Underweight Patients are at Increased Risk for Complications following Total Hip Arthroplasty.

BACKGROUND: Given the prevalence of obesity in the United States, much of the adult reconstruction literature focuses on the effects of obesity and morbid obesity. However, there is little published data on the effect of being underweight on postoperative outcomes. This study aimed to examine the risk of low body mass index (BMI) on complications after total hip arthroplasty (THA). METHODS: A large national database was queried between 2010 and 2020 to identify patients who had THAs. Using International Classification of Disease codes, patients were grouped into the following BMI categories: morbid obesity (BMI>40), obesity (BMI 30 to 40), normal BMI (BMI 20 to 30), and underweight (BMI<20). There were 58,151 patients identified, including 2,484 (4.27%) underweight patients, 34,710 (59.69%) obese patients, and 20,957 (36.04%) morbidly obese patients. Control groups were created for each study group, matching for age, sex, and a comorbidity index. Complications that occurred within 1 year postoperatively were isolated. Subanalyses were performed to compare complications between underweight and obese patients. Statistical analyses were performed using Pearson Chi-squares. RESULTS: Compared to their matched control group, underweight patients showed increased odds of THA revision (Odds Ratio (OR) = 1.32, P = .04), sepsis (OR = 1.51, P = .01), and periprosthetic fractures (OR = 1.63, P = .01). When directly comparing underweight and obese patients (BMI 30 and above), underweight patients had higher odds of aseptic loosening (OR = 1.62, P = .03), sepsis (OR = 1.34, P = .03), dislocation (OR = 1.84, P < .001), and periprosthetic fracture (OR = 1.46, P = .01). CONCLUSION: Morbidly obese patients experience the highest odds of complications, although underweight patients also had elevated odds for several complications. Underweight patients are an under-recognized and understudied high risk arthroplasty cohort and further research is needed.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018.

BACKGROUND: In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care. METHODS: Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery. RESULTS: A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management. CONCLUSIONS: This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges. LEVEL OF EVIDENCE: Level III-retrospective cohort.

Increased Medical and Implant-Related Complications in Total Hip Arthroplasty Patients With Underlying Chronic Obstructive Pulmonary Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with impaired bone metabolism. The purpose of this study is to investigate rates of readmission, respiratory complications, implant-related complications, and revision after total hip arthroplasty (THA) in patients with and without underlying COPD. METHODS: The PearlDiver Mariners database was used to divide patients undergoing primary THA (CPT-27130) into two cohorts: 1) THA with COPD (including asthma) or 2) THA without COPD. The incidence of 30-day readmission, COPD exacerbation, pneumonia, other respiratory complications as well as dislocations, mechanical loosening, and joint prosthetic infection was calculated through logistic regression. The risk of THA revision was also assessed through Cox-proportional hazards regression. All regression controlled for age, gender, and medical comorbidities found to be associated with COPD. RESULTS: Between 2010 and 2018, 97,784 THA patients with COPD and 338,243 THA patient without COPD were studied. THA patients with COPD had higher risk of 30-day readmission (aOR = 1.17, 95% CI 1.11-1.23, P < .0001). There was higher risk of 30-day pneumonia (aOR = 2.07, 95% CI 1.76-2.44, P < .0001). THA patients with COPD also faced higher risk of 30-day dislocations (aOR = 1.31, 95% CI 1.19-1.45, P < .0001), joint prosthetic infections (aOR = 1.25, 95% CI 1.14-1.37, P < .0001), and periprosthetic fracture (aOR = 1.19, 95% CI 1.07-1.32, P = .0015). Regarding revisions, 3.3% of THA patients with COPD underwent THA revision at 1 year, a higher risk than THA patients without COPD (aOR = 1.11, 95% CI 1.06-1.16, P < .0001). CONCLUSION: Patients undergoing THA with underlying COPD face a higher rate of comorbidities, respiratory complications, implant complications, and revision surgeries, than patients without COPD. LEVEL OF EVIDENCE: III.

Total Hip Arthroplasty After Hip Arthroscopy Has Increased Complications and Revision Risk.

BACKGROUND: There has been an increase in hip arthroscopy (HA) over the last decade. After HA, some patients may ultimately require a total hip arthroplasty (THA). However, there is a scarcity of research investigating the outcomes in patients undergoing THA with a history of ipsilateral HA. METHODS: The PearlDiver research program (www.pearldiverinc.com) was queried to capture all patients undergoing THA between 2015 and 2020. Propensity matching was performed to match patients undergoing THA with and without a history of ipsilateral THA. Rates of 30-day medical complications, 1-year surgical complications, and THA revision were compared using multivariate logistic regression. Kaplan-Meier analysis was conducted to estimate survival probabilities of each of the groups with patients undergoing THA . RESULTS: After propensity matching, cohorts of 1940 patients undergoing THA without prior HA and 1940 patients undergoing a THA with prior HA were isolated for analysis. The mean time from HA to THA was 1127 days (standard deviation 858). Patients with a history of ipsilateral HA had an increased risk for dislocation (odds ratio [OR] 1.56, P = .03) and overall decreased implant survival within 4 years of undergoing THA (OR 1.53; P = .05). Furthermore, our data demonstrate the timing of previous HA to be associated with the risk of complications, as illustrated by the increased risk for dislocation (OR 1.75, P = .03), aseptic loosening (OR 2.18, P = .03), and revision surgery at 2 (OR 1.92, P = .02) and 4 years (OR 2.05, P = .01) in patients undergoing THA within 1 year of HA compared twitho patients undergoing THA more than 1 year after HA or with no previous history of HA. CONCLUSION: Patients undergoing THA after HA are at an increased risk for surgical complications, as well as the need for revision surgery.

Incidence of Combat Sport-Related Mild Traumatic Brain Injuries Presenting to the Emergency Department From 2012 to 2016.

OBJECTIVES: We sought to investigate the incidence and characteristics of traumatic brain injuries [mild traumatic brain injury (MTBI)] presenting to the emergency department as a result of boxing, wrestling, and martial arts (MA). DESIGN: Retrospective cross-sectional study of MTBI in combat sport athletes who were evaluated in emergency departments in the United States. SETTING: Patient data were taken from the National Electronic Injury Surveillance System. PARTICIPANTS: All patients with MTBI from 2012 to 2016, which occurred during participation in boxing, MA, or wrestling. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The incidence of combat sport-related MTBI presenting to emergency departments in the United States. RESULTS: The mean annual incidence of MTBI due to wrestling was significantly larger (269.3 per 100 000 person-years) than boxing (85.6 per 100 000 person-years) and MA (61.0 per 100 000 person-years) (P < 0.01). The average age at injury was significantly lower for wrestling compared with boxing and MA (15.0 years [SD ± 3.9] vs 21.7 years [SD ± 8.2] vs 19.9 years [SD ± 10.5]; P < 0.01). A significantly larger proportion of MTBIs (95.3%; P < 0.01) in patients younger than 20 years were related to wrestling, compared with boxing (55.8%) and MA (54.1%). Most patients with combat sport-related MTBIs were treated and discharged (96.3%), with only 1.7% of patients being admitted and 0.6% of patients being held for observation. CONCLUSION: Combat sports athletes are at high risk of sustaining an MTBI. Such athletes presenting to the emergency department for combat sport-related MTBI were more likely to be male and younger than 20 years. Of these athletes, wrestlers experience the highest incidence of MTBI-related emergency department visits.

Matrilin-3 chondrodysplasia mutations cause attenuated chondrogenesis, premature hypertrophy and aberrant response to TGF-ß in chondroprogenitor cells.

Studies have shown that mutations in the matrilin-3 gene (MATN3) are associated with multiple epiphyseal dysplasia (MED) and spondyloepimetaphyseal dysplasia (SEMD). We tested whether MATN3 mutations affect the differentiation of chondroprogenitor and/or mesenchymal stem cells, which are precursors to chondrocytes. ATDC5 chondroprogenitors stably expressing wild-type (WT) MATN3 underwent spontaneous chondrogenesis. Expression of chondrogenic markers collagen II and aggrecan was inhibited in chondroprogenitors carrying the MED or SEMD MATN3 mutations. Hypertrophic marker collagen X remained attenuated in WT MATN3 chondroprogenitors, whereas its expression was elevated in chondroprogenitors expressing the MED or SEMD mutant MATN3 gene suggesting that these mutations inhibit chondrogenesis but promote hypertrophy. TGF-ß treatment failed to rescue chondrogenesis markers but dramatically increased collagen X mRNA expression in mutant MATN3 expressing chondroprogenitors. Synovium derived mesenchymal stem cells harboring the SEMD mutation exhibited lower glycosaminoglycan content than those of WT MATN3 in response to TGF-ß. Our results suggest that the properties of progenitor cells harboring MATN3 chondrodysplasia mutations were altered, as evidenced by attenuated chondrogenesis and premature hypertrophy. TGF-ß treatment failed to completely rescue chondrogenesis but instead induced hypertrophy in mutant MATN3 chondroprogenitors. Our data suggest that chondroprogenitor cells should be considered as a potential target of chondrodysplasia therapy.

Testosterone: A Review for Orthopaedic Surgeons.

¼ Testosterone replacement treatment (TRT) and anabolic androgenic steroid (AAS) use is common and possibly increasing.¼ Diagnosing and treating hypogonadism in men is controversial.¼ Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. The current literature on TRT and the musculoskeletal system shows an increased risk of tendon injury.¼ There may be a role for testosterone supplementation in the postoperative period.

Public Insurance Is Associated With Decreased Rates of Surgical Management for Glenohumeral Instability: An Analysis of the Rhode Island All-Payers Claims Database.

Background: Socioeconomic status has been shown to influence patients' ability to access health care. Purpose: To evaluate the socioeconomic status and/or insurance provider of patients and to determine whether these differences influence the management of shoulder instability. Study Design: Descriptive epidemiology study. Methods: The Rhode Island All-Payers Claims Database (APCD) was used to identify all patients between the ages of 5 and 64 years who made an insurance claim related to a shoulder instability event between January 1, 2011, and December 31, 2019. Chi-square analysis and multivariate logistic regression were utilized to determine whether insurance status, social deprivation index (SDI), or median income by zip code were significant predictors of treatment methodology and recurrent instability. Kaplan-Meier failure analysis and Cox regression were used to assess for variation in the cumulative rates of surgical intervention and recurrent instability over 20-year age groups (5-24, 25-44, and 45-64 years). Results: There were 3310 patients from the APCD query included in the analysis. Bivariate analysis demonstrated significant variation in the rates of surgical stabilization between patients with public and commercial insurance providers (P < .001). Patients with public insurance received surgery 1.8% of the time compared with 5.8% of the time in patients with commercial insurance. After controlling for recurrent instability, age, instability type (subluxation or dislocation) and directionality, and sex, patients with public insurance were 79% less likely to receive surgery within 30 days (P = .035) and 64% less likely to receive surgery within 1 year (P = .002). This disparity was most notable in the 5- to 24-year (hazard ratio [HR] = 0.28; 95% CI, 0.13-0.61) and 25- to 44-year (HR = 0.26; 95% CI, 0.08-0.89) age groups. Neither SDI quartile nor income quartile based on patient primary zip code had a clinically significant influence on rates of surgery or recurrent instability. Conclusion: These data demonstrate that patients with public insurance have a decreased likelihood of undergoing surgical stabilization to address glenohumeral instability compared with patients with commercial insurance.

The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty.

Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.

Characterization of Musculoskeletal Injuries in Gymnastics Participants From 2013 to 2020.

BACKGROUND: Many studies have analyzed gymnastics-related injuries in collegiate and elite athletes, but there is minimal literature analyzing the epidemiological characteristics of injuries in the greater gymnastics community. HYPOTHESIS: A higher incidence of injuries in younger gymnasts between the ages of 6 and 15 years compared with those 16 years and older and a difference in the distribution of injuries between male and female gymnasts. STUDY DESIGN: Retrospective cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all gymnastics-related musculoskeletal injuries presenting to the emergency department (ED) between 2013 and 2020. Incidence was calculated as per 100,000 person-years using the weighted estimates provided by NEISS and national participation data. Chi-square and column proportion z-testing was used to analyze where appropriate. RESULTS: The incidence of gymnastics-related musculoskeletal injuries was 480.7 per 100,000 person-years. Most ED visits were children between the ages of 6 and 15 years (84.0%). Younger gymnasts (ages 6 to 10) were most likely to experience a lower arm fracture, while those over the age of 10 years were most likely to experience an ankle sprain (P < 0.01). Men and boys presented with a much greater proportion of shoulder injuries (8.0% vs 3.9%), while women and girls presented with a greater proportion of elbow injuries (9.9 % vs 5.9%) and wrist (10.5% vs 8.3%) injuries (P < 0.01). CONCLUSION: As hypothesized, most gymnastics-related injuries between 2013 and 2020 were athletes between 6 and 15 years old. Many of these athletes are attempting new, more difficult, skills and are at increased risk of more acute injury when attempting skills they may be unfamiliar with. CLINICAL RELEVANCE: With increased pressure to specialize at an early age to maintain competitiveness and learn new, higher-level skills compared with their peers, younger athletes are most susceptible to acute injury. New injury prevention strategies could be implemented to help this high-risk population compete and train safely.

Epidemiology of Ankle Dislocations in the United States: 2009 to 2018.

BACKGROUND: Injuries to the ankle joint are common and often sustained during participation in athletic activities. There is little information regarding the overall epidemiology of ankle dislocation, both with and without associated fracture. DESIGN AND METHODS: The National Electronic Injury Surveillance System (NEISS) database was queried to characterize ankle dislocation presentations to U.S. Emergency Departments (ED) from 2009-2018. Ankle dislocations were analyzed by age, sex, mechanism, and race. RESULTS: From 2009-2018, 30,477 patients with ankle dislocations presented to U.S. EDs with a majority (59.8%) occurring in male patients. The overall incidence of ankle dislocations increased by 54% from 2009-2018 (p = 0.017). Over half (53%) of ankle dislocations occurred in association with sports. Ankle dislocations peaked in the third decade of life at 16.94 per million person-years. For male, the age at which ankle dislocation peaked was 33.33, whereas for females, ankle dislocations peaked at 39.27. CONCLUSION: Preventive strategies are necessary to decrease the risk of sustaining ankle dislocations in the adult population participating in jumping sports.

Lack of Consensus in Rehabilitation Protocols After Posterior Shoulder Stabilization.

Background: Posterior shoulder instability is being identified and treated more frequently by orthopaedic providers. After posterior shoulder stabilization, long-term outcomes in function and mobility are largely dependent on the postoperative rehabilitation period. Thus, it is important to assess the consistency between protocols at different institutions. Purpose/Hypothesis: The purpose of this study was to investigate the variability among rehabilitation protocols published by academic orthopaedic programs and their affiliates. It was hypothesized that there would be little consistency in the duration of immobilization, timing of functional milestones, and start dates of various exercises. Study Design: Cross-sectional study. Methods: Rehabilitation protocols after posterior shoulder stabilization that were published online from Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery programs and their affiliates were evaluated for recommendations on immobilization, exercises, activities, range of motion (ROM), and return-to-sport goals. Results: Of the 204 ACGME-accredited orthopaedic surgery programs, 22 programs and 17 program affiliates had publicly available rehabilitation protocols that were included for review. There were 37 programs (94.9%) that recommended the use of sling immobilization for a mean of 4.7 ± 1.8 weeks postoperatively. Active ROM of the elbow, wrist, and hand was the most common early ROM exercise to be recommended (36 programs; 92.3%). The goal of 90° passive external rotation demonstrated the widest range of recommended start dates (0-12 weeks postoperatively). Late ROM exercises and start dates varied between protocols, with the largest standard deviation found in achieving full active ROM (13.5 ± 3.6 weeks). Resistance exercises showed a wide range of recommended start dates. Bench presses and push-ups began, on average, at 13.1 ± 3.4 and 15.3 ± 3.2 weeks, respectively. Return to sport was recommended at 21.7 ± 3.6 weeks. Conclusion: There was a high level of variability in postoperative rehabilitation protocols after posterior shoulder stabilization among orthopaedic programs and their affiliates, suggesting that a standard protocol for rehabilitation has yet to be established.

Do Patient Demographic and Socioeconomic Factors Influence Surgical Treatment Rates After ACL Injury?

INTRODUCTION: Anterior cruciate ligament (ACL) injuries may be managed nonoperatively in certain patients and injury patterns; however, complete ACL ruptures are commonly reconstructed to restore anterior and lateral rotatory stability of the knee. While ACL reconstruction is well-studied, the literature is sparse with regard to which socioeconomic patient factors are associated with patients undergoing ACL reconstruction rather than nonoperative management after diagnosis of an ACL injury. The current study seeks to evaluate this relationship between patient demographics as well as socioeconomic factors and the rate of surgery following ACL injuries. METHODS: Patients ≤65 years of age with a primary ACL injury between 2011 and 2018 were retrospectively identified in the New York Statewide Planning and Research Cooperative System database. International Classification of Disease 9/10 and Current Procedural Terminology codes were used to identify these patients and their subsequent ACL reconstructions. Logistic regression was performed to determine the effect of patient factors on the likelihood of having surgery after the diagnosis of an ACL injury. RESULTS: Compared to White patients, African American patients were significantly less likely to undergo ACL reconstruction following an ACL injury (OR=0.65, 95% CI, 0.573-0.726). Patients older than 35 had decreased odds of undergoing ACL reconstruction compared to younger patients, with patients 55-64 having the lowest odds (OR=0.166, 95% CI, 0.136-0.203). Patients with Medicaid (OR=0.84, 95% CI, 0.757-0.933) or self-pay insurance (OR=0.67, 95% CI, 0.565-0.793), and those with worker's compensation (OR=0.715, 95% CI, 0.621-0.823) had decreased odds of undergoing ACL reconstruction relative to patients with private insurance. Patients with higher Social Deprivation Index (SDI) were significantly more likely to be treated nonoperatively after ACL injuries compared to those with lower SDI (mean nonoperative SDI score, 61, operative SDI, 56, P<0.0001). DISCUSSION: In patients with ACL injuries, there are socioeconomic and patient-related factors that are associated with increased odds of undergoing ACL reconstruction. These factors are important to recognize as they represent a source of potential inequality in access to care and an area with potential for improvement.

Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty.

Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.

The Relationship Between Testosterone Therapy and Rotator Cuff Tears, Repairs, and Revision Repairs.

INTRODUCTION: The purpose of this study was to evaluate rates of rotator cuff tears (RCTs), repairs (RCRs), and revision RCR in patients who were prescribed testosterone replacement therapy (TRT) and compare these patients with a control group. METHODS: The PearlDiver database was queried for patients who were prescribed testosterone for at least 90 days between 2011 and 2018 to evaluate the incidence of RCTs in this population. A second analysis evaluated patients who sustained RCTs using International Classification of Diseases, 9th/10th codes to evaluate these patients for rates of RCR and revision RCR. Chi square analysis and multivariate regression analyses were used to compare rates of RCTs, RCR, and subsequent or revision RCR between the testosterone and control groups, with a P -value of 0.05 representing statistical significance. RESULTS: A total of 673,862 patients with RCT were included for analysis, and 9,168 of these patients were prescribed testosterone for at least 90 days before their RCT. The TRT group had a 3.6 times greater risk of sustaining an RCT (1.14% versus 0.19%; adjusted odds ratio (OR) 3.57; 95% confidence interval (CI) 3.57 to 3.96). A 1.6 times greater rate of RCR was observed in the TRT cohort (TRT, 46.4% RCR rate and control, 34.0% RCR rate; adjusted OR 1.60; 95% CI 1.54 to 1.67). The TRT cohort had a 26.7 times greater risk of undergoing a subsequent RCR, irrespective of laterality, within 1 year of undergoing a primary RCR when compared with the control group (TRT, 47.1% and control, 4.0%; adjusted OR 26.4; 95% CI 25.0 to 27.9, P < 0.001). CONCLUSIONS: There is increased risk of RCTs, RCRs, and subsequent RCRs in patients prescribed testosterone. This finding may represent a musculoskeletal consequence of TRT and is important for patients and clinicians to understand. Additional research into the science of tendon injury in the setting of exogenous anabolic steroids remains of interest. LEVEL OF EVIDENCE: Level Ⅲ, retrospective cohort study.

Effect of Hospital Characteristics on Performance of Pediatric Digit Replantation in the United States.

Introduction Utilize a national pediatric database to assess whether hospital characteristics such as location, teaching status, ownership, or size impact the performance of pediatric digit replantation following traumatic digit amputation in the United States. Materials and Methods The Kid's Inpatient Database (KID) was used to query pediatric traumatic digit amputations between 2000 and 2012. Ownership (private and public), teaching status (teaching and non-teaching), location (urban and rural), hospital type (general and children's), and size (large and small-medium) characteristics were evaluated. Replantations were then divided into those that required subsequent revision replantation or amputation. Fisher's exact tests and multivariable logistic regressions were performed with p <0.05 considered statistically significant. Results Overall, 1,015 pediatric patients were included for the digit replantation cohort. Hospitals that were privately owned, general, large, urban, or teaching had a significantly greater number of replantations than small-medium, rural, non-teaching, public, or children's hospitals. Privately owned (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.06-3.06; p = 0.03) and urban (OR: 2.29; 95% CI: 1.41-3.73; p = 0.005) hospitals were significantly more likely to perform replantation. Urban (OR: 4.02; 95% CI: 1.90-8.47; p = 0.0003) and teaching (OR: 2.11; 95% CI: 1.17-3.83; p = 0.014) hospitals were significantly more likely to perform a revision procedure following primary replantation. Conclusion Private and urban hospitals were significantly more likely to perform replantation, but urban and teaching hospitals carried a greater number of revision procedures following replantation. Despite risk of requiring revision, the treatment of pediatric digit amputations in private, urban, and teaching centers provide the greatest likelihood for an attempt at replantation in the pediatric population. The study shows Level of Evidence III.

Trends in the surgical treatment of posterior shoulder instability in the United States from 2016 to 2020.

Background: The purpose of this study was to describe trends in the incidence of open versus arthroscopic management of posterior shoulder instability (PSI) as well as the patients undergoing these procedures in the United States over time. Methods: The PearlDiver Patient Records Database was utilized for this study. Cases of PSI and surgery were identified via the appropriate ICD-10-CM and CPT codes. Linear regression and two-sample Student's t-test were used to analyze incidence rates, procedure type, number of instability events, and patient age. Results: A total of 5655 patients were identified as having PSI, undergoing a total of 686 capsulorraphies. The incidence of PSI treated surgically increased across the years of the study at a rate of 0.0293 per 100,000 person-years with an incidence in 2019-2020 greater than in 2016-2018 (p = 0.0151). Patients undergoing arthroscopic capsulorrhaphy were on average younger than those undergoing open capsulorrhaphy (p = 0.0021). Patients experienced a higher number of posterior instability events before open surgery compared to arthroscopic (p = 0.0274). Discussion: The incidence of surgical treatment of PSI in the United States is steadily rising, with greater than 90% of cases being treated arthroscopically. Those undergoing arthroscopic posterior stabilization are both younger and face fewer instability events prior to surgery.

Risk Factors and Outcomes for Preoperative Stiffness Requiring Intervention Before Anterior Cruciate Ligament Reconstruction.

Background: To date, there is a scarcity of literature related to the incidence of prolonged stiffness after an anterior cruciate ligament (ACL) tear that requires manipulation under anesthesia/lysis of adhesions (MUA/LOA) in the preoperative period before ACL reconstruction (ACLR) and how preoperative stiffness influences outcomes after ACLR. Hypothesis: Preoperative stiffness requiring MUA/LOA would increase the risk for postoperative stiffness, postoperative complications, and the need for subsequent procedures after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver Research Program was used to identify patients who sustained an ACL tear and underwent ACLR using their respective International Classification of Diseases, 9th or 10th Revision, and Current Procedure Terminology (CPT) codes. Within this group, patients with preoperative stiffness were identified using the CPT codes for MUA or LOA. Significant risk factors for preoperative stiffness were identified through univariate and multivariate logistic regression analyses. Outcomes after ACLR were analyzed between patients with and without preoperative stiffness using multivariate logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index. Results: Between 2008 and 2018, 187,071 patients who underwent ACLR were identified. Of these patients, 241 (0.13%) underwent MUA/LOA before ACLR. Patients with preoperative stiffness began preoperative physical therapy significantly later than patients without stiffness (P = .0478) and had a delay in time to ACLR (P = .0003). Univariate logistic regression demonstrated that female sex, older age, anxiety/depression, obesity, and anticoagulation use were significant risk factors for preoperative stiffness (P < .05 for all). After multivariate regression, anticoagulation use was the only independent risk factor deemed significant (odds ratio, 6.69 [95% CI, 4.01-10.51]; P < .001). Patients with preoperative stiffness were at an increased risk of experiencing postoperative stiffness, deep vein thrombosis, pulmonary embolism, surgical-site infection, and septic knee arthritis after ACLR (P < .05 for all). Conclusion: Although the risk of preoperative stiffness requiring an MUA/LOA before ACLR is low, the study findings indicated that patients with preoperative stiffness were at increased risk for postoperative complications compared with patients with no stiffness before ACLR.

Increased Risk of Periprosthetic Fractures and Revision Arthroplasty in Patients Undergoing Shoulder Arthroplasty With a History of Prior Fragility Fractures: A Matched Cohort Analysis.

INTRODUCTION: As rates of anatomic and reverse total shoulder arthroplasty (SA) continue to grow, an increase in the number of osteoporotic patients undergoing SA, including those who have sustained prior fragility fractures, is expected. The purpose of this study was to examine short-term, implant-related complication rates and secondary fragility fractures after SA in patients with and without a history of fragility fractures. METHODS: A propensity score-matched retrospective cohort study was done using the PearlDiver database to characterize the effect of antecedent fragility fractures in short-term complications after SA. Rates of revision SA, periprosthetic fractures, infection, and postoperative fragility fractures were evaluated using multivariate logistic regression analysis. Risks of these complications were also studied in patients with and without preoperative osteoporosis treatment. Statistical significance was set at P < 0.05. RESULTS: A total of 91,212 SA patients were identified, with 13,050 (14.3%) experiencing a fragility fracture within the 3 years before SA. Two years after SA, there were increased odds of periprosthetic fracture (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.68 to 2.99), fragility fracture (OR 9.11, 95% CI 8.43 to 9.85), deep infection (OR 1.68, 95% CI 1.34 to 2.12), and all-cause revision SA (OR 1.68, 95% CI 1.44 to 1.96) within those patients who had experienced a fragility fracture within 3 years before their SA. Patients who were treated for osteoporosis with bisphosphonates and/or vitamin D supplementation before their SA had similar rates of postoperative periprosthetic fractures, fragility fractures, and all-cause revision SA to those who did not receive pharmacologic treatment. CONCLUSION: Sustaining a fragility fracture before SA portends substantial postoperative risk of periprosthetic fractures, infection, subsequent fragility fractures, and all-cause revision SA at the 2-year postoperative period. Pharmacotherapy did not markedly decrease the rate of these complications. These results are important for surgeons counseling patients who have experienced prior fragility fractures on the risks of SA.

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury.

Background: Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability. Hypothesis: Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment. Study Design: Cohort study; Level of evidence, 3. Methods: Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables. Results: While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049). Conclusion: In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.