Factors Associated With Same Day Discharge Post-Spinal Cord Stimulator Placement.

BACKGROUND: Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS. OBJECTIVE: The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge. STUDY DESIGN: Retrospective, cohort study using a nationwide database. METHODS: Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS. RESULTS: After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001). LIMITATIONS: Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results. CONCLUSION: These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

Cannabis and Anxiety: A Critical Review.

Introduction: Cannabis has been reported to have both anxiogenic and anxiolytic effects. Habitual cannabis use has been associated with anxiety disorders (AD). The causal pathways and mechanisms underlying the association between cannabis use (CU)/cannabis use disorder (CUD) and anxiety remain unclear. We examined the literature via a systematic review to investigate the link between cannabis and anxiety. The hypotheses studied include causality, the common factor theory, and the self-medication hypothesis. Methods: Critical systematic review of published literature examining the relationship of CU/CUD to AD or state-anxiety, including case reports, literature reviews, observational studies, and preclinical and clinical studies. A systematic MEDline search was conducted of terms including: [anxiety], [anxiogenic], [anxiolytic], [PTSD], [OCD], [GAD], [cannabis], [marijuana], [tetrahydrocannabinol], [THC]. Results: While several case-control and cohort studies have reported no correlation between CU/CUD and AD or state anxiety (N = 5), other cross-sectional, and longitudinal studies report significant relationships (N = 20). Meta-analysis supports anxiety correlating with CU (N = 15 studies, OR = 1.24, 95% CI: 1.06-1.45, p = 0.006) or CUD (N = 13 studies, OR = 1.68, 95% CI: 1.23-2.31, p = 0.001). PATH analysis identifies the self-medication hypothesis (N = 8) as the model that best explains the association between CU/CUD and AD or state-anxiety. Despite the support of multiple large cohort studies, causal interpretations (N = 17) are less plausible, while the common factor theory (N = 5), stress-misattribution hypothesis, and reciprocal feedback theory lack substantial evidential support. Conclusion: The association between cannabis and anxiety is best explained by anxiety predisposing individuals toward CU as a method of self-medication. A causal relationship in which CU causes AD incidence is less likely despite multiple longitudinal studies suggesting so.

Long-Term Outcomes After Spinal Cord Stimulator Placement in Patients with Pre-procedural Active Opioid Use Versus Patients Who Were Opioid-Naïve.

BACKGROUND: Outcome optimization after the placement of a spinal cord stimulator (SCS) is critical. The objective of this study was to determine if an association existed between pre-procedural opioid use (compared to patients who were opioid-naïve) and postoperative long-term outcomes following SCS placement. OBJECTIVE: To examine the impact of preprocedural opioid use on long-term outcomes after SCS therapy. STUDY DESIGN: Cohort study utilizing a nationwide database. SETTING: Retrospective. METHODS: With the use of data from HCA Healthcare's national database, a retrospective cohort study was performed to analyze differences in outcomes between opioid-naïve patients and preoperative opioid users who underwent SCS placements. The primary outcome of interest was device explantation at 6 months and 12 months. Secondary outcome measurements included reoperations and readmissions at 6 months and 12 months, as well as operative complications. Multivariable logistic regression models were performed to analyze the association of preoperative opioid use with those outcomes. The odds ratio (OR), 95% confidence intervals (CI), and P values were reported for the independent variables. RESULTS: The final study population consisted of 13,893 patients who underwent SCS placements. In univariate analyses, patients who used opioids preoperatively had higher 6-month (3.6% vs. 2.6%) and one-year removal rates (3.6% vs. 2.8%) (all P < 0.009). On multivariable logistic regression, those using opioids preoperatively had higher odds of removal at 6 months (OR = 1.290, 95% CI 1.05-1.58, P = 0.01) and at one year (OR = 1.23, 95% CI 1.01-1.50, P = 0.04). There was no difference between patients requiring preoperative opioids and patients who were opioid-naive as far as the odds of 6- or 12-month readmissions were concerned. Compared to the opioid-naive group, patients requiring preoperative opioids had increased odds of reoperation at 6 months (OR = 1.2, 95% CI 1.02-1.40, P = 0.03). There were no differences in the odds of complications between both cohorts. LIMITATIONS: Opioid use in this study was defined as using opioids preoperatively in the 30 days leading up to surgery. CONCLUSION: Patients requiring preoperative opioids before SCS placements had increased odds of SCS explantation at 6 months and 12 months, as well as increased odds of reoperation at 6 months.

Differences in Regional Anesthesia Utilization by Hospital Region in the United States.

BACKGROUND: Regional anesthesia has been associated with improved postoperative outcomes. Disparities in regional anesthesia utilization exist; however, no studies have examined utilization rates as a function of hospital region. METHODS: A national hospital database (Hospital Corporation of America {HCA}) was queried for patients aged 18 years or older that received selected surgical procedure codes between January 2016 and June 2021. Surgical procedures included were total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, total abdominal hysterectomy (TAH), open reduction and internal fixation (ORIF) of the ankle, and arteriovenous (AV) fistula creation. Regional anesthesia was defined as any form of neuraxial and/or peripheral nerve blocks. Basic summary statistics were utilized to calculate the rates of regional anesthesia (RA), and chi-squared analyses were calculated to determine significant differences in the rate of RA utilization. RESULTS: There were 52,068 patients included in this study, of which 2,114 (4.1%) received RA. The greatest RA rates were for TSA (5.8%), TKA (4.5), and anterior cruciate ligament reconstruction (ACLR) (3.6%), whereas the lowest RA rate was for TAH (1.1%). For the TKA cohort, the Midwest had a significantly greater utilization rate than the South or West (10.9% vs. 4.8% or 3.1%, p<0.001). The Midwest also had the highest utilization rate in the ACLR cohort (8.1%, p<0.001), TAH cohort (16.7%, p<0.001), and AV fistula cohort (6.4%, p<0.001). For the carpal tunnel cohort, the West had the highest utilization rate (11.8% vs. 8.1%, 1.1%, 0%, p<0.001). The West region also had the highest utilization rate for the ankle ORIF (7.8%, p<0.001). No significant differences were found by region for TSA (p=0.31). CONCLUSION: Significant variations in RA utilization rates were found by region, with the West having the highest utilization for ankle ORIF and carpal tunnel, and the Midwest having the highest rate for TKA, ACLR, TAH, and AV fistula.

Association of patient characteristics with the receipt of regional anesthesia.

BACKGROUND: Regional anesthesia (RA) may improve patient-related outcomes, including decreased operative complications, shortened recovery times, and lower hospital readmission rates. More analyses are needed using a diverse set of databases to examine characteristics associated with the receipt of RA. METHODS: A national hospital database was queried for patients 18 years or older who underwent total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, ankle open reduction, and internal fixation and arteriovenous fistula creation between January 2016 and June 2021. Regional techniques included neuraxial anesthesia and various upper and lower extremity peripheral nerve blocks to create a binary variable of RA receipt. Univariate statistics were used to compare characteristics associated based on RA receipt and multivariable regression identified factors associated with RA receipt. RESULTS: A total of 51 776 patients were included in the analysis, of which 2111 (4.1%) received RA. Factors associated with decreased odds of RA receipt included black race (vs white race; OR 0.73, 95% CI 0.62 to 0.86), other non-white race (vs white race; OR 0.71, 95% CI 0.61 to 0.86), American Society of Anesthesiologists (ASA) class (vs ASA 1; OR 0.85, 95% CI 0.79 to 0.93), and Medicaid insurance (vs private insurance; OR 0.65, 95% CI 0.51 to 0.82) (all p<0.05). When compared with TKA, ACLR (OR 0.67, 95% CI 0.53 to 0.84), ankle open reduction and internal fixation (OR 0.68, 95% CI 0.58 to 0.81), and carpal tunnel release (OR 0.68, 95% CI 0.59 to 0.78) demonstrated lower odds of RA receipt, whereas TSA (OR 1.31, 95% CI 1.08 to 1.58) demonstrated higher odds of RA receipt (all p<0.05). CONCLUSION: RA use varies with respect to race, insurance status, and type of surgery.

The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement.

BACKGROUND: Outcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation. MATERIALS AND METHODS: Inclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals. RESULTS: A total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36-1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37-1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6-1.8, p < 0.001). CONCLUSIONS: The presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.

Spinal Cord Stimulator (SCS) Placement: Examining Outcomes Between the Open and Percutaneous Approach.

BACKGROUND: Spinal cord stimulator (SCS) placement has been gaining traction as an approach to modulate pain levels for several different chronic pain conditions. This procedure can be performed via a percutaneous or open approach. Data regarding SCS complications are relatively limited. OBJECTIVE: The purpose of this study was to leverage a large national database to examine outcomes between the percutaneous and open SCS placement approaches. Outcomes in this study include length of stay (LOS), complication rates, reoperation rates, and 1-year readmission rates. MATERIALS AND METHODS: Inclusion criteria for the current study is SCS placement between 2015 and 2020, with receipt of an SCS using either a percutaneous approach or an open laminectomy based approach. Encounters included were limited to true SCS placement, such that trial placements were not included in the study. Univariate statistics and multivariable logistic regression was performed to compare outcomes between cohorts. RESULTS: Total SCS case volumes were 9935 between the percutaneous (n = 4477, 45.1%) and open (n = 5458, 54.9%) approach. Patients receiving the percutaneous approach were found to have a mean decrease in LOS of 9.91 hours when compared to those receiving the open approach. The percutaneous approach was significantly associated with the need for reoperation within one year compared to the open approach (odds ratio [OR]: 0.663, p < 0.001), as well as with the need for readmission within 30 days (51.2% vs 40.2%, OR: 0.759, p < 0.001). CONCLUSION: The open approach, when compared to the percutaneous approach, had a longer mean LOS, lower outpatient discharge rates, and higher odds of experiencing an operative complication in comparison to the percutaneous approach. The percutaneous approach had relatively increased odds of thirty-day readmission, although no significant difference in one-year readmission or removal was demonstrated.

Magnetic Resonance Imaging Findings of the Asymptomatic Shoulder May Impact Performance, Not Future Injury List Placement in Major League Baseball Pitchers.

Purpose: To evaluate preseason shoulder magnetic resonance images (MRIs) obtained from pitchers entering either major or minor league baseball (MLB) and correlate findings with subsequent injury, operative repair, and placement on the injured list (IL). Methods: Preseason-MRI of the throwing shoulders of professional-level baseball pitchers, taken during routine evaluations at a single organization (2004-2017) were retrospectively reviewed. Publicly available databases were queried to exclude pitchers with known injuries prior to pre-signing imaging. Three blinded reviewers reviewed all MRI scans independently to evaluate for the presence of abnormalities in the rotator cuff (RTC), labrum, capsule, long-head of the biceps tendon (LHBT), and humeral head. Binary imaging findings were correlated to future placement on the IL for subsequent shoulder complaints. Bivariate statistics using Student's t-tests and Fisher exact tests (both α = .05) were used in this study. Results: A total of 38 asymptomatic pitchers with shoulder MRIs were included. Pitchers had a mean (±SD) age of 28.2 ± 4.9 and had pitched an average of 119.6 ± 143.8 career games. Pitchers with partial articular-sided RTC tears (P = .04) or intra-articular BT hyperintensity (P = .04) on preseason MRI demonstrated an association with the need for future surgery. Pitchers with evidence of labral heterogeneity demonstrated greater total career pitch counts (10,034.1 vs 2,465.3; P = .04). Evidence of a posterior-superior humeral cyst was associated with decreased strikeouts per 9 innings (6.1 vs 8.0; P = .039) and total strikeout percentage (16.1% vs 23.2%; P = .04). Conclusion: Although there was a significant difference in the percent of various radiographic findings between the injured and healthy cohort, no MRI findings were predictive of future IL placement or duration of placement. The presence of a posterior superior humeral cyst was associated with decreased strikeout rates at 2 and 3 years, the presence of a labral tear was associated with decreased earned run average (ERA) at 3 years and decreased career strikeout percentages, and increased capsular signal was associated with decreased 5-year ERA. Level of Evidence: Level IV, retrospective study.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review.

PURPOSE: To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP. METHODS: Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies. RESULTS: Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP). CONCLUSIONS: Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

How Long Does It Take to Achieve Clinically Significant Outcomes After Isolated Biceps Tenodesis?

Background: Clinically significant outcomes (CSOs) connect patient-reported outcome measures data to patient-perceived benefit. Although investigators have established threshold values for various CSOs, the timeline to achieve these outcomes after isolated biceps tenodesis (BT) has yet to be defined. Purpose: To define the time-dependent nature of minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) achievement after isolated BT. Study Design: Case series; Level of evidence, 4. Methods: The American Shoulder and Elbow Surgeons score (ASES), the Single Assessment Numeric Evaluation, and the Constant-Murley score (CMS) were administered preoperatively and at 6 and 12 months postoperatively to patients undergoing isolated BT between 2014 and 2018 at our institution. Cumulative probabilities for achieving MCID, SCB, and PASS were calculated using Kaplan-Meier survival analysis. Weibull parametric regression evaluated the hazard ratios (HRs) of achieving earlier MCID, SCB, and PASS. Results: Overall cohort (N = 190) achievement rates ranged between 77.8% and 83.2% for MCID, between 42.2% and 80.2% for SCB, and between 59.7% and 62.9% for PASS. Median achievement time was 5.3 to 6.1 months for MCID, 5.9 to 6.4 months for SCB, and 6.07 to 6.1 months for PASS. Multivariate Weibull parametric regression identified older age, male sex, higher body mass index, preoperative thyroid disease, smoking history, and higher preoperative CMS as predictors of delayed CSO achievement (HR, 1.01-6.41), whereas normal tendon on arthroscopy, defined as absence of tenosynovitis or tendon tear on arthroscopy, predicted earlier CSO achievement (HR, 0.19-0.46). Location of tenodesis and worker compensation status did not significantly predict the time to achieve CSOs on multivariate analysis. Conclusion: After isolated BT, patients can expect to attain CSO by 13 months postoperatively, with most patients achieving this between 5 and 8 months. Patients tend to take longer to achieve PASS than MCID and SCB.

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement.

BACKGROUND: The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery. METHODS: Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05. RESULTS: 379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID). CONCLUSION: Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis.

This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m2) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all P<.001) and SCB achievement (chi-square=26.02-53.24, all P<.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, P<.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [Orthopedics. 2021;44(5):299-305.].

The Influence of Hospital Urbanicity on Mortality in Patients With Acute Respiratory Failure: A National Cohort Retrospective Analysis.

BACKGROUND: The primary objective of this study was to employ a national database to evaluate the association of hospital urbanicity, urban versus rural, on mortality and length of hospital stay in patients hospitalized with acute respiratory failure. METHODS: We used the 2014 National Inpatient Sample database to evaluate the association of hospital urbanicity with (1) mortality and (2) prolonged hospital stay, defined as ≥ 75th percentile of the study population. We conducted a mixed-effects logistic regression analysis adjusting for sociodemographic variables and medical comorbidities. The random effect was hospital identification number (a unique value assigned in the NIS database for a specific institution). The odds ratio (OR), 95% CI, and P values were reported for each independent variable. RESULTS: The odds of inpatient mortality were significantly higher among urban teaching (OR 1.39, 95% CI 1.39-1.66, P < .001) and urban nonteaching hospitals (OR = 1.39, 95% CI 1.26-1.52, P < .001) compared to rural hospitals. The odds of prolonged hospital stay were significantly higher among urban teaching (OR = 1.82, 95% CI 1.66-2.0, P < .001) and urban nonteaching compared to rural hospitals (OR = 1.50, 95% CI 1.36-1.65, P < .001). CONCLUSIONS: This study supports the current body of literature that there are significant differences in patient populations among hospital type. Differences in health outcomes among different types of hospitals should be considered when designing policies to address health equity as these are unique populations with specific needs.

Short-Term Clinical and Return-to-Work Outcomes After Arthroscopic Suprapectoral Onlay Biceps Tenodesis With a Single Suture Anchor.

PURPOSE: To describe short-term outcomes of arthroscopic suprapectoral onlay biceps tenodesis using a single all-suture anchor with respect to validated outcome measures, return to work, objective strength and motion data, and biceps-specific testing. METHODS: This study describes a consecutive series of patients undergoing arthroscopic suprapectoral onlay biceps tenodesis performed by a single surgeon from January to December 2017. Patients were evaluated preoperatively and postoperatively with the American Shoulder and Elbow Surgeons questionnaire, visual analog scale, Single Assessment Numeric Evaluation, Veterans RAND 12-Item Health Survey, and 12-Item Short Form survey, and return-to-work survey. Postoperative strength, range of motion, and biceps-specific testing was also performed. RESULTS: This study included 50 patients (26 men and 24 women), with an average age (± standard deviation) of 50.1 ± 10.9 years and average final follow-up of 21.3 ± 8.5 months. Among employed patients, 32 (71.1%) returned to work at an average of 4.6 ± 2.3 months. Light-duty workers returned to work at a significantly greater rate (85.7% vs 33.3%, P = .016) and in less time (2.6 ± 2.0 months vs 6.8 ± 4.2 months) than heavy-duty workers. No differences were found between operative and nonoperative sides in the biceps apex distance (P = .636) or range of motion in elbow flexion and extension (P > .9 for both), supination (P = .192), or pronation (P = .343) postoperatively. Strength in elbow flexion (P = .002), as well as shoulder forward elevation (P < .001) and external rotation (P < .001), increased postoperatively. Significant patient-reported improvements were noted in the American Shoulder and Elbow Surgeons score, visual analog scale pain score, Single Assessment Numeric Evaluation score, Constant-Murley score, and Veterans RAND 12-Item Health Survey and 12-Item Short Form physical component scores (P ≤ .001 for all). A postoperative Popeye deformity developed in 5 patients (10%). CONCLUSIONS: Arthroscopic suprapectoral onlay biceps tenodesis with a single all-suture anchor can provide overall excellent clinical outcomes regarding strength, motion, and validated patient-reported outcome questionnaires. Return to occupational activities may be less predictable and more prolonged for heavy laborers. A small number of patients may experience cosmetic deformity postoperatively. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Microdrilling Demonstrates Superior Patient-Reported Outcomes and Lower Revision Rates Than Traditional Microfracture: A Matched Cohort Analysis.

PURPOSE: The purpose of this study was to compare patient-reported outcomes and revision rates between the standard microfracture awl versus the microdrilling technique. METHODS: Microfracture patients were queried from a single-institution database between 2001 and 2016. Patient-reported outcome measure data were collected at preoperative and 6- and 12-month time points, inclusive of the International Knee Documentation Committee (IKDC) score, Short Form 12 (SF12) Physical Component Score (PCS) and Mental Component Score, and all Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales. A matching algorithm based on previous procedures, lesion size, and demographic factors created 2 technique-based cohorts. Outcomes including revision rates and both statistically and clinically significant differences (i.e., the minimally clinically important difference [MCID]) between awl and microdrill cohorts were compared using univariate statistics. RESULTS: A total of 68 patients (aged 32.0 ± 13.1 years, 48.5% female, body mass index 26.7 ± 5.3 kg/m2), with 34 patients in each group, were included after the match. At 6 months, the microdrilling group demonstrated significantly greater levels of improvement than the awl group on the IKDC, SF12 PCS, and KOOS Pain, Symptom, Sport, and Quality of Life (P < .04), although differences at 1 year were only maintained on the SF12 PCS instrument (P < .001). With respect to MCID achievement, the microdrilling group demonstrated greater achievement rates at 6 months on the IKDC, KOOS Pain, and KOOS Sport (P < .04). The awl group demonstrated a higher rate of revision surgery (P = .02) within 3 years of follow-up and a greater likelihood to require multiple subsequent procedures (41.1% vs 17.6%, P = .03). CONCLUSIONS: Microdrilling demonstrated superior outcomes relative to traditional microfracture awl techniques with respect to patient-reported outcomes at 6 months and revision rates within 3 years of follow-up. In addition, clinically meaningful differences were evident at 6 months in the microdrilling group. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Preoperative psychometric properties of Patient-Reported Outcomes Measurement Information System Upper Extremity, Pain Interference, and Depression in Bankart repair and rotator cuff repair.

BACKGROUND: We aimed to examine the preoperative performance of Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE, versions 1.2 and 2.0), Pain Interference (PI, version 1.1), and Depression (version 1.0) testing across multiple orthopedic procedures for the upper extremity and define its susceptibility to preoperative floor and ceiling effects. METHODS: We conducted a retrospective analysis of prospectively collected patient-reported outcome measures using an electronic outcome registry for procedures performed between May 2017 and April 2019. Current Procedural Terminology (CPT) codes were used to examine cohorts for 2 upper-extremity orthopedic procedures: Bankart repair and arthroscopic rotator cuff repair (ARCR). Shapiro-Wilk normality testing was used to assess score distributions for normalcy; given non-normal score distributions, Spearman correlation coefficients were calculated for preoperative patient-reported outcome scores. Absolute floor and ceiling effects were calculated for preoperative time points based on CPT code. RESULTS: A total of 488 patients were included across the Bankart repair cohort (n = 109; mean age, 29.3 ± 12.5 years) and ARCR cohort (n = 379; mean age, 57.5 ± 9.5 years). In the Bankart repair cohort, the PROMIS PI score demonstrated strong correlations with the American Shoulder and Elbow Surgeons score (r = -0.63), Constant score (r = -0.75), PROMIS UE score (r = -0.75), and Veterans RAND-6 Domain score (r = -0.61). The PROMIS Depression score (r = 0.23 and r = 0.17, respectively), Short Form 12 Mental Composite Scale score (r = 0.34 and r = 0.11, respectively), and Veterans RAND 12-item health survey Mental Composite Scale score (r = 0.44 and r = 0.15, respectively) exhibited poor correlations with the PROMIS PI and UE scores. In the ARCR cohort, the PROMIS PI score demonstrated a good correlation with the PROMIS UE score (r = 0.61). The Constant score (r = 0.58 and r = 0.67, respectively), Veterans RAND 12-item health survey Physical Composite Scale score (r = 0.58 and r = 0.47, respectively), and Veterans RAND-6 Domain score (r = 0.67 and r = 0.53, respectively) exhibited good correlations with the PROMIS PI and UE measures. No significant absolute floor or ceiling effects were observed for the PROMIS instruments except the PROMIS Depression measure: An absolute floor effect was noted for both the Bankart repair (n = 12, 30%) and ARCR (n = 38, 14.7%) groups. CONCLUSION: The PROMIS PI and UE instruments perform favorably compared with legacy outcome instruments in patients receiving Bankart repair, as well as those undergoing ARCR. Furthermore, in both populations, the PROMIS Depression instrument exhibits absolute floor effects whereas the PROMIS PI and UE instruments fail to demonstrate any absolute floor or ceiling effects.

Monitored Anesthesia Care Versus General Anesthesia as the Primary Anesthetic for Ankle Amputations.

OBJECTIVES: The authors hypothesized that monitored anesthesia care (MAC)-either by local sedation or regional anesthesia (RA)-compared with general anesthesia (GA), would be associated with lower odds of significant 30-day postoperative complications and mortality in patients undergoing an ankle amputation. DESIGN: Retrospective cohort study. SETTING: Inpatient. PARTICIPANTS: The authors used data from patients who underwent ankle amputation from the American College of Surgeons National Surgical Quality Improvement Program registry. INTERVENTION: RA as primary anesthetic. MEASUREMENTS AND MAIN RESULTS: A multivariate logistic regression was used to evaluate the association of primary anesthesia type with the outcomes. The regression analysis included all covariates to test the association of the primary exposure variable (anesthesia type) with each outcome of interest. The odds ratio (OR), with associated 95% confidence interval (CI), was reported for each covariate. There were a total of 3,368 patients undergoing guillotine amputation through the tibia/fibula (n = 2,935) or ankle disarticulation (n = 433). Among these patients, 15.5% (n = 491) received MAC as their primary anesthetic. Among all patients, 11.4% (n = 363) experienced a significant postoperative complication. On multivariate logistic regression, MAC was found to decrease odds of postoperative complications (OR 0.57, 95% CI 0.40-0.82, p = 0.002), but not mortality (OR 1.26, 95% CI 0.87-1.84, p = 0.22). CONCLUSION: This study showed that MAC was associated with improved outcomes, as opposed to GA, as the primary anesthetic in ankle amputations.

Association of race and ethnicity in the receipt of regional anesthesia following mastectomy.

BACKGROUND: Regional anesthetic techniques have become increasingly used for the purpose of pain management following mastectomy. Although a variety of beneficial techniques have been described, the delivery of regional anesthesia following mastectomy has yet to be examined for racial or ethnic disparities. We aimed to examine the association of race and ethnicity on the delivery of regional anesthesia in patients undergoing surgical mastectomy using a large national database. METHODS: We used the American College of Surgeons-National Surgical Quality Improvement Program database to identify adult patients aged ≥18 years old who underwent mastectomy from 2014 to 2016. We reported unadjusted estimates of regional anesthesia accordingly to race and ethnicity and examined differences in sociodemographic characteristics and health status. Multivariable logistic regression was used to report the association of race and ethnicity with use of regional anesthesia. RESULTS: A total of 81 345 patients who underwent mastectomy were included, 14 887 (18.3%) of whom underwent regional anesthesia. The unadjusted rate of use of regional anesthesia was 18.9% for white patients, 16.8% for black patients, 15.6% for Asian patients, 16.5% for Native Hawaiian/Pacific Islander patients, 17.8% for American Indian or Alaska Native and 17.4% for unknown race (p<0.001). With respect to ethnicity, the unadjusted rate of regional anesthesia use was 18.4% for non-Hispanic patients vs 16.1% for Hispanic patients vs 18.6% for the unknown ethnicity cohort (p<0.001). On multivariable logistic regression analysis, the odds of receipt of regional anesthesia was 12% lower in black patients and 21% lower in Asian patients compared with white patients (p<0.001). The odds of regional anesthesia use were 13% lower in Hispanic compared with non-Hispanic patients (p<0.001). CONCLUSION: Black and Asian patients had lower odds of undergoing regional anesthesia following mastectomy compared with white counterparts. In addition, Hispanic patients had lower odds of undergoing regional anesthesia than non-Hispanic counterparts. These differences underlie the importance of working to deliver equitable healthcare irrespective of race or ethnicity.

The Patient Acceptable Symptomatic State in Primary Anterior Cruciate Ligament Reconstruction: Predictors of Achievement.

PURPOSE: To identify thresholds for patient acceptable symptomatic state (PASS) achievement in a cohort of primary anterior cruciate ligament reconstruction (ACLR) recipients, and to identify factors predictive of PASS achievement. METHODS: A prospective clinical registry was queried for primary ACLR patients from January 2014 to April 2017 with serial patient-reported outcome measure (PROM) completion at 6, 12, and 24 months. Exclusion criteria included significant concomitant procedures. Knee-based PROMs included the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores. PASS threshold values were calculated using receiver operating characteristic (ROC) curves with area under the curve (AUC) analysis. A stepwise multivariate regression identified preoperative and operative predictors of PASS achievement. RESULTS: A total of 144 primary ACLR patients (30.86 ± 12.78 years, body mass index 25.51 ± 4.64, 41.0% male) were included in the analysis. PASS threshold values were established using ROC curve analysis, all of which exceeded 0.7 on AUC analysis (0.742 to 0.911). Factors impacting odds of PASS achievement in the ACLR cohort included preoperative exercises (odds ratio [OR] 2.95 to 4.74, P = .003 to .038), worker's compensation status (OR 0.25 to 0.28, P = .014 to .033), preoperative scores (OR 1.03 to 1.07, P = .005 to <.001), iliotibial band tenodesis (OR 11.08, P = .010), and anteromedial approach (OR 18.03 to 37.05, P < .001). CONCLUSION: Factors predictive of PASS achievement in recipients of primary ACLR include functional status (e.g., preoperative exercise, preoperative KOOS Sport/Recreation score), worker's compensation status, technique (e.g., anteromedial) and preoperative PROMs. The results of our study are important in better informing shared decision-making models and improving evidence-based guidelines to optimize patient outcomes.

Cost-effectiveness analyses in shoulder arthroplasty: a critical review using the Quality of Health Economic Studies (QHES) instrument.

HYPOTHESIS: The purpose of this study was to perform a systematic review to identify cost-analysis studies pertaining to shoulder arthroplasty, provide a comprehensive review of published studies, and critically evaluate the quality of the available literature using the Quality of Health Economic Studies (QHES) instrument. METHODS: A systematic review of the literature was performed to identify cost analyses examining shoulder arthroplasty. The inclusion criteria included studies pertaining to either shoulder hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA. Articles were excluded based on the following: nonoperative studies, nonclinical studies, studies not based in the United States, and studies in which no cost analysis was performed. The quality of studies was assessed using the QHES instrument. One-sided Fisher exact testing was performed to identify predictors of both low-quality (ie, QHES score < 25th percentile) and high-quality (ie, QHES score > 75th percentile) cost analyses based on items within the QHES checklist. RESULTS: Of the 196 studies screened, 9 were included. Seven studies conducted cost analyses comparing reverse TSA vs. arthroscopic rotator cuff repair, HA, or total hip arthroplasty, and 2 studies examined TSA vs. HA for primary glenohumeral arthritis. The average QHES score among all studies was 86.22 ± 13.39 points. Failure to include an annual cost discounting rate was associated with a low-quality QHES score (P = .03). In addition, including a discussion of the magnitude and direction of potential biases was associated with a high-quality score (P = .03). CONCLUSIONS: Shoulder arthroplasty is a cost-effective procedure when used to treat a multitude of shoulder pathologies. The overall quality of cost analysis in shoulder arthroplasty is relatively good, with an average QHES score of 86.22 points. Studies failing to include an annual cost discounting rate are more likely to score below the 25th percentile, whereas those including a discussion of the magnitude and direction of potential biases are more likely to achieve a score in excess of the 75th percentile.