Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute submassive pulmonary embolism: a propensity-matched analysis.

PURPOSE: To determine if mechanical thrombectomy (MT) for submassive pulmonary embolism (PE) positively impacts length of hospital stay (LOS), intensive care unit stay (ICU LOS), readmission rate, and in-hospital mortality compared with conservative therapy. METHODS: This was a retrospective review of all patients with submassive PE who either underwent MT or conservative therapy (systemic anticoagulation and/or inferior vena cava filter) between November 2019 and October 2021. Pediatric patients (age <18) and those with low-risk and massive PEs were excluded from the study. Patient characteristics, comorbidities, vitals, laboratory values (cardiac biomarkers, hospital course, readmission rates, and in-hospital mortality) were recorded. A 2:1 propensity score match was performed on the conservative and MT cohorts based on age and the PE severity index (PESI) classification. Fischer's exact test, Pearson's χ2 test, and Student's t-tests were used to compare patient demographics, comorbidities, LOS, ICU LOS, readmission rates, and mortality rates, with statistical significance defined as P < 0.05. Additionally, a subgroup analysis based on PESI scores was assessed. RESULTS: After matching, 123 patients were analyzed in the study, 41 in the MT cohort and 82 in the conservative therapy cohort. There was no significant difference in patient demographics, comorbidities, or PESI classification between the cohorts, except for increased incidence of obesity in the MT cohort (P = 0.013). Patients in the MT cohort had a significantly shorter LOS compared with the conservative therapy cohort (5.37 ± 3.93 vs. 7.76 ± 9.53 days, P = 0.028). However, ICU LOS was not significantly different between the cohorts (2.34 ± 2.25 vs. 3.33 ± 4.49, P = 0.059). There was no significant difference for in-hospital mortality (7.31% vs. 12.2%, P = 0.411). Of those that were discharged from the hospital, there was significantly lower incidence of 30-day readmission in the MT cohort (5.26% vs. 26.4%, P < 0.001). A subgroup analysis did not demonstrate that the PESI score had a significant impact on LOS, ICU LOS, readmission, or in-hospital mortality rates. CONCLUSION: MT for submassive PE can reduce the total LOS and 30-day readmission rates compared with conservative therapy. However, in-hospital mortality and ICU LOS were not significantly different between the two groups.

Urinoma formation following renal mass cryoablation treated with nephroureteral stent placement.

Renal cryoablation (CA) has become an accepted treatment option for patients with small renal tumors and co-morbidities that make them less favorable for surgical intervention. Complications from renal CA have been previously reported and are generally associated with increasing size and central location of the tumor. Ureteral injury from renal CA, although rare, can be difficult to manage and may require complex surgeries in patients who are poor surgical candidates to begin with. We report a case of a renal mass CA complicated by proximal ureteral necrosis and transection, treated with multiple minimally invasive procedures ultimately resulting in successful bridging of the necrotic segment with nephroureteral stent and thus avoiding major surgery.

Outcomes Following Primary Anterior Cruciate Ligament Reconstruction Using a Partial Transphyseal (Over-the-Top) Technique in Skeletally Immature Patients.

Background: The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is increasing, with ACL reconstruction preferred in this population due to reported chondroprotective benefits. Due to concerns with growth disturbance following ACL reconstruction in skeletally immature patients, various physealsparing and partial transphyseal techniques have been developed. Currently, there is no consensus on the most effective ACL reconstruction technique in skeletally immature patients. The purpose of the current study was to report the outcomes of a partial-transphyseal over-the-top (OTT) ACL reconstruction in a cohort of skeletally immature patients. Methods: All patients with radiographic evidence of open tibial and femoral physes that underwent primary ACL reconstruction using a partial-transphyseal OTT technique between 2009-2018 at a single tertiary-care institution with at least twelve months of clinical follow-up were retrospectively reviewed. Patient demographics, physical examination findings, graft ruptures, return to sport, and Tegner activity levels were analyzed. Statistical significance was defined as p<0.05. Results: Overall, 11 males and 1 female (12 knees) with a mean age of 12.8±1.8 (range: 10-16) years were included in the study. The mean postoperative follow-up of the cohort was 2.3±1.2 (range: 1.1-5.2) years. All ACLs were reconstructed with hamstring autograft with allograft augmentation utilized in a single patient. There were two cases of ACL graft rupture (16.7%). All patients were able to return to the same or higher level of sporting activity at an average of 7.4+2.7 months. There were no cases of clinically significant longitudinal or angular growth disturbance. Conclusion: Partial transphyseal ACL reconstruction using a transphyseal tibial tunnel and an extra-articular OTT technique on the femur in skeletally immature patients affords minimal risk of growth disturbance with a graft rupture rate consistent with what has been reported in this high-risk population. All patients were able to return to sport at the same or higher level. Level of Evidence: IV.

Utilization of Arthroscopy During Ankle Fracture Fixation Among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part II Oral Examination Database.

Background: Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra-articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization. Methods: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination database was queried to identify all candidates performing at least one ankle fracture ORIF from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy. Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05. Results: During the study period, there were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained ABOS Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeons (293/6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to arthroscopic cases, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151). Conclusion: Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend. Level of Evidence: IV.

Gastroduodenal artery embolization for peptic ulcer hemorrhage refractory to endoscopic intervention: A single-center experience.

Objective: To determine the efficacy of gastroduodenal artery embolization (GDAE) for bleeding peptic ulcers that failed endoscopic intervention. To identify incidence and risk factors for failure of GDAE. Materials and Methods: A retrospective review of patients who underwent GDAE for hemorrhage from peptic ulcer disease refractory to endoscopic intervention were included in the study. Refractory to endoscopic intervention was defined as persistent hemorrhage following at least two separate endoscopic sessions with two different endoscopic techniques (thermal, injection, or mechanical) or one endoscopic session with the use of two different techniques. Demographics, comorbidities, endoscopic and angiographic findings, significant post-embolization pRBC transfusion, and index GDAE failure were collected. Failure of index GDAE was defined as the need for re-intervention (repeat embolization, endoscopy, or surgery) for rebleeding or mortality within 30 days after GDAE. Multivariate analyzes were performed to identify independent predictors for failure of index GDAE. Results: There were 70 patients that underwent GDAE after endoscopic intervention for bleeding peptic ulcers with a technical success rate of 100%. Failure of index GDAE rate was 23% (n = 16). Multivariate analysis identified ≥2 comorbidities (odds ratio [OR]: 14.2 [1.68-19.2], P = 0.023), days between endoscopy and GDAE (OR: 1.43 [1.11-2.27], P = 0.028), and extravasation during angiography (OR: 6.71 [1.16-47.4], P = 0.039) as independent predictors of index GDAE failure. Endoscopic Forrest classification was not a significant predictor for the failure of index GDAE (P > 0.1). Conclusion: The study demonstrates safety and efficacy of GDAE for hemorrhage from PUD that is refractory to endoscopic intervention. Days between endoscopy and GDAE, high comorbidity burden, and extravasation during angiography are associated with increased risk for failure of index GDAE.

Incidence and risk factors for symptomatic venous thromboembolism following anterior cruciate ligament reconstruction.

PURPOSE: To determine the incidence of symptomatic venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction using a large national database and to identify corresponding independent risk factors. METHODS: The Humana administrative claims database was reviewed for patients undergoing ACL reconstruction from 2007 to 2017. Patient demographics, medical comorbidities, as well as concurrent procedures were recorded. Postoperative incidence of VTE was measured by identifying symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) at 30 days, 90 days, and 1 year postoperatively. Univariate analysis and binary logistic regression were performed to determine independent risk factors for VTE following surgery. RESULTS: A total of 11,977 patients were included in the study. The incidence of VTE was 1.01% (n = 120) and 1.22% (n = 146) at 30 and 90 days, respectively. Analysis of VTE events within the first postoperative year revealed that 69.6% and 84.3% of VTEs occurred within 30 and 90 days of surgery, respectively. Logistic regression identified age ≥ 45 (odds ratio [OR] = 1.88; 95% confidence interval [CI] 1.32-2.68; p < 0.001), inpatient surgery (OR = 2.07; 95% CI 1.01-4.24; p = 0.045), COPD (OR = 1.51; 95% CI 1.02-2.24; p = 0.041), and tobacco use (OR = 1.75; 95% CI 1.17-2.62; p = 0.007), as well as concurrent PCL reconstruction (OR = 3.85; 95% CI 1.71-8.67; p = 0.001), meniscal transplant (OR = 17.68; 95% CI 3.63-85.97; p < 0.001) or osteochondral allograft (OR = 15.73; 95% CI 1.79-138.43; p = 0.013) as independent risk factors for VTE after ACL reconstruction. CONCLUSIONS: The incidence of symptomatic postoperative VTE is low following ACL reconstruction, with the majority of cases occurring within 90 days of surgery. Risk factors include age ≥ 45, inpatient surgery, COPD, tobacco use and concurrent PCL reconstruction, meniscal transplant or osteochondral allograft. LEVEL OF EVIDENCE: III.

Resident Participation During Revision Total Knee Arthroplasty Is Not Associated With Increased Risk of 30-Day Postoperative Complication.

Background: Academic teaching institutions perform approximately one third of all orthopedic procedures in the United States. Revision total knee arthroplasty (rTKA) is a complex and challenging procedure that requires expertise and extensive planning, however the impact of resident involvement on outcomes is poorly understood. The aim of the study was to investigate whether resident involvement in rTKA impacts postoperative complication rates, operative time, and length of hospital stay (LOS). Methods: The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent rTKA procedures from 2006-2012 using CPT codes 27486 and 27487. Cases were classified as resident involved or attending only. Demographics, comorbidities, and 30-day postoperative complications were analyzed. Multiple logistic regression analysis was performed to identify independent risk factors for increased 30-day postoperative complications. Wilcoxon rank sum tests were performed to determine the impact of resident involvement on operative time and LOS with significance defined as p<0.05. Results: In total, 2,396 cases of rTKA were identified, of which 972 (40.6%) involved residents. The two study groups were similar, however the resident involved cohort had more patients with hypertension and ASA class 3 (p=0.02, p=0.04). There was no difference in complications between the cohorts (No Resident vs Resident-involved: 7.0% vs 6.7%, p=0.80). Multivariate analysis identified obesity (OR: 1.81, 95% CI: 1.18-2.79, p=0.01), morbid obesity (OR: 1.66, 95% CI: 1.09-2.57, p=0.02), congestive heart failure (OR: 5.97, 95% CI: 1.19-24.7, p=0.02), and chronic prosthetic joint infection (OR: 3.16, 95% CI: 2.184.56, p<0.01), as independent risk factors for 30-day complications after rTKA. However, resident involvement was not associated with complications within 30-days following rTKA (OR: 0.91, 95% CI: 0.65-1.26, p=0.57). Resident involvement was associated with increased operative time (p<0.001) and LOS (P<0.001). Conclusion: Resident involvement in rTKA cases is not associated with an increased risk of 30-day postoperative complications. However, resident operative involvement was associated with longer operative time and length of hospital stay. Level of Evidence: III.

Utilization of Physical Therapy Prior to Consultation for Hip Preservation Surgery.

Background: Comprehensive conservative care prior to arthroscopic hip surgery is recommended, but not all patients pursue a course of physical therapy (PT) prior to consulting a hip surgeon. The purpose of this study is to investigate the incidence and type of PT administered to patients with hip pain prior to consulting a hip surgeon. Methods: We conducted a single-center, questionnaire-driven study at a young adult hip preservation clinic that exclusively treats patients with hip pain. Thirty (88%) of thirty-four consecutive new patients answered the 15-item questionnaire. The questionnaire was designed to inquire about the reason for the visit, type of formal PT received (hip strengthening, leg strengthening etc.), and additional treatments received prior to the visit (electric stimulation, narcotics etc.). Descriptive statistics were utilized to quantify the reason for visit, PT prior to the visit, and type of exercises performed during physical therapy. Results: Overall, 21 (70%) patients received physical therapy prior to consulting with a hip surgeon. Of those who received PT, 91% (n=19) did hip strengthening exercises, 76% (n=16) did focused hip stretching exercises, 62% (n=13) did leg strengthening exercises, 57% (n=12) did joint mobilization exercises, and 52% (n=11) did focused core strengthening exercises. Only 48% (n=10) reported improvement in symptoms with PT. Of those who received additional treatments, 77% (n=20) took anti-inflammatory medications regularly, 50% (n=13) underwent electric stimulation, 31% (n=8) had chiropractic manipulation, 19% (n=5) underwent soft tissue mobilization, 15% (n=4) received steroid injections, and 12% (n=3) were prescribed narcotics for hip pain. Conclusion: The present study offers insight into the incidence and type of formal PT patients with hip pain receive before consulting a hip surgeon. Treatment methods during PT visits are variable, which makes determining outcomes of conservative care difficult to assess in this population.Level of Evidence: IV.

Hip Arthroscopy Prior to Periacetabular Osteotomy Does Not Increase Operative Time or Complications: A Single Center Experience.

BACKGROUND: Periacetabular osteotomy (PAO) is a well-established procedure to improve function and reduce pain in the non-arthritic dysplastic hip. PAO and hip arthroscopy are often performed together; however, there is concern that hip arthroscopy increases difficulty of PAO due to arthroscopic fluid extravasation. The purpose of the current study was to examine the effect of performing hip arthroscopy prior to PAO under the same anesthetic on PAO operative time and postoperative complications. METHODS: A retrospective review of all PAO cases during a two-year period at a single academic institution was performed. Cases were stratified into two groups based on whether concomitant hip arthroscopy was performed. In the combined hip arthroscopy and PAO group, hip arthroscopy was performed prior to PAO under the same general anesthetic in all cases. Student t-test was utilized to compare the operative times between the two study groups and Chi Square was used to compare categorical variables. RESULTS: During the two-year study period, 93 total PAO cases in 86 patients (mean age: 23.5 + 8.7 years; 81.4% female) were performed. Of these, 67 PAO surgeries (72.0%) were performed following hip arthroscopy. The total complication rate was 2.2% with one postoperative complication occurring in each group. There was no difference in mean PAO operative time between the two study groups (PAO: 127.6 + 18.0 minutes; PAO with hip arthroscopy: 125.4 + 16.8 minutes; p=0.570). CONCLUSION: Performing hip arthroscopy prior to PAO under the same general anesthetic does not significantly increase PAO operative time or postoperative complications.Level of Evidence: IV.

Computerized tomography-Guided Microwave Ablation of Patients with Stage I Non-small Cell Lung Cancers: A Single-Institution Retrospective Study.

OBJECTIVES: The objective of the study was to retrospectively investigate the safety and efficacy of computerized tomography-guided microwave ablation (MWA) in the treatment of Stage I non-small cell lung cancers (NSCLCs). MATERIAL AND METHODS: This retrospective, single-center study evaluated 21 patients (10 males and 11 females; mean age 73.8 ± 8.2 years) with Stage I peripheral NSCLCs treated with MWA between 2010 and 2020. All patients were surveyed for metastatic disease. Clinical success was defined as absence of FDG avidity on follow-up imaging. Tumor growth within 5 mm of the original ablated territory was defined as local recurrence. Welch t-test and Fisher's exact test were used for univariate analysis. Hazard ratio (HR) and odds ratio (OR) were determined using Cox regression and Firth logistic regression. Significance was P < 0.05. Data are expressed as mean ± standard deviation. RESULTS: Ablated tumors had longest dimension 17.4 ± 5.4 mm and depth 19.7 ± 15.1 mm from the pleural surface. Median follow-up was 20 months (range, 0.6-56 months). Mean overall survival (OS) following lung cancer diagnosis or MWA was 26.2 ± 15.4 months (range, 5-56 months) and 23.7 ± 15.1 months (range, 3-55 months). OS at 1, 2, and 5 years was 67.6%, 61.8%, and 45.7%, respectively. Progression-free survival (PFS) was 19.1 ± 16.2 months (range, 1-55 months). PFS at 1, 2, and 5 years was 44.5%, 32.9%, and 32.9%, respectively. Technical success was 100%, while clinical success was observed in 95.2% (20/21) of patients. One patient had local residual disease following MWA and was treated with chemotherapy. Local control was 90% with recurrence in two patients following ablation. Six patients (28.6%) experienced post-ablation complications, with pneumothorax being the most common event (23.8% of patients). Female gender was associated with 90% reduction in risk of death (HR 0.1, P = 0.014). Tumor longest dimension was associated with a 10% increase in risk of death (P = 0.197). Several comorbidities were associated with increased hazard. Univariate analysis revealed pre-ablation forced vital capacity trended higher among survivors (84.7 ± 15.2% vs. 73 ± 21.6%, P = 0.093). Adjusted for age and sex, adenocarcinoma, and neuroendocrine histology trended toward improved OS (OR: 0.13, 0.13) and PFS (OR: 0.88, 0.37) compared to squamous cell carcinoma. CONCLUSION: MWA provides a safe and effective alternative to stereotactic brachytherapy resulting in promising OS and PFS in patients with Stage I peripheral NSCLC. Larger sample sizes are needed to further define the effects of underlying comorbidities and tumor biology.

Development of a Machine Learning Algorithm to Predict Nonroutine Discharge Following Unicompartmental Knee Arthroplasty.

BACKGROUND: Reliable and effective prediction of discharge destination following unicompartmental knee arthroplasty (UKA) can optimize patient outcomes and system expenditure. The purpose of this study is to develop a machine learning algorithm that can predict nonhome discharge in patients undergoing UKA. METHODS: A retrospective review of a prospectively collected national surgical outcomes database was performed to identify adult patients who underwent UKA from 2015 to 2019. Nonroutine discharge was defined as discharge to a location other than home. Five machine learning algorithms were developed to predict this outcome. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. RESULTS: Overall, of the 7275 patients included, 263 (3.6) patients were unable to return home upon discharge following UKA. The factors determined most important for identification of candidates for nonroutine discharge were total hospital length of stay, preoperative hematocrit, body mass index, preoperative sodium, American Society of Anesthesiologists classification, gender, and functional status. The extreme boosted model achieved the best performance based on discrimination (area under the curve = 0.875), calibration, and decision curve analysis. This model was integrated into a web-based open access application able to provide both predictions and explanations. CONCLUSION: The present model can, following appropriate external validation, be used to augment clinician decision-making in patients undergoing elective UKA. Patients with high preoperative probabilities of nonroutine discharge based on nonmodifiable risk factors should be counseled to start the insurance authorization process with case management to avoid unnecessary inpatient stay, and those with modifiable risk can attempt prehabilitation to optimize these parameters before surgery.

Preoperative Performance of Patient-Reported Outcomes Measurement Information System in Patients with Meniscal Root Tears.

The purpose of this study was to establish preoperative validity of the Patient-Reported Outcomes Measurement Information System physical function computer adaptive test (PROMIS PF-CT) with legacy patient-reported outcome measures (PROMs) for meniscal root tears (MRTs). Our study included 51 patients (52 knees) with MRT. Patients completed PROMIS PF-CT, Short Form 36 (SF-36 physical function, pain, general health, vitality, social function, emotional well-being, role limitations due to physical health, and role limitations due to emotional problems), Knee Injury and Osteoarthritis Outcome Score (KOOS pain, symptoms, activities of daily living [ADLs], sports, and quality of life [QOL]), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC pain, stiffness, and function), EuroQol-5 dimensions (EQ-5D), and Knee Activity Scale questionnaires at their preoperative visit. Correlations between the PROMs listed above were evaluated along with floor and ceiling effects. Correlations were defined as weak (0.2-0.39), moderate (0.4-0.59), strong (0.6-0.79), and very strong (0.8-1.0). Preoperative data showed that PROMIS PF-CT has a strong correlation with SF-36 PF, KOOS-ADL, WOMAC-function, and EQ-5D; and moderate correlation with KOOS-sport, KOOS-pain, KOOS-symptoms, KOOS-QOL, WOMAC-pain, and WOMAC-stiffness. The Knee Activity Scale did not show any significant correlation with PROMIS PF-CT (r = 0.12, p = 0.2080). Of all the PROMs administered, PROMIS PF-CT demonstrated no floor or ceiling effects compared with 11.54% ceiling effect in KOOS-sports, and 5.77% floor effect in KOOS-ADL. On average, patients answered fewer PROMIS PF-CT questions (4.15 ± 0.72). PROMIS PF-CT is a valuable tool to assess preoperative patient-reported physical function in patients that may undergo MRT repair. It correlates strongly with other well-established PROMs. It also demonstrated no floor or ceiling effects and demonstrated a low test burden in our sample of 52 knees. This is a level III, prognostic retrospective comparative study.

Inpatient Arthroscopic Rotator Cuff Repair Is Associated With Higher Postoperative Complications Compared With Same-Day Discharge: A Matched Cohort Analysis.

PURPOSE: To compare 90-day postoperative complications between patients undergoing outpatient versus inpatient arthroscopic rotator cuff repairs (RCR) and identify risk factors associated with postoperative complications. METHODS: An administrative claims database was used to identify patients undergoing arthroscopic RCR from 2007 to 2015. Patients were categorized based on length of hospital stay (LOS) with inpatient RCR defined as patients with ≥1 day LOS, and outpatient RCR as patients discharged day of surgery (LOS = 0). Inpatient and outpatient RCR groups were matched based on age, sex, Charlson comorbidity index (CCI), and various medical comorbidities using 1:1 propensity score analysis. Patient factors, concomitant procedures, total adverse events (TAEs), medical adverse events (MAEs), and surgical adverse events (SAEs) were compared between the matched groups. Multiple logistic regression analysis was performed to identify risk factors associated with increased complications. RESULTS: After matching, there were 2812 patients (50% outpatient) included in the study. Within 90 days following arthroscopic RCR, the incidence of TAEs (8.9% vs 3.6%, P < .0001), SAEs (2.7% vs 0.9%, P = .0002), and MAEs (6.4% vs 3.0%, P < .0001) were significantly greater for the inpatient RCR group. The multivariate model identified inpatient RCR (LOS ≥1 day), greater CCI, and anxiety or depression as independent predictors for TAEs after arthroscopic RCR. Open biceps tenodesis and inpatient RCR were independent predictors of SAEs, whereas greater CCI, anxiety or depression, and inpatient RCR were independent predictors for MAEs within 90 days after arthroscopic RCR. CONCLUSIONS: Inpatient arthroscopic RCR is associated with increased risk of 90-day postoperative complications compared with outpatient. However, there is no difference for all-cause or pain-related emergency department visits within 90 days after surgery. In addition, the multivariate model identified inpatient RCR, greater CCI, and diagnosis of anxiety or depression as independent risk factors for 90-day TAEs after arthroscopic RCR. LEVEL OF EVIDENCE: III, Retrospective cohort study.

Increased Prevalence and Associated Costs of Psychiatric Comorbidities in Patients Undergoing Sports Medicine Operative Procedures.

PURPOSE: To evaluate the prevalence of preoperatively diagnosed psychiatric comorbidities and the impact of these comorbidities on the healthcare costs of ten common orthopaedic sports medicine procedures. METHODS: Patients undergoing 10 common sports medicine procedures from 2007 to 2017q1 were identified using the Humana claims database. These procedures included anterior cruciate ligament reconstruction; posterior cruciate ligament reconstruction; medial collateral ligament repair/reconstruction; Achilles repair/reconstruction; Rotator cuff repair; meniscectomy/meniscus repair; hip arthroscopy; arthroscopic shoulder labral repair; patellofemoral instability procedures; and shoulder instability repair. Patients were stratified by preoperative diagnoses of depression, anxiety, bipolar disorder, or schizophrenia. Cohorts included patients with ≥1 psychiatric comorbidity (psychiatric) versus those without psychiatric comorbidities (no psychiatric). Differences in costs across groups were compared using Mann-Whitney U tests, with significance defined as P < .05. Linear regression analysis was used to assess rates of procedures per year from 2006 to 2016. RESULTS: In total, 226,402 patients (57.7% male) from 2007 to 2017q1 were assessed. The prevalence of ≥1 psychiatric comorbidity within the entire database was 10.31% (reference) versus 21.21% in those patients undergoing the 10 investigated procedures. Patients with psychiatric comorbidity most frequently underwent rotator cuff repair (28%), hip labral repair (26.3%) and meniscectomy/meniscus repair (25.0%%) had ≥1 psychiatric comorbidity. Compared with the no psychiatric cohort, diagnosis of ≥1 psychiatric comorbidity was associated with increased health care costs for all 10 sports medicine procedures ($9678.81 vs $6436.20, P < .0001). CONCLUSIONS: The prevalence of preoperatively diagnosed psychiatric comorbidities among patients undergoing orthopaedic sports medicine procedures is high. The presence of psychiatric comorbidities preoperatively was associated with increased postoperative costs following all investigated orthopaedic sports medicine procedures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty.

BACKGROUND: The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA. METHODS: Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA. RESULTS: In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all). CONCLUSION: Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis.

PURPOSE: To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation. METHODS: A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ2 test was used to compare postoperative complications with statistical significance defined as P < .05. RESULTS: In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85). CONCLUSIONS: The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days. LEVEL OF EVIDENCE: III, retrospective matched cohort.

Big Data in Total Shoulder Arthroplasty: An In-depth Comparison of National Outcomes Databases.

INTRODUCTION: The practice of identifying trends in surgical decision-making through large-scale patient databases is commonplace. We hypothesize that notable differences exist between claims-based and prospectively collected clinical registries. METHODS: We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a prospective surgical outcomes database, and PearlDiver (PD), a claims-based private insurance database, for patients undergoing primary total shoulder arthroplasties from 2007 to 2016. Comorbidities and 30-day complications were compared. Multiple regression analysis was performed for each cohort to identify notable contributors to 30-day revision surgery. RESULTS: Significant differences were observed in demographics, comorbidities, and postoperative complications for the age-matched groups between PD and NSQIP (P < 0.05 for all). Multiple regression analysis in PD identified morbid obesity and dyspnea to lead to an increased risk for revision surgery (P = 0.001) in the <65 cohort and dyspnea and diabetes to lead to an increased risk for revision surgery in the ≥65 cohort (P = 0.015, P < 0.001). Multiple regression did not reveal any risk factors for revision surgery in the <65 age group for the NSQIP; however, congestive heart failure was found to have an increased risk for revision surgery in the ≥65 cohort (P < 0.001). CONCLUSIONS: Notable differences in comorbidities and complications for patients undergoing primary total shoulder arthroplasty were present between PD and NSQIP. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications.

PURPOSE: To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction. METHODS: The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05. RESULTS: From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001). CONCLUSIONS: Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk. LEVEL OF EVIDENCE: III.

Preoperative Opioid Usage, Male Sex, and Preexisting Knee Osteoarthritis Impacts Opioid Refills After Isolated Arthroscopic Meniscectomy: A Population-Based Study.

PURPOSE: To identify risk factors for opioid consumption after arthroscopic meniscectomy using a large national database. METHODS: Patients undergoing primary arthroscopic meniscectomy from 2007 to 2016 were retrospectively accessed from the Humana database. Patients were categorized as those who filled opioid prescriptions within 3 months (OU), within 1 month (A-OU), between 1 and 3 months (C-OU), and never filled opioid prescriptions (N-OU) before surgery. Rates of opioid use were evaluated preoperatively and longitudinally tracked for each cohort. Prolonged opioid use was defined as continued opioid prescription filling at ≥3 months after surgery. Multiple logistic regression analysis was used to identify factors associated with opioid refills at 12 months after surgery. RESULTS: There were 88,120 patients (53.7% female) who underwent arthroscopic meniscectomy, of whom 46.1% (n = 39,078) were N-OU. About a quarter (25.3%) of patients continued filling opioid prescriptions at 1 year postoperatively. In addition, opioid fill rate at 1 year was significantly greater in the OU group compared with the N-OU group with a relative risk of 2.89 (40.7% vs 14.1%; 95% confidence interval 2.81-2.98; P < .0001). Multiple logistic regression model identified C-OU (odds ratio 3.67; 95% confidence interval 3.53-3.82; P < .0001) as the strongest predictor of opioid use at 12 months postoperatively. Furthermore, male sex, A-OU, knee osteoarthritis, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, fibromyalgia, anxiety or depression, alcohol use disorder, and tobacco use (P < .02 for all) had significantly increased odds of opioid use at 12 months postoperatively. However, patients <40 years (P < .0001) had significantly decreased odds of opioid use 12 months postoperatively. CONCLUSIONS: Preoperative opioid filling is a significant risk factor for opioid use at 12 months postoperatively. Male sex, preexisting knee osteoarthritis, and diagnosis of anxiety or depression were independent risk factors for opioid use 12 months following arthroscopic meniscectomy. LEVEL OF EVIDENCE: Level-III, Retrospective Cohort Study.

Resident Involvement Is Not Associated With Increased Risk of Postoperative Complications After Arthroscopic Knee Surgery: A Propensity-Matched Study.

PURPOSE: To investigate whether resident involvement in knee arthroscopy procedures affects postoperative complications or operative times. METHODS: The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common knee arthroscopy procedures between 2006 through 2012. Patients with a history of knee arthroplasty, septic arthritis or osteomyelitis of the knee, concomitant open or mini-open procedures, or without information on resident involvement were excluded. A 1:1 propensity score match was performed based on age, sex, obesity, smoking history, and American Society of Anesthesiologist classification to match cases with resident involved to nonresident cases. Fisher exact tests, Pearson's χ2 tests, and Wilcoxon rank sum tests were used to compare patient demographics, comorbidities, and 30-day complications. Wilcoxon rank sum tests were used to compare operative time and length of hospital stay between the 2 groups, with statistical significance defined as P < .05. RESULTS: After matching, 2954 cases (50% resident involvement) were included in the study with no significant differences in demographics or comorbidities between the 2 cohorts. The overall rate of 30-day complications was 1.1% in the nonresident and resident involved group (P = 1.000). There was no significant difference in postoperative surgical (nonresident vs resident involved: 0.48% vs 0.83%, P = .2498) or medical (nonresident vs resident involved: 0.62% vs 0.83%, P = .5111) complications. However, knee arthroscopy cases that residents were involved with had significantly longer operative times (69.8 vs 66.8 minutes, P = .0002), and length of hospital stay (0.85 vs 0.21 days, P = .0332) when compared with cases performed without a resident. CONCLUSIONS: Resident involvement in knee arthroscopy procedures is not a significant risk for medical or surgical 30-day postoperative complications. Resident participation in knee arthroscopy was associated with statistically significant but likely clinically insignificant increased operative time as well as length of hospital stay. LEVEL OF EVIDENCE: Level III: Retrospective Cohort Study.