Perioperative complications and outcomes in patients with paraplegia undergoing rotator cuff repair.

Background: Patients with paraplegia often experience chronic shoulder pain due to overuse. We sought to determine if these patients have an increased prevalence of perioperative complications and higher rates of re-admissions and rotator cuff re-tears relative to able-bodied controls following rotator cuff repair (RCR). Methods: We queried the NRD (2011-2018) to identify all patients undergoing primary RCR (n = 34,451) and identified cohorts of matched paraplegic and non-paraplegic patients (n = 194 each). We compared demographic factors, comorbidity profiles, perioperative complication rates, length of stay, revision rates, and re-admission rates between the two groups. Results: Patients with paraplegia had lower rates of chronic obstructive pulmonary disease (p = 0.02), hypertension (p = 0.007), congestive heart failure (p = 0.027), obesity (p < 0.001), and prior myocardial infarction (p = 0.01). Additionally, patients with paraplegia experienced higher rates of urinary tract infections (11.9% vs. 2.1%, p < 0.001), lower rates of acute respiratory distress syndrome (0% vs. 3.1%, p = 0.041), and had a longer length of stay (4-days vs. 1-day, p < 0.001). Revision rates were similar for the two groups. Conclusions: Compared to matched controls, patients with paraplegia were found to have similar demographic characteristics, less comorbidities, similar perioperative complication rates, and similar revision rates. These findings address a gap in the literature regarding surgical management of shoulder pain in patients with paraplegia by providing a matched comparison with a large sample size.

Identification of Independent Predictors of Increased 90-Day Complication and Revision Rates Following Total Elbow Arthroplasty.

Introduction: Total elbow arthroplasty (TEA) is an increasingly popular surgical option for many debilitating conditions of the elbow. There currently exists a paucity of literature regarding patient and hospital factors that lead to inferior outcomes following TEA. The purpose of this study is to identify independent predictors of increased complication and revision rates following TEA. Methods: The National Readmissions Database (NRD) was queried from 2011 to 2018 to identify all cases of TEA (n = 8932). Relevant patient demographic factors, comorbidities, and hospital characteristics were identified and run in a univariate binomial logistic regression model. All significant variables were included in a multivariate binomial logistic regression model for data analysis. Results: Independent predictors of increased complication rates included age, female sex, Medicare and Medicaid payer status, medium bed-sized center, and 18 of 34 medical comorbidities (all P < .05). Independent predictors of increased revision rates included medium bed-sized centers, non-teaching hospital status, chronic pulmonary disease, depression, and pulmonary circulatory disorders (all P < .05). Conclusion: This study identified several patient and hospital characteristics that are independently associated with both increased complication and revision rates following TEA. This information can aid orthopedic surgeons during shared decision making when considering TEA in patients. Level of Evidence: Level III, retrospective cohort study.

Risk Factors for Failure of Conservative Management of Insertional Achilles Tendinosis.

INTRODUCTION: While many patients benefit from nonoperative treatment of insertional Achilles tendinopathy (IAT), some elect for surgical debridement and reconstruction. The purpose of this study is to determine the relationship of patient demographic characteristics, comorbidity profiles, and radiological parameters with failure of conservative management of IAT. METHODS: A retrospective chart review was performed to identify patients who received either surgical or nonsurgical treatment of IAT at an academic institution from September 2015 to June 2019 (N = 226). Demographic and comorbidity data, and the presence and magnitude of relevant radiological parameters were collected and compared between the surgically (n = 48) and nonsurgically (n = 178) treated groups. RESULTS: No significant differences could be detected between groups regarding demographic factors or previous procedures. The surgery group was significantly more likely to have evidence of Haglund's deformity on clinical exam (83% vs 69%, P = .005), lower SF-12 physical scores (25.5 vs 35.5, P < .001), higher VAS pain scores (6.3 vs 5.3, P = .033), any mental illness (33% vs 20%, P = .044), and depression (27% vs 12%, P = .012). DISCUSSION: Patients who received surgery for IAT were significantly more likely to have evidence of Haglund's deformity on clinical exam, depression, higher VAS pain scores, and lower SF-12 physical scores. Both patients and surgeons should be aware of the higher rates of failure of conservative treatment in these patients. LEVEL OF EVIDENCE: Level III.

Variability and reliability of 2-dimensional vs. 3-dimensional glenoid version measurements with 3-dimensional preoperative planning software.

BACKGROUND: Preoperative planning for total shoulder arthroplasty (TSA) may change according to the measured degree of glenoid version. Both 2-dimensional (2D) and 3-dimensional (3D) computed tomographic (CT) scans are used to measure glenoid version, with no consensus on which method is more accurate. However, it is generally accepted that 3D measurements are more reliable, yet most 3D reconstruction software currently in clinical use have never been directly compared to 2D. The purpose of this study is to directly compare 2D and 3D glenoid version measurements and determine the differences between the two. METHODS: CT scans were performed preoperatively on 315 shoulders undergoing either anatomic or reverse TSA. 2D measurements of glenoid version were obtained manually using the Friedman method, whereas 3D measurements were obtained using the Equinoxe Planning Application (Exactech Inc.) 3D-reconstruction software. Negative version values indicate retroversion, whereas positive values indicate anteversion. Two observers collected the 2D measurements 2 separate times, and intra- and interobserver measurements were calculated. Groups were compared for variability using intraclass correlation coefficients (ICCs), and for differences in sample means using Student t tests. Additionally, samples were stratified by version value in order to better understand the potential sources of error between measurement techniques. RESULTS: For the 2D measurements, intraobserver variability indicated excellent reproducibility for both observer 1 (ICC = 0.928, 95% confidence interval [CI] 0.911-0.942) and observer 2 (ICC = 0.964, 95% CI 0.955-0.971). Interobserver variability measurements also indicated excellent reproducibility (ICC = 0.915, 95% CI 0.778-0.956). The overall 2D version measurement average (-4.9° ± 10.3°) was significantly less retroverted than the 3D measurement average (-8.4° ± 9.1°) (P < .001), with 3D measurements yielding a more retroverted value 73% of the time. When stratified on the basis of version value with outliers excluded, there was no significant difference in the distribution of high-error samples within the data. DISCUSSION: There was excellent reproducibility between the 2 observers in terms of both intra- and interobserver variability. The 3D measurement techniques were significantly more likely to return a more retroverted measurement, and high-error samples were evenly distributed throughout the data, indicating that there were no discernable trends in the degree of error observed. Shoulder surgeons should be aware that different glenoid version measurement strategies can yield different version measurements, as these can affect preoperative planning and surgeon decision making.

Assessing the hospital volume-outcome relationship in total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is an effective intervention for multiple elbow disorders including complex fracture in elderly patients, post-traumatic arthropathy, inflammatory arthropathy, and distal humeral nonunion. Given its known therapeutic value and low utilization rate, an investigation into the thresholds for TEA institutional volume-outcome relationships is warranted. The purpose of this study was to identify TEA volume thresholds that serve as predictors of institutional outcomes including complications, readmissions, revisions, cost of care, length of stay (LOS), and non-home discharge. We hypothesized that increased institutional volume would be associated with decreased 90-day adverse outcomes and resource utilization. METHODS: The Nationwide Readmission Database was queried from 2010 to 2017 to identify all cases of TEA. Hospital volume was calculated using a unique hospital identifier and divided into quartiles. Outcomes such as complications, readmissions, revisions, cost of care, LOS, and non-home discharge were then analyzed by quartile. The same outcomes were assessed via stratum-specific likelihood ratio (SSLR) analysis to define volume strata among institutions. RESULTS: SSLR analysis defined statistically significant hospital volume categories for each 90-day outcome. The volume category with the lowest complication rate was ≥21 TEAs per year (5.6%). The volume categories with the lowest readmission rates were 1-3 TEAs per year (4.7%) and ≥18 TEAs per year (9.2%). Revision rates were lowest in the volume categories of 1-5 TEAs per year (0.1%) and ≥18 TEAs per year (0.1%). Hospitals with ≥21 TEAs per year had the lowest cost of care and the highest rate of extended LOS (>2 days). SSLR analysis showed that non-home discharges decreased in a stepwise manner as volume increased. The lowest non-home discharge rate was associated with the volume category of ≥22 TEAs per year (20.3%). CONCLUSION: This study defines TEA volume strata for institutional outcomes. The highest TEA volume strata were associated with the lowest rates of 90-day complications, revisions, and non-home discharges and the lowest cost of care. This trend is likely attributable to the benefits of high-volume institutional experience and standardized patient-care processes.

Effects of obesity on clinical and functional outcomes following anatomic and reverse total shoulder arthroplasty.

BACKGROUND: Limited data exist regarding the clinical and functional outcomes following primary total shoulder arthroplasty in obese patients. The purpose of this study is to determine the effects of obesity on the clinical and functional outcomes following primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) in a large patient population with mid-term follow-up. METHODS: Patients in a multi-institutional shoulder registry receiving either primary aTSA (n = 1520) or rTSA (n = 2054) from 2004 to 2018 with a minimum follow-up period of 2 years were studied. All patients received the same single-platform shoulder prosthesis. Study groups were assigned based on implant type (anatomic or reverse), and further stratification was based on patient body mass index (BMI), with obese patients having a BMI ≥ 30 and non-obese patients having a BMI < 30. Patients were evaluated and scored preoperatively and at latest follow-up by use of 5 scoring metrics and range of motion (ROM). RESULTS: The mean follow-up period was 5 years (range, 2-14 years). Obese patients comprised 41% of the aTSA group and 35% of the rTSA group. Significant postoperative improvements in visual analog scale pain scores, ROM, and all 5 scoring metrics occurred in both obese and non-obese patients (P < .05). Obese patients in both groups reported higher preoperative and postoperative visual analog scale pain scores and less preoperative and postoperative ROM compared with non-obese patients. Compared with non-obese patients, obese patients receiving aTSA reported significantly worse postoperative Simple Shoulder Test, Constant-Murley, American Shoulder and Elbow Surgeons, University of California, Los Angeles, and Shoulder Pain and Disability Index scores compared with non-obese patients, and those receiving rTSA reported significantly worse American Shoulder and Elbow Surgeons and Shoulder Pain and Disability Index scores (all P < .05). However, these differences did not exceed the minimal clinically important difference or substantial clinical benefit criteria. Radiographic analysis showed that in the rTSA group, obese patients had significantly less postoperative scapular notching and a lower scapular notching grade compared with non-obese patients (P < .05). DISCUSSION: Both non-obese and obese patients can expect clinically significant improvements in pain, motion, and functional outcome scores following both aTSA and rTSA. Obese patients reported significantly more postoperative pain, lower outcome scores, and less ROM compared with non-obese patients after both aTSA and rTSA at a mean follow-up of 5 years. However, statistically significant differences were not found to be clinically significant with respect to established minimal clinically important difference and substantial clinical benefit criteria. Therefore, obese and non-obese patients experience similar clinical outcomes following total shoulder arthroplasty, regardless of BMI. However, obese patients have more comorbidities, greater intraoperative blood loss, and less scapular notching compared with non-obese patients.

Biomechanical evaluation of an intramedullary clavicle screw in simple oblique and butterfly wedge fractures.

This biomechanical study evaluates the performance of a solid titanium-alloy intra-medullary (IM) clavicular screw in torsion and cantilever bending in cadaveric clavicle specimens with simulated simple oblique and butterfly wedge midshaft fractures. Thirty-two fresh-frozen male clavicles were sorted into six experimental groups: Torsion Control, Torsion Simple Oblique Fracture, Torsion Butterfly Wedge Fracture, Bending Control, Bending Simple Oblique Fracture, and Bending Butterfly Wedge Fracture. The experimental groups were controlled for density, length, diameter, and laterality. All other samples were osteotomy-induced and implanted with a single 90 mm × 3 mm clavicle screw. All groups were tested to physiologically relevant cutoff points in torsion or bending. There were no statistically significant differences in the performance of the oblique and butterfly wedge fracture models for any torsion or bend testing measures, including maximum torsional resistance (p = 0.66), torsional stiffness (p = 0.51), maximum bending moment (p = 0.43), or bending stiffness (p = 0.73). Torsional testing of samples in the direction of thread tightening tended to be stronger than samples tested in loosening, with all groups either approaching or achieving statistical significance. There were no significant differences between the simple oblique or the butterfly-wedge fracture groups for any of the tested parameters, suggesting that there is no difference in the gross biomechanical properties of the bone-implant construct when the IM clavicle screw is used in either a simple midshaft fracture pattern or a more complex butterfly wedge fracture pattern.

Effects of the Obesity Epidemic on Total Hip and Knee Arthroplasty Demographics.

BACKGROUND: Higher body mass index (BMI) is a well-known risk factor for the development of hip and knee osteoarthritis and predicts total hip arthroplasty (THA) and total knee arthroplasty (TKA) at an earlier age. The purpose of this study is to document the nationwide trends in age and obesity in primary THA and TKA throughout the obesity epidemic. METHODS: A retrospective analysis of the National Inpatient Sample database was conducted on patients undergoing primary THA and TKA for primary OA between 2002 and 2017. Analysis of variance and chi-square tests were performed to examine changes in age and obesity percentage over time, respectively. Pearson correlations were used to assess the relationship between patient age, BMI, and year of surgery. RESULTS: A total of 688,371 THA and 1,556,651 TKA were identified over the sixteen-year period. Between 2002 and 2017, the proportion of obese patients increased for both THA (7.0% to 22.7%, P < .001) and TKA (10.7% to 30.4%, P < .001). Mean age significantly decreased for both THA (66.7 to 65.9 years, P < .001) and TKA (67.6 to 66.8 years; P < .001). Over time, BMI significantly increased (THA: r = 0.221 vs. TKA: r = 0.272) and patient age decreased (THA: r = -0.031 vs. TKA: r = -0.137) for both procedures (P < .001 for all). CONCLUSION: THA and TKA patients have become younger and increasingly more obese throughout the obesity epidemic, as obesity rates have tripled over this time period. The current investigation is the first to demonstrate significant trends in both age and obesity in the THA and TKA populations on a national level. LEVEL OF EVIDENCE: III.

Increased perioperative complication rates in patients with solid organ transplants following rotator cuff repair.

BACKGROUND: Rotator cuff repair is the second most common soft tissue procedure performed in orthopedics. Additionally, an increasing percentage of the population has received a solid organ transplant (SOT). The chronic use of immunosuppressants as well as a high prevalence of medical comorbidities in this population are both important risk factors when considering surgical intervention. The purpose of this study is to determine the demographic profile, comorbidity profile, and perioperative complication rate of SOT patients undergoing inpatient rotator cuff repair surgery compared to nontransplanted patients. METHODS: The Nationwide Inpatient Sample (NIS) database was queried from years 2002-2017 to identify all patients who underwent inpatient rotator cuff repair (n = 144,528 weighted). This group was further divided into SOT (n = 286 weighted) and nontransplant (n = 144,242 weighted) cohorts. Demographic and comorbidity analyses were performed between these groups. Additionally, a matched cohort of nontransplanted patients controlled for the year of procedure, age, sex, race, income, and hospital region was created in a 1:1 ratio to the SOT group (n = 286 each) for perioperative complication rate analysis. RESULTS: Compared to nontransplanted patients, SOT patients were more likely to have at least 1 significant medical comorbidity (98% vs. 69%, P < .001), had a higher number of total comorbidities (3.1 vs. 1.4, P < .001), and had a higher Charlson-Deyo Comorbidity Index (2.6 vs. 0.54, P < .001). Compared to the matched cohort, SOT patients experienced longer hospital stays (2.9 vs. 1.8 days, P < .001), higher surgery costs ($12,031 vs. $8476, P < .001), and were more likely to experience a perioperative complication (24% vs. 3%, P < .001) with an odds ratio of 7.7 (95% confidence interval: 3.9-15.1). CONCLUSION: Compared with nontransplanted patients, SOT patients undergoing rotator cuff repair had a significantly higher comorbidity index, longer hospital stays, costlier surgeries, and were >7 times more likely to experience a perioperative complication. With nearly a quarter of all SOT patients experiencing a perioperative complication following rotator cuff repair, careful consideration for surgery as well as increased postoperative surveillance should be considered in this unique population.

Orthopaedic Application of Cryotherapy: A Comprehensive Review of the History, Basic Science, Methods, and Clinical Effectiveness.

¼: Cold therapy, also known as cryotherapy, includes the use of bagged ice, ice packs, compressive cryotherapy devices, or whole-body cryotherapy chambers. Cryotherapy is commonly used in postoperative care for both arthroscopic and open orthopaedic procedures. ¼: Cryotherapy is associated with an analgesic effect caused by microvasculature alterations that decrease the production of inflammatory mediators, decrease local edema, disrupt the overall inflammatory response, and reduce nerve conduction velocity. ¼: Postoperative cryotherapy using bagged ice, ice packs, or continuous cryotherapy devices reduced visual analog scale pain scores and analgesic consumption in approximately half of research studies in which these outcomes were compared with no cryotherapy (11 [44%] of 25 studies on pain and 11 [48%] of 23 studies on opioids). However, an effect was less frequently reported for increasing range of motion (3 [19%] of 16) or decreasing swelling (2 [22%] of 9). ¼: Continuous cryotherapy devices demonstrated the best outcome in orthopaedic patients after knee arthroscopy procedures, compared with all other procedures and body locations, in terms of showing a significant reduction in pain, swelling, and analgesic consumption and increase in range of motion, compared with bagged ice or ice packs. ¼: There is no consensus as to whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with bagged ice or ice packs. However, complications from cryotherapy, including skin irritation, frostbite, perniosis, and peripheral nerve injuries, can be avoided through patient education and reducing the duration of application. ¼: Future Level-I or II studies are needed to compare both the clinical and cost benefits of continuous cryotherapy devices to bagged ice or ice pack treatment before continuous cryotherapy devices can be recommended as a standard of care in orthopaedic surgery following injury or surgery.

Increased Risk of Perioperative Complications in Dialysis Patients Following Rotator Cuff Repairs and Knee Arthroscopy.

PURPOSE: To determine the effects of dialysis on postoperative and perioperative complications following rotator cuff repair (RCR) and knee arthroscopy (KA). METHODS: The National Surgical Quality Improvement Program (NSQIP) was queried from 2006 to 2018. Groups were matched for age, sex, body mass index, smoking status, preoperative functional status, and the American Society of Anesthesiologists (ASA) status. Chi-squared tests and Fisher's exact tests were used to analyze the comorbidities. Differences in occurrences of postoperative adverse events (AE), mortality within 30 days, reoperations with 30 days, extended hospital stay (≥2 days), and readmissions within 30 days were analyzed using the Mantel-Haenszel test. Sign tests were used to evaluate differences in operative time, as well as length of hospital stay. RESULTS: Dialysis patients in both the RCR and KA groups had greater odds of experiencing any AE (OR: 6.33 and 7.46, P value: .031 and <.001, respectively) and readmission within 30 days (OR: 10.5 and 4.1, P value: .015 and .014, respectively). They also had significantly greater operating times (P = .049 for both). Dialysis patients undergoing KA had greater odds of staying in the hospital ≥2 days (OR: 10, P = <.001) and being reoperated on within 30 days (OR: 3.78, P = .033). The total hospital stay was significantly greater for dialysis patients in the KA group (P < .001) but not in the RCR group (P = .088). None of the individual AE's significantly differed between the dialysis and non-dialysis patients in the RCR cohort; however, dialysis patients in the KA cohort had greater incidences of three AE's. CONCLUSIONS: This study identified significantly worse short-term complication rates in dialysis patients undergoing RCR and KA. Careful preoperative evaluation and postoperative surveillance are warranted in this high-risk patient group. Patients should be counseled appropriately on the increased complication risks associated with RCR and KA surgeries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.