Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture.

BACKGROUND: A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications. RESULTS: In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001). CONCLUSION: Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture.

Investigating immediate postoperative medical complication risks relative to in-hospital length of stay after total shoulder arthroplasty.

Background: The purpose of this study was to investigate the association between in-hospital length of stay (LOS) and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA). Methods: All patients who underwent either anatomic or reverse TSA between 2015 and 2019 were queried from the American College of Surgeons National Surgical Quality Improvement database. The study population was stratified into three cohorts as follows: LOS 0 (same-day discharge), LOS 1 (next-day discharge), and LOS 2-3 (LOS of 2-3 days). Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression analysis was conducted to investigate the relationship between LOS and postoperative complications. Results: In comparison to the LOS 0 day cohort, LOS 2-3 day cohort had a greater likelihood of developing overall complication (OR, 2.598; P < .001), major complication (OR, 1.885; P < .001), minor complication (OR: 3.939; P < .001), respiratory complication (OR: 12.979; P = .011), postoperative anemia requiring transfusion (OR, 23.338; P < .001), non-home discharge (OR, 10.430; P < .001), and hospital readmission (OR, 1.700; P = .012). Similarly, in comparison to the LOS 1 cohort, LOS 2-3 cohort had a greater likelihood of developing overall complication (OR: 2.111; P < .001), major complication (OR, 1.423; P < .001), minor complication (OR, 3.626; P < .001), respiratory complication (OR, 2.057; P < .001), sepsis or septic shock (OR: 2.795; P = .008), urinary tract infection (OR, 1.524; P = .031), postoperative anemia requiring transfusion (OR, 10.792; P < .001), non-home discharge (OR: 10.179; P < .001), hospital readmission (OR, 1.395; P < .001), and return to the operating room (OR. 1.394; P = .014). There was no significant difference in the risk of developing postoperative complications between LOS 0 day and LOS 1 day cohort. On baseline, the LOS 1 and LOS 2-3 day cohort had a higher proportion of patients with the following demographics and comorbidities compared to LOS 0 day cohort: advanced age, higher body mass index, female gender, positive smoking status, insulin-dependent diabetes, noninsulin-dependent diabetes, dyspnea at rest and moderate exertion, partially dependent functional status, an American Society of Anesthesiologists classification of 3 or higher, a history of severe chronic obstructive pulmonary disease, a history of congestive heart failure, the use of hypertension medication, disseminated cancer, wound infection, the use of steroids, and a history of bleeding disorder. Conclusion: Patients who were discharged on the same and next day following TSA demonstrated a reduced probability of experiencing respiratory complications, infections, postoperative anemia requiring transfusion, non-home discharge, and readmission in comparison to those with a LOS of 2-3 days. There was no difference in postoperative complications between same and nextday discharged patients. Patients who underwent outpatient arthroplasty were healthier at baseline compared to those who underwent inpatient arthroplasty.

Outcomes of reverse shoulder arthroplasty in patients with previous rotator cuff repair: a systematic review and meta-analysis.

Background: Rotator cuff tears are a common injury encountered by orthopedic surgeons. Reverse shoulder arthroplasty (RSA) has become a treatment option for those with acute tears, as well as those with prior failed rotator cuff repair (RCR). The objective of this study was to determine if there are differences in postoperative outcomes for patients with previous RCR compared to those undergoing primary RSA for rotator cuff tears. Methods: A comprehensive literature search was conducted using PubMed, EMBASE, Scopus, and Cochrane Library databases. All relevant studies were reviewed by two authors according to inclusion and exclusion criteria defined in the study. Demographics and postoperative outcomes including functional scores, range of motion, pain scores, and complications were recorded. Results: Six level III articles encompassing 2176 shoulders were included in the analysis (846 with previous RCR and 1330 without). Average postoperative American Shoulder and Elbow Surgeons scores were 75.41 in the prior RCR group and 81.61 in the group without prior repair (mean difference [MD] = -5.95, P ≤ .0001 I2 = 36). Average postoperative Simple Shoulder Test scores were 8.40 in the RCR group and 9.57 in the group without prior RCR (MD = -0.93, P ≤ .0001, I2 = 66). Average postoperative Constant Score was 62.97 in the RCR group and 66.63 in the group without prior RCR (MD = -5.02, P ≤ .0001, I2 ≤ 0.001). Average postoperative University of California at Los Angeles Shoulder Scale score was 28.27 in the RCR group and 29.13 in the group without prior RCR (MD = -1.75, P ≤ .001, I2 ≤ 0.001). Average postoperative visual analog scale pain score was 1.77 in the RCR group and 0.95 in the group without prior RCR (MD = 0.75, P ≤ .0001, I2 = 35). Conclusion: Patients with prior RCR undergoing RSA have worse postoperative functional scores and pain scores than those without prior RCR. However, these differences are below the minimal clinically important difference for each outcome.

Middle Finger Metacarpophalangeal Joint Locked in Flexion Caused by Entrapped Ulnar Collateral Ligament.

Type 1 finger metacarpophalangeal (MCP) joint locking is characterized by maintained flexion of the MCP, with a lack of active and passive extension. Metacarpophalangeal joint locking is rare but has several identified causes, most commonly involving a radial-sided osteophyte. We report a case of right middle finger ulnar collateral ligament (UCL) entrapment characterized as type 1 MCP joint locking. The physical examination demonstrated that the right middle finger was locked in flexion at 60° at the MCP joint. Magnetic resonance imaging (MRI) demonstrated a possible tear of the distal attachment of the UCL at the MCP joint. Closed manipulation was unsuccessful in the office, and the patient underwent MCP ulnar osteophyte excision with full postoperative recovery. Although diagnosing the cause of UCL locking may be complicated by the lack of evidence in imaging studies, patients can return to full function by restoring the integrity of the joint with surgical treatment.

Readmission, reoperation, and nonhome discharge rates in patients receiving surgical treatment for proximal humerus fractures.

Background: Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs. Methods: Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation. Results: A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF. Conclusion: Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.

Acute Limb Ischemia Following a Mild Case of COVID-19.

Coronavirus disease 2019 (COVID-19) was a novel virus that originated in China in November 2019 and is most known for its respiratory compromise; however, many patients have experienced vascular thrombosis as sequelae of COVID-19. It is thought that the virus causes endothelial cell damage and increased platelet and leukocyte adhesion, causing a hypercoagulable state. While the most common presentation of hypercoagulability associated with COVID-19 is venous thrombosis, there are reports of patients who present with acute limb ischemia. We present a case of acute leg ischemia in an otherwise asymptomatic patient with no atherosclerotic risk factors.

Atypical Appendicitis in the Elderly.

Amyand's hernia is an extremely rare condition in which the appendix is positioned in the inguinal hernia sac. Acute appendicitis is much less common in this situation, especially in the elderly population, and few reports are found in the literature. Whether the presence of the appendix within the inguinal sac increases the chance of developing appendicitis or the relationship is coincidental is unclear. Majority of cases reported are in the male pediatric population. The varying surgical approaches are entirely case-specific without much standardization. Perioperative planning remains difficult in all cases as this condition is exceedingly rare, especially outside of the pediatric population. We present such a case with the hope that we increase awareness about this uncommon condition, in which preoperative diagnosis and planning remains difficult.

Clinical outcomes following reverse total shoulder arthroplasty with tuberosity excision for treatment of proximal humerus fractures: a case series.

Background: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment option for complex 3- and 4-part proximal humerus fractures in elderly patients. The literature has demonstrated that tuberosity repair likely improves postoperative range of motion (ROM). However, the difference between tuberosity repair and excision may not be appreciable to patients in their day-to-day lives. This case series reports both objective and subjective clinical outcomes of patients who underwent RTSA with tuberosity excision for proximal humerus fractures. Methods: We reviewed the records of 41 patients who underwent RTSA for complex 3- and 4- part proximal humerus fractures. All RTSA procedures were performed by a single surgeon between 2014 and 2017. All patients underwent RTSA with extended proximal stem cementation and tuberosity excision. Postoperative outcomes were measured at least 2 years postoperatively and included ROM measurements for forward flexion, internal rotation, abduction, and external rotation. Patient-reported outcome measures included Simple Shoulder Test scores, American Shoulder and Elbow Surgeons scores, and Penn Shoulder Score were also reported. Results: In this case series, we report on 41 patients, 33 females and 8 males. Objective measurements of ROM for forward flexion, abduction, and external rotation were 125, 95, and 36 degrees, respectively. On average, patients had an internal rotation score of 2.06 and were able to get their thumb to their iliac crest. Clinical outcome scores of these patients were 9.11, 77.79, and 74.12 for the Simple Shoulder Test, American Shoulder and Elbow Surgeons, and Penn Shoulder Score, respectively. Strength of the deltoid was 5/5 in all 41 patients. Conclusions: When compared with the current literature, our tuberosity excision patients demonstrated deficits in forward flexion and abduction, with preserved external rotation. Our clinical outcome score measurements were consistent with clinical outcome measurements from previous studies of patients undergoing RTSA with tuberosity repair. We believe that tuberosity excision may be a reasonable and simpler surgical option for surgeons with lower volumes of shoulder fractures and patients with multiple comorbidities and higher surgical risk, owing to the similarity of outcome scores between our cohort and previous tuberosity repair groups.