Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

A thoracoscopic anterior approach to the spine for adolescent idiopathic scoliosis does not have a detrimental effect on pulmonary function at 2 years compared to posterior-only surgery.

PURPOSE: This study aims to examine pulmonary function outcomes in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF) with an anterior thoracoscopic release compared to those undergoing PSF alone. METHODS: A retrospective review of patients with AIS over a 9-year period at a single institution compared 2 groups: PSF with video-assisted thoracoscopic surgery (PSF/VATS) and patients undergoing a posterior spinal fusion (PSF) alone. Standard radiographs and Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were obtained preoperatively and at regular follow up periods up to 2-year post-operatively. Within group and between-group comparisons were performed. RESULTS: There were 110 patients in the study: 12 in the PSF/VATS cohort and 98 in the PSF only cohort. The PSF/VATS group were younger (12.6 vs. 14.6, p = 0.003) and had larger coronal curves (80.8° vs. 60.7°, p = 0.001), and worse preoperative FVC (64.7% vs. 79.6%, p = 0.018) and FEV1 (62.3% vs. 77.6%, p = 0.003). At 2 years, the percent coronal Cobb correction was greater in the PSF/VATS group (67.9% vs. 48.4%, p < 0.001) with greater improvement in thoracic height (32.8 mm vs. 20.7 mm, p = 0.028). While the 2-year PFTs were the same for FEV1% (75.8% vs. 81.8%, p = 0.368) and FVC% (77.3% vs. 83.7%, p = 0.562), there was greater percent improvement over the 2 years in the PSF/VATS cohort: FEV1% (13.5% vs. 4.2%, p = 0.082) and FVC% (12.7% vs. 4.1%, p = 0.112). CONCLUSION: AIS patients who have a VATS approach in addition to PSF have greater coronal plane correction and improved pulmonary function compared to PSF alone despite more severe spinal deformity and worse baseline pulmonary function.

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis.

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Subsequent Surgery Up to 10 Years After Osteochondral Allograft and Osteochondral Autograft: An Analysis of More Than 2000 Patients.

Background: Osteochondral allograft transplant (OCA) and osteochondral autograft transfer (OAT) replace damaged cartilage with a plug of bone and overlying articular cartilage; however, limited research is available regarding the survival of these osteoarticular grafting procedures. Hypothesis: We hypothesized that patients who underwent OCA would have a higher rate of subsequent surgery over the course of 5 years compared with patients who underwent OAT. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Mariner administrative database was used to identify patients 10 to 59 years old who had undergone OCA or OAT between 2010 and 2018. All included patients were assessed for subsequent knee surgeries, defined by the occurrence of a subsequent osteochondral procedure (OCA or OAT) or any type of knee arthroplasty for the duration of the time they were included in the data set (maximum of 10 years). Analyses were performed for the total population and those with allograft versus autograft (compared using the Fisher exact test). The 5-year Kaplan-Meier survival curves for operation-free survival were compared using a Mantel-Cox log-rank test. Results: In total, 2598 patients were identified: 1631 patients who underwent OCA (34.5 ± 12.1 years old; 51.6% female) and 967 patients who underwent OAT (32.1 ± 12.9 years old; 51.0% female). Both groups had similarly high rates of subsequent knee surgeries (23.9% vs 21.9%, respectively; P = .249), with no statistical differences in rates of subsequent surgery between groups. Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs OAT, 89.5%; P = .235). Conclusion: Both osteochondral grafting procedures carried a relatively high rate of secondary surgery, which increased with time. The 5-year survival analysis revealed similarly high rates of subsequent surgery.

Abaloparatide Enhances Fusion and Bone Formation in a Rabbit Spinal Arthrodesis Model.

STUDY DESIGN: Prospective randomized placebo controlled animal trial. OBJECTIVE: Determine the effect of daily subcutaneous abaloparatide injection on the intervertebral fusion rate in rabbits undergoing posterolateral fusion. STUDY OF BACKGROUND DATA: Despite the wide utilization of spine fusion, pseudarthrosis remains prevalent, and results in increased morbidity. Abaloparatide is a novel analog of parathyroid hormone-related peptide (1-34) and has shown efficacy in a rat posterolateral spine fusion model to increase fusion rates. The effect of abaloparatide on the fusion rate in a larger animal model remains unknown. MATERIALS AND METHODS: A total of 24 skeletally mature New Zealand White male rabbits underwent bilateral posterolateral spine fusion. Following surgery, the rabbits were randomized to receive either saline as control or abaloparatide subcutaneous injection daily. Specimens underwent manual assessment of fusion, radiographic analysis with both x-ray and high-resolution peripheral quantitative computed tomography, and biomechanical assessment. RESULTS: Rabbits that received abaloparatide had a 100% (10/10) fusion rate compared with 45% (5/11) for controls ( P <0.02) as assessed by manual palpation. Radiographic analysis determined an overall mean fusion score of 4.17±1.03 in the abaloparatide group versus 3.39±1.21 for controls ( P <0.001). The abaloparatide group also had a greater volume of bone formed with a bone volume of 1209±543 mm 3 compared with 551±152 mm 3 ( P <0.001) for controls. The abaloparatide group had significantly greater trabecular bone volume fraction and trabecular thickness and lower specific bone surface and connectivity density in the adjacent levels when compared with controls. Abaloparatide treatment did not impact trabecular number or separation. There were no differences in biomechanical testing in flexion, extension, or lateral bending ( P >0.05) between groups. CONCLUSIONS: Abaloparatide significantly increased the fusion rate in a rabbit posterolateral fusion model as assessed by manual palpation. In addition, there were marked increases in the radiographic evaluation of fusion.

Single-level posterior lumbar fusions in patients with Ehlers Danlos Syndrome not found to be associated with increased postoperative adverse events or five-year reoperations.

Background: Ehlers Danlos Syndrome (EDS) is a rare connective tissue disorder that results from mutations in collagen genes. Potentially related to laxity and resultant degenerative changes, adult EDS patients may require posterior lumbar fusion (PLF). However, with low numbers, adequately powered outcome studies have been limited. The purpose of this study was to investigate risk of complications, readmissions and reoperations in adult patients with EDS following single-level PLF. Methods: A retrospective study using the 2010 to 2020 MSpine Pearldiver dataset was performed. Adult patients undergoing single-level PLF (excluding any with anterior procedures) with and without EDS for which at least 90-day follow up was available were identified. Any cases performed for trauma, tumor, or infection were excluded.Single-level PLF EDS patients were then matched 1:4 with PLF non-EDS patients based on age, sex, and Elixhauser Comorbidity Index (ECI). Rates of ninety-day any, severe, and minor adverse events as well as readmissions were tabulated and compared with chi-square tests. Multivariate logistical regression was then performed (controlling for age, sex, and ECI).Reoperation surgeries over five years were assessed, Kaplan-Meier survival curves generated, and curves of those with and without EDS were compared with log rank test. Results: In total, there were 170,100 single-level PLF case identified, of which 242 (0.14%) had EDS. After matching, there were 957 without EDS and 239 with EDS. On multivariate regression, there were no significant differences in 90-day any, severe, or minor adverse events, or readmissions (p>0.05 for each). Over five years, there were also not significant differences in rates of reoperation (p> 0.05). Conclusions: For EDS patients undergoing PLF, the current study identified similar 90-day adverse events and 5-year reoperation rates compared to those without EDS. These findings may be useful for patient counseling and surgical planning for those with this rare condition.

Predictors of Physical Abuse in Elder Patients With Fracture.

INTRODUCTION: Elder abuse is a public health issue requiring attention. Unlike abuse in the pediatric population, predictors of elder abuse in patients with fracture have not been well defined. METHODS: Elderly patients with physical abuse and fracture were abstracted using the 2007 to 2017 National Emergency Department Sample database. Univariate comparisons, multivariate regression, and adjusted odds ratios were used to determine independent predictors of elder abuse compared with nonabuse fracture controls. RESULTS: Thirteen percent of elder physical abuse patients presenting to the emergency department had fracture. Of all patients with fracture, elder abuse patients tended to be younger; be female; belong to lower income quartiles; and have codiagnoses of volume depletion, mental disorders, dementia, and intellectual disability. Presentation with other forms of elder abuse, such as psychological abuse, neglect, and sexual abuse, and multiple fractures were also associated with elder physical abuse. Multivariate regression found elder abuse to be more likely in the setting of skull and rib fractures and less likely in the setting of femur and foot and ankle fractures. DISCUSSION: This study identified predictors of elder physical abuse in fracture patients older than 60 years. As with pediatric abuse, heightened awareness of potential physical abuse should be considered, especially in higher risk patients.

The Utility of MRI With Multiacquisition Variable-Resonance Image Combination (MAVRIC) in Diagnosing Deep Total Hip Arthroplasty Infection.

Background: The 2010 American Academy of Orthopaedic Surgeons Clinical Practice Guidelines report insufficient evidence to address the diagnostic efficacy of magnetic resonance imaging (MRI) for periprosthetic joint infection (PJI). Questions/Purposes: The purpose of this study was to determine the utility of MRI with multiacquisition variable-resonance image combination (MAVRIC) metal artifact suppression techniques in diagnosing PJI in the setting of total hip arthroplasty (THA). Methods: Multiacquisition variable-resonance image combination MRIs obtained of THAs between November 2012 and November 2016 were queried. Radiology reports were classified as positive (suspicious for infection), negative (no features of infection), or inconclusive (infection cannot be excluded or correlation with aspiration suggested if clinically concerned). Chart review identified cases of deep PJI according to the modified Musculoskeletal Infection Society criteria. Results: Of 2156 MRIs of THAs included, MRI was concerning for infection in 1.8% (n = 39), inconclusive in 1.2% (n = 26), and negative in 97.0% (n = 2091). Deep PJI was identified in 53 (2.5%) patients, 30 of whom (56.6%) had conclusively positive finding on MRI (false-negative rate: 43.4%, sensitivity: 56.6%). Of 2103 aseptic THAs, only 9 (0.4%) MRIs were read as suspicious for infection (false-positive rate: 0.4%; specificity: 99.6%). Conclusion: Magnetic resonance imaging with MAVRIC is a highly specific test for PJI with a low false-positive rate. This indicates that when clinicians are provided with an MRI that unexpectedly suggests infection, a formal evaluation for infection is indicated. In patients with otherwise equivocal diagnostic findings, MRI may help confirm, but not refute, a diagnosis of PJI. Prospective study with more experienced image reviewers may further support the use of MRI in PJI.

Emergency department visits within 90 days of single-level anterior cervical discectomy and fusion.

Background: Postoperative readmissions are a commonly used metric for quality-of-care initiatives, but emergency department (ED) visits have received far less attention despite their substantial impact on patient satisfaction and healthcare spending. The current study described the incidence and timing of ED visits following single-level ACDF, determined predictive factors and reasons for ED utilization, and compared reimbursement for patients with and without ED use. Methods: Single-level ACDF procedures from 2010-2020 were identified in PearlDiver using CPT codes. Patients' age, sex, Elixhauser comorbidity index (ECI) score, region of the country, and insurance coverage were extracted. The incidence, timing, and primary diagnoses for 90-day ED visits and readmissions were determined, as well as total 90-day reimbursement. Variables were compared using univariate analysis and multivariate logistic regression. Results: Out of 90,298 patients, 90-day ED visits were identified for 10,701 (11.9%), with the greatest incidence in postoperative weeks 1-2. Readmissions were identified for 3,325 (3.7%) patients. Independent predictors of ED utilization included younger age (OR 1.25 per 10-year decrease, p<0.001), greater ECI score (OR 1.40 per 2-point increase, p<0.001), and insurance type (relative to Medicare, Medicaid [OR 2.15, p<0.001] and commercial plans [OR 1.14, p=0.004]). In postoperative weeks 1-2, 51% of primary ED diagnoses involved the surgical site, while 23% involved the surgical site in weeks 3-13. Compared to patients without ED visits, those who visited the ED had 65% greater mean 90-day reimbursement (p<0.001). Conclusions: More than three times as many patients in the current study were found to present to the ED than be readmitted within ninety days of surgery. The identified predictive factors and reasons for ED visits can direct attention to high-risk patients and common postoperative issues. Additional postoperative counseling and integrated care pathways may reduce ED visits, thereby improving patient care and reducing healthcare spending.

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis.

BACKGROUND: Patients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized. METHODS: The PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts. RESULTS: In total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001). CONCLUSION: Compared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA. LEVEL OF EVIDENCE: Level III.

Marfan syndrome and adolescent idiopathic scoliosis patients have similar 90-day postoperative outcomes and 5-year reoperation rates after spinal deformity surgery.

PURPOSE: Outcomes after spinal deformity surgery in patients with Marfan syndrome (MFS) are poorly characterized given the rarity of the condition. Updated analyses from nationally representative samples, and comparison to outcomes after more commonly performed procedures for conditions such as adolescent idiopathic scoliosis (AIS) could help define the relative risks. METHODS: Using the 2010-2020 PearlDiver administrative databases, patients who underwent posterior spinal fusion for > 7 segments were extracted. MFS patients were matched 1:4 to AIS patients based on age, sex, and Elixhauer comorbidity index (ECI). Ninety-day outcomes and 5-year reoperation rates were compared. Significance was set at p < 0.05. RESULTS: In total, 206 MFS patients were matched to 825 AIS patients. After adjusting for age, sex, and ECI, multivariate odds ratios (OR) for 90-day any, serious, and minor adverse events, as well as readmissions, were not significantly different for those with MFS compared to those with AIS (p > 0.05 for each). Five-year reoperation rates were also not significantly different (13.1% for the MFS cohort and 13.0% for the AIS cohort (no difference by log-rank, p = 0.9). CONCLUSION: While deformity surgery is much less commonly performed for MFS than AIS, it is not uncommonly considered for patients with this condition. Despite some known technical challenges for MFS deformity surgery, the current study leveraged a large, national database to find that 90-day adverse events and 5-year reoperations were not different for matched MFS and AIS patients undergoing deformity surgery. For select patients, these findings should be useful for surgical planning and patient counseling.

Unicompartmental Knee Arthroplasty in Octogenarians: A National Database Analysis Including Over 700 Octogenarians.

Background: Unicompartmental knee arthroplasty (UKA) may be considered for select patients to relieve pain and restore function of the knee joint. Little research to date has explored the complication profile of UKA in an older population. The current study uses a large national surgical database to examine the 30-day postoperative adverse events in octogenarians compared with those in nonoctogenarians. Material and methods: The 2012-2018 National Surgical Quality Improvement Program database was queried for all patients undergoing UKA for osteoarthritis. Those patients aged 80 years or older composed the octogenarian age group. Demographics and medical comorbidities were cataloged, in addition to 30-day adverse events. Multivariate regression analysis controlled for differences in demographics and comorbidities. Significance was set at P < .05. Results: A total of 10,103 patients undergoing UKA were identified, of which 728 (7.2%) were octogenarians. The octogenarian cohort had significantly higher comorbidity burden than nonoctogenarians. After controlling for demographics other than age, American Society of Anesthesiologists score, and medical comorbidities, octogenarians had higher 30-day odds of death (odds ratio [OR] = 6.12, P = .024), minor adverse events (OR = 2.97, P = .001), prolonged hospital length of stay (OR = 2.30, <0.001), nonhome discharge (OR = 4.50, P < .001), and readmission (OR = 1.72, P = .015), but did not experience increased odds of serious adverse events (OR = 1.07, P = .172) or return to the operating room (OR = 0.97, P = .881). Conclusion: The present study found a statistically significant increase in several adverse events within 30 days of surgery for patients aged ≥80 years when compared with patients younger than 80 years. Namely, UKA in octogenarians was associated with significantly increased odds of short-term mortality, urinary tract infection, transfusion, prolonged hospital stay, and readmission.

Characterization of More Than a Third of a Million Toy-Related Fractures.

INTRODUCTION: The toy industry has grown substantially over time, with billions of dollars of toys sold each year in the United States alone. Even after safety considerations, injuries can result. This study examined toy-related fractures in the US Emergency Departments (ED). METHODS: The 1999 to 2018 National Electronic Injury Surveillance System from the US Consumer Product Safety Commission was examined data for fractures involving a toy-related injury. The incidence, trends, and anatomic locations for such fractures were assessed. RESULTS: In total, 347,135 toy-related fractures were identified, of which 237,754 (68%) were in patients younger than 18 years, 182,516 (53%) were sustained by male subjects, and a 95% yearly incidence increase was observed over the years of the study. Anatomically, 37% were shoulder/arm/elbow, 24% wrist/hand/finger, 19% ankle/toe/foot, 10% leg/knee, 6% face/neck/head, and 4% trunk/pubic region. DISCUSSION: Despite safety considerations with toy design, more than a third of toy-related fractures were seen in the ED, with a nearly doubling yearly incidence over the study period. This could be contributed to by increased production and prevalence of toys and/or rougher play and increased overall violence. These results are important not only for patient safety but also for orthopaedic surgeons, EDs, toy manufacturers, and policymakers.

Jump in Elective Total Hip and Knee Arthroplasty Numbers at Age 65 Years: Evidence for Moral Hazard?

INTRODUCTION: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are outstanding options for many older patients at the discretion of the patient and the surgeon. As patients turn 65 years, greater than 98% of the US population becomes eligible for Medicare, and this represents a time of changing healthcare coverage for many. METHODS: Patients undergoing elective TKA and THA were abstracted from the 2012 to 2018 National Surgical Quality Improvement Program database. Incidences of TKA and THA (combined and separate) were plotted and assessed by age. To assess factors associated with who "delayed" surgery until 65 years, demographic and preoperative characteristics, and postoperative adverse events were compared for the 2 years above and the 2 years below the 65-year-old mark with multivariate analysis. Significance was set at P < 0.05. RESULTS: In total, 515,139 TKA and THA patients were identified (62.04% TKA and 37.95% THA). When the number of procedures was plotted by age, a discontinuity in the bell-shaped curve was noted at age 65 years. Highlighting this finding, the changes in percent population between 63 and 64 years was -1.52%, between 64 and 65 years was +15.36%, and between 65 and 66 years was -2.32%. Relative to those who were 63 and 64 years (n = 36,511), those who were 65 and 66 years (n = 41,671) were more likely to be female, be non-Hispanic White, have a lower body mass index, and have a lower functional status but were not different in the preoperative American Society of Anesthesiologists class. CONCLUSION: In this large national sample, there was a clear step increase in undergoing TKA or THA once patients reached the age of 65 years (Medicare eligibility). This discontinuity in the bell-shaped curve may be evidence for a moral hazard in healthcare markets. Although factors in decision-making were not assessed, there were demographic factors associated with this step finding.

Emergency Department Visits Within 90 Days of Anterior Cruciate Ligament Reconstruction.

Background: Emergency department (ED) visits after orthopaedic surgery such as anterior cruciate ligament reconstruction (ACLR) affect patients and health care systems and should be better understood. Purpose: To determine the incidence, predictors, and reasons for ED visits within 90 days after ACLR. Study Design: Descriptive epidemiologic study. Methods: Patients who had undergone ACLR between 2010 and 2020 were identified in a national database, and 90-day ED visits, readmissions, risk factors, and primary diagnoses for visits were determined. One-year postoperative data were used to establish baseline weekly ED visits for the cohort. Patient age, sex, Elixhauser comorbidity index, region of the country (Northeast, Midwest, West, South), and insurance coverage (Medicare, Medicaid, and commercial) were extracted, and these variables were compared using univariate analysis and multivariate logistic regression. Results: Out of 81,179 patients, ED visits were identified for 6764 (8.3%), and readmissions were identified for 592 (0.7%). Overall, 5300 patients had 1 ED visit, 1020 patients had 2 visits, 275 patients had 3 visits, and 169 patients had ≥4 or more visits; visits occurred within 2 weeks of surgery 38% of the time. Notably, weekly visits returned to baseline at week 3. Independent predictors of ED utilization from multivariate analysis were insurance type (relative to commercial insurance: Medicaid [odds ratio [OR], 2.41; 95% CI, 2.23-2.60] and Medicare [OR, 1.38; 95% CI, 1.19-1.60]), higher Elixhauser comorbidity index (per 2-point increase: OR, 2.24; 95% CI, 2.18-2.29), younger age (per 10-year decrease: OR, 1.23; 95% CI, 1.21-1.24), female sex (OR, 1.05; 95% CI, 1.02-1.08), and region of the country (relative to the West: Midwest [OR, 1.33; 95% CI, 1.26-1.39], Northeast [OR, 1.24; 95% CI, 1.18-1.30], and South [OR, 1.17; 95% CI, 1.12-1.23]). In the first 2 weeks, 67.5% of ED visits were for issues involving the surgical site, most commonly surgical-site pain (29% of all visits). In the total 90-day period, 39.4% of visits involved the surgical site. Conclusion: Within 90 days of ACLR, >8% of patients visited the ED, while 0.7% were readmitted. ED visits increased in the first 2 postoperative weeks and returned to baseline rates around week 3. Within the first 2 weeks, two-thirds of visits involved the surgical site. Younger patients, patients with greater comorbidity burden, those in certain regions of the country, and those with Medicaid had greater odds of ED utilization.

Total Hip Arthroplasty in Patients With Classic Hemophilia: A Matched Comparison of 90-Day Outcomes and 5-Year Implant Survival.

BACKGROUND: Patients with classic hemophilia can develop joint hemarthroses, degenerative changes, and eventually require total hip arthroplasty (THA). Little data exist concerning THA outcomes in this population, and evidence-based guidelines specifically addressing venous thromboembolism (VTE) prophylaxis in this population are lacking. METHODS: A retrospective study was conducted using the 2010-2020 PearlDiver MHip database. Patients undergoing primary THA were identified, and those with classic hemophilia were matched 1:10 with non-hemophilia patients based on age, gender, and Elixhauser Comorbidity Index. Ninety-day serious adverse events, minor adverse events, and any adverse events were compared with multivariate analysis. Reoperation at 5 years was assessed using Kaplan-Meier analysis. RESULTS: Five hundred eighteen classic hemophilia THA patients were matched 1:10 with 5,193 non-hemophilia patients. On multivariate analysis, those with classic hemophilia had greater odds of aggregated any adverse events (odds ratio [OR] 1.76), serious adverse events (OR 2.30), and minor adverse events (OR 1.52) (P < .001 for each). Patients with classic hemophilia had greater odds of bleeding issues (transfusion, OR 1.98; hematoma, OR 4.23; P < .001 for both), VTE (deep vein thrombosis, OR 2.67; pulmonary embolism, OR 4.01; P < .001 for both), and acute kidney injury (OR 1.63; P = .03). Five-year implant survival was lower in hemophilia patients (91.9%) relative to matched controls (95.3%; P = .009). CONCLUSION: Hemophilia patients undergoing THA had elevated risks of both 90-day bleeding complications (transfusion and hematoma) and VTE (deep vein thrombosis and pulmonary embolism) relative to matched controls. These findings emphasize the need to balance factor replacement and VTE prophylaxis. Although the 5-year implant survival was lower in hemophilia patients, this represented a difference of 3.4% at 5 years, suggesting that THA remains effective in this cohort.

Total shoulder arthroplasty for osteoarthritis in patients with Parkinson's disease: a matched comparison of 90-day adverse events and 5-year implant survival.

BACKGROUND: Patients with Parkinson's disease and shoulder osteoarthritis may be indicated for total shoulder arthroplasty. However, short- and long-term outcomes after total shoulder arthroplasty in this population remain poorly characterized. METHODS: A retrospective matched case-control study was performed using data abstracted from the 2010-2018 PearlDiver Mariner administrative database. Patients undergoing total shoulder arthroplasty were identified, and those with and without the diagnosis of Parkinson's disease were matched (1:10) based on age, gender, Elixhauser comorbidity index, diabetes, chronic kidney disease, obesity, coronary artery disease, and congestive heart failure. Ninety-day incidence of adverse events were compared with multivariate regressions. Implant survival was also assessed for up to 5 years, based on the occurrence of revision surgery. Kaplan-Meier implant survival curves were compared using a log-rank test. RESULTS: In total, 478 patients with Parkinson's disease were matched to 4715 patients without Parkinson's disease. After adjusting for demographic and comorbid factors, patients with Parkinson's disease had significantly higher odds of prosthetic dislocation (odds ratio = 3.07, P = .001), but did not experience increased odds of other 90-day adverse events. Five-year follow-up was available for 428 (89.5%) of those with Parkinson's disease and 3794 (80.5%) of those without Parkinson's disease. There was 97.2% implant survival in the Parkinson's disease cohort and 97.7% implant survival in the matched control cohort (not significantly different, P = .463). CONCLUSIONS: Patients with Parkinson's disease undergoing total shoulder arthroplasty, compared with patients without Parkinson's disease, have 3-fold higher odds of periprosthetic dislocation in the 90-day postoperative period, but equivalent rates of other short-term adverse events as well as implant survival at 5 years. Accordingly, surgeons should be mindful of the short-term risk of implant instability but should have confidence in long-term total shoulder implant success in the Parkinson's disease population.

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients.

BACKGROUND: Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied. METHODS: All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint. RESULTS: Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon. CONCLUSION: Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

Delayed Surgery Does Not Reduce Transfusion Rates in Low-Energy Hip Fractures on Direct Oral Anticoagulants.

OBJECTIVES: To compare transfusion rates in patients on direct oral anticoagulants (DOACs) with nonanticoagulated patients undergoing hip fracture surgery and, secondarily, to determine whether time to surgery or complications differ between these groups. DESIGN: Multicenter retrospective cohort. SETTING: Three tertiary care, academic, Level I trauma centers. PATIENTS: Acute, operatively treated, low-energy hip fracture patients 55 years of age and older were included. Anticoagulated patients were matched in a 1:2 ratio to "control" nonanticoagulated hip fracture patients using propensity score matching. MAIN OUTCOME MEASUREMENTS: The primary outcome was incidence of perioperative transfusion. The secondary outcomes included time to surgery, length of stay, and 90-day complications, readmissions, reoperations, and mortality. RESULTS: One hundred thirty-two patients with hip fracture admitted on DOACs were identified (107 factor Xa inhibitors, 25 dabigatran) and were matched to 262 "control" nonanticoagulated patients. There was no difference in overall transfusion rates between anticoagulation and control groups (43.2%; n = 57 DOAC vs. 39.7%; n = 104 control; P = 0.517). The median time from admission to surgery was 41.7 hours in the DOAC group and 26.0 hours in the control group (P < 0.001). There were no differences in 90-day complication, readmission, reoperation, or mortality rates between DOAC and control groups. Comparing DOAC patients undergoing surgery within 24 hours and after 24 hours, there were no differences in transfusion rates (P = 0.558) or overall complication rates (P = 0.179). CONCLUSIONS: This study supports growing evidence that DOAC use should not be a determining factor in delaying surgery for patients with hip fracture who are otherwise medically optimized. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients With Ehlers-Danlos Syndromes Experience Higher Rates of Prosthetic Dislocation After Total Hip Arthroplasty and Worse Implant Survival at 5 Years.

INTRODUCTION: Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after total hip arthroplasty in this cohort remain poorly characterized. METHODS: Data were abstracted from the 2010 to 2018 PearlDiver Mariner administrative database. Patients with EDS undergoing total hip arthroplasty for osteoarthritis were identified and matched 1:10 to patients without a diagnosis of EDS. Ninety-day incidence of postoperative complications and hospital readmission were identified and compared. Odds of 90-day adverse events were compared using multivariate logistic regression. Finally, 5-year implant survival was compared using a log-rank test. Significance was set at P < 0.005 after Bonferroni correction. RESULTS: Matching was done for 354 patients with EDS to 3,518 patients without EDS. Patients with EDS had markedly higher rates of periprosthetic dislocation within 90 days of surgery (4.2% dislocation rate in EDS vs. 1.7% in matched control subjects, P = 0.001). On multivariate analysis, patients with EDS continued to have increased odds of dislocation in the 90-day postoperative period (Odds Ratio=2.64, P = 0.001), whereas the rates of the other studied adverse events were not markedly different between groups. At 5 years, 92.7% of patients with EDS and 96.1% of the matched control subjects remained unrevised (significant log rank difference, P = 0.004). CONCLUSION: Compared with patients without EDS, patients with EDS were found to have a higher rate of perioperative dislocation and markedly lower implant survival at 5 years. These findings are consistent with the increased connective tissue laxity associated with EDS.