The Impact of Patient Characteristics on Outcomes of Surgically Managed Vertebral Osteomyelitis in the United States: Insights from a National Database Study.

This study was conducted to assess the patient characteristics, types of treatment, and outcomes of patients who are surgically treated for vertebral osteomyelitis (VO) in the United States. VO can be treated with or without surgical intervention. Surgically treated cases of VO are associated with significant morbidity and mortality, and incur major healthcare costs. There are few studies assessing the characteristics and outcomes of patients with VO who are treated surgically, as well as the overall impact of surgically managed VO on the healthcare system of the United States. Utilizing the Nationwide Inpatient Sample (NIS) database, 44,401 patients were identified who underwent surgical treatment for VO over a fifteen year period. Severity of comorbidity burden was calculated using the Deyo Index (DI). Surgical approach and comorbidities were analyzed in regard to their impact on complications, mortality rate, LOS, and hospitalization charges. The incidence of surgical intervention for patients who had VO increased from 0.6 to 1.1 per U.S. persons over the study period. Surgically treated patients had a mean age of 56 years, were 75.8% white, were 54.5% male, 37.9% carried Medicare insurance, and they had a mean DI of 0.88. Anterior/posterior approach (OR: 3.53), thoracolumbar fusion (OR: 2.69), thoracolumbar fusion (OR: 19.94), and anterior/posterior approach (OR: 64.73) were the surgical factors that most significantly predicted any complication, mortality, increased LOS, and increased hospital charges, respectively (P < 0.001). The mean inflation-adjusted total hospital cost increased from $20,355 to $39,991 per patient over the study period. VO has been steadily increasing in the United States. Incidence and inflation-adjusted costs nearly doubled. Anterior/posterior approach and thoracolumbar fusion most significantly predicted negative outcomes. VO is associated with lengthy and expensive hospital stays resulting in a significant burden to patients and the healthcare system.

Tommy John: Elbow Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace.

Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.

Improved Short-Term Outcomes of Osteochondral Lesions of the Knee Following Arthroscopic Treatment With Bone Marrow Aspirate Concentrate and Cartilage-Derived Matrix.

PURPOSE: To assess the postoperative objective, subjective, and functional outcomes as well as complication rates in osteochondral defect patients treated with bone marrow aspirate concentrate (BMAC) and cartilage-derived matrix (CDM) during knee arthroscopy. METHODS: A retrospective chart review was performed for patients treated arthroscopically with BMAC and CDM between August 2015 and August 2018 and had more than 1-year follow-up. Demographic factors such as age, sex, body mass index, and comorbidities were collected for all patients. Size and location of the osteochondral lesions also were documented. RESULTS: A total of 14 patients were identified with a mean follow-up of 19 months. On average, patients were 34 years of age (range 16-58 years) and 43% were female. Postoperatively, knee flexion increased by 8° from 124° to 132° (P = .002). All patients regained full extension; however, 1 patient later acquired a 2° extension contracture after a traumatic event. The average hamstring strength significantly increased from 4.1 to 4.6 postoperatively (P = .33). The average quadriceps strength significantly increased from 4.0 to 4.5 postoperatively (P = .007). Mean visual analog scale scores significantly decreased postoperatively (4.5 vs 1.4; P = .001). There was a significant increase in Knee Outcome Survey Activities of Daily Living scores (53.8 vs 92.9; P = .007). Mean Knee Outcome Survey-Sports scores also increased, although this was nonsignificant (28.2 vs 79.5; P = .560). No significant differences were noted in pain and functional outcomes when stratified by the osteochondral defect size and location. Complications included a stitch abscess, Baker's cyst, and residual pain treated with hyaluronic acid injection. CONCLUSIONS: This study demonstrated arthroscopic BMAC and CDM implantation appears to be safe and has the potential to improve patient outcomes in the short-term postoperative period. LEVEL OF EVIDENCE: IV, therapeutic case series.

Use of Preoperative Magnetic Resonance Imaging to Predict Clinical Outcomes After Core Muscle Injury Repair.

BACKGROUND: Core muscle injury (CMI), often referred to as a sports hernia or athletic pubalgia, is a common cause of groin pain in athletes. Imaging modalities used to assist in the diagnosis of CMI include ultrasound (US) and magnetic resonance imaging (MRI). PURPOSE: To determine if preoperative MRI findings predict clinical outcomes after surgery for CMI. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed on a consecutive series of patients who were operatively treated for CMI by a single surgeon. CMI was diagnosed based on history, physical examination, and a positive US. In addition, all patients underwent a preoperative MRI. Patients were divided into 2 groups based on whether the MRI was interpreted as positive or negative for CMI. All patients underwent mini-open CMI repair. Patient-reported outcomes (PROs) were collected both pre- and postoperatively and included a visual analog scale (VAS) for pain, the University of California, Los Angeles (UCLA) activity score, and the modified Harris Hip Score. RESULTS: A total of 39 hips were included in this study, of which 17 had a positive MRI interpretation for CMI (44%) and 22 had a negative MRI interpretation (56%). Mean age at the time of surgery was 35 years (range, 17-56 years), and mean follow-up was 21 months (range, 12-35 months). No significant difference was found between groups in mean age or time to follow-up. Patients in both groups demonstrated significant improvement from preoperative to most recent follow-up in terms of the UCLA activity score (P < .05). VAS scores significantly improved for patients with a positive MRI interpretation (P = .001) but not for those with a negative MRI interpretation (P = .094). No significant difference on any PROs was found between groups at the most recent follow-up. CONCLUSION: Successful clinical outcomes can be expected in patients undergoing surgery for CMI diagnosed based on history, physical examination, and US. Patients with a preoperative MRI consistent with CMI may experience greater improvement in pain postoperatively, although MRI does not predict postoperative activity level in these patients.

Risk Factors for Requiring a Revision Anterior Cruciate Ligament Reconstruction: A Case-Control Study.

Anterior cruciate ligament (ACL) reconstruction is considered as a successful orthopaedic procedure that attempts to help patients return to their preinjury level of activity. However, some patients may need to undergo revision surgery, and this potentially may be associated with certain surgery-specific or patient risk factors. Therefore, the purpose of this study was to assess the potential role of (1) demographics, (2) family history, (3) graft choice, (4) sport, and (5) mechanism of injury (contact vs. noncontact) in the risk for needing a revision ACL for improved clinical outcomes. All patients who had undergone a primary ACL reconstruction between 2012 and 2016 were identified from at a single institution. About 312 patients who had a mean age of 24 years (range, 9-62 years) and a mean follow-up of 4 years (range, 1-10). Patients were further evaluated to identify those who had a revision. There were 19 patients (6.1%) with a mean age of 22 years (range, 13-38 years) and a mean follow-up of 5 years (range, 1-10) that required a revision reconstruction. Gender ratios (p = 0.56) and mean age (p = 0.44) were similar among the cohorts. Family history of ACL reconstruction had no association with revision risk (p = 0.57). Those with tibialis anterior allografts (37 vs. 4%; p = 0.0001) and hamstring allografts (16 vs. 1%; p = 0.0001) were far more likely to undergo a revision. Bone-tendon-bone (BTB) patella autografts were less likely (26 vs. 73%; p = 0.0001). Sport did not play a role in revision with those injured playing basketball (p = 0.61), football (p = 0.52), lacrosse (p = 0.52), soccer (p = 0.83), and volleyball (p = 0.61). There were a greater percentage of contact injuries that required revision (95 vs. 77%; p = 0.07). Graft selection played a significant role in requiring revision surgery with allografts portending to higher revision rates and BTB patella autografts conferring a lower risk.

Factors Complicating Discharge to Home following Total Knee Arthroplasty-A Single Institution Initiative.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.

Effect of biceps tenodesis on speed of recovery after arthroscopic rotator cuff repair.

BACKGROUND: Concomitant biceps tendon pathology is often present in patients undergoing rotator cuff repair (RCR). Management of biceps pathology has been reported to influence outcomes of RCR; however, the impact on the pace of recovery remains unclear. The purpose of this study was to analyze the effects of simultaneous RCR with biceps tenodesis (RCR-BT) on time to achieve maximum improvement and recovery speed for pain and function. METHODS: A retrospective review of 535 patients who underwent primary RCR for full-thickness tears. Patients treated with simultaneous RCR-BT were compared with RCR-only. Outcome measures and motion were recorded at preoperative routine postoperative intervals. Plateau in maximal improvement and recovery speed were analyzed for both pain and functional recovery. RESULTS: Baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) function was significantly lower for the RCR-BT cohort (20.5) compared with RCR-only (23.9; P = .008). For visual analog scale (VAS) pain and measured motion, the plateau in maximal improvement occurred at 6 months for RCR-BT compared with 12 months for the RCR-only group. The remainder of the patient-reported outcome measures took 12 months to achieve a plateau in maximal improvement. At 3 months, 79% of improvement in pain and 42%-49% of functional improvement was achieved in the RCR-BT cohort. Similarly, at 3 months, the RCR-only cohort achieved 73% of pain improvement and 36%-57% of functional improvement at 3 months. CONCLUSION: Patients requiring RCR with simultaneous biceps tenodesis have lower baseline ASES function and earlier postoperative plateaus in pain relief and motion improvement following surgery. Nonetheless, the speed of recovery was not influenced by the biceps tenodesis.

Diagnostic Accuracy of Physical Examination Tests in Core Muscle Injury.

BACKGROUND: Core muscle injury (CMI), often referred to as a sports hernia, is a common cause of groin pain in athletes characterized by concomitant injury to the insertion of the adductor longus and the rectus abdominis muscles. Currently, the literature on CMI is sparse with no standardized physical examination tests used in the diagnosis of this type of injury. PURPOSE: To determine the diagnostic accuracy of various physical examination tests in the diagnosis of CMI. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: A consecutive series of patients evaluated by the senior author with symptoms consistent with CMI were included. Four physical examination tests were routinely performed in these patients by the senior author and were noted in each patient's chart as positive or negative: (1) pain with resisted cross-body sit-up in figure-of-4 position, (2) pain with straight-leg sit-up, (3) pain with resisted hip flexion in external rotation (external rotation Stinchfield test), and (4) the presence of an adductor contracture. CMI was independently diagnosed by a reference standard (magnetic resonance imaging [MRI]). All MRI scans were read by a musculoskeletal fellowship-trained radiologist. The sensitivity and specificity of each physical examination test alone and in combination were calculated based on this reference standard. RESULTS: A total of 81 patients were included in this study. MRI was positive for a CMI in 39 patients (48%) overall. Both the cross-body sit-up test and the presence of an adductor contracture were found to have a sensitivity of 100% (specificity, 3% for both). The external rotation Stinchfield test was found to have the highest specificity of 60% (sensitivity, 15%). The sensitivity of all 4 physical examination tests in combination was found to be 100% (specificity, 0%). CONCLUSION: Certain physical examination maneuvers can be used to assist in the diagnosis of a CMI. The cross-body sit-up test and the presence of an adductor contracture are highly sensitive but nonspecific tests for CMI and therefore should be used in conjunction with diagnostic imaging before deciding on an appropriate treatment course.

Superior Capsular Reconstruction with Achilles Tendon Allograft.

Superior capsular reconstruction (SCR) has become an increasingly popular choice in the treatment of massive, irreparable rotator cuff tears, pseudoparalysis, and in cases in which revision of previous rotator cuff repair is indicated. The SCR procedure is intended to restore the superior stabilizing forces of a deficient rotator cuff. This technique is accomplished by substituting an autograft or allograft between the superior glenoid and the greater tuberosity of the humerus, thus keeping the humeral head centered in the glenoid during shoulder forward flexion and abduction. Since its advent, numerous techniques have been described for this procedure. A fascia lata autograft was initially described; however, many surgeons in the United States have advocated for the use of a humeral dermal allograft. Yet, biomechanical studies have demonstrated elongation and thinning of this material. Thus, the Achilles tendon allograft may be an attractive choice for SCR, given its previous success with ligamentous and tendinous reconstructions. In this article, we present our technique of SCR using an Achilles tendon allograft.

Accelerated Discharge following Total Knee Arthroplasty May Be Safe in a Teaching Institution.

Total knee arthroplasty (TKA) is one of the most commonly performed yet costly surgical procedures in orthopaedics. With national trends and reimbursements moving in favor of shorter hospital length-of-stay (LOS), it is important to understand the complications associated with discharging patients earlier. This is particularly more challenging in a teaching institution due to complexity and variety of layers of care. Therefore, the purpose of this study was to evaluate the 90-day postoperative outcomes among those who were discharged on postoperative day 2 (POD-2) and compare them to a cohort whom had a LOS ≥ 3 days. A retrospective review of all patients who underwent a primary TKA from at a single-teaching institution from 2015 to 2017 was performed. During this time, an accelerated discharge protocol was designed and implanted in our institution. We identified 485 patients who were then substratified into two groups: patients who were discharged on POD-2 (n = 91) with the accelerated protocol and those who were discharged ≥ 3 days (n = 394). Outcomes evaluated included (1) demographics, (2) readmission rates, (3) emergency room (ER) visits, and (4) complication rates within 90 days of TKA. The POD-2 cohort was significantly younger than patients with ≥ 3-day LOS (64 vs. 69 years; p = 0.0001). There were no differences in gender ratios between the 2-day and 3-day cohorts (women, 67 vs. 72%; p = 0.34). Readmission rates (2 vs. 5%; p = 0.31) and ER visits were similar between cohorts (9 vs. 6%; p = 0.4). Medical and surgical complication rates did not differ between the two cohorts, with an overall complication rate of 5.5% in POD-2 versus 5.6% in >3 days LOS (p = 0.97). Patients discharged on POD-2 from TKA did not demonstrate an increased risk of complications, ER visits, or readmissions within 90 days in a teaching institution. However, older patients tended to have a longer LOS.

Comparative Outcomes of Various Combinations of Bilateral Shoulder Arthroplasty.

Background: In the setting of bilateral shoulder arthroplasty (BSA), differences in functional outcomes and motion between anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are unknown. The purpose of this study was to compare the effectiveness of treatment for various combinations of TSA procedures. Methods: A review of prospectively collected data from an institutional shoulder surgery repository was performed for patients who underwent any combination of bilateral TSA or RSA surgery. Based on the combination of shoulder arthroplasty, patients were divided into the following subgroups: bilateral TSA (TSA/TSA), bilateral RSA (RSA/RSA), or unilateral TSA with contralateral RSA (TSA/RSA). A total of 73 patients (146 shoulders), with a minimum of 2-year follow-up, who underwent any combination of bilateral TSA or RSA from 2007 to 2014 were included. Pre- and postoperative patient-reported outcome measures and measured motion were evaluated between the 3 groups. Results: There were 47 TSA/TSA, 17 RSA/RSA, and 9 TSA/RSA patients with a mean age of 72 years and mean follow-up of 51 months. Preoperatively, TSA/TSA had significantly higher Simple Shoulder Test scores, Visual Analog Scale (VAS) function, active elevation, and active external rotation compared with RSA/RSA. Postoperative scores were significantly superior in TSA/TSA compared with other combinations of shoulder arthroplasty except VAS pain and function. Change in pre- to postoperative (effectiveness of treatment) internal rotation was superior in the TSA/TSA group compared with RSA/RSA and TSA/RSA; however, no other differences were observed. Conclusions: Bilateral TSA patients have higher preoperative function and motion. Although some postoperative outcomes differ among combinations of BSA, the overall effectiveness of treatment for patients undergoing BSA is similar between various combinations of arthroplasty.

Short-Term Outcomes Following Endoscopic Proximal Hamstring Repair.

PURPOSE: The purpose of this study was to evaluate the outcomes of endoscopic proximal hamstring repair (ePHR), specifically: (1) functional and subjective outcomes, (2) effectiveness of treatment (preoperative-to-postoperative change), (3) complications, (4) acute versus chronic tears, and (5) partial versus complete tears. METHODS: A retrospective case series of a single-surgeon database for all patients who underwent ePHR between November 2014 and January 2019 with a minimum 1-year follow-up (range, 12 to 48 months) was performed. Charts were analyzed for preoperative and postoperative passive range of motion (PROM), strength, VAS pain, UCLA activity, and modified Harris Hip Score (mHHS). Manual muscle strength testing based on standard grading scale of 0 to 5 was performed. Complications including re-tear of the repair site, infection, iatrogenic nerve injury, inability to return to work/sport at the same level as preinjury, persistent hamstring weakness, pain with sitting, and subsequent surgery were recorded. RESULTS: We identified 20 ePHR (6 males, 14 females) with a mean age of 46 years (range, 18 to 63 years). At most recent follow-up, mean VAS pain was 1.85 (SD 2), UCLA activity was 8 (SD 2), mHHS was 90.6 (SD 10.5), and PROM hip flexion of 121.7° (SD 14.5°). Effectiveness of treatment demonstrated significant improvement in objective hamstring strength, hip flexion PROM by 17.3°, UCLA activity by 3, and VAS pain by 3 points. Subjective hamstring weakness was reported in 8 (42.1%) and persistent pain with sitting in 3 (15.8%). Return to work and sport were 100% and 95%, respectively. mHHS was significantly higher postoperatively in patients with complete versus partial tears (95.5 versus 85.7). CONCLUSION: Endoscopic proximal hamstring repair is an effective approach that provides patients significant improvement in pain and function. LEVEL OF EVIDENCE: IV, Case Series.

The procedure value index: a new method for quantifying value in shoulder arthroplasty.

BACKGROUND: The purpose of this study was to introduce the procedure value index (PVI) and apply this value instrument to shoulder arthroplasty. The PVI uses the value equation in units of minimal clinically important difference (MCID) to provide an objective system of quantifying value-driven care. Secondarily, we describe the PVI for both primary anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) to highlight value differences between these patient populations. METHODS: Patients undergoing primary shoulder arthroplasty with minimum 2-year follow-up were identified retrospectively. MCIDs were determined for the Simple Shoulder Test (SST) score, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and Single Assessment Numeric Evaluation (SANE) score. Cost data were reported as total hospitalization costs, total charges, and total reimbursements. The PVI was calculated as the ratio of outcome improvement in units of MCID over the cost of care. Mean PVIs for TSA and RSA were compared. RESULTS: Five hundred thirty-four patients met the inclusion criteria. MCIDs for the SST, ASES, VAS pain, and SANE scores were 3.61, 29.49, 3.28, and 37.05, respectively. With the exception of the ASES score, improvements in units of MCID were not different between TSA and RSA. However, total hospitalization costs and charges were significantly higher for RSA (P < .001). PVIs based on total hospitalization costs and total charges for the SST, ASES, and VAS pain scores were significantly greater for TSA (P < .05). No other PVI was significantly different. CONCLUSIONS: The PVI was greater for TSA when total hospitalization costs and total charges were considered. The PVI helps highlight value differences in shoulder arthroplasty.

Value comparison of humeral component press-fit and cemented techniques in reverse shoulder arthroplasty.

BACKGROUND: Press-fit humeral fixation for reverse shoulder arthroplasty (RSA) has been shown to have loosening rates and outcomes similar to a cemented technique; however, increased value has not been reported. The purpose of this study was to determine whether the press-fit technique could improve the value of RSA using the procedure value index (PVI). METHODS: Primary RSA patients with complete hospitalization cost data, preoperative and minimum 2-year postoperative Simple Shoulder Test (SST) scores, and postoperative satisfaction were included. The PVI was calculated as improvement in the SST score (in units of minimal clinically important difference) divided by total cost and normalized. Itemized cost data were obtained from hospital financial records and categorized. Radiographic complications, infections, and revisions were noted. Comparisons were made between the press-fit and cemented RSA cohorts. RESULTS: A total of 176 primary RSA patients (83 cemented and 93 press fit) met the inclusion criteria (mean follow-up period, 44.6 months). Surgical indications (except failed rotator cuff repair), baseline SST scores, and demographic characteristics were similar. The calculated minimal clinically important difference for the SST score was 3.98. The average PVI was significantly greater in the press-fit cohort (1.51 vs 1.03, P < .001), representing a 47% difference. SST score improvement was not significantly different (P = .23). However, total hospitalization costs were significantly lower for the press-fit cohort ($10,048.89 vs $13,601.14; P < .001). CONCLUSION: Use of a press-fit technique led to a 47% increase in value over a cemented technique. This appeared to be a function of decreased total costs rather than increased outcome scores.

Racial Disparities in Revision Total Knee Arthroplasty: Analysis of 125,901 Patients in National US Private Payer Database.

INTRODUCTION: There is a relative paucity of studies that characterized racial disparities in revision total knee arthroplasty (TKA). Therefore, this study was specifically conducted to evaluate the following: (1) incidence; (2) annual burden; (3) causes; and (4) age group distribution of revision TKA among different racial groups in the US sample population. METHODS: The PearlDiver database was utilized to identify patients with knee osteoarthritis (OA) who underwent primary then subsequent revision TKA from January 2007 to December 2014. Patients were stratified by race, and subset stratification by age was also performed. In each racial cohort, the overall incidence of revision TKA, annual revision burdens, and causes of revisions were calculated and compared. Additionally, a sub-analysis for the incidence of revision TKA stratified by age, in each cohort, was performed. Statistical analysis was performed to demonstrate revision incidence, burden, causes, and age distribution. RESULTS: Revision incidence and burden were the highest in the African-American cohort (12.4%, 11.1%), (p < 0.001) and was lowest in the Asian cohort (3.4%, 3.3%) (p < 0.001). Across all cohorts, mechanical complications of the joint prosthesis were the most common cause of revision followed by periprosthetic joint infection, while contracture was the least common (p < 0.001). Subset analysis by age revealed that the highest incidence of revision TKA was in patients less than 40 years old in the Caucasian cohort (27.1%). The African-American (17.8%), other races (7.9%), and Hispanic (16.5%) cohorts had the highest incidence of revision in the 40 to 64 years age range. Among the Asian (4.1%) and Native American (9.7%) cohorts, revision incidence was highest in patients older than 65 years. CONCLUSION: The present study demonstrated that racial disparities, highlighted by previous studies mainly in primary TKA, extend to influence revision TKA. Among the studied racial cohorts, race may affect outcomes and our results will help expand the current literature particularly on its role in revision TKA.

Cervical Spinal Stenosis with Coexisting Rotator Cuff Tear: A Nationwide Review of Records from 2005 to 2014.

Rotator cuff tear (RCT) and cervical spinal stenosis (CSS) are common pathologies in the elderly. Both conditions may present with lateral shoulder pain and weakness or numbness of the upper extremity, potentially affecting patients' ability to live independently. Few data are available on the incidence of CSS among patients with concurrent RCT. The purpose of this study was to investigate the incidence of CSS among RCT patients, demographics, and surgical management using a national insurance database. The Medicare database was used to identify patients with RCT and concomitant CSS by ICD-9 codes from 2005-2014. Trends based on age, gender, and body mass index (BMI) were assessed. Utilization of open and arthroscopic rotator cuff repair (RCR) was compared. A total of 86,501 patients were identified. The number of patients diagnosed with RCT and CSS significantly increased (p< 0.0001). The incidence of CSS in patients with RCT increased from 9% to 13% (p < 0.05). Females < 64 years were more likely to exhibit combined pathology than age-matched males (OR 1.15, 95% CI 1.12 to 1.18) or females > 65 years (OR 1.64, 96% CI 1.61 to 1.67). A BMI of 30-40 kg/m2 demonstrated the highest incidence (43%, p < 0.0001). Arthroscopic RCR increased by 2% (p = 0.03) in RCT-CSS. The incidence of CSS in RCT patient is increasing. Orthopedic surgeons should maintain high clinical suspicion for concurrent CSS pathology in patients with RCT, particularly in obese female patients > 65 years with several medical comorbidities. Further investigation into the influence of these concurrent pathologies on patient outcomes is warranted.

Preoperative Opioid Use Among Patients Undergoing Shoulder Arthroplasty Predicts Prolonged Postoperative Opioid Use.

INTRODUCTION: This study determines the incidence of opioid use before shoulder arthroplasty and analyzes its influence on postoperative use. METHODS: A retrospective analysis of patients undergoing shoulder arthroplasty with at least 2-year follow-up was performed. Then, at pre- and postoperative appointments, the patients were asked "Do you take narcotic pain medication (codeine or stronger)?" RESULTS: Among 490 patients included in the study, 35.5% reported preoperative opioid use. These patients had higher incidence of opioid use at 1-year follow-up (29.1% versus 4.9%; odds ratio, 8.320; P < 0.001) and at final follow-up (35.1% versus 7.3%; odds ratio, 6.877; P < 0.001). Opioid usage did not change markedly from 1 year follow-up to final follow-up (P > 0.18). DISCUSSION: Approximately one-third of patients used opioids preoperatively and were seven times more likely to continue opioid use postoperatively. Opioid usage did not change from 1 year follow-up to final follow-up, suggesting that patients still using opioids at their 1-year appointment were likely to continue opioid use. LEVEL OF EVIDENCE: Level III.

Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014.

The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Restoration of External Rotation Following Reverse Shoulder Arthroplasty without Latissimus Dorsi Transfer.

BACKGROUND: Latissimus dorsi transfers have been considered necessary to restore active external rotation following reverse shoulder arthroplasty (RSA). The purpose of this study was to assess the effectiveness of an RSA system that lateralizes the center of rotation in restoring active external rotation without a latissimus dorsi transfer in patients with a preoperative external rotation deficit (external rotation of <0°). METHODS: We retrospectively reviewed the records of patients who had undergone RSA with a lateralized center of rotation without a latissimus dorsi transfer. All patients had had a preoperative external rotation deficit (active external rotation of <0°), and all were followed for a minimum of 2 years. Patients were stratified into 2 groups on the basis of the preoperative diagnosis: (1) those with a combined loss of active elevation and external rotation as a result of rotator cuff tear arthropathy (CLEER group) and (2) those with a combined loss of active elevation and external rotation as a result of other posttraumatic etiologies (non-CLEER group). The mean improvement of external rotation was analyzed. Subgroup analysis was performed on the basis of the Goutallier classification, glenosphere lateralization, and total prosthetic lateralization. RESULTS: Thirty-three patients (24 in the CLEER group and 9 in the non-CLEER group) met the inclusion criteria. The average follow-up was 43.4 months (range, 24 to 77 months). External rotation improved significantly in both the CLEER group (from -21° preoperatively to 28° postoperatively; p < 0.001) and the non-CLEER group (from -19° preoperatively to 26° postoperatively; p = 0.001). Goutallier classification, glenosphere lateralization, and total prosthetic lateralization were not correlated with the degree of improvement of external rotation in either group (p > 0.05 for all). CONCLUSIONS: RSA with a lateralized center of rotation can effectively restore external rotation without the use of a latissimus dorsi transfer in patients with a preoperative external rotation deficit as a result of rotator cuff arthropathy or other posttraumatic etiologies. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.