Patient age at time of reverse shoulder arthroplasty remains stable over time: a 7.5-year trend evaluation.

PURPOSE: There is a common belief among some shoulder surgeons that the increased utilization of reverse shoulder arthroplasty (RSA) is driven by the operation being performed in younger patients. The primary purpose of this study was to evaluate the change in patient age at the time of primary RSA in the USA. METHODS: All patients undergoing primary RSA (January 2011-June 2018) were identified in the Mariner database. The mean age at the time of primary RSA was evaluated for each patient and assessed in 6-month intervals. A longitudinal comparison over time was performed for all patients. RESULTS: A total of 56,141 primary RSA were evaluated, with the mean age increasing from 69 in the 2011 to 71 in 2018 (p < 0.001). The largest increase in RSA utilization occurred in patients > 70 (1092 in 2011 to 3499 in 2018), with patients < 50 years demonstrating the slowest growth (13 in 2011 to 65 in 2018). However, when evaluated by percentage increase from 2011 to 2018, RSA volumes for patients < 60 have increased 390% compared to 220% for those > 70 years (p < 0.001). CONCLUSION: RSA continues to be performed at a similar mean age despite expanded indications and surgeon comfort. However, patients < 60 years have had a greater increase in utilization compared to patients > 70 years. The volumetric growth of RSA has largely been driven by the older population, but younger patients have shown a higher percentage of growth, which may explain the generalized observation that RSA is performed in younger patients. LEVEL OF EVIDENCE: Level III; Retrospective comparative study; Treatment study.

Nonarthroplasty Management of Shoulder Arthritis in the Aging Athlete: Biologics and Arthroscopy.

Glenohumeral arthritis in athletes or young and active individuals constitutes a challenging clinical problem, and multiple factors should be taken into consideration when deciding on nonsurgical or surgical treatment in this patient cohort. Selection of therapy should be based on clinical evidence, but the therapeutic strategy should align with patient expectations. Patient education on the nature and progression of shoulder osteoarthritis may facilitate the decision-making process regarding the selection of treatment. The orthopaedic surgeon should be knowledgeable about the nonarthroplasty options for the management of shoulder osteoarthritis in the aging athlete, with special focus on nonsurgical treatment options and shoulder arthroscopy.

Shoulder Arthroplasty in the Aging Athlete: Considerations in the Younger Patient.

Shoulder arthroplasty has become an increasingly common option for the management of glenohumeral osteoarthritis in younger, higher demand, and athletic individuals. Patients with shoulder arthritis in whom nonsurgical measures fail and who are not candidates for arthroscopic treatment may be evaluated for shoulder arthroplasty. Available options include shoulder hemiarthroplasty, with or without biologic glenoid resurfacing, total shoulder arthroplasty, and less commonly reverse total shoulder arthroplasty. The orthopaedic surgeon should be aware of the evolution and current use of the different shoulder replacement techniques in young active patients with glenohumeral osteoarthritis. In addition, it is important to review practical guidelines and issues with the implementation of those techniques when treating patients with shoulder arthritis who want to return to sport activity postoperatively.

Reinjury Rates in Adolescent Patients 2 Years Following ACL Reconstruction.

BACKGROUND: Sports injuries have increased dramatically in the pediatric and adolescent population. Return-to-sport testing and criteria are increasingly utilized, however, the guidelines for return to play in adolescents are unclear. The purpose of this study was to compare strength and function at the time of the return-to-sport progression to those with and without a failed anterior cruciate ligament reconstruction (ACLR). METHODS: A total of 105 adolescent patients with primary ACLR were assessed at the time of return to sport. We identified graft failures/contralateral injury through medical records, clinic visits, or phone interviews at minimum 2 years of postsurgical follow-up. All patients completed bilateral isokinetic strength tests of the knee extensor/flexor groups and hop tests. Strength was expressed as torque-normalized-to-mass (Nm/kg), and limb-symmetry-index was expressed as a percentage of the uninvolved limb's strength. All patients completed outcome surveys. The χ2 analysis was used to compare failures between sexes and graft types. Independent sample t tests were used to compare knee extensor/flexor strength, symmetry, and hop test results between patients with and without secondary anterior cruciate ligament (ACL) injury. One-way analysis of variance was used to compare knee extensor/flexor strength and symmetry, hop test, and survey results between those (1) without secondary injury, (2) ACLR graft failure, and (3) contralateral ACL injury. RESULTS: A total of 100 of 105 patients (95.2%) were included with 4±1.2 years of follow-up, with 28 (28%) sustaining subsequent injury (12% graft, 16% contralateral). Patients with graft failure demonstrated (1) stronger quadriceps strength (2.00±0.46 Nm/kg) compared with those with contralateral ACL injury (1.58±0.35 Nm/kg, P=0.039) and patients that did not have a secondary injury (1.58±0.44 Nm/kg, P=0.007), (2) greater quadriceps strength symmetry (85.7±0.11.2%) compared with patients without secondary injury ACL (72.9±17.9%, P=0.046), (3) a greater proportion of hamstring grafts compared with those without reinjury (P=0.028). CONCLUSIONS: Adolescent patients who sustained ACLR graft failure had greater and more symmetric quadriceps strength at the time of return to sport compared with patients with no secondary injury. Objective measures of quadriceps strength at the time of the return-to-sport progression may not solely identify individuals that have a secondary ACL injury. STUDY DESIGN: Level IV-retrospective cohort study.

The relationship of bilateral shoulder arthroplasty timing and postoperative complications.

BACKGROUND: Though several case series have described bilateral shoulder arthroplasty results with range of motion, patient-reported outcomes, and complications, little guidance exists regarding the optimal interval timing between surgeries. METHODS: All patients from 2 insurance databases who underwent staged bilateral shoulder arthroplasty between 2005 and 2016 were identified. These patients were then stratified by elapsed time between surgeries into 4 study groups: (1) less than 3 months, (2) 3-6 months, (3) 6-9 months, and (4) 9-12 months. Surgical and perioperative medical complications of these patient cohorts were compared to a control group that underwent bilateral shoulder arthroplasty with a greater than 1-year interval between surgeries. RESULTS: From 2005-2016, a total of 1764 patients (6.3%) underwent bilateral shoulder arthroplasty out of 27,962 shoulder arthroplasties performed in the 2 databases. Of the bilateral patients, 49.1% waited more than 1 year before their second shoulder arthroplasty. Patients waiting less than 3 months between surgeries comprised 4.9% of the total number of staged bilateral surgeries. Demographics and comorbidities were similar between the study groups. Overall, implant complications were higher in patients with surgeries less than 3 months apart compared to controls, including revision arthroplasty (11.6% vs. 5.4%, odds ratio [OR] 2.29, P = .037), loosening/lysis (8.1% vs. 3.5%, OR 2.46, P = .032), and periprosthetic fracture (4.7% vs. 1.2%, OR 4.18, P = .010). There were no significant increases in any implant-related complications when surgeries were staged by 3 months or more compared to controls. Venous thromboembolism (VTE; 8.1% vs. 2.2%, OR 3.95, P = .001) and blood transfusion (9.3% vs. 1.7%, OR 5.82, P < .001) occurred at a significantly higher rate in patients with less than 3 months between surgeries compared with controls. There were no differences in any medical complications when surgeries were staged by 3 months or more compared with controls. CONCLUSIONS: Patients with staged bilateral shoulder arthroplasty who have the second arthroplasty within 3 months have significantly higher rates of revision surgery, loosening/lysis, periprosthetic fracture, VTE, and blood transfusions. Based on these lower complication rates, surgeons should consider waiting a minimum of 3 months before performing the second portion of a staged bilateral shoulder arthroplasty.

The Cost of Outpatient Arthroscopic Rotator Cuff Repairs: Hospital Reimbursement Is on the Rise While Surgeon Payments Remain Unchanged.

PURPOSE: To better understand the relative increases in rotator cuff charges and to analyze national and regional trends between hospital, anesthesiologist, and surgeon charges and reimbursements for contemporary rotator cuff repairs (RCRs) performed in the United States. METHODS: A representative Medicare sample was used to capture hospital, surgeon, and anesthesiologist charges and payments for outpatient RCR from 2005 to 2014. The charges and reimbursements were calculated using Current Procedural Terminology codes. Two ratios were calculated to compare surgeon and hospital charges and reimbursements. The charge multiplier (CM) is the ratio of hospital to surgeon charges, and the payment multiplier (PM) is the ratio of hospital to surgeon reimbursements. Trends were evaluated using national and regional charges, reimbursements, Charlson Comorbidity Index, CM, and PM. RESULTS: In total, 12,617 patients were included in this study. Between 2005 and 2014, hospital charges for RCR significantly increased from $4877 to $11,488 (136% increase; P < .0001), anesthesiologist charges increased from $1319 to $2169 (64% increase; P < .0001), and surgeon charges increased from $7528 to $9979 (33% increase; P < .0001). Reimbursements during the same period significantly increased from $3007 to $6696 (123% increase; P < .0001) for hospitals, from $203 to $239 (17% increase; P = .005) for anesthesiologists. Reimbursements for surgeons remained relatively unchanged (from $1821 to $1885, 3% increase; P = .116). Increases in national CM (P = .003) and PM (P < .0001) were both statistically significant. Charlson Comorbidity Index did not change significantly over the period (P = .1178). CONCLUSIONS: Although outpatient RCR charges increased significantly for hospitals, surgeons, and anesthesiologists, hospital reimbursements increased substantially relative to surgeon and anesthesiologist reimbursements despite stable patient complexity. In 2005, hospitals were reimbursed 65% more than surgeons. By 2014, hospitals were reimbursed 255% more than surgeons, indicating that hospitals disproportionally drove increases in charges and reimbursements over this period. LEVEL OF EVIDENCE: Level IV, economic analysis.

Surgeon charges and reimbursements are declining compared with hospital payments for shoulder arthroplasty.

BACKGROUND: The relationship between surgeon and hospital charges and payments for total shoulder arthroplasty (TSA) has not been well examined. The goal of this study was to report trends and variation in hospital charges and payments compared with surgeon charges and payments for TSA. METHODS: The 5% Medicare sample was used to capture hospital and surgeon charges and payments for TSA from 2005 to 2014. Two values were calculated: (1) the charge multiplier (CM), which is the ratio of hospital to surgeon charges, and (2) the payment multiplier (PM), which is the ratio of hospital to surgeon payments. The year-to-year variation and regional trends in patient demographic characteristics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated. RESULTS: The study included 10,563 patients. Per-patient hospital charges increased from $33,836 to $67,177 (99.9% increase), whereas surgeon charges increased from $4284 to $4674 (9.1% increase) (the CM increased from 7.9 to 14.4, P < .0001). Hospital payments increased from $8758 to $14,167 (61.8%), whereas surgeon payments decreased from $1028 to $884 and the PM increased from 8.5 to 16.0 (P < .0001). The LOS decreased significantly (P < .0001), whereas the Charlson Comorbidity Index remained stable. Both the CM (r2 = 0.931) and PM (r2 = 0.9101) were strongly negatively associated with the LOS. CONCLUSIONS: Hospital charges and payments relative to surgeon charges and payments have increased substantially for TSA despite stable patient complexity and a decreasing LOS. These results encourage the need for future studies with detailed cost analyses to identify the reasons for hospital and surgeon financial malalignment.

Perioperative Serum 25-Hydroxyvitamin D Levels Affect Revision Surgery Rates After Arthroscopic Rotator Cuff Repair.

PURPOSE: To examine any association between perioperative serum 25-hydroxyvitamin D levels and failure of arthroscopic rotator cuff repair (RCR) requiring revision surgery. METHODS: Using a private-payer national insurance database, patients who underwent arthroscopic RCR with perioperative serum 25-hydroxyvitamin D levels recorded were included. Patients were stratified into groups of (1) serum 25-hydroxyvitamin D deficiency (<20 ng/mL), (2) insufficiency (20-30 ng/mL), or (3) sufficient (>30-<150 ng/mL). The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair, debridement, or reverse shoulder arthroplasty. A multivariable logistic regression analysis was used to control for patient demographics and comorbidities during comparisons. RESULTS: A total of 982 patients were included in the study. The rate of revision rotator cuff surgery was significantly higher in patients in the serum 25-hydroxyvitamin D-deficient group (5.88%) compared with the serum 25-hydroxyvitamin D-sufficient control group (3.7%) (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.6-5.8; P = .007). Patients with serum 25-hydroxyvitamin D deficiency (5.88%) also had a significantly higher incidence of revision surgery compared with patients with serum 25-hydroxyvitamin D insufficiency (OR, 2.4; 95% CI, 1.5-3.9; P = .011). There was no significant difference in the incidence of revision surgery in the serum 25-hydroxyvitamin D-insufficient group (4.97%) compared with the serum 25-hydroxyvitamin D-sufficient control group (3.7%) (OR, 1.4; 95% CI, 0.8-2.3; P = .250). The absolute risk reduction of revision surgery for 25-hydroxyvitamin D-deficient patients compared with controls was 2.2%, corresponding to a number needed to treat to avoid 1 revision surgery of 46 patients, relative risk reduction = 0.59. CONCLUSIONS: Although the present study found a significant statistical association between serum 25-hydroxyvitamin D deficiency and insufficiency and the rate of revision rotator cuff surgery after primary arthroscopic RCR, the absolute differences of these revision rates are minimal and are accompanied with overlapping confidence intervals limiting the clinical significance of these findings. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Association of Osteoporosis and Bisphosphonate Use With Revision Shoulder Surgery After Rotator Cuff Repair.

PURPOSE: To examine any association between osteoporosis and the failure of arthroscopic rotator cuff repair (ARCR) leading to revision surgery and to investigate whether the use of bisphosphonates had any influence on the observed associations. METHODS: Patients who underwent ARCR with a diagnosis of osteoporosis were identified from the PearlDiver database and stratified according to whether there was a filled prescription for a bisphosphonate in the perioperative period. Patients with osteoporosis who underwent ARCR with bisphosphonate use were compared with age- and sex-matched patients who underwent ARCR with osteoporosis without a prescription for a bisphosphonate within 1 year of surgery and patients who underwent ARCR without a diagnosis of osteoporosis and no bisphosphonate use. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair, debridement for a diagnosis of a rotator cuff tear, or reverse shoulder arthroplasty. A multivariable logistic regression analysis was used to control for patient demographic characteristics and comorbidities during comparisons. RESULTS: We identified 2,706 patients, including 451 in the bisphosphonate study group; 902 in the osteoporosis, no-bisphosphonate control group; and 1,353 in the non-osteoporosis control group. Patients with osteoporosis, including those to whom bisphosphonates were prescribed, had a significantly higher rate of revision rotator cuff surgery (6.58%) than patients without osteoporosis (4.51%) (odds ratio, 1.60; 95% confidence interval, 1.30-1.97; P = .008). No significant difference in the rate of revision surgery was found between patients with osteoporosis using bisphosphonates (6.65%) and age- and sex-matched patients with osteoporosis not using bisphosphonates (6.54%, P = .718). CONCLUSIONS: By using an administrative database, this study was able to show a substantial difference in the revision surgery rate after ARCR in patients with osteoporosis compared with matched controls. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery.

PURPOSE: To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. METHODS: Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. RESULTS: A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations. CONCLUSIONS: A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Dialysis dependence and modality impact complication rates after shoulder arthroplasty.

BACKGROUND: The goals of the study were to determine (1) the incidence of dialysis patients undergoing shoulder arthroplasty (SA), (2) the association of dialysis modality with complications after SA, and (3) the association of dialysis dependence with death in patients undergoing SA and nonsurgical dialysis-dependent controls. METHODS: Using an insurance database, we identified dialysis-dependent patients undergoing SA and compared them with a matched control cohort without dialysis use. We performed an analysis comparing patients using peritoneal dialysis (PD), patients using hemodialysis (HD), matched non-dialysis-dependent controls, and matched PD and HD nonsurgical patients. Complications including in-hospital death, emergency department visits, hospital readmission, infection, and revision surgery were assessed. RESULTS: The incidence of SA in dialysis patients has significantly increased. Compared with controls, dialysis-dependent patients had increased rates of in-hospital death (odds ratio [OR], 7.60; P < .0001), emergency department visits (OR, 4.16; P < .0001), hospital admission (OR, 1.63; P < .0001), and infection within 1 year (OR, 1.90; P = .009). Compared with patients receiving HD, PD patients had lower rates of death (OR, 0.40; P = .008), hospital readmission (OR, 0.43; P = .047), and revision surgery (OR, 0.23; P = .037). as well as a lower incidence of infection (OR, 0.30; P = .018). Compared with controls, PD patients had similar rates of most complications. Compared with nonsurgical dialysis-dependent patients, the SA procedure itself was not associated with an increased mortality rate. CONCLUSIONS: Although dialysis represents a significant independent risk factor for complications after SA, this risk is highly influenced by the type of dialysis.

Early postoperative fluoroquinolone use is associated with an increased revision rate after arthroscopic rotator cuff repair.

PURPOSE: To evaluate the association of postoperative fluoroquinolone use following arthroscopic primary rotator cuff repair with failure requiring revision rotator cuff repair. METHODS: An insurance database was queried for patients undergoing rotator cuff repair from 2007 to 2015. These patients were divided into three groups: (1) patients prescribed fluoroquinolones within 6 months postoperatively (divided into 0-2, 2-4, and 4-6 months), (2) a matched negative control cohort of patients not prescribed fluoroquinolones, and (3) a matched positive control cohort of patients prescribed fluoroquinolones between 6 and 18 months following rotator cuff repair. Rates of failure requiring revision rotator cuff repair were compared within 2 years. RESULTS: A total of 1292 patients were prescribed fluoroquinolones within 6 months after rotator cuff repair, including 442 within 2 months, 433 within 2 to 4 months, and 417 within 4 to 6 months, and were compared to 5225 matched negative controls and 1597 matched positive controls. The rate of revision rotator cuff repair was significantly higher in patients prescribed fluoroquinolones within 2 months (6.1 %) compared to matched negative (2.2 %, P = 0.0009) and positive controls (2.4 %, P = 0.0026). There were no significant differences in the rate of revision rotator cuff repair when fluoroquinolones were prescribed >2 months after rotator cuff repair. CONCLUSIONS: Early use of fluoroquinolones following rotator cuff repair was independently associated with significantly increased rates of failure requiring revision rotator cuff repair. This is the first clinical study examining the association of postoperative fluoroquinolone use with failure following arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: III.

Utility of postoperative radiography in routine primary total shoulder arthroplasty.

BACKGROUND: The medical relevance and cost-benefit of routine radiographs after primary anatomic total shoulder arthroplasty (TSA) up to a year postoperatively are unknown. This study was performed to assess the medical relevance and cost-benefit of radiography after TSA during the first postoperative year. METHODS: During the period 2010 to 2015, 160 consecutive patients undergoing anatomic TSA by a single fellowship-trained surgeon had radiographs obtained at 2 weeks, 6 weeks, 4 months, and 1 year postoperatively. Radiographs and clinic notes were assessed to determine if a change in postoperative care happened because of radiographic findings, including postoperative fracture, hardware complication, or any concerning radiographic feature. Cost data and amount billed were obtained. RESULTS: Patients underwent radiography at 1.8 ± 0.2 weeks, 6.5 ± 1.2 weeks, 14.9 ± 2.9 weeks, and 46.8 ± 19.5 weeks postoperatively. Findings on the radiologist's reading were normal/unremarkable for 100.0%, 96.8%, 95.9%, and 95.2%, respectively, at each visit. Results were documented in the note for 92.5%, 97.4%, 98.0%, and 92.4%, respectively, at each visit. Review of the radiographs yielded no change in management based on these parameters. The amount billed for radiographs was $284,281 ($1776.76 per patient). CONCLUSIONS: A lack of clinically meaningful impact from routine postoperative radiography does not justify the per-patient expense, as routine imaging did not cause a change in postoperative management. The available data suggest that routine radiographs after primary anatomic TSA may be unnecessary or perhaps the described frequency in which radiographs are obtained is in excess.

Is Hepatitis C Infection Associated With a Higher Risk of Complications After Total Shoulder Arthroplasty?

BACKGROUND: Despite recent advances in the treatment of hepatitis C, it is estimated that nearly 4 million Americans have a chronic form of the disease. Although research in lower-extremity arthroplasty suggests patients with hepatitis C are at risk for increased complications, including postoperative bleeding, acute postoperative infection, and general medical complications, no similar studies have investigated this question in patients undergoing total shoulder arthroplasty (TSA). QUESTIONS/PURPOSES: We asked whether there is an increased risk of postoperative complications after TSA among patients who have hepatitis C, and if so, what complications in particular seem more likely to occur in this population? METHODS: Patients who underwent TSA, including anatomic or reverse TSA, were identified in the PearlDiver database using ICD-9 procedure codes. This is a for-fee insurance patient-records database that contains more than 100 million individual patient records from 2005 to 2012. The Medicare data in the database are the complete 100% Medicare Standard Analytical File indexed to allow for patient tracking with time. Patients with hepatitis C who underwent shoulder arthroplasty then were identified using ICD-9 codes. Patients with hepatitis B coinfection or HIV were excluded. A control cohort of patients without hepatitis C who underwent TSA was created and matched to the study cohort based on age, sex, obesity, and diabetes mellitus. A total of 1466 patients with hepatitis C and 21,502 control patients were included. The two cohorts were statistically similar in terms of sex (53% females in study and control groups), age (nearly ½ of each cohort younger than 65 years), obesity (approximately 17% of each cohort were obese), diabetes (approximately 40% of each cohort had diabetes), and followup of each cohort occurred throughout the length of the database from 2005 to 2012. Postoperative complications were assessed using ICD-9 and Current Procedural Terminology codes and compared between cohorts. RESULTS: Patients with hepatitis C, when compared with matched control subjects, had greater odds of infection within 3 months (odds ratio [OR], 1.7; 95% CI, 1.1-2.6; p = 0.015), 6 months (OR, 1.7; CI, 1.3-2.4; p = 0.001), and 1 year (OR, 2.1; CI, 1.7-2.7; p < 0.001); revision TSA within 1 year (OR, 1.5; CI, 1.1-2.9; p = 0.008) and 2 years (OR, 1.6; CI, 1.2-2.0; p = 0.001), dislocation within 1 year (OR, 1.6; CI, 1.2-2.2; p < 0.001); postoperative fracture within 1 year (OR, 1.8; CI, 1.2-2.6; p = 0.002); systemic or medical complications within 3 months (OR, 1.3; CI, 1.0-1.6; p = 0.022); and blood transfusion within 3 months (OR, 1.7; CI, 1.4-1.9; p < 0.001). CONCLUSIONS: Hepatitis C is associated with an increased risk for complications after TSA, including infection, dislocation, fracture, revision TSA, systemic complications, and blood transfusion compared with matched control subjects. Although this study is able to identify increased odds of complications in patients with hepatitis C, the mechanism by which these occur is likely not solely related to the virus, and is more likely related to a higher degree of case complexity in addition to other postoperative socioeconomic factors. LEVEL OF EVIDENCE: Level III, therapeutic study.

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair.

BACKGROUND: Although the general health consequences of tobacco use have been well defined, the effects of perioperative tobacco use on arthroscopic shoulder procedures remain largely unknown. The purpose of this study is to use a national database to investigate the relationship between tobacco use and rates of superior labrum anterior and posterior (SLAP) repair failure and postoperative infection after primary SLAP repair compared with matched controls. METHODS: A national private-payer insurance database was queried for patients who underwent arthroscopic primary SLAP from 2005-2012. These patients were divided into tobacco use and non-tobacco use cohorts using International Classification of Diseases, Ninth Revision coding. The non-tobacco use patients were then matched to the patients with coded tobacco use. Both cohorts were assessed for postoperative infection within 90 days and subsequent ipsilateral revision SLAP repair or biceps tenodesis within up to 7 years postoperatively. RESULTS: The incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls. CONCLUSIONS: SLAP repair in patients who use tobacco is associated with significantly increased rates of postoperative infection and revision SLAP repair or conversion to a biceps tenodesis.

The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients.

BACKGROUND: The goal of this study was to employ a national database to evaluate the association of preoperative injection before shoulder arthroscopy and arthroplasty with the incidence of postoperative infection. METHODS: A national database of Medicare patients was queried for patients who underwent shoulder arthroscopy or arthroplasty after ipsilateral shoulder injection. Three arthroscopy cohorts were created: arthroscopy within 3 months of injection (n = 3625), arthroscopy between 3 and 12 months after injection (n = 7069), and matched control arthroscopy without prior injection (n = 186,678). Three arthroplasty cohorts were created: arthroplasty within 3 months of injection (n = 636), arthroplasty between 3 and 12 months after injection (n = 1573), and matched control arthroplasty (n = 6211). Infection rates within 3 and 6 months postoperatively were assessed. RESULTS: The incidence of infection after arthroscopy at 3 months (0.7%; odds ratio [OR], 2.2; P < .0001) and 6 months (1.1%; OR, 1.6; P = .003) was significantly higher in patients who underwent injection within 3 months before arthroscopy compared with controls. The incidence of infection after arthroplasty at 3 months (3.0%; OR, 2.0; P = .007) and 6 months (4.6%; OR, 2.0; P = .001) was significantly higher in patients who underwent injection within 3 months before arthroplasty compared with controls. CONCLUSIONS: There was a significant increase in postoperative infection in Medicare patients who underwent injection within 3 months before shoulder arthroscopy and arthroplasty. This association was not noted when shoulder arthroscopy or arthroplasty occurred >3 months after injection.

Increased Failure Rates After Anterior Cruciate Ligament Reconstruction With Soft-Tissue Autograft-Allograft Hybrid Grafts.

PURPOSE: To compare the rate of failure between a group of patients who underwent anterior cruciate ligament (ACL) reconstruction with an autograft-allograft hybrid soft-tissue graft and a matched group of patients who underwent ACL reconstruction with hamstring autograft. METHODS: From 2007 to 2012, 29 patients underwent hybrid ACL reconstruction performed by 4 fellowship-trained sports medicine surgeons at a single institution. Patients who underwent ACL reconstruction with hamstring autograft comprised the control group and were matched to patients in the hybrid group by sex, age, date of surgery, reconstruction technique, and method of femoral fixation. Graft failure was defined as revision ACL reconstruction or complete graft rupture on magnetic resonance imaging. Graft compromise was defined as magnetic resonance imaging evidence of partial graft rupture or arthroscopically identified partial graft rupture. Lysholm Knee Scoring Scale and International Knee Documentation Committee scores were obtained. RESULTS: Both groups included 10 men and 19 women, with a mean postoperative follow-up period of 44.4 ± 16.9 months in the hybrid group and 48.0 ± 15.2 months in the control group. Follow-up was obtained in 25 of 29 patients (86.2%) in the hybrid group, and each was matched to 1 patient who received hamstring autograft. The failure rate was 13.8% (4 of 29 patients) in the hybrid group compared with 3.4% (1 of 29) in the control group (P = .160). An additional 27.6% of hybrid group patients (7 of 29) had compromised grafts as defined earlier, as compared with 1 (3.4%) of the control patients (P = .022). Thus the overall hybrid graft failure/compromise rate was 37.9% (11 of 29) compared with 6.9% (2 of 29) for the hamstring autograft group (P = .005). In the hybrid group, the Lysholm score (80.2 ± 12.1) was significantly lower than that in the control autograft ACL group (89.9 ± 11.8) (P = .030). The International Knee Documentation Committee score for the hybrid ACL group (71.26 ± 19.5) was significantly worse than that for the autograft ACL group (85.7 ± 13.0) (P = .012). CONCLUSIONS: Allograft-autograft hybrid hamstring ACL grafts fail or become structurally compromised at a higher rate than matched autograft hamstring controls. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of restoration of length-tension and mechanical strength between techniques.

PURPOSE: This study aimed to (1) evaluate the ex vivo restoration of the long head biceps length-tension for both arthroscopic suprapectoral biceps tenodesis (ASPBT) and open subpectoral biceps tenodesis (OSPBT) techniques and (2) assess how location in the proximal humerus affects pullout strength for tenodesis using an interference screw implant. METHODS: Eighteen matched cadaveric shoulders were randomized to OSPBT or ASPBT groups (9 each). Tenodesis was performed using clinical techniques. Preoperatively, a metallic bead was placed in the biceps tendon and a fluoroscopic image was obtained. Postoperatively, an image was obtained to evaluate the location of the tenodesis and the metallic bead and determine tensioning. Biomechanical load-to-failure testing was then performed. RESULTS: The ASPBT technique resulted in an average of 2.15 ± 0.62 cm of biceps overtensioning compared with 0.78 ± 0.35 cm (P < .001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared with 197 ± 38.6 N (P = .002) in the OSPBT group. Failure caused by implant pullout was significantly more frequent in the ASPBT group (7 of 9) than in the OSPBT group (1 of 9). CONCLUSIONS: The described ASPBT technique using an interference screw implant has the tendency to overtension the biceps and has a significantly decreased ultimate load to failure compared with an open subpectoral technique in matched cadaveric specimens. CLINICAL RELEVANCE: This study shows differences in the biomechanical properties of OSPBT and ASPBT. Modification of currently published ASPBT techniques may be necessary to improve restoration of the physiological length-tension relationship of the biceps. Clinical studies may need to clarify if the lower ultimate load to failure for the ASPBT technique is clinically significant.

Superobesity (body mass index >50 kg/m2) and complications after total shoulder arthroplasty: an incremental effect of increasing body mass index.

BACKGROUND: The prevalence of obesity in the United States continues to increase. Attention has recently turned to an emerging population of extremely overweight patients, termed superobese and defined as those with body mass index (BMI) ≥50 kg/m(2). The goal of this study was to use a national database to evaluate postoperative complication rates after total shoulder arthroplasty (TSA) in superobese patients and to compare patients of different BMI classes. METHODS: Patients who underwent TSA or reverse TSA were identified in the PearlDiver database by International Classification of Diseases, Ninth Revision (ICD-9) codes. These patients were then divided into nonobese, obese, morbidly obese, and superobese cohorts by ICD-9 codes. Postoperative complications were assessed and compared between cohorts. RESULTS: From 2005 to 2012, 144,239 unique patients who underwent TSA or reverse TSA were identified, including 105,661 nonobese patients, 23,864 obese patients, 13,759 morbidly obese patients, and 955 superobese patients. Superobese patients had a significantly higher rate of infection, dislocation, component loosening, revision shoulder arthroplasty, venous thromboembolism, and medical complications after shoulder arthroplasty compared with nonobese controls. CONCLUSIONS: Obesity is associated with significantly increased rates of numerous complications after TSA, including infection, dislocation, component loosening, revision surgery, venous thromboembolism, and medical complications, compared with nonobese controls. Superobesity (BMI > 50 kg/m(2)) is associated with significantly increased rates of several complications compared with even obese and morbidly obese patients, including infection, component loosening, venous thromboembolism, and medical complications.

Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures.

BACKGROUND: Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database. METHODS: Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated. RESULTS: From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications. CONCLUSIONS: Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.