Ankle fracture open reduction and internal fixation in patients with cerebral palsy.

AIM: To examine patients with cerebral palsy (CP) undergoing open reduction and internal fixation (ORIF) for ankle fractures. METHOD: This was a retrospective study of adult patients undergoing ankle fracture ORIF for closed, isolated ankle fractures identified in between 2010 and 2021 in the Q1 PearlDiver M151 database. Patients with CP were identified with International Classification of Diseases (ICD)-9 and ICD-10 codes, and were matched to those without 1:10 on age, sex, and Elixhauser comorbidity index (ECI). Ninety-day adverse events were assessed with multivariable logistic regression. RESULTS: A total of 148 993 patients with isolated ankle fracture ORIF were identified, of whom 407 (0.27%) had CP. After matching, 3863 without CP were compared to 389 with CP. Patients with CP were at increased odds of: 90-day urinary tract infection (odds ratios [OR] 6.26), pneumonia (OR 3.50), minor adverse events (OR 3.46), sepsis (OR 3.30), any adverse events (OR 3.04), emergency department visits (OR 2.28), serious adverse events (OR 1.77), and prolonged length of stay more than 4 days (OR 22.44) (p < 0.001 for all). INTERPRETATION: Patients with CP undergoing ORIF for isolated, closed ankle fractures are at increased odds of several 90-day adverse events and prolonged length of stay compared to matched patients without CP.

Utilization and timing of surgical intervention for central cord syndrome in the United States.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: CCS is the most common type of incomplete spinal cord injury and can occur without or with bony injury. Surgical intervention and its timing for patients diagnosed with CCS has been controversial. The current study assessed utilization of and factors associated with operative intervention and its timing in patients diagnosed with central cord syndrome (CCS) in the absence of bony injury. METHODS: Adult patients diagnosed with CCS in the absence of vertebral fracture were queried from the national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and timing of operative intervention following CCS were assessed. Patient characteristics associated with surgical intervention and its timing were determined. RESULTS: From 2015 to 2020, 11,653 patients meeting inclusion criteria were identified, of which surgical intervention was identified for 2,003 (17.2%) and thus nonsurgical intervention for 9,650 (82.8%). The proportion of patients undergoing operative intervention evolved from 11.5% in 2015 to 19.7% in 2020 (p < 0.0001). Of those undergoing surgical intervention, the greatest increase was seen for those undergoing surgery within two days of diagnosis (5.5% in 2015 to 12.3% in 2020, p < 0.0001). On multivariable analysis, more recent year of service, region of service, younger age, and higher comorbidity burden were independent predictors of operative management (p < 0.05 for all). CONCLUSION: The majority of a large cohort of patients with first diagnosis CCS in the absence of bony injury were managed non-operatively. Operative management increased over the years of study, were performed earlier after diagnosis, and varied based on patient characteristic and geographic region.

Total Shoulder Arthroplasty in Patients With Hemophilia A: Greater Odds of Postoperative Bleeding and Thromboembolic Events but No Difference in 5-year Implant Survival.

BACKGROUND: Patients with hemophilia A can develop joint hemarthroses, degenerative changes, and eventually undergo total shoulder arthroplasty (TSA). Few data exist concerning complications and prosthesis survival after TSA in this population. QUESTIONS/PURPOSES: (1) Is hemophilia A associated with more bleeding and thromboembolic adverse events after TSA relative to matched controls? (2) Is 5-year TSA prosthesis survival reduced in patients with hemophilia A compared with matched controls? METHODS: The 2010 to 2022 PearlDiver M161 database was used to identify patients who underwent primary anatomic or reverse TSA. Given that the X-linked recessive condition hemophilia A presents nearly exclusively in males, male patients with hemophilia A who underwent TSA were matched 1:10 with male patients without hemophilia who underwent TSA based on age and Elixhauser comorbidity index (ECI). This yielded 73 patients with hemophilia A who underwent TSA who were matched 1:10 with 729 patients without hemophilia. Ninety-day adverse events were compared with multivariable analysis. Revision within 5 years was assessed using Kaplan-Meier analysis. RESULTS: Compared with the control cohort, patients with hemophilia had greater odds of bleeding issues (hematoma, OR 6.8 [95% CI 3.0 to 15.3]; p < 0.001; anemia, OR 2.5 [95% CI 1.5 to 4.2]; p < 0.001, transfusion, OR 5.0 [95% CI 2.4 to 10.3]; p < 0.001), venous thromboembolic events (VTE) (OR 1.9 [95% CI 1.1 to 3.1]; p = 0.01), and prosthetic loosening (OR 3.5 [95% CI 1.4 to 8.0]; p = 0.004). Based on available data, 5-year implant survival was not different in patients with hemophilia (97.3% [95% CI 93.6% to 100.0%]) relative to matched controls (95.2% [95% CI 93.4% to 97.2%]; p = 0.60). CONCLUSION: The elevated risks of both 90-day bleeding complications (hematoma, anemia, and transfusion) and VTE (DVT and PE) in patients with hemophilia emphasize the special challenges of carefully balancing factor replacement and VTE prophylaxis pre-, intra-, and postoperatively on an individual patient basis with careful hematologist coordination. Further study on Factor VIII levels and targets as well as tranexamic acid and VTE prophylaxis in this population is necessary to provide further guidance. Furthermore, 5-year implant survival was not different between patients with hemophilia and matched controls (patients without hemophilia) based on available data, suggesting that TSA survivorship remains durable and may be offered to patients in this population as indicated. LEVEL OF EVIDENCE: Level III, therapeutic study.

Medicaid Insurance Is Associated With More Complications and Emergency Department Visits but Equivalent 5-Year Secondary Surgery Rate After Primary Hip Arthroscopy.

PURPOSE: To compare 90-day complications, 30-day emergency department (ED) visits, and 5-year rate of secondary surgeries for patients with Medicaid vs commercial insurance undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and/or labral tears using a large national database. METHODS: The PearlDiver Mariner151 database was used to identify patients with International Classification of Diseases, Tenth Revision diagnosis codes for FAIS and/or labral tear who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021. Patients with Medicaid were matched 1:4 to a control group of commercially insured patients based on age, sex, body mass index, and Elixhauser Comorbidity Index. Rates of 90-day complications and 30-day ED visits were compared using multivariate regression models. Five-year rates of secondary surgeries-revision arthroscopy or total hip arthroplasty-were compared between cohorts by Kaplan-Meier analysis. RESULTS: A total of 2,033 Medicaid patients were matched with 8,056 commercially insured patients. Rates of adverse events were low; however, Medicaid patients were significantly more likely than commercially insured patients to experience any 90-day complication (2.12% vs 1.43%; odds ratio [OR], 1.2; P = .02). Medicaid patients also experienced more 30-day ED visits than commercially insured patients (8.61% vs 4.28%), and on multivariate logistic regression, insurance status was the strongest determinant of 30-day ED visits (relative to commercial, Medicaid OR, 2.02; P < .001). Despite these differences, 5-year rates of secondary surgeries were comparable between groups (6.1% vs 6.0%; P = .6). CONCLUSIONS: In this large national database study, Medicaid patients undergoing primary hip arthroscopy showed significantly greater odds of experiencing 90-day postoperative complications and 30-day ED visits compared to commercially insured patients. Nevertheless, both groups had similar survivorship rates at 5-year follow-up, similar to prior estimates irrespective of insurance. These results document encouraging secondary surgery rates in Medicaid patients.

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients.

PURPOSE: To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability. METHODS: A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis. RESULTS: Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P = .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P = .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P = .4). CONCLUSIONS: Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits. LEVEL OF EVIDENCE: Level III, retrospective comparative case series.

The Association of Surgical Setting With Opioid Prescribing Patterns Following Wide-Awake Trigger Finger Release.

INTRODUCTION: Wide-awake and office-based hand surgeries are increasingly common. The association of these techniques with postoperative pain and pain control has garnered recent attention. A prior study demonstrated that office-based trigger finger release (TFR) were associated with decreased perioperative opioid prescriptions compared to those performed in the operating room. The current study provides an in-depth analysis of the association between surgical setting and perioperative opioid prescriptions for wide-awake TFR. METHODS: Patients undergoing TFR between 2010 and 2021 were identified in PearlDiver, a national administrative claims database. Exclusion criteria were age <18 years, <6 months of preoperative data, <1 month of postoperative data, bilateral TFR, and concomitant hand surgery. To identify wide-awake cases, patients with procedural codes for general anesthesia, monitored anesthesia care, sedation and regional blocks were excluded. Patients were stratified by surgical setting (office or operating room), then matched based on age, sex, Elixhauser Comorbidity Index score, and geographic region. Patients with prior opioid prescriptions, opioid dependence, opioid abuse, substance use disorder, chronic back/neck pain, generalized anxiety, and major depression were identified. Perioperative opioid prescriptions (those filled within 7 days before or 30 days after surgery) were characterized. RESULTS: There were 16,604 matched wide-awake TFR patients in each cohort. In the cohort of office-based patients, 4,993 (30%) filled a prescription for perioperative opioids, in contrast to 8,763 (53%) patients who underwent surgery in the operating room. This disparity was statistically significant in both univariate and multivariate analyses. Univariate analysis indicated that office-based surgeries were linked to lower morphine milligram equivalents (MME) in opioid prescriptions than those performed in operating rooms (median of 140 vs 150, respectively). However, multivariate analysis demonstrated that opioid prescriptions for office-based surgeries were actually associated with greater MME. CONCLUSIONS: Patients undergoing office-based TFR were less likely to fill perioperative opioid prescriptions but were prescribed opioids with greater MME. In wide-awake TFR, it appears that a disparity may exist in patient and provider beliefs about postoperative pain control. Future patient- and provider-level investigations may produce insights into perceptions of postoperative pain and pain control, which may be useful for reducing opioid prescriptions across surgical settings.

Total shoulder arthroplasty in patients with factor V Leiden.

BACKGROUND: Anatomic and reverse total shoulder arthroplasty (TSA) are effective treatment options for end-stage glenohumeral osteoarthritis. However, consideration for pre-existing conditions must be taken into account. Factor V Leiden (FVL), the most common inherited thrombophilia, is one such condition that predisposes to a prothrombotic state and may affect perioperative and longer-term outcomes following TSA. METHODS: Adult patients undergoing primary TSA for osteoarthritis indication were identified in the 2010 through October 2021 PearlDiver M157 database. Patients with or without FVL were matched at a 1:4 ratio based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and 5-year revision rates were assessed and compared with multivariable logistic regression and rank-log tests, respectively. Finally, the relative use and bleeding/clotting outcomes were assessed based on venous thromboembolic (VTE) prophylactic agents used, with categories defined as (1) warfarin, heparin, or direct oral anticoagulant (DOAC) or (2) aspirin/no prescription found. RESULTS: Of 104,258 TSA patients, FVL was identified for 283 (0.27%). Based on matching, 1081 patients without FVL and 272 patients with FVL were selected. Multivariable analyses demonstrated that those with FVL displayed independently greater odds ratios (ORs) of deep vein thrombosis (DVT, OR = 9.50, P < .0001), pulmonary embolism (PE, OR = 10.10, P < .0001), and pneumonia (OR = 2.43, P = .0019). Further, these events contributed to the increased odds of aggregated minor (OR = 1.95, P = .0001), serious (OR = 6.38, P < .0001), and all (OR = 3.51, P < .0001) adverse events. All other individual 90-day adverse events, as well as 5-year revision rates, were not different between the study groups. When compared to matched patients without FVL on the same anticoagulant agents, FVL patients on warfarin, heparin, or DOAC agents demonstrated lesser odds of 90-day DVT and PE (OR = 4.25, P < .0001, and OR = 2.54, P = .0065) than those on aspirin/no prescription found (OR = 7.64 and OR = 21.95, P < .0001 for both). Interestingly, those on VTE prophylactic agents were not at greater odds of bleeding complications (hematoma or transfusion). DISCUSSION AND CONCLUSIONS: TSA patients with FVL present a difficult challenge to shoulder reconstruction surgeons. The current study highlights the strong risk of VTE that was reduced but still significantly elevated for those with stronger classes of VTE chemoprophylaxis. Acknowledging this risk is important for surgical planning and patient counseling, but also noted was the reassurance of similar 5-year revision rates for those with vs. without FVL.

Outcomes following total shoulder arthroplasty in patients with systemic lupus erythematosus.

BACKGROUND: Total shoulder arthroplasty (TSA) is a common procedure that may be considered for patients with glenohumeral osteoarthritis. Patients undergoing this procedure may be afflicted by comorbid conditions, such as systemic lupus erythematosus (SLE), which may impact odds of various postoperative complications. METHODS: Adult patients with and without SLE who underwent TSA (anatomic or reverse) were queried from the Jan 2010 to Oct 2022 PearlDiver M165 database. Patients with and without SLE were matched (1:4) based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse events and five-year implant survival were assessed and compared with multivariable analysis. Sub-analyses were done for SLE patients with and without a prescription of immunomodulatory therapy (IMT - corticosteroids, hydroxychloroquine, and/or biologics) within 90 days prior to surgery and compared to non-SLE patients with multivariable analyses. Lastly, SLE patients with and without a 90-day history of IMT were directly compared with multivariate logistic regression. A Bonferroni correction was applied to univariable analyses and multivariable regressions. RESULTS: Of 211,832 TSA patients identified, SLE was noted for 2,228 (1.1%). After matching, 8,261 patients without SLE and 2,085 patients with SLE were selected. SLE patients were at an increased odds of 90-day aggregated events including severe (OR=3.50), minor (OR=3.13), all (OR=2.35), and orthopedic-related (OR=1.41) adverse events (p<0.0030 for all). There was no difference in 5-year implant survival. Of those with SLE, IMT medications were being received by 1,267 (60.8%). Any, severe, minor, and orthopedic 90-day adverse events were significantly elevated for both those with and without IMT relative to those without SLE (p<0.0030 for all except for orthopedic-related adverse events for those not on IMT which were not significant). Relative to those not on IMT medications, those on IMT medications were at significantly higher odds of any, severe, minor, and orthopedic-related adverse events. CONCLUSION: Following TSA, patients with SLE were found to be at an increased odds of 90-day adverse events but not of 5-year revisions. Furthermore, those on IMT medications were at higher risk of any, severe, minor, and orthopedic-related adverse events compared to those who were not on these medications. These findings may help with patient counselling and surgical planning when those with SLE are considered for TSA.

Total Hip Arthroplasty in Patients Who Have Factor V Leiden: Elevated Risks Isolated to Venous Thromboembolism Events.

BACKGROUND: Total hip arthroplasty (THA) is a common procedure that requires consideration of preexisting comorbidities. Factor V Leiden (FVL), an inherited thrombophilia, is one such condition that predisposes patients to venous thromboembolism (VTE, deep vein thrombosis, and pulmonary embolism). The present study aimed to characterize the risks associated with FVL patients undergoing THA and evaluate the effect of VTE chemoprophylactic agents on these risks. METHODS: A total of 544,022 adult patients who underwent primary THA for osteoarthritis indications between 2010 and October 2021 were identified in an administrative claims database. Of these, FVL was identified in 1,138 (0.21%). Patients who had and did not have FVL were matched at a 1:4 ratio (1,131 with FVL and 4,519 without FVL) based on age, sex, and Elixhauser comorbidity index. Univariable and multivariable analyses were assessed for 90-day complications. Implant survival at 5 years was assessed and compared with log-rank tests. The relative use of different chemoprophylactic agents, including aspirin, warfarin, heparin, or direct oral anticoagulant (DOAC), was assessed. Bleeding events and VTE were compared for those prescribed either aspirin or warfarin, heparin, or DOAC. A Bonferroni correction was applied. RESULTS: On multivariable analysis, FVL patients were found to have increased odds of 90-day deep vein thrombosis (odds ratio (OR) = 9.20), pulmonary embolism (OR = 6.89), and aggregated severe and all adverse events (OR = 4.74 and 1.98, respectively), but not elevated risk of other perioperative adverse events or 5-year reoperations. More potent chemoprophylactic agents (warfarin, heparin, DOAC) reduced, but did not completely eliminate, the increased VTE risks (without increasing bleeding events). CONCLUSIONS: This study quantified the significantly elevated VTE risk associated with FVL patients undergoing THA. The lack of difference in other specific adverse events and 5-year reoperations is reassuring. Clearly, chemoprophylactic agents are important in this population and may need further attention.

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation.

BACKGROUND: Von Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival. METHODS: Adult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events. RESULTS: Of 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006). CONCLUSIONS: Patients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

The role of Vertebral Augmentation Procedures in the management of vertebral compression fractures secondary to multiple myeloma.

Multiple myeloma (MM) is a systemic disorder characterised by proliferation of B-lymphocytes and plasma cells in the bone marrow. The primary aims of the management of spinal lesions in MM are pain control and fracture stabilisation. Vertebral augmentation procedures (VAP) can be subdivided into percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP). BKP involves the placement of orthopaedic balloons into the fractured vertebral body, creating a void into which polymethylmethacrylate bone cement is injected. This review outlines the management of spinal lesions in patients with MM, with a focus on the comparative risks and efficacy of vertebroplasty (VP) and balloon kyphoplasty (BKP). Soft tissue masses in MM are highly radiosensitive. Bisphosphonates and newer oncological therapies have decreased the indications for palliative radiotherapy, while spinal bracing can be utilised in selected cases to provide stability. BKP and VP provide equivalent long term pain control after MM vertebral compression fractures (VCF). BKP is superior to non-operative management and VP for restoration of vertebral body height and prevention of segmental kyphosis. Current evidence suggests a greater degree of correction of kyphotic deformity and restoration of mid vertebral height (MVH) with BKP when compared with VP. The literature supports the use of BKP even in the presence of posterior vertebral body wall (PVBW) fractures, a group previously considered a contraindication to VAP. Superior functional outcomes have been reported in patients undergoing early versus delayed BKP (<6-8 weeks). Current evidence supports a lower risk of cement extrusion with BKP than with VP, but serious complications following VAP are rare. MM spinal pathology should be managed in a multidisciplinary setting. Surgical decompression and instrumentation are rarely indicated, due to the radio-sensitivity of soft tissue lesions in MM. BKP is a safe and effective procedure for VCF secondary to MM.

Low Rates of 5-Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients.

PURPOSE: To evaluate 90-day complications, 5-year secondary surgery rates, and risk factors for secondary surgery following primary hip arthroscopy performed for femoroacetabular impingement and/or labral tears using a large national dataset. METHODS: A retrospective analysis was conducted using the PearlDiver Mariner151 database. Patients with International Classification of Diseases, Tenth Revision, diagnosis codes for femoroacetabular impingement and/or labral tear undergoing primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021 were identified. Those with concomitant International Classification of Diseases, Tenth Revision, codes for infection, neoplasm, or fracture were excluded, as were patients with a history of previous hip arthroscopy or total hip arthroplasty, or age ≥70 years. Rates of complications within 90 days of surgery were assessed. Five-year rates of secondary surgery-revision hip arthroscopy or conversion to total hip arthroplasty-were determined by Kaplan-Meier analysis, and risk factors for secondary surgery were identified by multivariate logistic regression. RESULTS: A total of 31,623 patients underwent primary hip arthroscopy from October 2015 to April 2021, with annual volumes ranging from 5,340 to 6,343 surgeries per year. Femoroplasty was the most frequent surgical procedure (performed in 81.1% of surgical encounters), followed by labral repair (72.6%) and acetabuloplasty (33.0%). Ninety-day postoperative complication rates were low, with 1.28% of patients experiencing any complication. The 5-year secondary surgery rate was 4.9% (N = 915 patients). Multivariate logistic regression identified age <20 years (odds ratio [OR] 1.50; P < .001), female sex (OR 1.33; P < .001), class I obesity (body mass index 30-34.9: OR 1.30; P = .04), and class II/III obesity (body mass index ≥35.0: OR 1.29; P = .02) as independent predictors of secondary surgery. CONCLUSIONS: In this study of primary hip arthroscopy, 90-day adverse events were low at 1.28%, and the 5-year secondary surgery rate was 4.9%. Age younger than 20 years, female sex, and obesity were risk factors for secondary surgery, suggesting the need for increased surveillance in these patient groups. LEVEL OF EVIDENCE: Level IV, case series.

Wide Awake Trigger Finger Releases Performed in the United States: Trends in Volume, Operative Setting, and Reimbursement.

BACKGROUND: Trigger finger release (TFR) has traditionally been performed in outpatient operating rooms. More recently, TFR may be performed in the office setting to achieve greater efficiency and cost savings. METHODS: The 2010-2020 Q2 PearlDiver M91Ortho data set was analyzed for cases of TFR. Exclusion criteria were age less than 18 years, <30 days of postoperative records, concomitant hand surgery, monitored anesthesia use, and inpatient surgery. Age, sex, and Elixhauser comorbidity index were recorded. Operating room and office procedures were matched 4:1 based on patient characteristics. Total and physician reimbursement for the day of surgery, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI) were determined. RESULTS: Before matching, TFRs were found to be increasingly performed in the office (from 7.9% in 2010 to 14.6% in 2020). Matched cohorts consisted of 63,951 operating room and 15,992 office procedures. Office procedures had lower mean total reimbursements ($435 vs $752, P < 0.001), slightly lower mean physician reimbursements ($420 vs $460, P < 0.001), and lower rates of narcotic prescriptions (30.5% vs 50.5%, P < 0.001) and 30-day ED visits (2.2% vs 2.9%, P < 0.05). There was no difference in 30-day SSI (0.5% vs 0.6%, P = 0.374). CONCLUSIONS: In-office TFR is becoming increasingly prevalent. After matching, in-office TFRs were associated with lesser costs to the system, lower narcotic prescriptions, and fewer postoperative ED visits, without increased SSI. Although it is important to perform procedures in the best location for the patient, physician, and system, the current study supports the increased value offered by in-office TFR.

Total Hip Arthroplasty in Patients Who Have Marfan Syndrome: Adverse Events and 5-Year Revision Rates.

BACKGROUND: Marfan syndrome is a rare inherited connective tissue disease, which may be present in patients who have advanced hip pathologies that may require total hip arthroplasty (THA). The postoperative course of patients who have Marfan syndrome following THA has not yet been defined. METHODS: Adult patients who have and do not have Marfan syndrome and underwent THA were identified in a national database. Patients diagnosed who had infection, trauma, or neoplasms within the 90 days prior to surgery were excluded. Those who have versus those who did not have Marfan syndrome were matched 1:10 based on age, sex, and a comorbidity index. After matching, 144 patients who have Marfan syndrome and 1,440 who do not have Marfan syndrome were identified. The 90-day postoperative adverse events and 5-year revisions were assessed and compared with multivariable analyses and log rank tests, respectively. RESULTS: Multivariable analyses demonstrated that Marfan syndrome was independently associated with greater odds of 90-day adverse events: venous thromboembolic events (odds ratio [OR]: 2.9, P = .001), cardiac events (OR: 4.5, P = .034), pneumonia (OR: 3.5, P < .001), and urinary tract infections (OR: 5.2, P < .001). There was no significant difference in 5-year rates of revision. CONCLUSIONS: Following THA, Marfan syndrome was independently associated with greater rates of several 90-day adverse events, but not higher 5-year rates of revision. The identified at-risk adverse events may help guide surgeons to improve perioperative care pathways, while having confidence regarding joint survival of THA in this rare disease population.

Adverse Events After Total Hip Arthroplasty are not Sufficiently Characterized by 30-Day Follow-Up: A Database Study.

BACKGROUND: Many previous studies of total hip arthroplasty (THA) have focused on adverse events occurring within 30 days of surgery. Studies examining 90-day postoperative adverse events have typically not focused on the timing of adverse events within that period. The current study evaluated the rate and timing of adverse events within 90 days of THA. METHODS: Adult THA patients between 2010 and 2020 Q3 were identified from a large administrative dataset. Rates and timing of 90-day adverse events were determined. The median, interquartile range, and middle 80% were calculated based on the time of diagnosis for each adverse event. These were also dichotomized as occurring before or after 30 days and predictive factors for later adverse events were determined. RESULTS: Overall, 81,158 adverse events were noted, of which 56,500 (69.0%) were diagnosed within 30 days of surgery and 25,355 (31.0%) were diagnosed 31-90 days after surgery. The proportion of adverse events occurring 31-90 days after surgery ranged from 6% (transfusion) to 45% (wound dehiscence). Patients experiencing a later adverse event were more likely to be women and to have higher Elixhauser Comorbidity Index (ECI) scores. CONCLUSION: Almost one-third of adverse events following THA were diagnosed between postoperative days 31 and 90, highlighting the importance of looking beyond 30 days when estimating patients' risk of postoperative adverse events. These data may inform future research, patient counseling, and prevention strategies.

Total Knee Arthroplasty: Variables Affecting 90-day Overall Reimbursement.

BACKGROUND: Total knee arthroplasty (TKA) is commonly considered to address symptomatically limiting knee osteoarthritis. With increasing utilization, understanding the variability and related drivers may help the healthcare system optimize delivery to the large numbers of patient to whom it is offered. METHODS: A total of 1,066,327 TKA patients who underwent primary TKA were isolated from a 2010 to 2021 PearlDiver national dataset. Exclusion criteria included patients less than 18 years old and traumatic, infectious, or oncologic indications. Overall, 90-day reimbursements and variables associated with the patient, surgical procedure, region, and perioperative period were abstracted. Multivariable linear regressions were performed to determine independent drivers of reimbursement. RESULTS: The 90-day postoperative reimbursements had an average (standard deviation) of $11,212.99 ($15,000.62), a median (interquartile range) of $4,472.00 ($13,101.00), and a total of $11,946,962,912. Variables independently associated with the greatest increase in overall 90-day reimbursement were related to admission (in-patient index-procedure [+$5,695.26] or hospital readmission [+$18,495.03]). Further drivers were region (Midwest +$8,826.21, West +$4,578.55, South +$3,709.40; relative to Northeast), insurance (commercial +$4,492.34, Medicaid +$1,187.65; relative to Medicare), postoperative emergency department visits (+$3,574.57), postoperative adverse events (+$1,309.35), (P < .0001 for each). CONCLUSION: The current study assessed over a million TKA patients and found large variations in reimbursement/cost. The largest increases in reimbursement were associated with admission (readmission or index procedure). This was followed by region, insurance, and other postoperative events. These results underscore the necessity to balance performing out-patient surgeries in appropriate patients versus the risk of readmissions and defined other areas for cost containment strategies.

Total Hip Arthroplasty Imageless Navigation Does Not Reduce 90-Day Adverse Events or Five-Year Revisions in a Large National Cohort.

BACKGROUND: Computer navigation is an increasingly utilized technology that is considered with total hip arthroplasty (THA). However, the evidence to support this practice is mixed. The current study leveraged a large national administrative database to compare 90-day adverse events as well as 5-year all-cause revision and dislocation rates following THA performed with and without imageless navigation. METHODS: From 2010 to 2020, a large national database was queried for THA cases performed for osteoarthritis. Cases with or without imageless navigation were matched at 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI) score. Ninety-day adverse events were assessed and compared with multivariate analyses. Five-year incidence of revision and dislocation were also assessed between cohorts. RESULTS: Use of THA imageless navigation increased from 2010 (2.5% of cases) to 2020 (5.5% of cases; P < .001). After matching, 11,990 THA patients with navigation and 47,948 without navigation were identified. Overall, 90-day adverse events were observed in 7.0% of the population. Multivariate analysis controlling for age, sex, and ECI demonstrated a difference in only one 90-day adverse event; wound dehiscence, which had higher odds in the navigation group (odds ratio, 1.60, P < .001). At 5 years, revisions for the navigated group were higher (4.4 versus 3.6%: P = .006), while dislocations were not significantly different. CONCLUSION: THA imageless navigation was not found to be associated with improved 90-day postoperative adverse events or differences in the 5-year rates of revision or dislocation. The current data were unable to identify clear advantages of this evolving technology for primary THA.

Urgent Care Visits Sought After Primary Total Hip Arthroplasty: A Potentially Overlooked Resource.

BACKGROUND: Following total hip arthroplasty (THA), readmissions and emergency department (ED) visits have been studied. Urgent care utilization is not well-characterized and may represent an overlooked avenue to facilitate lesser acuity patient needs. METHODS: Primary THAs performed for osteoarthritis indications were identified from 2010 to April of 2021 from a large national database. The incidence and timing of 90-day postoperative ED and urgent care visits were determined. Univariable and multivariable analyses assessed factors associated with urgent care relative to ED utilization. Reasons and acuity of diagnoses for these visits were determined. For 213,189 THA patients, 90-day ED visits were identified for 37,692 (17.7%) and urgent care visits for 2,083 (1.0%). The greatest incidence of both ED and urgent care visits were in the first two postoperative weeks. RESULTS: Independent predictors of urgent care utilization relative to ED utilization were: procedures being performed in the Northeast or South, insurance plan being Commercial, women, and lesser comorbidity burden (P < .0001). Reason for visits to the ED was directly related to the surgical site for 25.6% but for urgent care were just 4.8% (P < .0001). Reasons for visits to the ED were classified as low-acuity for 57.4% and for urgent care 96.9% (P < .0001). CONCLUSION: Following THA, patients may need urgent evaluation. While many issues can be addressed through the office, urgent care visits may represent a viable and underused resource relative to the ED for a large percentage of patients who have lower acuity diagnoses.

Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Postoperative Antibiotics Following Reduction Mammaplasty Does Not Reduce Rates of Surgical Site Infection.

BACKGROUND: The efficacy of antibiotic utilization following reduction mammaplasty has not been well studied. Furthermore, there is a lack of data describing subgroups who are historically at high risk for surgical site infection (SSI), specifically the obese population. OBJECTIVES: This study compares SSI rates in reduction mammaplasty patients who received postoperative courses of antibiotics with those who did not. Additional analysis was performed for the subgroup of patients with a body mass index (BMI) ≥30 kg/m2. METHODS: The 2010 to 2021 PearlDiver Mariner data set was reviewed to identify reduction mammaplasty patients. Patients were confirmed to have received perioperative antibiotics. Postoperative antibiotic use was determined based on the presence of postoperative prescriptions, and 1:1 matching was performed for those with and without postoperative antibiotics based on age and the Elixhauser Comorbidity Index. Rates of SSI, emergency department (ED) visits, and readmissions for the 90 days following surgery were recorded and compared. A subgroup analysis was performed on patients with a BMI of ≥30 kg/m2. RESULTS: Among patients who were confirmed to have received perioperative antibiotics, 2230 patients who also received postoperative antibiotics were identified and matched to 2230 patients who did not. Rates of SSI, ED visits, and readmission were not statistically different. A total of 218 obese patients were identified from this group and matched. Rates of SSI, ED visits, and readmission were not statistically different. CONCLUSIONS: In the current study, no difference in SSI rates between patients who received postoperative antibiotics and those who did not was found. These observations were corroborated in the obese population. These data may assist surgeons when considering postoperative antibiotics following reduction mammaplasty.