Delayed elective total shoulder arthroplasty: causes and eventual outcomes.

PURPOSE: The purpose of this study is to identify risk factors for delays in planned total shoulder arthroplasty (TSA) and determine the perioperative outcomes of TSAs that experienced a delay. METHODS: The American College of Surgeons National Quality Improvement Program (NSQIP) database was queried from 2006 to 2019 for primary TSA. Delayed TSA was defined as surgery that occurred greater than one day after hospital admission. Patient demographics, comorbidities, and post-operative complications were collected and compared; the incidence of delayed TSA was analyzed. RESULTS: The delayed patients were older, had a higher BMI, a higher rate of recent prior major surgery, and more comorbidities. Delayed patients had higher rates of postoperative complications, return to the OR, and 30-day readmission. Between 2006 and 2019, the rate of delayed TSA decreased. CONCLUSION: Surgeons should take care to ensure that patients with comorbidities undergo thorough preoperative clearance to prevent same-day cancellations and postoperative complications.

Impact of opioid dependence on outcomes following total shoulder arthroplasty.

INTRODUCTION: The opioid epidemic is a well-established problem encountered in orthopedic surgery in the United States. Evidence in lower extremity total joint arthroplasty and spine surgery suggests a link between chronic opioid use and increased expense and rates of surgical complications. The purpose of this study was to study the impact of opioid dependence (OD) on the short-term outcomes following primary total shoulder arthroplasty (TSA). METHODS: A total of 58,975 patients undergoing primary anatomic and reverse TSA were identified using the National Readmission Database from 2015 to 2019. Preoperative opioid dependence status was used to divide patients into 2 cohorts, with 2089 patients being chronic opioid users or having opioid use disorders. Preoperative demographic and comorbidity data, postoperative outcomes, cost of admission, total hospital length of stay (LOS), and discharge status were compared between the 2 groups. Multivariate analysis was conducted to control for the influence of independent risk factors other than OD on postoperative outcomes. RESULTS: Compared to nonopioid-dependent patients, OD patients undergoing TSA had higher odds of postoperative complications including any complications within 180 days (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.7), readmission within 180 days (OR 1.2, 95% CI 1.1-1.5), revision within 180 days (OR 1.7, 95% CI 1.4-2.1), dislocation (OR 1.9, 95% CI 1.3-2.9), bleeding (OR 3.7, 95% CI 1.5-9.4), and gastrointestinal complication (OR 14, 95% CI 4.3-48). Total cost ($20,741 vs. $19,643), LOS (1.8 ± 1.8 days vs. 1.6 ± 1.7 days), and likelihood for discharge to another facility or home with home health care (18 vs. 16% and 23% vs. 21%, respectively) were higher in patients with OD. CONCLUSION: Preoperative opioid dependence was associated with higher odds of postoperative complications, rates of readmission and revision, costs, and health care utilization following TSA. Efforts focused on mitigating this modifiable behavioral risk factor may lead to better outcomes, lower complications, and decreased associated costs.

How using body mass index cutoffs to determine eligibility for total shoulder arthroplasty affects health care disparities.

BACKGROUND: The prevalence of obesity in the United States is continuously rising and is associated with increased morbidity, mortality, and health care costs. Body mass index (BMI) has been used as a risk stratification and counseling tool for patients undergoing total joint arthroplasty in an effort to focus on outcome-driven care. Although the use of BMI cutoffs may have benefits in minimizing complications when selecting patients for total shoulder arthroplasty (TSA), it may impact access to care for some patient populations and further increase disparities. The purpose of this study is to determine the implications of using BMI cutoffs on the eligibility for TSA among different ethnic and gender patient populations. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify 20,872 patients who underwent anatomic and reverse TSA between 2015 and 2019. Patient demographics, including age, sex, race and ethnicity, and BMI, were compared between eligible and ineligible patients based on BMI for 5 cutoff values: 30, 35, 40, 45, and 50 kg/m2. RESULTS: Of the total patient population studied, the mean age was 69 years, 55% were female, and the mean BMI was 31 kg/m2. For all BMI subgroups, there were more ineligible than eligible patients who were female or Black (P < .001). The relative rate of eligibility for Black patients was lower in each BMI cutoff group, whereas the relative rate of eligibility for White and Asian patients was higher for each group. There were more eligible than ineligible Asian patients for BMI cutoffs of 30 and 35 kg/m2 (both P < .001), and there were no differences in eligibility and ineligibility in Hispanic patients (P > .05). Furthermore, White patients were more eligible than ineligible for all BMI cutoff groups (P < .001). CONCLUSIONS: Enforcing BMI cutoffs for access to TSA may limit the procedure for female or Black patients for all BMI cutoffs, thus furthering the health care disparities these populations already face. However, there are more eligible than ineligible White patients for all BMI cutoff groups, which indicates a disparity in the access to TSA based on sex and race. Physicians may inadvertently increase health care disparities observed in TSA if they use BMI as the sole risk stratification tool for patients, even though BMI has been known to increase complications after TSA. Moreover, orthopedic surgeons should only use BMI as one of many factors in a more holistic process when determining if a patient should undergo TSA.

Surgical Construct Type Is Associated With Time to Fusion and Reoperation Rate in Double and Isolated Talonavicular Arthrodeses.

BACKGROUND: This study evaluates the effect of surgical construct on postoperative outcomes in patients undergoing isolated talonavicular (TN) or double (TN and subtalar ST) arthrodesis. TN constructs included plate and screw, screw and staple, and isolated staple constructs. Subtalar constructs included 1- and 2-screw constructs. METHODS: Retrospective chart review identified 52 patients who underwent double or isolated TN arthrodesis between 2016 and 2021 by a single fellowship-trained foot and ankle surgeon with minimum 6 months of follow-up (mean = 1.62 years, range = 0.50-4.39 years). Data collected included demographics, medical history, surgical indication, surgical constructs used, complications, reoperations, patient-reported outcome measures, and radiographic measures. RESULTS: Overall complication and reoperation rates were 26.3% and 12.3%, respectively. Among TN constructs, time to ST (P = .026) and TN (P = .018) fusion was significantly slower among patients receiving a plate and screw construct. Complication rate did not differ, but reoperation rate was significantly higher for plate and screw TN constructs (P = .039). Postoperative Foot and Ankle Outcome Score (FAOS) Quality of Life (P = .028) and Total (P = .016) scores were significantly better among plate and screw TN constructs. CONCLUSION: Utilization of screw and staple or isolated staple construct have significantly quicker time to fusion and lower reoperation rates than plate and screw constructs for the TN joint. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Preoperative Hypoalbuminemia Not Associated With Total Ankle Arthroplasty Outcomes.

BACKGROUND: This study aims to investigate the effect of hypoalbuminemia on the rates of 30-day complication, readmission, and reoperation following total ankle arthroplasty (TAA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2007 to 2019 to identify 710 TAA patients. Patients were then stratified into normal (n = 673) or low (n = 37) albumin groups. Demographics, medical comorbidities, concomitant procedures, hospital length of stay, and 30-day complication, readmission, and reoperation rates were compared between groups. Preoperative serum albumin level was also used as a continuous variable when analyzing postoperative outcomes. RESULTS: The overall cohort was predominantly male (51.5%), and the mean age was 65.02 (range, 45-87) years. We found there to be no statistically significant difference in demographics between cohorts. However, hypoalbuminemia patients were significantly more likely to use long-term steroids for a chronic condition (normal = 6.1%, low = 18.9%; P = .009). Additionally, there was no difference in 30-day complication (normal = 3.0%, low = 0.0%; P = .618), readmission (normal = 2.4%, low = 0.0%; P = .632), and reoperation (normal = 1.0%, low = 0.0%; P = 1.000) rates between groups. CONCLUSION: The results of this study show that malnourished patients are not at an increased risk of 30-day complication, readmission, or reoperation following TAA despite having a worse preoperative comorbidity profile. LEVEL OF EVIDENCE: Level III, Retrospective cohort study.

Low Preoperative Albumin Associated With Increased Risk of Superficial Surgical Site Infection Following Midfoot, Hindfoot, and Ankle Fusion.

BACKGROUND: This study investigates the effect of malnutrition, defined by hypoalbuminemia, on rates of complication, readmission, reoperation, and mortality following midfoot, hindfoot, or ankle fusion. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2019 to identify 500 patients who underwent midfoot (n = 233), hindfoot (n = 261), or ankle (n = 117) fusion. Patients were stratified into normal (n = 452) or low (n = 48) albumin group, which was defined by preoperative serum albumin level <3.5 g/dL. Demographics, medical comorbidities, hospital length of stay (LOS), and 30-day complication, readmission, and reoperation rates were compared between groups. The mean age of the cohort was 58.7 (range, 21-89) years. RESULTS: Hypoalbuminemia patients were significantly more likely to have diabetes (P < .001), be on dialysis (P < .001), and be functionally dependent (P < .001). The LOS was significantly greater among the low albumin group (P < .001). The hypoalbuminemia cohort also exhibited a significantly increased likelihood of superficial infection (P = .048). Readmission (P = .389) and reoperation (P = .611) rates did not differ between the groups. CONCLUSION: This study shows that malnourished patients have an increased risk of superficial infection following foot and ankle fusions but are not at an increased risk of readmission or reoperation, suggesting that low albumin confers an elevated risk of surgical site infection. LEVELS OF EVIDENCE: Level III, Retrospective cohort study.

Patient outcomes after revision total shoulder arthroplasty in an inpatient vs. outpatient setting.

BACKGROUND: Total shoulder arthroplasty (TSA) is becoming an increasingly common surgical procedure for numerous shoulder conditions. The incidence of revision TSA is increasing because of the increase in primary TSA and the increased utilization of TSA in younger patients. Conducting revision TSA as an outpatient procedure would be beneficial in limiting expenditure and resource allocation but must show a similar complication profile compared to inpatient revision TSA in order to justify its clinical value. The purpose of this study is to compare the outcomes of outpatient revision TSA to inpatient revision TSA and outpatient primary TSA. METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify all patients who underwent revision TSA (n = 1456) in either an inpatient or outpatient setting, as well as patients who underwent primary TSA in an outpatient setting (n = 2630). Relevant demographic characteristics were compared between the outpatient revision group and both the inpatient revision and outpatient primary groups. Postoperative complications, readmission, and reoperation rates were also compared between the groups. RESULTS: Patients undergoing inpatient revision TSA exhibited increased rates of preoperative hypertension (P = .013) and had increased prevalence of severe American Society of Anesthesiologists classification (P = .021) compared to patients undergoing outpatient revision TSA. Patients undergoing outpatient revision TSA were significantly more likely to experience complications (P < .001), have longer surgical times (P < .001), and undergo readmission (P = .006) and reoperation (P = .049) compared to patients undergoing outpatient primary TSA. There was no significant increase in rates of overall complication, readmission, or reoperation between patients undergoing revision TSA in an outpatient vs. an inpatient setting. CONCLUSION: Outpatient revision TSA has higher complication rates, readmission, and reoperation rates compared to outpatient primary TSA, similar to previous findings when comparing revision and primary TSA done as an inpatient. However, there was no increased risk of complications, readmission, or reoperation for outpatient revision TSA compared to inpatient revision TSA. Outpatient revision TSA should be considered by orthopedic surgeons in patients who are medically healthy to undergo the procedure as an outpatient surgery.