High Levels of Satisfaction and Adequate Patient-Reported Outcomes After Operative Reconstruction of Multiligament Knee Injury With Allograft Among Patients Aged 40 Years and Older.

Purpose: To describe injury characteristics and patient-reported outcomes (PROs) among patients aged 40 years and older who underwent allograft reconstruction for multiligament knee injury (MLKI). Methods: Records of patients aged 40 years and older who underwent allograft multiligament knee reconstruction at a single institution between 2007 and 2017 with a minimum of 2 years of follow-up were retrospectively reviewed. Demographic information, concomitant injuries, patient satisfaction, and PROs including International Knee Documentation Committee and Marx activity scores were obtained. Results: Twelve patients were included with a minimum follow-up time of 2.3 years (mean, 6.1; range, 2.3-10.1 years) and a mean age at surgery of 49.8 years. Seven patients were male, and the most common mechanism of injury was sport-related. The most frequently reconstructed MLKIs were anterior cruciate ligament and medial collateral ligament (4), anterior cruciate ligament and posterolateral corner (2), and posterior cruciate ligament and posterolateral corner (2). The majority of patients reported satisfaction with their treatment (11). Median International Knee Documentation Committee and Marx scores were 73 (interquartile range, 45.5-88.0) and 3 (interquartile range 0-5), respectively. Conclusions: Patients aged 40 years and older can expect a high level of satisfaction and adequate PROs at 2-years follow-up after operative reconstruction for a MLKI with allograft. This demonstrates that allograft reconstruction for a MLKI in older patients may have clinical utility. Level of Evidence: IV, therapeutic case series.

Revision Soft-Tissue Allograft Anterior Cruciate Ligament Reconstruction Is Associated With Lower Patient-Reported Outcomes Compared With Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older.

PURPOSE: To evaluate patient-reported outcomes (PROs) and graft failure rates in revision allograft anterior cruciate ligament reconstruction (ACLR) in patients aged 40 and older and compare them with primary ACLRs. METHODS: Patients aged 40 and older who underwent arthroscopic soft-tissue allograft ACLR between 2005 and 2016 with a minimum 2-year follow-up were retrospectively reviewed. Patients were grouped based on revision versus primary ACLR. The rate of achieving an International Knee Documentation Committee (IKDC) patient acceptable symptom state (PASS) score was recorded. Patient satisfaction, PROs, and graft failure were compared between groups using the χ2 test, Fisher exact test, and Mann-Whitney U test. RESULTS: We identified 32 patients who underwent revision ACLR and 201 patients who underwent primary ACLR aged 40 and older who met inclusion criteria with a mean follow-up of 6.2 and 6.9 years, respectively (P = .042). There was a lower rate of concomitant meniscal repair in the primary ACLR group (6% vs 21.9%, P = .007) There were no other differences in chondral injuries, mechanism of injury, or meniscal injuries between groups. The median IKDC score was greater in the primary ACLR group as compared with the revision ACLR group (83.9 vs 70.6, P < .001). Patients who underwent revision ACLR were less likely to achieve the IKDC PASS threshold (82.5% vs 56.3%, P = .001) and were less likely to report satisfaction as compared with patients who underwent primary ACLR (90.5% vs 78.1%, P =.038). No difference in graft failure rates was identified between groups (8% vs 15.6%, P = .180). CONCLUSIONS: Revision allograft ACLR in patients aged 40 and older was associated with lower PROs compared with primary ACLR. Patients who underwent revision ACLR failed to meet the IKDC PASS threshold more often and were dissatisfied with procedure results more than twice as often as patients that underwent primary ACLR. LEVEL OF EVIDENCE: III, retrospective cohort study.

The Cost-Effectiveness of Silver-Impregnated Occlusive Dressings for Infection Prevention After Total Joint Arthroplasty.

BACKGROUND: Prosthetic joint infection (PJI) is a catastrophic complication after total joint arthroplasty that exacts a substantial economic burden on the health-care system. This study used break-even analysis to investigate whether the use of silver-impregnated occlusive dressings is a cost-effective measure for preventing PJI after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: Baseline infection rates after TKA and THA, the cost of revision arthroplasty for PJI, and the cost of a silver-impregnated occlusive dressing were determined based on institutional data and the existing literature. A break-even analysis was then conducted to calculate the minimal absolute risk reduction needed for cost-effectiveness. RESULTS: The use of silver-impregnated occlusive dressings would be economically viable at an infection rate of 1.10%, treatment costs of $25,692 for TKA PJI, and $31,753 for THA PJI and our institutional dressing price of $38.05 if it reduces infection rates after TKA by 0.15% (the number needed to treat [NNT] = 676) and THA by 0.12% (NNT = 835). The absolute risk reduction needed to maintain cost-effectiveness did not change with varying initial infection rates and remained less than 0.40% (NNT = 263) for infection treatment costs as low as $10,000 and less than 0.80% (NNT = 129) for dressing prices as high as $200. CONCLUSION: The use of silver-impregnated occlusive dressings is a cost-effective measure for infection prophylaxis after TKA and THA.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

Injection Drug Use in Patients With Spinal Epidural Abscess: Nationwide Data, 2000 to 2013.

STUDY DESIGN: Retrospective review of the Healthcare Cost and Utilization Project National Inpatient Sample, 2000 to 2013. OBJECTIVE: To determine the proportion of spinal epidural abscess (SEA) cases that were related to injection drug use (IDU) and to compare length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between SEA cases with and without IDU. SUMMARY OF BACKGROUND DATA: The US opioid epidemic impacts all aspects of healthcare, including spinal surgeons. Although injection drug use (IDU) is a risk factor for spinal epidural abscess (SEA), IDU among SEA patients and its effect on clinical outcomes is not well understood. METHODS: Cases aged 15 to 64 with principal diagnosis of SEA were classified as IDU-related (IDU-SEA) or non-IDU-related (non-IDU-SEA) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for illicit drug use and hepatitis C. We determined the proportion of SEA patients with IDU and compared length of stay, leaving against medical advice, paralysis, cauda equina syndrome, radiculitis, and in-hospital mortality between IDU-SEA and non-IDU-SEA patients. RESULTS: From 2000 to 2013, there were 20,425 admissions with a principal diagnosis of SEA (95% confidence interval (CI), 19,281-21,568); 19.1% were associated with IDU (95% CI, 17.7%-20.5%). The proportion of white IDU-SEA cases increased by 2.4 percentage points annually (95% CI, 1.4-3.4). After adjusting for age, sex, and race, IDU-SEA patients stayed a mean of 6.7 more days in the hospital (95% CI, 5.1-8.2) and were 4.8 times more likely to leave against medical advice (95% CI, 2.9-8.0). Mean hospital charges for IDU-SEA patients were $31,603 higher (95% CI: $20,721-$42,485). Patients with IDU-SEA were less likely to have cauda equina syndrome (adjusted odds ratio, 0.48, 95% CI, 0.26-0.87). CONCLUSION: IDU-SEA patients stay in the hospital longer and more often leave against medical advice. Providers and hospitals may benefit from exploring how to better facilitate completion of inpatient treatment and achieve superior outcomes. LEVEL OF EVIDENCE: 3.