Association Between Delays in Radiography and Surgery With Hip Fracture Outcomes in Elderly Patients.

Appropriate waiting time for hip fracture surgery is disputed. The American Academy of Orthopaedic Surgeons recommends surgery within 48 hours of presentation, although evidence suggests that earlier surgery (within 24 hours) reduces the risks of complications and death. The authors asked: (1) Do patients who receive earlier radiographic evaluation of hip fracture undergo surgery earlier? and (2) Is "surgery delay" (time from presentation to surgery) associated with postoperative opioid use, duration of hospital stay, and 30-day and 1-year mortality rates? The authors identified 511 adults 60 years or older who were admitted to their emergency department with hip fractures from 2015 through 2017. Patients were divided into 6 cohorts according to length of surgery delay and 3 cohorts according to length of radiography delay (time from presentation to first hip radiograph). The authors found that medium radiography delay (>2 to 4 hours) was associated with an additional 11 hours of surgery delay compared with short radiography delay (≤2 hours; P=.026). Longer surgery delay (>12 hours) was associated with use of 9.6 more morphine equivalents (95% confidence interval, 0.7 to 8.6) during the first 24 hours postoperatively compared with shorter surgery delay (≤12 hours). Surgery delay of greater than 36 hours was an independent risk factor for longer hospital stay (odds ratio, 2.8; 95% confidence interval, 1.7 to 4.8). Thirty-day and 1-year mortality rates were significantly higher among patients who experienced a surgery delay of greater than 36 hours compared with those who experienced a surgery delay of 36 hours or less. [Orthopedics. 2020;43(6):e609-e615.].

Anchorless Arthroscopic Transosseous and Anchored Arthroscopic Transosseous Equivalent Rotator Cuff Repair Show No Differences in Structural Integrity or Patient-reported Outcomes in a Matched Cohort.

BACKGROUND: Anchored transosseous equivalent suture-bridge technique (TOE) is widely used for arthroscopic rotator cuff repair. It is unknown how patient outcomes scores, ROM, and integrity of the rotator cuff after repair using this anchored technique compare with those after repair using an anchorless transosseous technique (TO). QUESTIONS/PURPOSES: (1) What are the differences in patient-reported outcomes (American Shoulder and Elbow Surgeons [ASES] score) and shoulder ROM between TO and TOE rotator cuff repair techniques at 1 and 2 years after surgery? (2) What is the difference in repair integrity as measured by the re-tear rate, assessed ultrasonographically at 1 year, between these two techniques? (3) What is the difference in procedure duration between the two techniques when performed by a surgeon familiar with each? METHODS: We reviewed 331 arthroscopic rotator cuff repairs performed by one surgeon from December 2011 to July 2016 in this retrospective, matched-pair study. Of these patients, 63% (208 of 331) underwent repair with standard anchored technique (anchors placed in a double-row, TOE manner) and 37% (123 of 331) underwent anchorless TO repair, with the same indications for surgery between groups. Forty-four percent (91 of 208) of patients in the TOE group and 61% (75 of 123) of patients in the TO group met the inclusion criteria. Eighty percent (73 of 91) of patients in the TOE group and 88% (66 of 75) in the TO group had minimum 2-year follow-up. We matched each group to a cohort of 50 patients by sex, age, smoking status, and tear size (by Cofield classification: small, < 1 cm; medium, 1-3 cm; large, > 3-5 cm; or massive, > 5 cm). The resulting cohorts did not differ in mean age (TO, 62 years [range 53-65 years]; TOE, 58 years [range 53-65 years]; p = 0.79), mean BMI value (TO, 30 [range 27-33]; TOE, 29 [range 27-35]; p = 0.97), or dominant arm involvement (TO, 80%; TOE, 78%; p = 0.81). The cohorts were followed for at least 2 years (median, 3.2 years [interquartile range (IQR) 2.2-4.3] for TO and 2.9 years [IQR 2.0-3.5 years] for TOE). ASES scores and ROM were evaluated before surgery and at follow-up visits and were recorded in a longitudinally maintained institutional database. Repair integrity was assessed using ultrasonography at 1 year, as is standard in our practice. For each tear-size group, we calculated the proportion of intact tendon repairs versus the proportion of re-tears. Duration of surgery was recorded for each patient. RESULTS: At 1 year, we observed no difference in median ASES scores (90 [IQR 92-98] for TO and 88 [IQR 72-98] for TOE; p = 0.44); external rotation (50° [IQR 45°-60°) for TO and 50° [IQR: 40°-60°] for TOE; p = 0.58); forward flexion (165° [IQR 160°-170°] for both groups; p = 0.91); or abduction (100° [IQR 90°-100°] for TO and 90° [IQR 90°-100°] for TOE; p = 0.06). Fourteen percent of shoulders (seven of 50) in each treatment group had evidence of re-tear at 1 year (p > 0.99): 0 of 2 small tears in each group, 0 of 7 medium tears in each group, five of 32 large tears in each group, and two of 9 massive tears in each group (all, p > 0.99). At 2 years, we found no differences in median ASES scores (92 [IQR 74-98)] for TO and 90 [IQR 80-100] for TOE; p = 0.84); external rotation (60° [IQR 50°-60°] for both groups; p = 0.74); forward flexion (170° [IQR 160°-170°] for both groups; p = 0.69); or abduction (100° [IQR 90°-100°] for both groups; p = 0.95). We found no differences between groups in mean ± SD procedure time, which was 103 ± 20 minutes for TO repair and 99 ± 20 minutes for TOE repair (p = 0.45). CONCLUSIONS: TO and TOE techniques for arthroscopic rotator cuff repair results in no differences in ROM, ASES scores, re-tear rates, and surgical time. Randomized control trials are needed to confirm these similarities or determine a superior method of repair. Future cost analyses may also help to determine the relative value of each technique. LEVEL OF EVIDENCE: Level III, therapeutic study.

Single Assessment Numeric Evaluation scores correlate positively with American Shoulder and Elbow Surgeons scores postoperatively in patients undergoing rotator cuff repair.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) shoulder score and the Single Assessment Numeric Evaluation (SANE) measure shoulder function. Relative to the ASES questionnaire, the SANE questionnaire is shorter and easier to score. We sought to determine (1) the correlation between ASES and SANE scores preoperatively and at 2 years postoperatively in patients undergoing rotator cuff repair (RCR) or shoulder arthroplasty and (2) the correlation between the change in ASES scores and change in SANE scores. METHODS: We reviewed the records of 107 patients who underwent RCR (n = 74) or shoulder arthroplasty (n = 33), which included patients undergoing total shoulder arthroplasty (n = 18) and reverse total shoulder arthroplasty (n = 15), at our institution from 2014 to 2015 and who completed the ASES and SANE questionnaires preoperatively and at least 2 years postoperatively. Pearson correlation coefficients were calculated to determine the relationship between SANE and ASES scores in RCR patients and arthroplasty patients (both total shoulder arthroplasty and reverse total shoulder arthroplasty) at each time point. RESULTS: In the RCR group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.30) and strongly positive postoperatively (r = 0.86). In the arthroplasty group, correlations between SANE and ASES scores were moderately positive preoperatively (r = 0.46) and strongly positive postoperatively (r = 0.78). CONCLUSION: SANE scores correlate positively with ASES scores postoperatively in patients undergoing RCR. Therefore, SANE scores, together with clinician-based and combination scores, can be used to assess postoperative shoulder function in these patients.

Racial Disparities are Present in the Timing of Radiographic Assessment and Surgical Treatment of Hip Fractures.

BACKGROUND: Hip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care. QUESTIONS/PURPOSES: Our purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest? METHODS: We retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest. RESULTS: After adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates. CONCLUSIONS: After adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay. LEVEL OF EVIDENCE: Level III, therapeutic study.

Liposomal Bupivacaine vs Interscalene Nerve Block for Pain Control After Shoulder Arthroplasty: A Retrospective Cohort Analysis.

The aim of this study was to compare liposomal bupivacaine and interscalene nerve block (ISNB) for analgesia after shoulder arthroplasty. We compared 37 patients who received liposomal bupivacaine vs 21 who received ISNB after shoulder arthroplasty by length of hospital stay (LOS), opioid consumption, and postoperative pain. Pain was the same in both groups for time intervals of 1 hour and 8 to 14 hours postoperatively. Compared with ISNB patients, liposomal bupivacaine patients reported less pain at 18 to 24 hours (P = .001) and 27 to 36 hours (P = .029) and had lower opioid consumption on postoperative days 2 (P = .001) and 3 (P = .002). Mean LOS for liposomal bupivacaine patients was 46 ± 20 hours vs 57 ± 14 hours for ISNB patients (P = .012). Sixteen of 37 liposomal bupivacaine patients vs 2 of 21 ISNB patients were discharged on the first postoperative day (P = .010). Liposomal bupivacaine was associated with less pain, less opioid consumption, and shorter hospital stays after shoulder arthroplasty compared with ISNB.