 to 2012 and 2016 to 2018, respectively. Patients were matched 1:1 based on comorbidities and Elixhauser Comorbidity Index. All patients were assessed for postoperative complications within 18 months of surgery. Rate of complication was compared between cohorts. Results: Overall, the all-cause complication rate was 2%. There were significantly more quadriceps tendon rupture, patella tendon rupture, lysis of adhesion, and infection in the early cohort. There were significantly more instances of deep vein thrombosis in the late cohort. We found no significant difference in manipulations under anesthesia between the 2 cohorts. Conclusions: Patients who underwent surgery in the late cohort had lower rates of postoperative complications, except for deep vein thrombosis. The rate of postoperative quadriceps tendon rupture decreased despite considerable increase in the use of quadriceps tendon autograft. Clinical Relevance: As there has been an increased use of quadriceps tendon autografts, but little is known about the postoperative complications after ACL reconstruction with these grafts. This information has the potential to improve patient outcomes.

Effect of Body Mass Index on Femur Fracture Location: A Retrospective Database Study.

OBJECTIVES: Use a large database design and multivariable analyses to assess the associations between body mass index (BMI) and femur fracture patterns after controlling for other risk factors. DESIGN: Retrospective cohort study. SETTING: National insurance claims database of patient records from 2010 to 2018. PATIENTS/PARTICIPANTS: Patients with femur fracture diagnoses were identified. Patients with multiple fractures within 1 week (polytrauma patients), patients without a BMI diagnosis code within 6 months of fracture, and patients with multiple BMI diagnosis codes (implying a substantial change in weight) were excluded. INTERVENTION: N/A. MAIN OUTCOME MEASUREMENTS: Patients were divided into groups based on fracture location: proximal (OTA/AO 31), shaft (OTA/AO 32), or distal (OTA/AO 33). The distribution of femur fractures was compared across BMI categories. RESULTS: A total of 57,042 patients with femur fracture were identified: 45,586 proximal fractures, 4216 shaft fractures, and 7240 distal fractures. Patients with BMI <29.9 have increased odds ( P < 0.0001) of proximal fracture and decreased odds ( P < 0.0001) of shaft or distal fractures. Patients with BMI >30.0 have decreased odds ( P < 0.0001) of proximal fracture and increased odds ( P < 0.0001) of distal fractures. CONCLUSIONS: Increasing BMI is associated with a decreased proportion of proximal femur fractures and a corresponding increase in the proportion of shaft and distal fractures. Regression analyses determined that age, sex, osteoporosis, diabetes, and tobacco use are not the cause of this trend. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of the Cost and Efficacy of Intra-Articular Knee Injections.

INTRODUCTION: Intra-articular joint injections have been used with the goal of providing patients with symptomatic relief. Recently, however, the efficacy of corticosteroid (CS) and hyaluronic acid (HA) injections in the management of knee osteoarthritis (OA) is questionable. In this analysis, we investigated the costs associated with injections by assessing overall use, conversion and average time to total knee arthroplasty (TKA), and reimbursement. METHODS: Patients aged 50 to 70 years with a knee-related diagnosis of pain, effusion, or OA were identified in the Humana insurance national data set. Patients who received intra-articular injections were stratified by the type and number of injection(s) received. The subsequent rates of TKA were compared with Kaplan-Meier curves for patients who underwent CS injections, HA injections, and a benchmarking cohort of patients with OA and no history of knee injections in the medical record. Average time to TKA was determined from index diagnosis, and total cost was compared using Wilcoxon rank sum analyses. RESULTS: A total of 778,686 patients were identified. Of these, 637,112 had no knee injection history, while 124,129 received CS and 17,445 received HA injections. The 10-year conversion to TKA was highest in HA cohort (31.6%), followed by the CS cohort (24.0%) and the noninjection cohort (7.3%) (P < 0.001). Time to TKA increased with number of injections for both injection types. For patients who underwent TKA, median cost was greater in HA ($16,687) and CS ($15,563) cohorts relative to noninjection cohort ($14,733) (P < 0.001). DISCUSSION: Compared with the noninjection cohort, both HA and CS cohorts experienced increased costs and increased time to TKA. However, while the cost incurred in HA cohort was greater than that in CS cohort, no appreciable benefit was demonstrated for conversion or time to TKA. Therefore, if intra-articular knee injections are indicated for the nonsurgical management of knee OA, the results of this study support CS over HA.

A Safe Interval between Preoperative Intra-articular Corticosteroid Injections and Subsequent Knee Arthroscopy.

The purpose of this study is to evaluate the influence of intra-articular corticosteroid injections prior to knee arthroscopy on the rate of postoperative infection and define a safe timing interval between intra-articular corticosteroid injections and subsequent knee arthroscopy. The PearlDiver Database was used to identify patients who underwent a knee arthroscopy from 2007 to 2017. Patients were sorted into an injection cohort if they received any intra-articular corticosteroid injections within 6 months before surgery and a control cohort if they received no such injections. The injection cohort was then stratified into subgroups based on the timing of the most recent injection. We identified two types of postoperative infection in the 6 months following surgery: a broad definition of infection using knee infection diagnoses, and a narrow definition of infection requiring surgical treatment. The effects of the timing of preoperative corticosteroid injections on the rates of postoperative infection were investigated. The rate of broadly defined postoperative infection was significantly higher in the 0 to 2 weeks injection group (6.90%, 20/290) than the control group (2.01%, 1,449/72,089, p < 0.001; odds ratio [OR]:3.61 [95% confidence interval [CI]: 2.29, 5.70]). We observed a significant difference regarding the rate of narrowly defined postoperative infection requiring surgical treatment between the 0 and 2 weeks injection group (1.38%, 4/290) and the control group (0.27%, 192/72,089, p < 0.001, OR:5.24 [95% CI: 1.94, 14.21]). No significant differences were observed between other subgroups and the control group in both types of postoperative infection. Intra-articular corticosteroid injections within 2 weeks of knee arthroscopy were statistically significantly associated with higher rates of postoperative infection. This is a Level III, retrospective comparative study.

Does lumbar spine fusion predispose patients to future total hip replacement?

OBJECTIVE: Hip-spine syndrome has been well studied since it was first described by Offierski and MacNab in 1983. Today, strong evidence links symptoms of hip and spine pathology to postsurgical outcomes. Recent studies have reported increased rates of hip dislocation in patients previously treated with total hip arthroplasty (THA) who had undergone lumbar fusion procedures. However, the effect of this link on native hip-joint degeneration remains an area of ongoing research. The purpose of this study was to characterize the relationship between use of lumbar fusion procedures and acceleration of hip pathology by analyzing the rate of future THA in patients with preexisting hip osteoarthritis. METHODS: This population-level, retrospective cohort study was conducted by using the PearlDiver research program. The initial patient cohort was defined by the presence of diagnosis codes for hip osteoarthritis. Patients were categorized according to use of lumbar fusion after diagnosis of hip pathology. Survival curves with respect to THA were generated by comparison of the no lumbar fusion cohort with the lumbar fusion cohort. To assess the impact of fusion construct length, the lumbar fusion cohort was then stratified according to the number of levels treated (1-2, 3-7, or ≥ 8 levels). Hazard ratios (HRs) were then calculated for the risk factors of number of levels treated, patient age, and sex. RESULTS: A total of 2,275,683 patients matched the authors' inclusion criteria. Log-rank analysis showed no significant difference in the rates of THA over time between the no lumbar fusion cohort (2,239,946 patients) and lumbar fusion cohort (35,737 patients; p = 0.40). When patients were stratified according to number of levels treated, again no differences in the incidence rates of THA over the study period were determined (p = 0.30). Patients aged 70-74 years (HR 0.871, p < 0.001), 75-79 years (HR 0.733, p < 0.001), 80-84 years (HR 0.557, p < 0.001), and ≥ 85 years (HR = 0.275, p < 0.001) were less likely to undergo THA relative to the reference group (patients aged 65-69 years). CONCLUSIONS: Although lumbar fusion was initially hypothesized to have a significant effect on rate of THA, lumbar fusion was not associated with increased need for future THA in patients with preexisting hip osteoarthritis. Additionally, there was no relationship between fusion construct length and rate of THA. Although lumbar fusion reportedly increases the risk of hip dislocation in patients with prior THA, these data suggest that lumbar fusion may not clinically accelerate native hip degeneration.

Acute Versus Delayed Reverse Shoulder Arthroplasty for the Primary Treatment of Proximal Humeral Fractures.

INTRODUCTION: Reverse total shoulder arthroplasty (rTSA) is gaining popularity as a treatment option for proximal humeral fractures in elderly patients. The impact of surgical timing on outcomes of primary rTSA is unclear. This study compared the rates of revision and complication, and surgery day cost of treatment between acute and delayed primary rTSA patients. METHODS: Elderly patients with proximal humeral fracture who underwent primary rTSA within a year of fracture were identified in a national insurance database from 2005 to 2014. Patients were separated into acute (<4 weeks) or delayed (>4 weeks) cohorts based on the timing of rTSA. The univariate 1-year rates of revision and complication and surgery day cost of treatment were assessed. Multivariate logistic regression analysis was conducted, accounting for the factors of age, sex, obesity, diabetes comorbidity, and tobacco use. RESULTS: Four thousand two hundred forty-five (82.6%) acute and 892 (17.4%) delayed primary rTSA patients were identified. Acute rTSA was associated with a higher surgery day cost (acute $15,770 ± $8,383, delayed $14,586 ± $7,271; P < 0.001). Delayed rTSA resulted in a higher 1-year revision rate (acute 1.7%, delayed 4.5%; P < 0.001) and surgical complication rates of dislocation (acute 2.8%, delayed 6.1%; P < 0.001) and mechanical complications (acute 1.9%, delayed 3.4%; P = 0.007). Multivariate analysis identified delayed primary treatment as independently associated with increased risk of revision (odds ratio: 2.29, 95% confidence interval 1.53 to 3.40; P < 0.001) and dislocation (OR: 2.05, 95% confidence interval 1.45 to 2.86; P < 0.001). CONCLUSION: Delayed primary rTSA was associated with higher short-term rates of revision and dislocation compared with acute primary rTSA. Our results suggest that delaying rTSA, whether because of attempted nonsurgical treatment or patients' lack of access, may result in increased complication and additional surgery. LEVEL OF EVIDENCE: Level III.

Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome.

BACKGROUND CONTEXT: Cauda equina syndrome (CES) occurs due to compression of the lumbar and sacral nerve roots and is considered a surgical emergency. Although the condition is relatively rare, the associated morbidity can be devastating to patients. While substantial research has been conducted on the timing of treatment, the literature regarding long-term rates of bladder dysfunction in CES patients is scarce. PURPOSE: The aim of this study was to identify long-term rates of bladder dysfunction in CES patients and to compare those rates to non-CES patients who underwent similar spinal decompression. STUDY DESIGN/SETTING: Retrospective database study. PATIENT SAMPLE: The CES cohort was comprised of 2,362 patients who underwent decompression surgery following CES diagnosis with a 5-year follow-up. These patients were matched to 9,448 non-CES control patients who underwent spinal decompression without a diagnosis of CES. OUTCOME MEASURES: Diagnosis of bladder dysfunction, surgical procedure to address bladder dysfunction METHODS: Using the national insurance claims database, PearlDiver, CES patients who underwent decompression surgery were identified and 1:4 matched to non-CES patients who underwent similar spinal decompression surgery. The 1-year, 3-year, and 5-year rates of progression to a bladder dysfunction diagnosis and surgical intervention to manage bladder dysfunction were recorded. The CES and non-CES groups were compared with univariate testing, and an analysis of risk factors for bladder dysfunction was performed with multivariate logistic regression analysis. RESULTS: A total of 2,362 CES patients who underwent decompression surgery were identified and matched to 9,448 non-CES control patients. After 5 years, CES patients had a 10%-12% increased absolute risk of continued bladder dysfunction and a 0.7%-0.9% increased absolute risk of undergoing a surgical procedure for bladder dysfunction, as compared to matched non-CES patients. Multivariate analysis controlling for age, sex, obesity, tobacco use, and diabetes, identified CES as independently associated with increased 5-year risk for bladder dysfunction diagnosis (odds ratio [OR]: 1.72; 95% confidence interaval [CI] 1.56-1.89; p<.001) and procedure (OR: 1.40; 95% CI 1.07-1.81; p=.012). CONCLUSIONS: Understanding the long-term risk for bladder dysfunction in CES patients is important for the future care and counseling of patients. Compared to non-CES patients who underwent similar spinal decompression, CES patients were observed to have a significantly higher long-term likelihood for both bladder dysfunction diagnosis and urologic surgical procedure.

The Influence of Selective Serotonin Reuptake Inhibitors on Lumbar Arthrodesis.

STUDY DESIGN: Retrospective analysis using the PearlDiver national insurance claims database. OBJECTIVE: To investigate the relationship between chronic preoperative selective serotonin reuptake inhibitor (SSRI) prescriptions and nonunion following spine fusion surgery. SUMMARY OF BACKGROUND DATA: Contemporary literature has linked SSRIs to decreased bone mineral density and increased rates of future bone fracture. Furthermore, a recent murine model has suggested a potential role in the quality of fracture healing itself. METHODS: All single-level lumbar fusion patients were identified. The rate of nonunion diagnosis between 6 and 24 months following surgery was assessed. A stratified analysis of chronic SSRI use and a number of comorbidities was conducted, followed by a multiple logistic regression analysis of nonunion accounting for qualifying risk factors. Finally, subanalyses of individual procedure codes were carried out. RESULTS: In total, 7905 single-level lumbar fusion patients were included. In the multivariate analysis, chronic SSRI [odds ratio (OR): 1.558, P=0.004] and tobacco use (OR: 1.500, P=0.011) were identified as independent risk factors for nonunion, whereas patient age over 60 years (OR: 0.468, P<0.001) was observed to be negatively associated with nonunion. In the individual procedure subanalyses, SSRIs were significantly associated with nonunion in 2 of 3 univariate analyses and observed to be an independent risk factor for nonunion in 2 of the 3 procedure populations. CONCLUSIONS: These data suggest that patients treated concomitantly for mental health disorders with SSRIs before arthrodesis may be at an increased risk of postoperative nonunion. Closer follow-up may be indicated in this patient population.

Comparing Bleeding and Thrombotic Rates in Spine Surgery: An Analysis of 119 888 Patients.

STUDY DESIGN: Retrospective, database review. OBJECTIVES: Examine the utilization rate of postoperative deep vein thrombosis (DVT) prophylaxis and compare the incidence and severity of bleeding and thrombotic complications in elective spine surgery patients. METHODS: We utilized PearlDiver, a national orthopedics claims database. All patients who underwent elective spine surgery from 2007 to 2017 were included. Patients were stratified by the presence of DVT prophylaxis drug codes, then by comorbidities for postoperative bleeding/thrombosis. The severity of all bleeding and thrombotic complications in each cohort was studied, including the incidence of complications requiring operative washout, diagnosis of pulmonary embolism, intensive care unit admission, and mortality. RESULTS: A total of 119 888 patients were included. The majority of patients (118 720, >99%) were not administered postoperative DVT chemoprophylaxis while a minority of patients (1168) were. The overall rates of bleeding and thrombotic complications within the population not receiving DVT prophylaxis were 1.96% and 2.45%, respectively (P < .001). The incidence of surgical intervention for a wound washout was 0.62% compared with 1.05% for pulmonary embolism (P < .001). Intensive care unit admission rates related to a wound washout procedure or pulmonary embolism also significantly differed (0.07% vs 0.34%, P < .001). There were no observed differences in mortality. When controlling for patient comorbidity, patients with atrial fibrillation, cancer, or a prior history of thrombotic complications experienced the greatest increased risks of postoperative thrombosis. CONCLUSIONS: DVT prophylaxis is not routinely utilized following elective spine procedures. We report that there exist specific populations which may receive benefit from these practices, although further study is necessary to determine optimal prevention strategies for both thrombotic and bleeding complications in spine surgery.

Chronic Preoperative Opioids Are Associated With Revision After Rotator Cuff Repair.

PURPOSE: We sought to clarify the relationship between chronic preoperative opioids and complications following rotator cuff repair. Specifically, we assessed revision, a definitive postoperative end point for surgical outcome. METHODS: This study used PearlDiver, a United States national insurance claims database. All patients undergoing rotator cuff repair from 2008 to 2018 were identified and stratified based on a minimum of 2 opioid prescriptions within the 6 months before surgery, with 1 prescription occurring within 0 to 3 months before surgery and a second prescription within 4 to 6 months before surgery. Univariate logistic regressions of risk factors were conducted, followed by multivariate analysis of comorbidities, including ongoing preoperative opioids, any preoperative nonsteroidal anti-inflammatory drug (NSAID) prescriptions, age, sex, diabetes, tobacco, and obesity. RESULTS: In total, 28,939 patients undergoing rotator cuff repair were identified, of whom 10,695 had opioid prescriptions within both 0 to 3 months and 4 to 6 months before index rotator cuff repair, whereas 18,244 had no opioid prescriptions within the 6-month preoperative period. In total, 977 (3.4%) patients underwent revision within 6 months, which increased to 1311 (4.5%) within 1 year of the index procedure. In the multivariate analysis controlling for age, preoperative NSAID prescriptions, tobacco, diabetes, obesity, and sex, we observed a significant association between chronic preoperative opioid prescriptions and rotator cuff repair revision (6-month odds ratio 1.12; P = .021, 1-year odds ratio 1.43; P < .001) following index procedure. CONCLUSIONS: We report increased rates of revision within both 6 months and 1 year in patients with prolonged preoperative opioid prescriptions. The opioid cohort had greater rates of preoperative NSAID use and tobacco use, which also were observed to be independent risk factors for revision at both timepoints. LEVEL OF EVIDENCE: III; Retrospective comparative study.

Do We Need to Wait 3 Months After Corticosteroid Injections to Reduce the Risk of Infection After Total Knee Arthroplasty?

BACKGROUND: Corticosteroid injections administered within 3 months before total knee arthroplasty (TKA) have been linked to increased risk of postoperative infection. However, it would be beneficial to further delineate the timing of injections to determine whether a narrower window exists for safe administration of corticosteroid injections. The purposes of our study were to (1) determine whether there were a different time frame between corticosteroid injection and primary TKA that increased infection risk and (2) determine risk factors associated with infection after TKA. METHODS: TKA patients were identified from a national database from 2007 to 2017 and stratified based on their history of corticosteroid injections within the 6-month preoperative period. Patients who received injections were stratified into biweekly cohorts by the timing of their most recent injection. The 1-year rate of postoperative infection treated by surgical débridement was compared between injection and noninjection cohorts. Univariate logistic regressions of risk factors and a multivariate analysis for patient comorbidities and injection cohorts associated with increased infection risk were conducted. RESULTS: In the 76,090 TKA patients identified, corticosteroid injection within 2 weeks before TKA increased the risk of postoperative infection (P = 0.02) and injections within 2 to 4 weeks trended toward increased infection in univariate regression. No significant differences were observed in any other injection time frames. In the multivariate analysis, injections within 2 weeks before TKA were identified as an independent risk factor (odds ratio: 2.89; P = 0.04) for postoperative infection. Additional risk factors included chronic obstructive pulmonary disease, coronary artery disease, diabetes, ischemic heart disease, obesity, rheumatoid arthritis, and tobacco, whereas female sex and patient aged older than 65 were protective. DISCUSSION: Our results suggest that TKA performed within four weeks of a corticosteroid injection may be associated with a higher risk of postoperative infection; however, delaying surgery more than four weeks may not provide additional infection risk reduction. Further prospective randomized studies are needed to determine the optimal timing of TKA after corticosteroid injections. LEVEL OF EVIDENCE: Level III.

Preoperative lumbar epidural steroid injections administered within 6 weeks of microdiscectomy are associated with increased rates of reoperation.

PURPOSE: Lumbar epidural steroid injections (LESIs) are widely utilized for back pain. However, as studies report adverse effects from these injections, defining a safe interval for their use preoperatively is necessary. We investigated the effects of preoperative LESI timing on the rates of recurrent microdiscectomy. METHODS: This study utilized the PearlDiver national insurance claims database. Microdiscectomy patients were stratified by the timing of their most recent LESI prior to surgery into bimonthly cohorts (0-2 months, 2-4 months, 4-6 months). This first cohort was further stratified into biweekly cohorts (0-2 weeks, 2-4 weeks, 4-6 weeks, 6-8 weeks). The 6-month reoperation rate was assessed and compared between each injection cohort and a control group of patients with no injections within 6 months before surgery. Univariate analyses of reoperation were conducted followed by multivariate analyses controlling for risk factors where appropriate. RESULTS: A total of 12,786 microdiscectomy patients were identified; 1090 (8.52%) received injections within 6 months before surgery. We observed a significant increase in the 6-month reoperation rates in patients who received injections within 6 weeks prior to surgery (odds ratio [OR] 1.900, 1.218-2.963; p = 0.005) compared to control. No other significant differences were observed. DISCUSSION: In this study, microdiscectomy performed within 6 weeks following LESIs was associated with a higher risk of reoperation, while microdiscectomy performed more than 6 weeks from the most recent LESI demonstrated no such association with increased risk. Further research into the interaction between LESIs and recurrent disk herniation is necessary.

The Effects of Chronic Preoperative Opioid Use on Single-level Lumbar Fusion Outcomes.

STUDY DESIGN: A retrospective study using a national insurance claims database. OBJECTIVE: The objective of this study was to assess the relationship between chronic preoperative opioids and the outcomes of revision surgery and nonunion after single-level lumbar fusion. SUMMARY OF BACKGROUND DATA: Opioids are widely utilized for pain management before spine procedures. Studies have associated opioids with unfavorable postoperative outcomes, and animal models have also linked opioid administration with unstable bone healing. METHODS: Single-level lumbar fusion patients were identified. Patients with any fracture history within 1 year before surgery were excluded. A chronic preoperative opioid cohort was defined by opioids prescriptions within 3 months prior and within 4-6 months before surgery. The rates of revision surgery within 6 months and nonunion within 6-24 months after surgery were assessed. Univariate analyses of chronic preoperative opioid prescriptions and various comorbidities for revision and nonunion were conducted followed by multivariate analyses controlling for these factors. Individual analyses were run for each of the 3 single-level lumbar fusion procedures. RESULTS: A total of 8494 single-level lumbar fusion patients were identified. Of the 3929 (46.3%) patients filled criteria for the chronic preoperative opioid cohort, while 3250 (38.3%) patients had no opioid prescriptions within 6 months before surgery. The opioid cohort experienced significantly higher rates of both revisions (3.92% vs. 2.71%, P=0.005) and nonunion (3.84% vs. 2.89%, P=0.027) relative to the opioid-naive cohort. In the multivariate analyses, chronic preoperative opioids were identified as an independent risk factor for revision (odds ratio: 1.453, P=0.006). CONCLUSIONS: We report that chronic opioid prescriptions before lumbar fusion may increase the risk of revision. Although these prescriptions were also associated with increased nonunion, the comparisons did not achieve statistical significance in the multivariate model. Chronic preoperative opioid use may be considered a potential risk factor in arthrodesis populations.

Chronic Opioid Use Is Associated With Surgical Site Infection After Lumbar Fusion.

STUDY DESIGN: Retrospective, database review. OBJECTIVE: The purpose of this study was to explore the association between preoperative opioid use and postoperative infection requiring operative wound washout in elective lumbar fusion patients. SUMMARY OF BACKGROUND DATA: Numerous peer-reviewed publications have conducted multivariate analyses of risk factors for surgical site infection. However, few have explored preoperative opioid use. Opioids have been widely prescribed preoperatively for pain management, but their effect on postsurgical infection is currently inconclusive. METHODS: We retrospectively queried the PearlDiver national insurance claims database and included patients from 2007 to 2017 with a history of lumbar fusion. Any interbody fusion history designated exclusion. We stratified patients by single or multilevel procedures and conducted univariate analyses of previously documented infection risk factors, as well as our variable of interest, chronic preoperative opioid use. Variables associated (P < 0.100) with the outcome measure of 90-day postoperative infection treated with operative irrigation and wound debridement were included in a multivariate analysis. RESULTS: A total of 12,519 patients matched our inclusion criteria. Among the single-level cohort, only diabetes was observed to be associated with infection requiring operative wound washout and thus no subsequent regression was performed. For the cohort of patients who underwent multilevel fusion, chronic opioid use, diabetes, congestive heart failure, chronic obstructive pulmonary disease, and hypertension trended toward significance in the univariate analysis and were included in a logistic regression model. In the multivariate analysis, chronic opioid use (odds ratio [OR] = 1.435, P = 0.025), diabetes (OR = 1.591 P = 0.003), and congestive heart failure (OR = 1.929, P = 0.003) were identified as independent risk factors for infection requiring operative wound washout. CONCLUSION: In this analysis, preoperative opioid use was significantly associated with infection requiring operative wound washout in multilevel lumbar fusion patients. Limiting opioid consumption may have the benefit of reducing the risk of infection following spine surgery. LEVEL OF EVIDENCE: 3.

Preoperative corticosteroid joint injections within 2 weeks of shoulder arthroscopies increase postoperative infection risk.

BACKGROUND: There is currently no consensus regarding the safe timing interval between corticosteroid shoulder injections and future shoulder arthroscopies. Our study assessed the relationship between preoperative corticosteroid injection timing and shoulder arthroscopy infectious outcomes. METHODS: We used an insurance database to identify and sort all shoulder arthroscopy patients by corticosteroid shoulder injection history within 6 months before surgery. Patients who received injections were stratified by the timing of their most recent preoperative injection. The overall infection rate and rate of severe infections requiring treatment through intravenous antibiotics or surgical débridement in the 6-month postoperative period were compared using χ2 tests between the injection cohorts and a control group of patients defined as those with no injection history. RESULTS: We identified 50,478 shoulder arthroscopy patients, of whom 4115 received injections in the 6-month preoperative period. We found a significant increase in both the overall infection rate (P < .0001) and severe infection rate (P < .0001) in patients who received injections within 2 weeks before surgery (n = 79; 8.86% and 6.33%, respectively) compared with those who received no injections in the 6-month preoperative period (n = 46,363; 1.56% and 0.55%, respectively). No other significant differences were observed. CONCLUSIONS: Our results suggest that in patients who have received corticosteroid injections, shoulder arthroscopic procedures may be safely performed after at least 2 weeks has passed since the most recent injection to minimize the risk of postoperative infection. In addition, procedures performed within 2 weeks of an injection may increase the risk of postoperative infection.

Common TMPRSS6 mutations and iron, erythrocyte, and pica phenotypes in 48 women with iron deficiency or depletion.

BACKGROUND: TMPRSS6 A736V is associated with lower transferrin saturation (TS), hemoglobin (Hb), and mean corpuscular volume (MCV) levels in general adult populations. We sought to identify relationships of TMPRSS6 K253E, A736V, and Y739Y to iron, erythrocyte, and pica phenotypes in women with iron deficiency or depletion. METHODS: We tabulated observations on 48 outpatient non-pregnant women who had iron deficiency (serum ferritin (SF) <14pmol/L and TS <10%) or iron depletion (SF<112pmol/L). We performed direct sequencing of TMPRSS6 exons 7 and 17 in each patient. We used age, TS, SF, Hb, MCV, pica, and TMPRSS6 allele positivity (dichotomous) or mutation genotypes (trichotomous) as variables for analyses. RESULTS: Forty-six women were white; two were black. 58.3% had iron deficiency. 45.8% had pica (pagophagia, each case). Allele frequencies were 41.7% (K253E), 36.5% (A736V), and 39.6% (Y739Y). K253E frequency was greater in women with TS ≥10% (p=0.0001). Y739Y was more frequent in women with TS <10% (p=0.0135). Mean TS was also lower in women positive for Y739Y (6±4% vs. 13±16%, respectively; p=0.0021). In multiple regressions, neither K253E, A736V, nor Y739Y genotypes were significantly associated with other variables. CONCLUSIONS: TMPRSS6 K253E frequency was greater in women with TS ≥10%. Frequency of Y739 was greater in women with TS <10%. Mean TS was lower in women with Y739Y. We observed no other significant relationship of TMPRSS6 K253E, A736V, or Y739Y with iron, erythrocyte, or pica phenotypes.