Market resilience of orthopaedic hip/knee arthroplasty sales during COVID-19.

INTRODUCTION: The coronavirus 2019 (COVID-19) pandemic led to a marked decrease in elective surgical volume and orthopaedic device sales. The aim of this paper was to quantify this decrease and the related financial impact on the largest hip/knee arthroplasty companies by: (1) tracking individual hip/knee company valuations; (2) calculating aggregate changes in overall hip/knee arthroplasty market valuations; and (3) quantifying quarterly hip/knee revenues relative to prior years. MATERIALS AND METHODS: Financial data on the top five hip/knee arthroplasty companies by size between January 1, 2019, and October 1, 2020, was collected from a Wall Street financial database, S&P Capital IQ. Changes in valuation of these companies were compared against benchmark market indices, the S&P500 and Vanguard Healthcare ETF. U.S. hip/knee arthroplasty-specific revenue for Q1 and Q2 of 2019 and 2020 was collected from Securities Exchange Commission 10-Q forms. Quarterly revenue changes were calculated using 1-2Q19 revenues as baselines and aggregate to approximate the overall hip/knee arthroplasty market. RESULTS: The top five hip/knee companies lost $179.2 billion (32.7% loss) in market value from pre COVID-19 market highs to COVID-19 market lows (March 2020), while S&P500 and Vanguard Healthcare ETF decreased 36.1 and 33.2%, respectively. From market lows to October 2020, arthroplasty companies rallied 38.6% while the S&P500 and Vanguard Healthcare ETF regained 43.5 and 56.4% respectively. Notably, this occurred while aggregate 1Q/2Q20 revenue lagged 7.1/41.8% relative to 2019, with an overall decrease of $1.58B (24.8%). CONCLUSIONS: Similar to the overall market and healthcare sector, the top five hip/knee arthroplasty companies have recovered from their COVID market lows. Our results reveal that the valuations of hip/knee companies remained robust during COVID, even as revenues fell, likely due to strong investor confidence in the industry outlook and the greater overall healthcare system utilization.

Preoperative Opioid Use Disorder is Associated with Longer Length of Stay, Infection Rate, and Healthcare Expenditure Following Primary Shoulder Arthroplasty.

Recent research efforts have focused on the complications and outcomes associated with opioid use disorder (OUD). However, there is a lack of evidence on the associated risks respective to each primary shoulder arthroplasty procedure. After separating patients by total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) and matching to controls, our study demonstrated significant association with longer LOS in both groups, higher risk of SSI and PJI in the TSA group, PJI in the RSA group, and higher costs regardless of procedure. Efforts to appropriately recognize OUD, optimize patients pre-operatively, and apply targeted surveillance postoperatively should be made. (Journal of Surgical Orthopaedic Advances 33(2):117-121, 2024).

Comparison of Patient Demographics and Risk of Surgical Site Infections Following Open Reduction and Internal Fixation of Trimalleolar Ankle Fractures: A Nationwide Analysis of a Private Payor.

Surgical site infections (SSIs) are a notable complication following open reduction and internal fixation (ORIF) for ankle fractures. The purpose of this study was to (1) compare baseline demographics of patients who did and did not develop SSIs within 90 days following ORIF for trimalleolar ankle fractures and (2) identify risk factors associated with SSIs in this setting. A retrospective analysis from 2010 to 2020 was completed using a national administrative database. The study group consisted of patients who underwent ORIF for trimalleolar ankle fractures and developed SSIs within 90 days postoperatively. Patients without SSIs served as the comparison cohort. Baseline demographics of the two cohorts were compared utilizing Pearson's Chi-Square Analyses. A multivariate binomial logistic regression model determined the association of various comorbidities on developing SSIs in this setting. Out of a total sample of 22,118 patients, 1000 individuals (4.52%) developed SSIs. The study revealed that the SSI cohort exhibited a greater burden of comorbidities, as evidenced by significant differences in various individual comorbidities and average Elixhauser-Comorbidity Indices scores. The most strongly associated risk factors for the development of SSIs following ORIF for trimalleolar ankle fractures were peripheral vascular disease (OR: 1.53, p < .0001), diabetes mellitus (OR: 1.26, p = .0010), iron deficiency anemia (OR: 1.24, p = .0010), male sex (OR: 1.22, p = .0010), and tobacco use (OR: 1.15, p = .0010). This study identified several patient risk factors that were associated with developing SSIs after ORIF for trimalleolar ankle fractures, recognizing potential patient-directed interventions that may reduce the rate of SSIs in this setting.

The association of congestive heart failure on in-hospital lengths of stay, morbidity, and financial burden following primary total knee arthroplasty.

BACKGROUND: Current literature states that 6.2 million adults in the United States are living with heart failure. Studies investigating the impact of congestive heart failure (CHF) following primary total knee arthroplasty (TKA) are scarce. Hence, this research aimed to investigate whether individuals with congestive heart failure (CHF) undergoing primary total knee arthroplasty (TKA) experience: (1) longer durations of in-hospital stay; (2) increased incidences of health complications; and (3) a higher financial load. METHODS: A retrospective query using the 100% Parts A and B of the Medicare claims was performed. Cohorts of interest were identified using International Classification of Disease, Ninth Revision (ICD-9) and Current Procedural Terminology. Inclusion criteria for the study group consisted of patients with CHF undergoing primary TKA, whereas patients without CHF undergoing primary TKA served as the comparison cohort. RESULTS: The query yielded 1,101,169 patients (CHF = 183,540; case-matched = 917,629). Patients with CHF had longer in-hospital LOS (5- vs. 4-days) and a higher incidence and odds of developing 90-day medical complications (49.22% vs. 7.45%) following primary TKA. CHF patients incurred higher day of surgery and total global ninety-day episode of care costs compared to their matched counterparts. CONCLUSION: This study illustrated those patients with preexisting CHF undergoing a primary TKA have longer in-hospital lengths of stay and higher rates of morbidity and financial burden. With the increasing prevalence of CHF worldwide, orthopedists and other healthcare professionals can utilize the information provided in this study to educate patients and establish comprehensive treatment plans to help mitigate postoperative effects associated with CHF.

A matched-control study on the impact of depressive disorders following lumbar fusion for adult spinal deformity: an analysis of a nationwide administrative database.

PURPOSE: In recent years, depression rates have been on the rise, resulting in soaring mental health issues globally. There is paucity of literature about the impact of depression on lumbar fusion for adult spine deformity. The purpose of this study is to investigate whether patients with depressive disorders undergoing lumbar deformity fusion have higher rates of (1) in-hospital length of stay; (2) ninety-day medical and surgical complications; and (3) medical reimbursement. METHODS: A retrospective study was performed using a nationwide administrative claims database from January 2007 to December 2015 for patients undergoing lumbar fusion for spine deformity. Study participants with depressive disorders were selected and matched to controls by adjusting for sex, age, and comorbidities. In total, the query yielded 3706 patients, with 1286 who were experiencing symptoms of depressive disorders, and 2420 who served as the control cohort. RESULTS: The study revealed that patients with depressive disorders had significantly higher in-hospital length of stay (6.0 days vs. 5.0 days, p < 0.0001) compared to controls. Study group patients also had higher incidence and odds of ninety-day medical and surgical complications (10.2% vs. 5.0%; OR, 2.50; 95% CI, 2.16-2.89; p < .0001). Moreover, patients with depressive disorders had significantly higher episode of care reimbursement ($54,539.2 vs. $51,645.2, p < 0.0001). CONCLUSION: This study illustrated that even after controlling for factors such as sex, age, and comorbidities, patients with depressive disorders had higher rates of in-hospital length of stay, medical and surgical complications, and total reimbursement.

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures.

PURPOSE: Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates. METHODS: A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission. RESULTS: The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss. CONCLUSION: This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Anterolateral knee complex considerations in contemporary anterior cruciate ligament reconstruction and total knee arthroplasty: a systematic review.

The anterolateral ligament (ALL) was first described in 1879 in the context of Segond fractures, which correlate with a 75-100% chance of an anterior cruciate ligament (ACL) tear or a 66-75% chance of a meniscal tear. The purpose of this paper is to provide an updated comprehensive review on the anterolateral ligament complex of the knee focusing on the: (1) anatomy of the ALL/ALC; (2) associated biomechanics/function; and (3) important surgical considerations in contemporary anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). A systematic review of studies on ALL was conducted on Pubmed/MEDLINE and Cochrane databases (May 7th, 2020 to February 1st, 2022), with 20 studies meeting inclusion/exclusion criteria. Studies meeting inclusion criteria were anatomical/biomechanical studies assessing ALL function, cadaveric and computer simulations, and comparative studies on surgical outcomes of ALLR (concomitant with ACL reconstruction). Eight studies were included and graded by MINOR and Newcastle-Ottawa scale to identify potential biases. The anatomy of the ALL is part of the anterolateral ligament complex (ALC), which includes the superficial/deep iliotibial band (including the Kaplan fiber system), iliopatellar band, ALL, and anterolateral capsule. Multiple biomechanical studies have characterized the ALC as a secondary passive stabilizer in resisting tibial internal rotation. Given the role of the ALC in resisting internal tibial rotation, lateral extra-articular procedures including ALL augmentation may be considered for chronic ACL tears, ACL revisions, and a high-grade pivot shift test. In the context of TKA, in the event of injury to the ALC, a more constrained implant or soft-tissue reconstruction may be necessary to restore appropriate knee stability.

Crohn's disease is associated with higher rates of implant-related complications following primary total knee arthroplasty.

INTRODUCTION: In Western countries, there has been a rise in the prevalence of Crohn's Disease (CD) and primary total knee arthroplasty (TKA). This study delves deeper into the effects of CD on TKA patients by examining (1) the length of in-hospital stay (LOS); (2) the rates of readmission; (3) complications related to implants; and (4) the costs associated with care. METHODS: A retrospective analysis using the PearlDiver database was conducted, encompassing the time frame between January 1st, 2005 and March 31st, 2014, focusing on patients who underwent TKA and were either diagnosed with CD or not. Patients with CD were paired with control subjects at a 1:5 ratio based on age, gender, and medical comorbidities. The analysis comprised a total of 96,229 patients (CD = 16,039; non-CD = 80,190). RESULTS: Patients with CD had a notably longer hospital stay (3 v. 2 days, p < 0.0001) and faced significantly higher rates of 90-day readmissions and complications (19.80% v. 14.91%, OR: 1.40, p < 0.0001; 6.88% v. 4.88%, OR: 1.43, p < 0.0001 respectively). Additionally, CD patients incurred greater expenses on the surgery day ($18,365.98 v. $16,192.00) and within 90 days post-surgery ($21,337.46 v. $19,101.42). CONCLUSION: This study demonstrates longer in-hospital LOS, higher rates of readmissions, implant-related complications, and costs of care among CD patients following primary TKA.

Trends and risk factors for readmissions following press-fit total knee arthroplasty for the treatment of end-stage osteoarthritis of the knee: a five-year analysis.

INTRODUCTION: The development of new prostheses with improved osseointegration, bone preservation, and reduced cost has renewed interest in uncemented total knee arthroplasty (UCTKA). In the current study, we aimed to: (1) assess demographic data of patients who were and were not readmitted and (2) identify patient-specific risk factors associated with readmission. METHODS: A retrospective query from the PearlDiver database was performed from January 1, 2015, to October 31, 2020. International Classification of Disease, Ninth Revision (ICD-9), ICD-10, or Current Procedural Terminology (CPT) coding was used to distinguish cohorts of patients who had osteoarthritis of the knee and underwent UCTKA. Patients readmitted within 90 days were classified as the study population, while those who were not readmitted were classified as control. A linear regression model was utilized to analyze readmission risk factors. RESULTS: The query yielded 14,575 patients, with 986 (6.8%) being readmitted. Patient demographics such as age (P < 0.0001), sex (P < 0.009), and comorbidity (P < 0.0001) were associated with annual 90-day readmission. Patient-specific risk factors associated with 90-day readmission following press-fit total knee arthroplasty were: arrhythmia (OR: 1.29, 95% CI: 1.11-1.49, P < 0.0005), coagulopathy (OR: 1.36, 95% CI: 1.13-1.63, P < 0.0007), fluid and electrolyte abnormalities (OR: 1.59, 95% CI: 1.38-1.84, P < 0.0001), iron deficiency anemia (OR: 1.49, 95% CI: 1.27-1.73, P < 0.0001), and obesity (OR: 1.37, 95% CI: 1.18-1.60, P < 0.0001). DISCUSSION: This study demonstrates that patients with comorbidities, such as fluid and electrolyte problems, iron deficiency anemia, and obesity, were at an increased risk of readmission after having an uncemented total knee replacement. The risks of readmission following an uncemented total knee arthroplasty can be discussed with patients who have certain comorbidities by arthroplasty surgeons.

Risk factors for nonunion following open reduction and internal fixation for proximal humerus fractures.

PURPOSE: The incidence of proximal humerus fractures (PHF) is rising and surgical intervention carries risk for fracture nonunion. The purpose was (1) to compare patient demographics of those that developed nonunion and (2) identify patient risk factors that predispose to nonunion following open reduction and internal fixation (ORIF) for PHF. METHODS: A retrospective review of the Medicare Claims Database from 2005 to 2014 for patients who underwent primary ORIF for PHFs. Patients who developed nonunion were identified as the study group (n = 1020) and compared to a control group (n = 51,209). Primary endpoints were to compare demographics of the study group and the comparison cohorts and to identify patient-related risk factors associated with nonunion within 6-months following the index procedure. A logistic regression model was constructed to determine the association of comorbid conditions on developing a nonunion. A p value of 0.001 was the significance threshold. RESULTS: Patients who developed nonunion were younger, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (7 vs. 5; p < 0.0001) when compared with controls. Iron deficiency anemia (OR: 1.32; p = 0.0001), tobacco use (OR: 1.32; p = 0.0004), rheumatoid arthritis (OR: 1.29; p = 0.0001), depression (OR: 1.28; p = 0.0002), and BMI range from 30-39 kg/m2 (OR: 1.21; p = 0.001) were significant risk factors for nonunion. CONCLUSIONS: Certain patient risk factors including tobacco use, iron deficiency anemia, rheumatoid arthritis, depression, and a BMI in the range of 30-39 were associated with nonunion within 6 months of ORIF for PHF. This study may help in the risk stratification of these patients.

Comparison of baseline demographics and risk factors for aseptic loosening following primary total elbow arthroplasty.

BACKGROUND: Aseptic loosening is a feared complication following total elbow arthroplasty (TEA); however, literature regarding factors that may contribute to this complication is limited. The aims of this investigation were to: (1) compare baseline demographics of patients who developed aseptic loosening following primary TEA; and (2) identify patient-specific risk factors for the development of loosening. METHODS: Retrospective analysis using a nationwide claims database was performed to identify patients who underwent primary TEA and developed aseptic loosening within 2 years (study n = 307, control n = 10,741). Multivariate regression analysis generated odds ratio (OR), 95% confidence interval (95% CI), and p-value of risk factors. p < 0.05 was considered statistically significant. RESULTS: Patients who developed aseptic loosening had significant differences in numerous demographics, including age (p = 0.0001), sex (p = 0.0251), and various comorbid conditions such as obesity (15.96% vs. 8.36%, p < 0.0001). Furthermore, the risk factors most associated with aseptic loosening were obesity (OR 1.65, 95% CI 1.18-2.28, p = 0.002), male sex (OR 1.51, 95% CI 1.13-2.00, p = 0.004), and concomitant opioid use disorder (OR 1.58, 95% CI 1.14-2.15, p = 0.004). DISCUSSION: This study is the first to identify demographics and patient-related risk factors associated with aseptic loosening following primary TEA. This evidence could be applied to the clinical setting in order to educate at-risk patients of this potential complication as well as inform their post-operative clinical management. LEVEL OF EVIDENCE: Level III: Prognostic.

The association of dementia on perioperative complications following primary total hip arthroplasty for femoral neck fractures.

INTRODUCTION: Studies evaluating the association of dementia in patients undergoing total hip arthroplasty (THA) for femoral neck fractures are limited. The aim was to investigate whether patients who have dementia undergoing THA for femoral neck fractures have higher rates of (1) in-hospital lengths of stay (LOS); 2) complications (medical and prostheses-related); and 3) healthcare expenditures. METHODS: A retrospective query using the PearlDiver database from January 1st, 2005 to March 31st, 2014 to identify patients with dementia undergoing primary total hip arthroplasty for the treatment of femoral neck fractures was performed. Dementia patients were 1:5 ratio matched to controls which yielded 22,758 patients in the study with (n = 3,798) and without (n = 18,960) dementia. Primary outcomes included comparing LOS, complications, and costs. A logistic regression was constructed to calculate the odds-ratios (OR) of dementia on complications. A p-value less than 0.004 was significant. RESULTS: Dementia patients had longer LOS (7-days vs. 6-days, p < 0.0001) and higher incidence and odds of medical complications (41.52 vs. 17.77%; OR 3.76, p < 0.0001), including cerebrovascular events (5.66 vs. 1.64%; OR 2.35, p < 0.0001), pneumoniae (9.98 vs. 3.82%; OR 1.82, p < 0.0001), and acute kidney injury (8.37 vs. 3.27%; OR 1.62, p < 0.0001). Study group patients had higher frequency of prostheses-related complications (9.53 vs. 8.31%; OR: 1.16, p = 0.012). The study group had greater total healthcare expenditures ($28,879.57 vs. $26,234.10, p < 0.0001) when analyzing ninety-day episode of care charges. CONCLUSION: Patients with dementia undergoing THA due to femoral neck fracture have increased LOS, medical and prostheses-related complications, and cost of care compared to their counterparts.

How Did Coronavirus-19 Impact the Expenses for Medical Students Applying to an Orthopaedic Surgery Residency in 2020 to 2021?

BACKGROUND: Orthopaedic surgery is one of the most competitive specialties for residency applicants. For the 2021 residency match, the coronavirus-19 pandemic introduced complexity for programs and applicants because away rotations were limited and in-person interviews were cancelled. This may have changed the landscape in terms of expenses for candidates in important ways, but this topic has been insufficiently studied. QUESTIONS/PURPOSES: Given that in 2021, students did not attend away rotations and all interviews were held virtually, we asked (1) What were the financial savings associated with this change? (2) Was medical school geographic region associated with differences in expenses when applying to residency? METHODS: A retrospective, cross-sectional analysis of the 2020 and 2021 Texas Seeking Transparency in Application to Residency Dashboard database was performed. The data were derived from an online survey of a nationwide pool of applicants from 87% (123 of 141) of US allopathic medical schools upon conclusion of the match. The response percentage was 29% (521 of 1794). We believe this nationwide dataset represents the largest and most current data for this applicant group. Responses from applicants applying to orthopaedic surgery residency in the year before the COVID-19 pandemic application changes (2020) and during COVID-19 (2021) were queried and compared. After the orthopaedic surgery match, the database was evaluated for individual (application costs, away rotation expenses, and interview expenses) and total expenses for medical school seniors applying to orthopaedic surgery residency. Applicant characteristics were compared between application cycles. The 2020 to 2021 Texas Seeking Transparency in Application to Residency Dashboard database had 521 responses (n = 263 in 2020 and n = 258 in 2021) from applicants applying to orthopaedic surgery residency. Demographic and applicant characteristics were comparable between application cycles. Median expenses are reported with percentile distributions and geographic comparisons. A Mann-Whitney U test or Kruskal-Wallis H test was used to determine whether there were statistically significant differences in expenses between years and between medical school regions at a p value threshold of < 0.05. RESULTS: For all applicants, the median total expenses (USD 7250 versus USD 2250), application costs (USD 2250 versus USD 1750), away rotation expenses (USD 2750 versus USD 250), and interview expenses (USD 2250 versus USD 75) declined in 2021 compared with 2020 (all p < 0.001). The median total savings in expenses for all applicants in 2021 compared with 2020 was USD 5000. In 2021, median total expenses were lower in all geographic regions with the greatest savings from applicants in the West (USD 6000); in addition, the difference in median total expenses between the geographic region with the highest total expenses and the lowest total expenses was lower in the pandemic year than it was in the year prior (USD 1000 versus USD 1500; p < 0.001). In 2021, there were differences in total expenses between the Northeast (USD 1750), West (USD 1750), and Central (USD 2750) regions (p < 0.001). From 2020 to 2021, only application fees from Northeast applicants differed (USD 2250 versus USD 1250; p < 0.001). In 2020, interview expenses were not different between all regions (USD 2250 Northeast and West versus USD 2750 Central and South; p = 0.19); similarly in 2021, interview expenses were similar between all regions (USD 75 versus USD 75; p = 0.82). Finally, in 2020, Northeast (USD 3250) and Western (USD 3250) applicants spent more for away rotations than Southern (USD 2750) and Central (USD 2250) applicants (p = 0.01). In 2021, applicants from schools in the South (USD 250) and Central (USD 250) regions spent more than their counterparts (USD 0; p = 0.028). CONCLUSION: In the COVID-19 application cycle, the median expenditures of orthopaedic residency candidates were USD 5000 lower than they were in the previous year; the difference can be attributed to the use of virtual interviews and the lack of away rotations. There are geographic implications, with applicants from Western United States medical schools potentially saving the most. Despite the financial savings during the 2021 match, further study related to the long-term success of the current application process (both for applicants and programs) is needed. The recommendation in May 2020 by the AOA Council of Orthopaedic Residency Directors (CORD) to limit the number of applications submitted by candidates with USMLE Step 1 scores greater than 235 did not result in any considerable decline in applications submitted or expenses. A better understanding of how differences in these expenses may influence our specialty's ability to attract socioeconomically diverse candidates would be important, and we need to explore perceived and actual financial obstacles to obtaining this diversity in the application process. Finally, avenues should be explored by program directors and chairpersons to reduce the expenses of the traditional application process while maintaining recruitment of top candidates. LEVEL OF EVIDENCE: Level IV, economic analysis.

Crohn's Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty.

BACKGROUND: As the incidence and prevalence of Crohn's disease continues to change worldwide, rates within North America have been increasing. The objective of this study was to evaluate whether patients who have Crohn's disease undergoing primary total hip arthroplasties have worse outcomes compared with matched cohorts. Specifically, we evaluated 1) medical complications, 2) in-hospital lengths of stay (LOS), and 3) costs of care. METHODS: Two cohorts of patients who underwent primary total hip arthroplasties from January 1, 2005 to March 31, 2014 were identified from the Medicare claims of the PearlDiver platform. Cohorts were matched by age, sex, and following comorbidities-anemia, diabetes, hyperlipidemia, hypertension, malnutrition, pulmonary disease, and renal failure, yielding 55,361 patients within the study (n = 9229) and matching cohorts (n = 46,132). Outcomes assessed included 90-day medical complications, in-hospital LOS, and costs of care. A P-value less than .005 was considered statistically significant. RESULTS: Patients with Crohn's disease were found to have significantly higher incidences and odds ratios of 90-day medical complications (30.2 vs 13.8; odds ratios: 2.2, P < .0001). They were also found to have significantly longer LOS (3.8- vs 3.6-days, P < .0001) and higher day of surgery ($12,662.00 vs 12,271.15, P < .0001) and 90-day episode costs ($16,933.18 vs $15,670.32, P < .0001). CONCLUSION: Crohn's disease is associated with higher rates of medical complications, longer in-hospital LOS, and increased costs of care. This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications in these patients.

Management of Adult Lumbar Spine Problems for General Orthopaedic Surgeons: A Practical Guide.

Low back pain is one of the most common reasons for physician visits, leading to high heath care costs and disability. Patients may present to primary care physicians, pain management physicians, chiropractors, physical therapists, or surgeons with these complaints. A thorough history and physical examination coupled with judicious use of advanced imaging studies will aid in determining the etiology of the pain. As most cases of low back pain are self-limited and will not develop into chronic pain, nonsurgical treatment is the mainstay. First-line treatment includes exercise, superficial heat, massage, acupuncture, or spinal manipulation. Pharmacologic treatment should be reserved for patients unresponsive to nonpharmacologic treatment and may include NSAIDs or muscle relaxants. Surgery is reserved for patients with pain nonresponsive to a full trial of nonsurgical interventions and with imaging studies which are concordant with physical examination findings.

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management.

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that although one pathology is managed, management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.

Depressive Disorder and Trimalleolar Fractures: An Analysis of Outcomes and Costs.

INTRODUCTION: Studies have suggested a strong association between depression and poor outcomes following various orthopaedic surgeries. However, depression's impact on complications following open reduction/internal fixation (ORIF) of trimalleolar fractures has not been elucidated. Therefore, this study aimed to determine whether depression is associated with higher rates of readmissions and medical complications following ORIF of trimalleolar fractures. METHODS: A database query from January, 2020, through March, 2021, identifying adults who underwent trimalleolar ORIF generated 50 154 patients. Those with depression were matched 1:1 to controls without depression by age, sex, chronic obstructive pulmonary disease, anxiety, and other prominent comorbidities. Primary endpoints compared 90-day all-cause readmissions and medical complications. Odds ratios (ORs) of the effect of depression on readmissions and medical complications were calculated. RESULTS: Patients with depression who underwent ORIF of trimalleolar fractures had significantly higher odds of being readmitted within 90 days of the initial procedure (OR: 1.37; P < .0001). Ninety-day odds of developing medical complications were significantly higher (OR: 4.61; P < .0001) in patients with depression compared with patients within the control group. CONCLUSION: Patients with depression undergoing trimalleolar ORIF face an increased risk of readmission and multiple postoperative complications. Orthopaedic surgeons should factor depression into their preoperative evaluation, given the already high burden of complications following ORIF of trimalleolar fractures. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.

Complications and Healthcare Cost of Total Hip Arthroplasty in Patients with Depressive Disorder.

Purpose: The purpose of this study was to determine whether the rates of (1) in-hospital lengths of stay (LOS), (2) readmissions, (3) medical complications, and (4) costs of care are higher for patients with depressive disorder (DD) undergoing primary total hip arthroplasty (THA) for treatment of femoral neck fractures (FNFs). Materials and Methods: A retrospective query of a national administrative claims database for patients undergoing primary THA from 2006 to 2014 was conducted. Patients with DD undergoing THA for treatment of FNF were 1:5 ratio propensity score matched to a cohort (DD=6,758, controls=33,708). Primary endpoints included LOS, 90-day medical complications, 90-day readmissions, and healthcare reimbursements. A P-value less than 0.05 was considered statistically significant. Results: Longer LOS were observed for patients with DD compared to those without DD (5.6 days vs. 5.4 days, P<0.001). Similar readmission rates (29.9% vs. 25.0%, odds ratio [OR] 1.03, P=0.281) were observed between groups. The odds of 90-day medical complications were higher for patients with DD compared to control subjects (60.6% vs. 21.4%, OR 1.57, P<0.0001). Within the 90-day episode of care interval, patients with a history of DD incurred significantly higher healthcare expenditures ($21,382 vs. $19,781, P<0.001). Conclusion: Our findings showed longer LOS, higher odds of 90-day medical complications, and higher healthcare expenditures within the 90-day episode of care following a primary THA for treatment of FNF for patients with DD compared to the matched cohort. Thus, accordingly, patients with DD should receive counseling prior to undergoing surgery.

Trends and impact of comorbidities on Guyon's Canal release for the treatment of Guyon's Canal syndrome: A decade long nationwide analysis.

Background: Guyon's Canal Syndrome (GCS) is a rare nerve entrapment condition with limited studies exploring the trends of GCS patients undergoing Guyon's Canal release. The aim of this study is to examine the trends associated with GCS: (1) Guyon's Canal release procedures performed; (2) surgically relevant comorbidities; (3) 90-day readmissions; and (4) same-day and 90-day reimbursement. Methods: A retrospective query was performed on the PearlDiver Mariner Database from 2010 to 2020 by CPT code 64719 to identify patients who underwent Guyon's Canal release. A total of 33,3764 patients were identified. Linear regression models were used to analyze trends in procedures performed, comorbidities, readmission, and reimbursement over this period. A P-value less than 0.05 was considered statistically significant. Results: Between 2010 and 2020, there was an overall significant decreasing trend in the number of Guyon's Canal release procedures performed (RC, -127.50; p < 0.001). There was an increase in number of GCS patients that had undergone Guyon's Canal release who drink alcohol (RC, 0.33; p < 0.001), are obese (RC, 0.81; p < 0.001), and use tobacco (RC, 0.56; p < 0.004), and decrease number of GCS patients with a history of diabetes (RC, -0.82; p < 0.001), hypothyroidism (RC, -0.56; p < 0.001), PVD (RC, -0.71; p < 0.001), and RA (RC, -0.33; p < 0.001). We also found an overall increasing trend in 90-day readmissions (RC, 0.09; p = 0.019) and increased same-day (RC, 68.09; p < 0.001) and 90-day average reimbursement (RC, 257.15; p < 0.001) from 2010 to 2020. Conclusion: The study demonstrated a decreasing trend in Guyon's Canal release performed in GCS patients but increasing cost of care implicated by the increased 90-day readmissions and same day and 90-day reimbursement. This may be attributed to the comorbidities present in GCS patients undergoing Guyon's Canal release. Therefore, it is imperative when consulting GCS patients with surgically relevant comorbidities to weigh the risk and benefits of the procedure.