Identification of Data-Driven Preoperative Hemoglobin Strata That Predict the Likelihood of Blood Transfusion and the Risk of Major Complications and Prosthetic Joint Infection After Total Hip Arthroplasty.

INTRODUCTION: Preoperative anemia is an independent risk factor of complications after primary total hip arthroplasty (THA). Currently used hemoglobin thresholds are not developed for risk stratification of arthroplasty patients and do not provide surgery-specific information on postoperative complication risk. Thus, we aimed to calculate THA-specific preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and determine whether these strata are associated with increased risk of 90-day complications and 2-year prosthetic joint infection (PJI). METHODS: A retrospective cohort analysis identified 56,101 patients who underwent primary THA from 2013 to 2022. Using the lowest hemoglobin value for each patient one month before THA, stratum-specific likelihood ratio (SSLR) analysis calculated sex-based hemoglobin strata associated with the likelihood of 90-day postoperative blood transfusion. Propensity score matching was performed. Incidence rates and risk of 90-day major complications and 2-year PJI were observed for each identified preoperative hemoglobin stratum. RESULTS: SSLR analysis identified five male (strata, likelihood ratio [<10.4 g/dL, 12.5; 10.5 to 11.4 g/dL, 8.0; 11.5 to 12.4 g/dL, 2.4; 12.5 to 13.4 g/dL, 1.3; 13.5 to 13.9 g/dL, 0.5]) and five female (<8.9 g/dL, 10.7; 9.0 to 10.9 g/dL, 4.0; 11.0 to 11.4 g/dL, 2.0; 12.0 to 12.9 g/dL, 1.0; 13.0 to 13.4 g/dL, 0.6) preoperative hemoglobin strata associated with varying likelihoods of 90-day blood transfusion after THA. After matching in both male and female cohorts, as the calculated preoperative hemoglobin strata decreased, the relative risk of overall 90-day major complications and 2-year PJI increased incrementally (all P < 0.05). CONCLUSION: SSLR analysis established THA-specific sex-based preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and predict the risk of 90-day medical complications and 2-year PJI. These strata are a first of their kind in THA research. While preoperatively optimizing patients, we recommend using these hemoglobin thresholds to help guide decisions on presurgery anemia optimization and to reduce the need for postoperative blood transfusion. LEVEL OF EVIDENCE: Level III.

Evaluating the Effect of Decreasing Preoperative Hemoglobin on Blood Transfusions, Major Complications, and Periprosthetic Joint Infection After Primary Total Knee Arthroplasty.

INTRODUCTION: Preoperative anemia is associated with increased postoperative transfusion and complication rates after total knee arthroplasty (TKA). We aimed to create TKA-specific data-driven preoperative hemoglobin strata that quantify the likelihood of 90-day postoperative blood transfusion and evaluate whether these strata are associated with increased risk of 90-day major complications and 2-year prosthetic joint infection (PJI). METHODS: Primary TKA patients from 2013 to 2022 were identified using a national database. Stratum-specific likelihood ratio (SSLR) analysis defined hemoglobin strata associated with the risk of 90-day blood transfusion. Each stratum was propensity score matched to the highest identified hemoglobin strata. Unmatched incidence rates and matched risk of 90-day major complications and 2-year PJI between strata were compared. RESULTS: SSLR identified four 90-day blood transfusion hemoglobin strata for men (strata [g/dL], likelihood ratio [<11.4, 8.06; 11.5 to 11.9, 4.34; 12.0 to 12.9, 1.70; 13.0 to 17.0, 0.54]) and women (<10.4, 8.22; 10.5 to 11.4, 2.84; 11.5 to 12.4, 1.38; 12.5 to 17.0, 0.50). Increased 2-year PJI risk was associated with three male strata (<11.4, 11.5 to 11.9, 12.0 to 12.9; all P < 0.001) and three female strata (<10.4, 10.5 to 11.4, 11.5 to 12.4; all P < 0.001). Increased 90-day major complication risk was associated with three male strata (<11.4, 11.5 to 11.9, 12.0 to 12.9; all P < 0.001) and three female strata (<10.4, 10.5 to 11.4, 11.5 to 12.4; all P < 0.001). CONCLUSIONS: Using SSLR analysis, we identified unique TKA-specific data-driven hemoglobin strata for both men and women that quantify the likelihood of 90-day blood transfusions and predict the risk of both 90-day major complications and 2-year PJI. These strata are a first in the TKA literature and can assist surgeons in stratifying patients' transfusion and complication risk based on their preoperative hemoglobin value. While optimizing patients in the preoperative setting, we recommend using these TKA-specific hemoglobin thresholds to help guide decision making on the need for presurgery anemia optimization and to help reduce the need for blood transfusion.

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head.

INTRODUCTION: Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies. METHODS: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness. RESULTS: In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all). CONCLUSION: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Evaluating The Effect of Arthroscopic Rotator Cuff Repair with Concomitant Subacromial Decompression on 2, 4, and 6 Year Reoperation Rates.

INTRODUCTION: The risks and benefits of including an arthroscopic subacromial decompression (ASD) during arthroscopic rotator cuff repair (RCR) are uncertain. Some studies suggest no difference in revision surgery rates, whereas others have found higher revision surgery rates associated with concomitant ASD. In this study, we compare mid-term revision surgery rates in patients undergoing arthroscopic RCR with or without concomitant ASD. METHODS: A retrospective cohort analysis was conducted using a national all-payer claims database. Current Procedural Terminology and International Classification of Disease, 10th Revision, codes were used to identify patients who underwent primary arthroscopic RCR with or without ASD in the United States. The primary study outcome was revision surgery at 2, 4, and 6 years. Univariate analysis was conducted on demographic variables (age, sex) and comorbidities in the Elixhauser Comorbidity Index using chi-square and Student t-tests. Multivariate analysis was conducted using logistic regression. RESULTS: A total of 11,188 patients were identified who underwent RCR and met the inclusion criteria. Of those, 8,994 (80%) underwent concomitant ASD. Concomitant ASD was associated with lower odds of all-cause revision surgery to the ipsilateral shoulder at 2 years (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.51 to 0.73), 4 years (OR, 0.60; 95% CI, 0.51 to 0.70), and 6 years (OR, 0.59; 95% CI, 0.51 to 0.69). Concomitant ASD was also associated with lower odds of revision RCR at 2 years (OR, 0.68; 95% CI, 0.53 to 0.86), 4 years (OR, 0.63; 95% CI, 0.50 to 0.78), and 6 years (OR, 0.61; 95% CI, 0.49 to 0.76). DISCUSSION: Arthroscopic RCR with concomitant ASD is associated with lower odds of all-cause revision surgery in the ipsilateral shoulder at 2, 4, and 6 years. The lower mid-term revision surgery rates suggest benefits to performing concomitant ASD with primary arthroscopic RCR. Continued research on the mid to long-term benefits of ASD is needed to determine which patient populations benefit most from this procedure. DATA AVAILABILITY: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Reverse Total Shoulder Arthroplasty Within 6 Weeks of Proximal Humerus Fracture is Associated with the Lowest Risk of Revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHF). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2-years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified two timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6 week cohort, the 7-52 week cohort was more likely to undergo revision surgery within 2-years (OR: 1.93, P < 0.001). Moreover, the 7-52 week cohort had significantly higher odds of revision indicated for dislocation (OR: 2.24, P < 0.001), mechanical loosening (OR: 1.71, P < 0.001), PJI (OR: 1.74, P < 0.001), and PPF (OR: 1.96, P < 0.001). CONCLUSIONS: Using SSLR, we were successful in identifying two data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4 to 6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Chronic Oral Corticosteroid Use and 10-Year Incidence of Major Complications Following Total Knee Arthroplasty.

BACKGROUND: Oral corticosteroids are the primary treatment for several autoimmune conditions. The risk of long-term implant, bone health, and infectious-related complications in patients taking chronic oral corticosteroids before total knee arthroplasty (TKA) is unknown. We compared the 10-year cumulative incidence of revision, periprosthetic joint infection (PJI), fragility fracture (FF), and periprosthetic fracture following TKA in patients who had and did not have preoperative chronic oral corticosteroid use. METHODS: A retrospective cohort analysis was conducted using a national database. Primary TKA patients who had chronic preoperative oral corticosteroid use were identified using Current Procedural Terminology and International Classification of Disease 9 and 10 codes. Exclusion criteria included malignancy, osteoporosis treatment, trauma, and < 2-year follow-up. Primary outcomes were 10-year cumulative incidence and hazard ratios (HRs) of all-cause revision (ACR), aseptic revision, PJI, FF, and periprosthetic fracture. A Kaplan-Meier analysis and a multivariable Cox proportional hazards model were utilized. Overall, 611,596 patients were identified, and 5,217 (0.85%) were prescribed chronic corticosteroids. There were 10,000 control patients randomly sampled for analysis. RESULTS: Corticosteroid patients had significantly higher 10-year HR of FF (HR; 95% confidence interval); P value (1.47; 1.34 to 1.62; P < .001)], ACR (1.21; 1.05 to 1.40; P = .009), and PJI (1.30; 1.01 to 1.69; P = .045) when compared to the control. CONCLUSIONS: Patients prescribed preoperative chronic oral corticosteroids had higher risks of ACR, PJI, and FF within 10 years following TKA compared to patients not taking corticosteroids. This information can be used by surgeons during preoperative counseling to educate this high-risk patient population about their increased risk of postoperative complications.

The Effect of Concomitant Biceps Tenodesis on Revision Surgery Rates After Primary Rotator Cuff Repair.

INTRODUCTION: We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT. METHODS: A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted. RESULTS: Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT. DISCUSSION: In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

Comparing the Intensity of Pain and Incidence of Flare Reaction Following Trigger Finger Injections Using Betamethasone and Methylprednisolone: A Double-Blinded, Randomized Controlled Trial.

BACKGROUND: Considerable evidence supports corticosteroid injection as an effective treatment for trigger finger. One common side effect, the flare reaction, is a well-documented phenomenon of increased pain following steroid injections. Its incidence and intensity may be related to steroid composition. The purpose of this study was to determine whether betamethasone and methylprednisolone injections for trigger fingers have differing intensity of pain or incidence flare reaction. METHODS: Patients with symptomatic trigger finger were recruited during their hand surgery visits. Patients were randomized into 2 treatment groups: betamethasone (40 mg) and methylprednisolone (6 mg) mixed with lidocaine 1%. Treatment group assignment was blinded to the patients and investigators. Visual analog scale pain measurements were taken prior to injection, 5 minutes postinjection, and daily thereafter for 7 days. RESULTS: Sixty-four patients were randomized into the 2 treatment groups. Patients in the betamethasone group reported slightly higher baseline pain compared with the methylprednisolone group, but lower pain on day 1. None of the following days showed a statistically significant difference. CONCLUSIONS: The incidence of flare and severe flare reactions of betamethasone injections for trigger finger management was roughly double that of methylprednisolone, but this difference was not statistically significant. Further studies are required to evaluate the relative course of nonflare postinjection pain for different corticosteroid injections for trigger finger injections.

Trends in total elbow arthroplasty in patients with rheumatoid arthritis receiving disease-modifying antirheumatic drug therapy based on payer status.

INTRODUCTION: Total elbow arthroplasty (TEA) is often used to manage advanced arthropathies of the elbow caused by inflammatory conditions such as rheumatoid arthritis (RA). Recent literature has shown that use of TEA is decreasing in patients with RA, part of which can be attributed to early medical management involving disease-modifying antirheumatic drugs (DMARDs). However, there is a significant economic barrier to accessing DMARD therapy. The purpose of this study was to compare the use of TEA between patients with and without DMARD therapy from 2010 to 2020. METHODS: A retrospective cohort analysis was performed using a national insurance claim database to investigate the trends of patients with RA undergoing TEA from 2010-2020. Patients who underwent TEA and had a diagnosis of RA were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)-9 and ICD-10 codes between 2010 and 2020. These patients were then stratified into 2 cohorts: those with DMARD prescription claims and those without. A linear regression, compound annual growth rate (CAGR) analysis, and χ2 analysis were conducted to compare trends and demographic variables, including insurance type, between cohorts. Additionally, a multivariable logistic regression was subsequently performed to observe odds ratios (ORs) and 95% confidence intervals. RESULTS: From 2010 to 2020, there has been no significant change in the incidence of TEA in RA patients without DMARD prescriptions, whereas there has been a statistically significantly decreasing rate of TEA observed in RA patients with DMARD prescription claims. The analysis showed that there was a CAGR of -4%. For patients with a diagnosis of RA and DMARD prescription claims, the highest incidence of undergoing TEA was seen in the age group of 60-69 years, whereas patients with a diagnosis of RA and no DMARD prescription claims had the highest incidence of undergoing TEA in the age group of 70-79 years. CONCLUSION: The incidence of patients undergoing TEA with a diagnosis of RA and DMARD prescription claims has shown a statistically significant decrease from 2010 to 2020, whereas no significant difference was observed for patients without DMARD prescription claims. There were no statistically significant differences in the insurance plans between cohorts.